7_Hand.pdf

Mr Georgios Arealis, MD, PhD, FRCS -Consultant Trauma & Orthopaedic Surgeon Shoulder & Upper Limb Specialist East Kent Hospitals University NHS Foundation Trust - Visiting Professor, Faculty of Medicine, Health and Social Care Canterbury Christchurch University -Honorary Researcher, School Of Engine...

Mr Georgios Arealis, MD, PhD, FRCS -Consultant Trauma & Orthopaedic Surgeon Shoulder & Upper Limb Specialist East Kent Hospitals University NHS Foundation Trust - Visiting Professor, Faculty of Medicine, Health and Social Care Canterbury Christchurch University -Honorary Researcher, School Of Engineering and Digital Arts University Of Kent - Clinical tutor Clinical and Educational Supervisor, Stage 3, Year 5 medical students, King's College London - Clinical tutor, Sutgical group, Kent and Medway Medical School HAND Bony Anatomy Phalanges: 14 Metacarpals: 5 Carpals – Proximal row: 4 – Distal row: 4 Radius and Ulna STRUCTURE INTRODUCTION Look Feel Move Function Neurology Special Tests THANK THE PATIENT OFFER TO COMPLETE EXAMINATION PRESENT EXAMINATION FINDINGS General for hand examination Start with the hand, inspect all sides: - Commence with the dorsal aspect - Proceed asking patient to reveal the palmar surface Then the patient to show their elbows Psoriasis & Rheumatoid Nodules For all three positions, examine all components of the hand: skin, soft tissue and bone Hand is the “face” of many medical conditions Introduction (WIPE) Wash hands, Intro, ?Patient (DOB, Name), Explain/ consent Expose arms above elbows, consider resting the hand on a pillow General inspection Look Deformities – ?Location Asymmetry Wasting/ atrophy Colour - ?Palmar Erythema ?Reynaud’s Swelling – ?Location Scars Mnemonic: DAWCSS Look skin Scars: previous surgery, injury Skin quality: plaques, scales Colour White (ischaemia); Blue (cyanosis); Red (reactive hyperaemia) infection Inflammation Liver disease Underlying Raynaud’s phenomenon Specific signs Gottron’s papules: Roughened red papules on the extensor surfaces of the fingers occur in dermatomyositis Telangiectasia: Especially if situated on palms and in nail folds are characteristic of systemic sclerosis Mechanics hands: This is a sign of thick, cracked skin over the tips and sides of the fingers and can be found in dermatomyositis and antisynthetase syndrome Tripe Hand: Thickened, velvety texture of hand. Often sign of visceral malignancy. Any vasculitis, including that secondary to RA or systemic lupus erythematosus (SLE) can cause finger-pulp infarcts Systemic sclerosis (SS) causes tight and thickened skin tapered over the fingertips Skin quality Psoriasis scaly silver plaques on extensor surfaces White (ischaemia) blue (cyanosis) Colour Red (reactive hyperaemia) Infection Raynaud’s phenomenon Liver disease Specific signs Gottron’s papules: Telangiectasia: systemic sclerosis dermatomyositis Mechanics hands: dermatomyositis and antisynthetase syndrome Tripe Hand: ? visceral malignancy Look Soft tissue Nails Soft tissue swelling - Generalised puffiness: ? early stages of connective tissue diseases. - Synovial hypertrophy occurs in RA and noting the site of the inflammation is important for diagnosing complications. Nodules - Osteoarthritis present at the PIPs (Bouchard’s nodes) and DIP joints (Heberden’s nodes)= “Outer Hebrides” - Rheumatoid nodules = proximal, often at the elbow and MCP swelling - @ flexor tendons = trigger finger Muscle wasting - Ulnar nerve: interosseous wasting Synovial hypertrophy - Median: thenar wasting Look - nails Nails – Onycholisis Idiopathic, trauma, smoking, psoriasis, thyrotoxicosis, Reynauds – Pitting psoriasis, eczema, reactive arthritis, alopecia areata – Clubbing Lung Ca, Endocarditis, IBD, Cirrhosis – Splinter Haemmorhage Endocarditis, SLE, Psoriasis – Paronychia Onycholisis Clubbing Pitting Splinter Haemorrhage Nails Nodules Heberden’s nodes Bouchard’s nodes Rheumatoid nodules Look muscle waisting Median: thenar wasting Ulnar nerve: interosseous wasting and claw Look bones - joints Dupuytren's contracture Ulnar deviation of the fingers at the MCP joint: Symmetrical ulnar deviation is commonly present in late stage rheumatoid arthritis. Boutonniere’s deformity: Flexion at the PIP joint with extension at the DIP joint. Swan neck deformity: Hyperextension at the PIP joint with flexion at the DIP joint Claw hand (wrist flexion and fingers flexed at PIP and distal interphalangeal (DIP) joints): This is a presentation in Klumpke’s palsy. Ulnar claw (flexion of the ring and little fingers only): This is a result of a lesion to the ulnar nerve. Claw hand Ulnar claw Deformity Ulnar deviation Dupuytren's contracture Swan neck deformity Boutonniere’s deformity Feel Radial- ulnar Pulse Temperature Feel Across MCP joints Bimanual examination of each joint – Wrist – MCP +PIP joints – ?Tender ?Fluctuance ?Hard Swelling – Anatomical snuffbox= scaphoid fracture Assess for any tendon thickening - ?dupuytren Move Active (passive if required) – wrist flexion 70 & extension 80, ulnar 40 & radial 20 deviation – Pronation 70 & supination 80 – finger extension & flexion – finger abduction – thumb abduction – thumb opposition Function Power Grip Pincer Grip Lifting a coin Doing up a button Holding a pen/cup Neurology Motor – Fingers Extend fingers  Radial & Ulnar Spread  Radial & Ulnar Thumb Abduction  Median ("LOAF" for Lumbricals 1 & 2, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis) OK sign Sensory Sensation Testing Dorsal hand Radial hand Neurological examination Capillary refill Special Tests compress the nail bed until it turns white and records the time taken for the color to return= less 3sec Phalen’s test (CTS) – Forced flexion of the wrist for 60 seconds reproducing the patient’s symptoms Tinel sign (CTS) Froment’s Sign – Ulnar nerve function. – ask patient to hold a piece of paper between their thumb and index finger - adductor pollicis. – In Ulnar nerve palsy the interphalangeal joint of the thumb will flex to compensate Wartenberg's Sign (ulnar nerve) Unposed function of EDM Finkelstein's test (De Quervain's tenosynovitis) : pulls the thumb of the patient in ulnar deviation and longitudinal traction. Finishing the Examination Thank the Patient Examination of joint above Dispose of PPE appropriately and wash your hands Present Examination finding’s – Positive Sign’s in a systematic fashion with relative negatives – differential diagnosis – Investigations