Hand Examination and Clinical Localisation
High Yield Overview
Hand Examination
Find the structure, level and urgency
Activetests muscle-tendon-nerve unit
Passivetests joint and soft-tissue range
Patternlocalises the lesion
Core Localisation Questions
Tendon problem
PatternActive motion is lost, passive motion is preserved, and the deficit follows one tendon unit.
TreatmentIdentify zone, open injury, timing, contamination and need for urgent repair.
Nerve problem
PatternWeakness and sensory change follow a nerve distribution or fascicular pattern.
TreatmentLocalise level, document baseline, splint, investigate and decide observation versus repair/decompression.
Joint problem
PatternActive and passive motion are both restricted, often with swelling, deformity or capsular tightness.
TreatmentInvestigate arthritis, fracture, dislocation, infection, contracture or instability.
Pain or vascular problem
PatternMovement is limited by pain, ischaemia, swelling, infection or complex regional pain.
TreatmentTreat the urgent driver first; do not mislabel pain inhibition as tendon or nerve rupture.
Critical Must-Knows
- A hand examination is a localisation exercise, not a list of tests.
- Compare active and passive motion before diagnosing tendon rupture.
- Test median, ulnar and radial motor function with one reliable muscle each, then add sensory testing.
- FDP, FDS, EPL, central slip and terminal extensor must be tested separately because combined finger motion can hide a rupture.
- Document preoperative sensation and motor function before any hand trauma procedure.
Clinical Pearls
- "If active motion is absent but passive motion is full, think tendon rupture, nerve palsy or pain inhibition.
- "If passive motion is restricted, the problem is at least partly joint, capsule, skin, tendon adhesions or swelling.
- "AIN palsy has motor findings without sensory loss.
- "A high ulnar nerve lesion can have less obvious clawing than a low ulnar lesion because FDP to ring and little may also be weak.
Do not call every weak hand a nerve palsy
Pain, swelling, tendon rupture, joint dislocation, compartment syndrome, infection and poor cooperation can all look like weakness. Localisation requires pattern recognition plus active-passive comparison.
At a Glance Table
Clinical Pattern Recognition
| Finding | Most likely structure | How to confirm | Important trap |
|---|---|---|---|
| Finger cannot flex DIP actively but passive DIP flexion is full | FDP | Hold PIP extended and ask for DIP flexion | Pain or poor effort can mimic rupture |
| Finger cannot flex PIP in isolation | FDS | Hold other fingers extended and ask tested finger to flex PIP | Little finger FDS may be absent or weak normally |
| Loss of thumb IP extension | EPL or radial/PIN | Check isolated thumb IP extension and other radial-nerve muscles | EPL rupture after distal radius fracture can be missed |
| Thenar weakness with index pulp numbness | Median nerve | APB strength and radial digit sensation | AIN palsy has no sensory loss |
| FDI weakness with little finger numbness | Ulnar nerve | Finger abduction/adduction and ulnar digit sensation | High versus low ulnar lesions behave differently |
| Finger and thumb extension weakness with dorsal web sensory loss | Radial nerve above PIN branch | EPL, wrist extension and first dorsal web sensation | PIN palsy has no sensory loss |
| Active and passive motion both limited | Joint, capsule, adhesions or swelling | Compare passive motion and end feel | Do not diagnose isolated tendon rupture without passive range |
Mnemonic
MAPHand Localisation
M
Movement
Compare active and passive motion at each joint.
A
Anatomy
Match the deficit to tendon, nerve, joint, vessel, skin or pain.
P
Pattern
Localise the level and decide whether the problem is urgent.
Memory Hook:Map the problem before naming the diagnosis.
Mnemonic
VINHand Trauma Red Flags
V
Vascular
Pale, cold, poorly perfused digit or absent Doppler signal.
I
Infection
Bite, flexor sheath tenderness, spreading cellulitis or deep-space signs.
N
Nerve/tendon
Open wound with sensory or motor deficit, or suspected tendon laceration.
Memory Hook:Vascular, infection and nerve findings change urgency.
Mnemonic
ACTActive-Passive Interpretation
A
Active
Tests tendon continuity, muscle power, nerve supply and pain inhibition.
C
Compare
Compare passive range and the opposite hand before naming a rupture or palsy.
T
Target
Target isolated tendon, nerve and joint tests to localise the lesion.
Memory Hook:Active loss must be compared with passive range.
Overview/Epidemiology
Hand examination is common in trauma clinics, emergency departments, fracture clinics, rheumatology, nerve clinics and elective hand practice. It is high-value because a careful clinical examination often identifies the injured structure before imaging or electrodiagnostic testing.
The common settings are:
- laceration with possible tendon, nerve or vessel injury
- finger deformity after trauma
- post-fracture stiffness or tendon rupture
- carpal tunnel, cubital tunnel or peripheral nerve compression
- ulnar or radial nerve palsy
- rheumatoid or inflammatory hand deformity
- Dupuytren disease, trigger finger and tendon imbalance
- infection, compartment syndrome or complex regional pain
The hand has many structures in a small space. A vague statement such as "weak grip" is not enough. The aim is to localise the weakness to a tendon, muscle, nerve level, joint, pain generator or vascular problem.
Anatomy/Biomechanics
Hand movement comes from three linked systems:
- Extrinsic tendons: flexors and extensors cross the wrist and fingers from the forearm.
- Intrinsic muscles: thenar, hypothenar, lumbricals and interossei control pinch, MCP flexion, IP extension and fine balance.
- Nerves: median, ulnar and radial nerve branches provide motor control and sensory feedback.
The same visible problem can arise from different levels. Thumb weakness can be APB weakness from median nerve compression, FPL weakness from AIN palsy, EPL rupture after distal radius fracture, pain inhibition from CMC arthritis or stiffness after immobilisation.
Active-Passive Logic
| Pattern | Interpretation | Next test |
|---|---|---|
| Active loss, passive preserved | Tendon rupture, nerve palsy, pain inhibition or poor effort | Isolate tendon and test nerve pattern |
| Active and passive both restricted | Joint stiffness, contracture, swelling, adhesions or mechanical block | Assess end feel, imaging and inflammatory/infective signs |
| Passive full but pain severe | Pain inhibition, infection, fracture, instability or CRPS | Do not force; investigate urgent causes |
| Motor deficit with sensory deficit | Peripheral nerve lesion above sensory branch | Map motor and sensory territories |
| Motor deficit without sensory deficit | AIN or PIN, tendon rupture, central cause or muscle injury | Use nerve-specific motor tests and tendon isolation |
Pathophysiology
Clinical signs in the hand arise from predictable failure patterns. Understanding the mechanism prevents misdiagnosis.
Why the Examination Looks Abnormal
| Mechanism | Clinical effect | Example | How to prove it |
|---|---|---|---|
| Tendon discontinuity | Loss of active movement across one joint while passive motion is preserved | FDP laceration causing absent DIP flexion | Isolate that tendon and check wound level |
| Nerve denervation | Weakness follows a nerve distribution, often with sensory or autonomic change | Ulnar palsy causing FDI wasting and pinch weakness | Map motor and sensory pattern, then localise level |
| Joint or capsular restriction | Active and passive motion are both limited | PIP contracture after injury | Assess passive end feel and radiographs |
| Pain inhibition | Apparent weakness without a consistent anatomical pattern | Acute fracture, infection or CRPS | Control pain, identify driver and repeat focused testing |
| Mechanical imbalance | Characteristic deformity from tendon, ligament or intrinsic imbalance | Boutonniere, swan neck or ulnar claw | Match posture to the disrupted stabiliser |
Important consequences:
- Tendon rupture is a mechanical failure and will not recover with nerve observation.
- Nerve palsy can recover, need decompression, need repair or need tendon transfer depending level, cause and time course.
- Joint stiffness becomes harder to reverse with time, especially in the PIP joint.
- Pain-limited motion can hide a tendon or nerve injury; reassess once pain is controlled but do not delay urgent referral.
Clinical Assessment
Position and exposure
Sit opposite the patient with both hands and forearms exposed. The hands should rest on a table so the cascade, resting posture, sweat pattern, scars, wasting and deformity can be compared side to side.
History
Ask questions that help localisation:
- Mechanism: sharp laceration, crush, fall, bite, closed rupture, gradual compression or inflammatory disease.
- Timing: acute tendon/nerve injury, delayed rupture, chronic compression or progressive deformity.
- Wound: location, depth, contamination, glass, bite, machinery, farm or water exposure.
- Symptoms: pain, numbness, paraesthesia, weakness, triggering, locking, cold intolerance, colour change.
- Function: writing, buttons, pinch, grip, tools, keyboard, sport, musical instrument and work demands.
- Previous pathology: distal radius fracture, rheumatoid disease, diabetes, cervical radiculopathy, previous tendon repair, carpal tunnel release or nerve injury.
Inspection
Look before touching:
- resting finger cascade
- rotational deformity or scissoring
- wounds in relation to tendon and nerve zones
- swelling, bruising, erythema, drainage or bite marks
- thenar, hypothenar and first dorsal interosseous wasting
- trophic skin changes, sweating asymmetry or dry skin
- nail-bed injury, mallet posture, boutonniere posture or swan-neck posture
- Dupuytren nodules, cords and contracture
- rheumatoid MCP ulnar drift, Z-thumb and tendon imbalance
Resting posture is a diagnostic test
An abnormal finger cascade may reveal tendon rupture, rotational malalignment, intrinsic imbalance or pain guarding before formal testing begins.
Tendon Examination
Flexor tendons
Flexor Tendon Testing
| Structure | How to test | Positive finding | Clinical meaning |
|---|---|---|---|
| FDP | Hold PIP extended and ask for DIP flexion | No active DIP flexion | FDP rupture or laceration; zone depends on wound and level |
| FDS | Hold other fingers extended and ask tested finger to flex PIP | No isolated PIP flexion | FDS rupture, laceration or normal variant, especially little finger |
| FPL | Stabilise thumb MCP and ask for thumb IP flexion | No active IP flexion | FPL rupture/laceration or AIN palsy depending pattern |
| Triggering | Palpate A1 pulley while flexing and extending | Clicking, locking or painful nodule | Stenosing tenosynovitis |
Important interpretation:
- A clean volar laceration over the finger with loss of isolated tendon function is a tendon injury until proven otherwise.
- Flexor tendon injury should be assessed before local anaesthetic blocks eliminate useful motor testing.
- The finger may still flex weakly through adjacent tendons, lumbricals or tenodesis, so isolated testing is essential.
- In an open flexor injury, document digital nerve and artery status before dressing and referral.
Extensor tendons
Extensor Tendon and Extensor Mechanism Testing
| Structure | Test | Positive finding | Meaning |
|---|---|---|---|
| Terminal extensor | Ask for active DIP extension | DIP extensor lag | Mallet injury or terminal tendon rupture |
| Central slip | Elson test with PIP flexed over table edge | Weak PIP extension with rigid DIP extension | Central slip rupture; boutonniere risk |
| EPL | Ask for thumb IP extension or thumb retropulsion | Loss of thumb IP extension | EPL rupture or radial/PIN lesion |
| EDC | Ask for MCP extension of fingers | Loss of MCP extension | Extensor tendon rupture, radial/PIN lesion or sagittal band problem |
| Sagittal band | Observe tendon tracking during MCP flexion/extension | Extensor tendon subluxation | Boxer's knuckle or inflammatory sagittal band rupture |
Open tendon injury needs zone, nerve and vessel documentation
The decision is not simply "tendon cut". Record wound level, tendon function, digital nerve sensation, perfusion, contamination, tetanus status and timing before definitive management.
Nerve Examination
Core motor tests
Motor Screening
| Nerve | Motor test | What it tests | Pattern clue |
|---|---|---|---|
| Median nerve at wrist | Abductor pollicis brevis | Thenar motor branch | Weak palmar thumb abduction with radial digit sensory symptoms |
| Anterior interosseous nerve | OK sign: FPL and FDP index | Pure motor branch | Weak thumb IP and index DIP flexion with no sensory loss |
| Ulnar nerve | First dorsal interosseous finger abduction | Deep motor branch and interossei | FDI wasting, Froment sign, clawing pattern |
| Radial nerve | Wrist, finger and thumb extension | Radial/PIN motor | High radial lesion has wrist drop; PIN lesion has motor loss without sensory loss |
Core sensory tests
Sensory Screening
| Nerve | Useful point | Why it helps | Pitfall |
|---|---|---|---|
| Median | Index finger pulp | Reliable radial digital sensory territory | Palmar cutaneous branch may be spared in carpal tunnel syndrome |
| Ulnar | Little finger pulp | Useful ulnar digital sensory territory | Dorsal ulnar sensation helps separate wrist from more proximal lesions |
| Radial | Dorsal first web space | Superficial radial sensory territory | PIN palsy has no sensory loss |
| Digital nerve | Radial and ulnar sides of each digit | Localises finger-level laceration | Compare with adjacent digit and opposite hand |
High-yield localisation patterns
Median nerve
Carpal tunnel causes thenar weakness and radial digit symptoms. AIN palsy causes FPL and FDP index weakness without sensory loss. A proximal median lesion adds forearm pronation and flexor involvement.
Ulnar nerve
Low ulnar lesions affect intrinsics more than FDP. High ulnar lesions add FCU and FDP ring/little weakness. Dorsal ulnar sensory sparing suggests a lesion distal to the dorsal cutaneous branch.
Radial/PIN
High radial nerve palsy affects wrist, finger and thumb extension and may have sensory loss. PIN palsy is motor only and commonly affects finger/thumb extension more than wrist extension.
Digital nerves
Test both sides of each digit after laceration. Two-point discrimination and light touch should be documented before repair or exploration.
AIN and PIN are motor-only clues
Motor deficit without sensory loss should make you consider AIN palsy, PIN palsy or tendon rupture. The pattern of individual tendons then separates nerve from tendon.
Joint and Deformity Assessment
Joint assessment explains stiffness, deformity and instability.
Range and end feel
- Measure MCP, PIP and DIP active and passive range.
- Look for extension lag versus fixed flexion contracture.
- Check whether motion improves when adjacent joints are positioned differently.
- Compare soft end feel, hard bony block and pain-limited movement.
Deformity localisation
Common Hand Deformities
| Deformity | Appearance | Mechanism | Clinical implication |
|---|---|---|---|
| Mallet | DIP flexion posture | Terminal extensor disruption or bony avulsion | Assess open injury, subluxation and extensor lag |
| Boutonniere | PIP flexion with DIP hyperextension | Central slip failure and lateral band migration | Early Elson test matters |
| Swan neck | PIP hyperextension with DIP flexion | Volar plate laxity, intrinsic imbalance or inflammatory disease | Treat underlying cause, not the shape alone |
| Ulnar claw | MCP hyperextension with IP flexion, worse ring/little | Ulnar intrinsic weakness | Low ulnar lesions claw more than high lesions |
| Rotational deformity | Finger overlap on flexion | Metacarpal or phalangeal malrotation | Radiographs may underestimate clinically important rotation |
Function
Assess real tasks:
- key pinch
- pulp pinch
- tripod pinch
- power grip
- hook grip
- writing grip
- opening jar or using tools if relevant
- occupation-specific or sport-specific function
Vascular and Sensory Testing
The hand is intolerant of missed vascular injury. A pink finger can still have a single digital artery injury; urgency depends on perfusion, contamination, nerve injury and associated structural damage.
Vascular assessment
- Capillary refill and colour.
- Temperature compared with adjacent digits.
- Radial and ulnar pulses.
- Digital Allen testing when digital artery injury is suspected.
- Doppler signal when clinical perfusion is uncertain.
- Pulse oximetry waveform on injured digit if available.
Sensory assessment
- Light touch and pinprick for screening.
- Static two-point discrimination for digital nerve injury.
- Semmes-Weinstein monofilament testing when quantifying sensory threshold.
- Compare with the opposite hand and adjacent digits.
- Document before local anaesthetic, exploration or repair.
A numb finger after a laceration is a nerve injury until proven otherwise
If sensory loss follows a digital nerve distribution after a sharp wound, the default assumption should be digital nerve injury. Document it and refer or explore appropriately.
Investigations
Clinical examination decides what imaging or tests are needed.
Investigations After Hand Examination
| Question | Investigation | What it adds |
|---|---|---|
| Fracture, dislocation, foreign body or malrotation? | Plain radiographs with appropriate views | Bone injury, alignment, joint congruity and radio-opaque foreign body |
| Occult carpal fracture or complex articular injury? | CT | Bone detail, articular fragments and surgical planning |
| Occult fracture, ligament, tendon, mass or infection extent? | MRI | Soft-tissue detail and marrow oedema |
| Dynamic tendon or nerve compression question? | Ultrasound | Dynamic tendon motion, neuroma, ganglion or compressive lesion |
| Persistent unexplained nerve deficit? | Nerve conduction study and EMG | Level, severity, denervation and recovery over time |
Imaging does not replace examination
A normal radiograph does not exclude tendon laceration, digital nerve injury, early infection, ligament injury or pain-limited instability.
Management Decisions
The examination should lead to a decision, not just a diagnosis.
Findings That Change Urgency
| Finding | Why it matters | Immediate action |
|---|---|---|
| Vascular compromise or threatened digit | Ischaemia can become irreversible | Urgent hand/vascular assessment and perfusion protection |
| Open fracture or open joint | Deep contamination and instability | Sterile dressing, antibiotics when indicated, splint and urgent referral |
| Flexor tendon laceration | Delayed diagnosis worsens repair and rehabilitation | Document tendon, nerve and vessel status, splint and refer |
| Digital nerve injury with open wound | Repair decision depends on timing and wound status | Document sensory deficit before anaesthetic and refer |
| Bite, flexor sheath infection or deep-space infection | Rapid spread in closed compartments | Antibiotics, elevation, urgent surgical assessment |
| High-pressure injection injury | Tissue toxicity and compartment necrosis | Emergency referral even if skin wound looks small |
Complications
Complications often come from missed localisation rather than from the examination itself.
Consequences of Missed Findings
| Missed finding | Possible consequence | Prevention |
|---|---|---|
| Digital nerve injury | Persistent numbness, painful neuroma, poor pinch and delayed repair | Test both sides of each digit before anaesthetic |
| Flexor tendon laceration | Delayed repair, adhesions, rupture, stiffness and poor function | Isolate FDP and FDS in every suspicious volar wound |
| Central slip injury | Delayed boutonniere deformity | Perform Elson test when PIP injury suggests extensor mechanism damage |
| Vascular injury | Ischaemia, cold intolerance or tissue loss | Check colour, capillary refill, temperature, Doppler and digital perfusion |
| Joint dislocation or malrotation | Stiffness, scissoring and functional grip loss | Assess passive range, cascade and radiographs |
| Infection | Deep-space infection, tendon sheath infection, stiffness or amputation risk | Recognise pain pattern, swelling, wounds and systemic signs early |
Evidence Base
Sensory testing after upper limb nerve injury
Systematic review authors • Journal of Hand Therapy (2021)
Key Findings:
- Multiple sensory tests are used after traumatic upper limb nerve injury.
- Two-point discrimination and monofilament testing measure different aspects of sensory recovery.
- Functional correlation matters because test scores alone do not fully describe hand use.
Clinical Implication: Document a repeatable sensory baseline, then interpret it with motor findings and functional complaints.
Clinical Scenarios
Use these scenarios to practise clinical reasoning and management decisions
CLINICAL SCENARIOStandard
Scenario 1: Volar finger laceration
CLINICAL PROMPT
"A patient has a clean volar laceration over the middle finger and says they cannot bend the fingertip."
PRACTICAL APPROACH
I would examine before local anaesthetic if possible. I would inspect the wound level and resting cascade, check capillary refill and colour, then test digital nerve sensation on both sides of the finger. For tendon testing, I would hold the PIP joint extended and ask for isolated DIP flexion to test FDP. I would then hold the other fingers extended and ask for isolated PIP flexion to test FDS. Loss of active DIP flexion with preserved passive motion suggests FDP laceration. I would document tendon, nerve and vascular findings, dress and splint the hand, give tetanus and antibiotics if indicated, and refer for hand-surgery assessment.
KEY CLINICAL POINTS
Examine before anaesthetic if possible.
Test FDP and FDS separately.
Document digital nerve and vascular status.
Splint and refer; do not repeatedly probe the wound.
COMMON PITFALLS
✗Testing only composite grip.
✗Missing digital nerve injury.
✗Calling it a partial tendon injury without isolated testing.
FURTHER QUESTIONS
"How would you test FDS to the little finger?"
"What information must be in the referral?"
CLINICAL SCENARIOChallenging
Scenario 2: Thumb weakness after distal radius fracture
CLINICAL PROMPT
"A patient recovering after distal radius fracture treatment reports inability to extend the thumb IP joint."
PRACTICAL APPROACH
I would distinguish EPL rupture from radial or PIN palsy. I would test isolated thumb IP extension and thumb retropulsion, then examine wrist extension, finger MCP extension and sensation in the dorsal first web space. If only EPL is absent and the other radial-nerve functions are preserved, delayed EPL rupture is likely. If multiple radial/PIN motor functions are weak, I would localise the nerve lesion. I would assess wrist radiographs, hardware position if relevant, and refer for hand-surgery management because EPL rupture often needs tendon transfer or reconstruction rather than observation.
KEY CLINICAL POINTS
Isolated EPL loss suggests tendon rupture.
PIN/radial nerve palsy produces a broader motor pattern.
Dorsal first web sensation helps separate high radial from PIN.
Distal radius fracture is a classic setting for delayed EPL rupture.
COMMON PITFALLS
✗Assuming all thumb extension loss is radial nerve palsy.
✗Not testing other radial-nerve muscles.
✗Missing hardware or fracture-related tendon attrition.
FURTHER QUESTIONS
"What tendon transfer is commonly used for EPL reconstruction?"
"How would PIN palsy differ clinically?"
CLINICAL SCENARIOAdvanced
Scenario 3: Ulnar nerve localisation
CLINICAL PROMPT
"A patient has hand intrinsic wasting, weak pinch and numbness in the little finger."
PRACTICAL APPROACH
I would localise the ulnar nerve lesion clinically. I would inspect for first dorsal interosseous and hypothenar wasting, clawing and Wartenberg posture. I would test finger abduction/adduction, first dorsal interosseous strength, Froment and Jeanne signs, and sensation in the little finger pulp. I would check FCU and FDP to ring and little fingers to assess for a high lesion. I would examine dorsal ulnar hand sensation because sparing can suggest a lesion distal to the dorsal cutaneous branch. I would also examine the cervical spine, elbow and Guyon canal depending the pattern, then use nerve conduction studies or ultrasound if the level or severity is unclear.
KEY CLINICAL POINTS
FDI is a key ulnar motor test.
Little finger pulp is a useful sensory point.
FCU and FDP ring/little help identify high ulnar lesions.
Dorsal ulnar sensation helps separate wrist-level from proximal lesions.
COMMON PITFALLS
✗Only doing Froment sign.
✗Not separating cubital tunnel from Guyon canal.
✗Forgetting cervical radiculopathy or brachial plexus differential.
FURTHER QUESTIONS
"Why can high ulnar palsy claw less than low ulnar palsy?"
"What are the zones of Guyon canal compression?"
Hand Examination Summary
Clinical summary
Sequence
- •Look: cascade, wounds, wasting, deformity.
- •Feel: tenderness, swelling, temperature, tendons.
- •Move: active then passive range.
- •Test: tendons, nerves, sensation, vessels.
- •Function: pinch, grip and task-specific use.
Tendons
- •FDP: isolated DIP flexion.
- •FDS: isolated PIP flexion with other fingers held extended.
- •EPL: thumb IP extension and retropulsion.
- •Central slip: Elson test.
- •Terminal extensor: DIP extension.
Nerves
- •Median: APB and index pulp.
- •AIN: OK sign, no sensory loss.
- •Ulnar: FDI and little finger pulp.
- •Radial/PIN: wrist, finger and thumb extension.
- •PIN: motor only.
Urgent
- •Vascular compromise.
- •Open joint, open fracture or tendon laceration.
- •Digital nerve injury with open wound.
- •Bite, flexor sheath infection or deep-space infection.
- •Compartment syndrome or high-pressure injection injury.
"A good hand examination identifies the failed structure, localises the level and decides urgency. Active-passive comparison and isolated tendon/nerve testing prevent most errors."
References
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