Examination of Hand Injuries

History

1. Determine the patient’s

• Age

• Sex

• Hand dominance

• Occupation

• Other medical problems

2. Confirm

• Location of the injury

• Cause of the injury

• Time of the injury

• Duration of the injury process

Physical Examination

First, perform a general exam of the hand:

• Verify any physical hand deformities

• Establish if there is any bleeding, pain, swelling, recent deformity, and ecchymosis

Can herald a closed fracture

• Confirm open wounds

• Note old scars

• Assess posture of the hand

Angulation of digits signals possible dislocations and fractures

• Palpate fingers, palm, and wrist for tenderness

• Determine the temperature of the hands and if they are dry or moist

Patient complaints of severe pain, paresthesia, and swelling of the hand, may indicate flexor tenosynovitis. These symptoms can be explained by Kanavel signs.

Kanavel Signs
• Pain overtendon sheath • Fusiform swelling of digit • Finger held inflexion • Pain on passive extension (Hallmark sign)

Kanavel Signs

• Pain overtendon sheath

• Fusiform swelling of digit

• Finger held inflexion

• Pain on passive extension (Hallmark sign)

Range of Motion

Check the resting hand position; this may indicate tendon injuries if the natural arcade is disrupted. Ask the patient to move all joints of the hand. Look at movement holistically and at each individual joint’s movement. Start with the fingertips and move proximally. Table 12–1 lists the normal ROM for each joint in the hand.

Distal Interpholangeal Joint

Look for tuft fractures distal to this joint. Normal ROM is 0-degree extension and 65 degrees of flexion. Also, look for Mallet finger, which is a result of the avulsion of the terminal extensor tendon, leaving the DIP joint in a flexed position. Stabilize the middle phalanx with the PIP joint extended to test flexion of the flexor digitorum profundus (FDP).

Table 12–1 Normal Range of Motion for Joints of the Hand

Joint	Degrees of Flexion
Finger DIP	65
PIP	110
MCP	85
Thumb IP	90
MCP	45–60

Proximal Interphalangeal Joint

Look for full ROM from 110 degrees of flexion to zero degrees extension in this joint. Inability to flex the PIP joint can result from disruption of the flexor digitorum superficialis (FDS) tendon/muscle, volar plate disruption, or contracture of the intrinsic muscle of the hand. Inability to extend the joint may be a result of extensor mechanism injury (boutonniére deformity) or contracture of the flexor mechanism.

Metacarpophalangeal Joint

The digit MCP joints progress through 85 degrees of flexion and zero degrees of extension. Often, tendons or the joint capsule may be exposed in cases of laceration. In cases of assault, look for an open laceration over the joint along with decreased prominence of the fifth metacarpal head. This signals the possibility of the fracture of the fifth metacarpal neck (boxer’s fracture). Joint dislocations may also be present. These may be difficult to reduce if tendons or volar plate entrapment occurs.

The Thumb

Normal MCP joint ROM for the thumb is 45 to 60 degrees of flexion and zero degrees of extension. Look for radial and ulnar deviation and pain in the MCP and CML joints. Radial deviation at the MCP joint is a sign of weakness of the ulnar collateral ligament (gamekeeper’s thumb).

Common Hand Deformities

Boutonniére Deformity

• PIP flexion with DIP extension caused by disruption of the extensor insertion of middle phalanx and volar migration of the lateral bands

Swan Neck Deformity

• PIP hyperextension with DIP flexion caused by lateral band tightness and volar plate laxity

Table 12–2 Intrinsic and Extrinsic Flexors and Extensors of the Hand by Joint

Joint	Flexion	Extension
Finger DIP	FDP	Lumbricales, interossei
Finger PIP	FDP, FDS, FDM, FPB	EDC, lumbricales, interossei
MCP	Lumbricales, interossei	EDC, EIP, EDM, EPB
Thumb IP	FPL	EPL
Wrist	FCR, FCU, PL	ECU, ECRL, ECRB