Hand Examination and Clinical Localisation

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.

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.

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Clinical signs in the hand arise from predictable failure patterns. Understanding the mechanism prevents misdiagnosis.

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.

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

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Flexor tendons

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

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Core motor tests

Core sensory tests

High-yield localisation patterns

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

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

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.

Clinical examination decides what imaging or tests are needed.

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The single most useful skill in hand examination is separating causes that produce the same surface appearance. Loss of active movement, weak grip and an abnormal posture each have several explanations, and the differentials carry very different urgencies.

The examination should lead to a decision, not just a diagnosis.

Complications often come from missed localisation rather than from the examination itself.

Hand and wrist trauma is one of the highest-volume presentations in any emergency or orthopaedic service worldwide, and the clinical examination is the universal first step regardless of resource setting.

Global epidemiology

• Hand and wrist injuries account for a large share of all emergency department trauma presentations across high-, middle- and low-income settings, with lacerations, fractures and tendon injuries predominating in working-age adults.
• Occupational and machinery-related mechanisms are over-represented in industrial and agricultural economies, while falls and sport dominate in many high-income settings.
• Flexor and extensor tendon, digital nerve and vascular injuries cluster in young working adults, making accurate first-contact examination economically as well as clinically important.

Side-by-side guidance

Registry and practice variation

• Distal radius fracture fixation is tracked in arthroplasty and trauma registries and large series; flexor and extensor tendon rupture (especially FPL and EPL) is a recognised complication of volar plating, which is why specific thumb-tendon testing belongs in every post-fixation review.
• In well-resourced settings, ultrasound, MRI and electrodiagnostics are readily available adjuncts after the clinical examination.
• In limited-resource settings, the structured clinical examination carries even greater weight because imaging and electrodiagnostics may be delayed or unavailable; the same look-feel-move-test-function sequence still localises the lesion and triages urgency.

Hand examination feels objective, but several widely taught manoeuvres are weaker than candidates assume. Knowing the limits is a hallmark of consultant-level reasoning.