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Observation, visual inspection, and palpation provide information regarding the patient’s general health status and present condition.
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Therapists and surgeons need to obtain a thorough patient history so that they can understand the patient’s problem and how it affects the patient physically, psychologically, and economically.
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Perform a systematic examination, documenting and organizing the results well.
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Include medical screening and systems review with all patients.
Clinical examination of the hand is a basic skill that both the surgeon and the therapist should master. To do so, it is necessary to understand the functional anatomy of the hand. A thorough history, a systematic examination, and knowledge of disease processes that affect the hand minimize the examiner’s diagnostic dilemmas. Radiographs, CT scans, MRI scans, electrodiagnostics, and specialized laboratory tests are ancillary tools that only confirm a diagnosis that has been made on a clinical basis (see Chapters 13 and 15 ).
An organized approach and clear and concise records are of paramount importance. Either line drawings of the deformities or clinical photographs should be prepared for each new patient examined. Digital photographs may be a more efficient means for storage with electronic medical records. Range of motion (ROM) of the affected parts should be recorded and dated, ideally in a table format. Any discrepancy between active and passive motion, if present, also should be noted. A good hand examination is useless if the results are not recorded accurately.
This chapter outlines one approach to examination of the hand. The most important points already have been made: perform a systematic, organized clinical examination and record the results accurately and clearly.
History
Before a patient’s hand is examined, an accurate history must be taken. The patient’s age, hand dominance, occupation, and avocations are elicited. Another option for determining hand dominance is to administer the Waterloo Handedness Questionnaire (see Fig. 12-3 ). If the patient has had an injury, the exact mechanism as well as the time and date of the injury and prior treatments are recorded. Prior surgical procedures, infections, medications, and therapy also are noted. After this background information is obtained, the patient is questioned specifically regarding the involved hand and extremity, including a pain interview. (See Box 114-1 and Chapter 114 for additional information on pain assessment.) Open-ended questions about the present signs and symptoms are included to determine what the patient is not able to do now that he or she could do before the injury or what brought the patient to the surgeon or therapist. Questions related to the history of present illness allow the clinician to develop a hypothesis about the level of irritability. Low irritability is defined as minimal to no pain at rest, transient pain with movement, and symptoms that are not easily provoked. Highly irritable conditions present with resting pain, higher pain levels with activity, and decreased mobility. The level of irritability determines how vigorously the surgeon or therapist may perform the tests and measures during the physical examination and direct treatment goals.
What are the patient goals? This question is extremely important. The patient’s reply assists the clinician in determining whether the patient has a realistic understanding of the true nature of the injury. Unrealistic expectations can never be fulfilled and result in both disappointment and frustration for both the patient and the therapist and surgeon. During this interview, it is also important to assess the effect that the injury or disease process has on the patient’s family and economic and social life. Patients who have litigation pending or possible significant secondary gain may be poorly motivated and are not optimal candidates for elective hand surgery. Successful hand surgery requires precise surgical techniques followed by expert hand therapy in conjunction with a well-motivated, compliant patient.
The patient’s pertinent medical history is obtained to determine general health status, especially regarding comorbidities that may affect the patient’s recovery or increase surgical risks? Additional questions should be asked about current medications (prescription and nonprescription), allergies, and lifestyle choices (smoking, alcohol use, or substance abuse). Current practice trends require hand surgeons and therapists to do medical screening and review of systems. This is a key component in medical education and training; however, it is a recent addition to the entry-level education for therapists, especially physical therapists. More information is provided later in this chapter.
The patient’s social history should be obtained. What is his support system? How well do the patient and his family understand the injury and required care? What are his avocational interests? The patient’s economic status may also influence ability to comply with therapy and follow-up care. What is his insurance coverage or co-pay amount? Does he have a limited number of authorized visits? Does his injury present a financial hardship or limit his ability to care for children or elderly parents?
If the patient is working, information should be gathered about his job description, physical demands, or essential functions, and the last date worked even if the injury is not work-related. This information may indicate the presence of risk factors associated with the injury. Therapists and surgeons can use these data to outline a plan of care that incorporates appropriate modified duty work, if available, and the use of work-oriented tasks in the clinic to keep the patient on track to return to full duty. Although it may be too early in the examination process to discern a return to work date, an experienced clinician can usually tell how motivated the patient is to return to his job based on the patient’s answers regarding employment. Patient’s who are receiving compensation for an injury or illness may be more difficult to treat, more likely to have a prolonged course of rehabilitation, and more likely to become disabled than patients with similar conditions who are not receiving compensation.
Self-report health-related outcome measures such as Disabilities of the Arm, Shoulder, and Hand (DASH), Carpal Tunnel Instrument, or Michigan Hand Outcomes Questionnaire (MHQ) can serve as valuable tools for gathering information on pain, function, activity participation, disability, and patient satisfaction. , These measures have all proven to be reliable and valid. The Carpal Tunnel Instrument is a condition-specific measure, whereas the DASH and MHQ are region-specific. Global measures such as the SF-36 and patient-specific scales that contain no standardized questions may also be used. , These questionnaires can be invaluable in gathering information about problems with activities of daily living (ADL), such as toileting or sexual activity. Patients are not usually comfortable addressing these issues upfront. It is important for the examiner to become familiar with self-report health-related outcome measures to determine which would be most useful and clinically relevant for the patient. Chapter 16 discusses the measurement issues and use of outcome measurement in the upper extremity.
The history is completed only after the surgeon or therapist has a complete understanding of the patient’s problem and how it affects the patient physically, psychologically, and economically.
Physical Examination
Observation, Inspection, and Palpation
Hands are used to interact with the surrounding environment and for communication. People “actively” use their hands for a variety of functional activities. “Passively” the hands communicate to clinicians about the health status of their patients. When examining a patient’s upper extremity, one must be able to observe the shoulder, arm, forearm, and hand. Therefore, the patient’s entire upper extremity should be exposed. The gross appearance of the entire extremity is inspected. Table 6-1 outlines the physical characteristics of the skin and musculoskeletal tissues that should be observed, inspected, and palpated during the physical examination to determine the presence of diseases such as arthritis, impairments such as edema and loss of motion, as well as level of irritability.
| General Observations | Clinical Significance |
|---|---|
| Cradling the arm or guarded posture is a sign of patient apprehension to movement typically due to high levels of pain associated with a high level of irritability. |
| Signs of muscle weakness or loss of motion that may be related to nerve injury, disuse, or joint contracture |
| Is the patient able to place his or her hand in a functional position? | If not, the elbow and shoulder motion may be limited and should be examined. If the hand cannot be placed in a functional position, a brilliantly reconstructed hand is useless. |
| Visual Inspection | Clinical Significance |
|---|---|
| Muscle atrophy | Muscle weakness due to disuse or nerve injury |
| Blisters and small cuts | Sign of decreased cutaneous sensibility due to nerve injury |
| Needle marks | Indication of current or previous substance abuse or the use of injectable prescription medication for disease such as insulin-dependent diabetes |
| Wounds and scars | Scars indicate previous injuries or surgeries. Wounds may indicate decreased cutaneous sensibility. |
| Skin color, tone, moisture, and trophic changes |
|
| Normal skin creases or ridges | Diminished due to presence of edema or trophic changes of the skin associated with nerve injury |
| Nail changes linked to chronic diseases of the kidney, liver, respiratory system. Spoon nails found in patients with iron deficiency. Changes may be related to peripheral nerve injury. |
| Edema, hematoma, ecchymosis | Indicates acute tissue injury and healing |
| Loss of resting attitude of the hand | Indicates a tendon laceration, a contracture, or peripheral nerve injury |
| Contractures | Loss of motion |
| Gross deformities | Congenital, acquired, traumatic |
| Preservation of hand arches | Flattening of the aches associated with intrinsic muscle atrophy due to nerve injury or disuse |
| Palpation | Clinical Significance |
|---|---|
| Temperature |
|
| Nodules, tumors | Likely benign lesions that may be associated with wrist instability, arthritis, Dupuytren’s or other soft tissue conditions |
| Edema |
|
| Capillary refill | Skin should blanch when palpated and resume normal color when pressure removed. |
| Skin mobility | Lack of mobility due to fibrosis, scar, and edema |
| Scar | Painful to touch (tactile allodynia) indicates hypersensitivity. |
* See Table 14-4 in archived Chapter 14 in the fifth edition located on companion Web site.
Skin and nail changes may be associated with chronic diseases of the kidney or liver as well as the respiratory system. A review of systems and past medical history should determine the associated condition. These changes are chronic, and the patient should already be aware of the condition. Normally, with the hand resting and the wrist in neutral, the fingers are progressively more flexed from the radial to the ulnar side of the hand. A loss of the normal resting attitude of the hand can indicate a tendon laceration, a contracture, or, possibly, a peripheral nerve injury ( Fig. 6-1 ).
Edema
Another important component of the clinical examination of the hand is to assess edema if noted on visual inspection. Edema may be assessed using circumferential or volumetric measurements. Volumetry is primarily used if the entire hand is edematous, but not for an isolated finger. Chapter 63 , Chapter 64 , Chapter 65 present detailed information on the examination and management of edema and lymphedema in the hand and upper extremity.
Range of Motion
The motion of the entire upper extremity and cervical region should be screened with hand injuries and compared with that of the opposite side for possible loss of motion and pain. Joints that demonstrate loss of active or passive motion (or both) should be measured with an appropriately sized goniometer. Measurements have been shown to be relatively reliable within and between examiners; intrarater and inter-rater variability is in the range of 5 to 10 degrees. If possible, the same examiner should take measurements.
Digital motion is typically assessed with the metal finger goniometer placed on the dorsal aspect of the phalanges ( Fig. 6-2 ). If it is not possible to place the goniometer on the dorsal aspect of the digit, then a lateral goniometer placement may be used and this exception should be documented. When possible, active measurements of the finger joints are taken in a composite manner by asking the patient to make a fist for flexion and then straighten the hand for extension. Isolated motions may be performed for an individual joint, typically with stabilization of the proximal joint; however, this should be recorded ( Fig. 6-3 ).
Total active motion (TAM) and total passive motion (TPM) measurements can be assessed for the individual digits. TAM is calculated by adding the composite flexion measurement of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints and subtracting the sum of any extension deficits at these joints. TPM is computed the same way, except passive measurements are used. Both TAM and TPM provide relevant data on composite motion of the finger and allow ease of comparison over time. This type of documentation is frequently used in research.
Goniometry manuals should be reviewed for detailed information on measuring joint motion of the hand and upper extremity. , When measuring carpometacarpal (CMC) motion of the thumb, some manuals describe the procedures differently. The starting angle for CMC extension or abduction is never 0 degrees; it is typically 25 to 30 degrees. Some manuals direct the clinician to measure the starting angle and subtract it from the measurements at the end of the available ROM. Some manuals just recommend that the examiner measure the end range motion. In terms of clinical relevance, only the end range motion is significant as it correlates with the patient’s ability to open the first webspace. Therapists and surgeons working together should agree on a standard procedure for their patients to allow comparison of measurements.
If motion is lacking, the distance from the tip of the finger to the distal palmar crease (DPC) is measured. If the finger touches the palm but does not reach the crease, as occurs with profundus tendon disruption, this should be noted, and the distance from the tip of the finger to the DPC should be recorded; however, it should be stated that the finger did touch the palm but did not reach the DPC ( Fig. 6-4 ).
After all active and passive motions have been examined; the wrist is flexed and extended to see if the normal tenodesis effect is present. In an uninjured hand, when the wrist is flexed, the fingers and the thumb extend, and as the wrist is extended, the fingers assume an attitude of flexion and the thumb opposes the fifth digit ( Fig. 6-5 ). This is an automatic motion of the hand and requires only that the patient be relaxed. The alignment of the digits is then inspected. The nail plates all should be parallel to one another, and their alignment should be similar to that of the other hand. Each finger should point individually to the scaphoid tuberosity, and the longitudinal axis of all fingers when flexed should point in the direction of the scaphoid ( Fig. 6-6 ).
Muscle Testing
The hand is powered by intrinsic and extrinsic muscles. The extrinsic muscles have their origin in the forearm and the tendinous insertions in the hand. The extrinsic flexors are on the volar side of the forearm and flex the digits and the wrist. The extrinsic extensors originate on the dorsal aspect of the forearm and extend the fingers, thumb, and wrist. The intrinsic muscles originate and insert in the hand. These include the thenar and hypothenar muscles as well as the lumbricals and the interossei. The thenar and hypothenar muscles help position the thumb and the fifth finger and also aid in opposition of the thumb and with pinch. The interossei assist in abduction and adduction of the digits. The interossei flex the MCP joints and extend the interphalangeal (IP) joints along with the lumbricals.
Extrinsic Muscle Testing—The Extrinsic Flexors
As each specific extrinsic muscle–tendon unit is tested, its strength should be graded and recorded ( Table 6-2 ). The extrinsic muscles should be tested with respect to gravity, but this is not essential for the intrinsic muscles. Note tendon excursion during muscle contraction, which is reflected in ROM of the joints that the tendon acts on.
| Numeric Grade | Result | Qualitative Grade |
|---|---|---|
| 0 | No evidence of contractility or tension | Zero |
| 1 | Slight evidence of contractility; no motion | Trace |
| 2 |
| Poor |
| 3 | Muscle action present; full ROM against gravity | Fair |
| 4 | Muscle action present; full ROM against gravity with moderate resistance | Good |
| 5 | Muscle action present; full ROM against gravity with maximum resistance | Normal |
It is not necessary to test each hand muscle during examination. Key muscles for each nerve, radial, ulnar, and median, can be selected for screening. For each nerve, select one muscle that is innervated proximally (“high”) and one muscle that is innervated distally (“low”). Table 6-3 provides examples. If nerve injury is present, all muscles innervated by the injured nerve should be assessed to determine the level of injury and to document return.
| Nerve | Innervated Proximally (“High”) or Distally (“Low”) | Muscle |
| Radial nerve | High | Extensor carpi radialis longus and brevis |
| Low | Extensor digitorum or extensor pollicis longus | |
| Median nerve | High | Flexor carpi radialis or flexor digitorum superficialis |
| Low | Thenar muscles | |
| Ulnar nerve | High | Flexor carpi ulnaris or flexor digitorum profundus (ring, small) |
| Low | Palmar or dorsal interossei |
The flexor pollicis longus (FPL) long flexor of the thumb flexes the IP joint of the thumb. This muscle is tested by asking the patient to actively flex the last joint of his thumb ( Fig. 6-7 ).
The flexor digitorum profundus of the fingers are then tested, in sequence, by having the patient flex the DIP joint of the finger being tested while the examiner holds the digit in full extension and blocks motion at the PIP joint and the MCP joint. During the testing of each profundus tendon, the other fingers may unintentionally flex due to the common muscle belly of the long, ring, and small finger profundus tendons, and this is permitted ( Fig. 6-8 ).
