import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Hand Examination Hand examination tests detailed anatomical knowledge. Examiners expect you to systematically assess skin, tendons (flexor and extensor), nerves, joints, and function. Common scenarios include rheumatoid arthritis, nerve injuries, and tendon pathology. ## Quick Reference One-Pager ## Introduction and Setup **Patient Positioning:** Seated opposite examiner with hands resting on table, palms down initially **Exposure:** Both hands and forearms exposed **Consent Script:** "I'm going to examine your hands. I'll look at both, feel the joints and tendons, and test the movements and strength. Please tell me if anything is painful." **Key Concept:** The hand is a complex integration of: - Bones (27 per hand) and joints - Extrinsic muscles (forearm) and intrinsic muscles (hand) - Three major nerves (median, ulnar, radial) - Specialized skin (palmar vs dorsal) ## Look (Inspection) - **Swelling**: MCP (RA), PIP (OA Bouchard's, RA), DIP (OA Heberden's) - **Deformities**: Swan neck (PIP hyperextension, DIP flexion), Boutonniere (PIP flexion, DIP hyperextension) - **Muscle wasting**: Interossei (ulnar nerve), thenar eminence (median) - **Skin**: Scars, rheumatoid nodules, psoriatic plaques - **Nails**: Pitting (psoriasis), clubbing, splinter hemorrhages - **Alignment**: Ulnar drift at MCPs, rotational deformity - **Thenar eminence**: Wasting (carpal tunnel, C8/T1 lesion) - **Hypothenar eminence**: Wasting (ulnar nerve, Guyon's canal) - **Palmar fascia**: Dupuytren's nodules, cords, contractures - **Skin creases**: Pallor (anemia), palmar erythema - **Callosities**: Occupational, functional use pattern - **Scars**: Carpal tunnel release, tendon repairs - **Finger cascade**: All fingers should point toward scaphoid tubercle when flexed - **Rotational deformity**: Overlap or scissoring of fingers - **Tenodesis effect**: Passive wrist extension causes finger flexion - **Resting position**: MCP flexed, IP slightly flexed **Classic Deformities in Rheumatoid Arthritis:** - **Swan neck**: PIP hyperextension + DIP flexion (FDS rupture, intrinsic tightness) - **Boutonniere**: PIP flexion + DIP hyperextension (central slip rupture) - **Z-thumb**: MCP flexion + IP hyperextension - **Ulnar drift**: MCP joints deviate ulnarward ## Feel (Palpation) **Joints (Each finger, thumb):** - MCP joints: Dorsal swelling (synovitis), lateral squeeze test - PIP joints: Fusiform swelling (RA), bony enlargement (OA) - DIP joints: Heberden's nodes (OA), mucous cysts **Tendons:** - Flexor tendons: Nodules, triggering, crepitus - Extensor tendons: Integrity, subluxation - A1 pulley: Tenderness at MCP level (trigger finger) **Nerves:** - Tinel's: Carpal tunnel, Guyon's canal - Digital nerves: Pinprick sensation **Other:** - Temperature: Compare hands - Sweating: Absent in nerve injury - Pulses: Radial, ulnar, Allen's test ## Move (Range of Motion) ## Special Tests ### Flexor Tendon Integrity ### Extensor Tendon Integrity ### Intrinsic Function ### Nerve Function ### Other Tests ## Neurovascular Assessment **Median Nerve:** - Sensory: Tip of index finger (most reliable) - Motor: Thumb abduction (APB) - "Point thumb at ceiling" - APB test: Resisted palmar abduction **Ulnar Nerve:** - Sensory: Tip of little finger - Motor: Finger abduction (1st dorsal interosseous) - Test: Spread fingers against resistance **Radial Nerve:** - Sensory: First dorsal web space - Motor: Wrist and finger extension (assessed at wrist level) - Rarely tested in isolated hand exam **Two-Point Discrimination:** - Normal: less than 6mm at fingertip (static) - Use paper clip or calipers - Tests for nerve regeneration quality ## Complete the Examination **Always state to the examiner:** "To complete my examination, I would like to: - Examine the **wrist** as the proximal joint - Examine the **elbow and shoulder** - Perform **cervical spine examination** for referred symptoms - Assess **function** (grip strength, key pinch, tripod pinch) - Obtain **X-rays** of the hand if indicated" ## Summary Presentation ## Common Conditions Table ## Examiner Tips