Examination of the Upper Limbs

Examination of the upper limbs is the portion of physical examination involving the assessment of the shoulder, elbow, forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm, wrist, and hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand to evaluate for signs of pathology. The examination includes inspection, palpation, tests of range of movement, and provocative maneuvers. A good history should be taken and concurrently used with the exam findings to obtain a presumptive diagnosis.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

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Overview

Initial steps

  • Briefly explain each step of the examination to the individual and obtain consent.
  • Position the individual in a sitting position.
  • Expose the shoulders, arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm, forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm, and hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand adequately.
  • Ensure good lighting.

Components of the examination

  • Inspection
  • Palpation
  • Range of motion
  • Special tests

Anatomy

The upper limb is divided into 3 regions:

  • Arm
  • Forearm
  • Hand 

The joints involved include:

  • Shoulder joint
  • Elbow joint Elbow joint The elbow is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm. The elbow consists of 3 joints, which form a functional unit enclosed within a single articular capsule. The elbow is the link between the powerful motions of the shoulder and the intricate fine-motor function of the hand. Elbow Joint
  • Wrist joint Wrist joint The wrist connects the forearm to the hand. It consists of 8 carpal bones, multiple joints, and various supporting ligaments, as well as the distal bones of the forearm and the proximal portion of the 5 metacarpal bones of the hand. Wrist Joint
  • Carpometacarpal (CMC) joints
  • Metacarpophalangeal (MCP) joints
  • Proximal interphalangeal (PIP) joints
  • Distal interphalangeal (DIP) joints 

These joints are surrounded and supported by many muscles, tendons, ligaments, and fibrocartilaginous structures to ensure support and stability and to absorb shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock during locomotion.

Shoulder Examination

Inspection

Inspect the following structures of the shoulder/shoulder girdle bilaterally:

  • Bony structures:
    • Clavicle
    • Scapula
    • Humerus
  • Muscular structures:
    • Deltoid
    • Pectoralis major
    • Trapezius
    • Rhomboid

Note:

  • Asymmetry
  • Swelling
  • Deformity
  • Muscle atrophy or fasciculations
  • Abnormal positioning
  • Winging

Palpation

Palpate the various components of the shoulder girdle, including:

  • Sternoclavicular joint
  • Clavicle
  • Acromioclavicular joint
  • Acromion
  • Coracoid process of the scapula
  • Head of the humerus
  • Greater tubercle of the humerus
  • Spine of the scapula

Note:

  • Swelling
  • Crepitus
  • Bony irregularities
  • Tenderness (palpate tender areas last and compare with nontender areas)

Range of motion

Each shoulder joint should be assessed and compared with the others. First assess active movement and then passive movement.

  • Compound movements:
    • Rapid screening tool for shoulder joint pathology
    • Test the rotator cuff muscles in a few movements.
    • External rotation and abduction of the shoulder joint:
      • Instruct individual to put the hands behind the head.
      • Elbows point out to the side.
    • Internal rotation and adduction of the shoulder joint:
      • Instruct individual to place the hands behind the lower back.
      • Reach as far up the spine as possible.
  • Shoulder flexion:
    • Individual raises the arms forward.
    • Normal range of movement: 150–180 degrees
  • Shoulder extension:
    • Individual stretches out the arms behind them.
    • Normal range of movement: 40 degrees
  • Shoulder abduction:
    • Individual raises the arms out to the side in an arc-like motion until the hands touch above the head.
    • Normal range of movement: 180 degrees
  • Shoulder adduction:
    • Individual keeps the arms straight and moves them across the front of the body to the opposite side.
    • Normal range of movement: 30–40 degrees
  • Shoulder external rotation:
    • Individual keeps elbows by the sides flexed at 90 degrees while they move the forearms outward in an arc-like motion.
    • Normal range of movement: 80–90 degrees
  • Shoulder internal rotation:
    • Ask the individual to place each hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand behind the back and reach as far up the spine as possible.
    • Normal range of movement: able to reach level T4–T8

Tests for shoulder stability

Anterior/posterior drawer test:

  • Positioning: supine, prone, or seated
  • Procedure:
    • Stabilize the scapula by placing one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand on the spine of the scapula and the coracoid process.
    • Manipulate humeral head anteriorly with the other hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand.
  • Positive result: joint laxity compared to the contralateral side
  • Test significance: possible ligamentous, tendinous, or capsular injury 

Inferior drawer test:

  • Positioning: supine, prone, or seated
  • Procedure:
    • Stabilize the scapula by placing one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand on the spine of the scapula and the coracoid process.
    • Apply distal traction on the elbow.
  • Positive result: 
    • Visible depression between the edge of the acromion and the humeral head (positive sulcus sign)
    • Joint laxity compared to the contralateral side
  • Test significance: possible ligamentous, tendinous, or capsular injury 

Anterior apprehension test:

  • Positioning: seated
  • Procedure: 
    • Stabilize the scapula by placing one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand on the spine of the scapula and the coracoid process.
    • Abduct shoulder to 90 degrees with the elbow flexed at 90 degrees.
    • Externally rotate the joint while observing for subluxation, apprehension, or discomfort.
  • Positive result: subluxation, apprehension, or discomfort
  • Test significance: possible ligamentous, tendinous, or capsular injury

Posterior apprehension test:

  • Positioning: seated
  • Procedure: 
    • Stabilize the scapula by placing one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand on the spine of the scapula and the coracoid process.
    • Flex shoulder and elbow to 90 degrees and rotate internally.
    • Apply posterior force on the elbow while observing for subluxation, apprehension, or discomfort.
  • Positive result: subluxation, apprehension, or discomfort
  • Test significance: possible ligamentous, tendinous, or capsular injury

Rotator cuff tests

Lateral Jobe test:

  • Positioning: seated
  • Procedure: 
    • Abduct the shoulder to 60 degrees. 
    • Internally rotate the shoulder with the thumb pointing down toward the floor.
    • Push down on the arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm as the individual resists.
  • Positive result: pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain or weakness against examiner’s resistance
  • Test significance: suggests a tear in the supraspinatus tendon or muscle

Lift-off test:

  • Positioning: seated
  • Procedure:
    • Individual places the dorsum of the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand on the lower back with the elbow flexed to 90 degrees.
    • The examiner lifts the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand off the back against the individual’s resistance (the individual is asked to maintain the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand in this position).
  • Positive result: inability to maintain the above position against resistance
  • Test significance: suggests a tear in the subscapularis tendon or muscle

Resisted external rotation:

  • Positioning: seated
  • Procedure:
    • Individual adducts and flexes the arms to 90 degrees with the thumb turned up.
    • The examiner stabilizes the elbow with one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand and applies pressure proximal to the individual’s wrist.
    • The individual presses the wrists outward in external rotation.
  • Positive result: pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain or weakness against examiner’s resistance
  • Test significance: suggests a tear in the infraspinatus tendon or muscle

Impingement tests

Painful arc test:

  • Positioning: seated
  • Procedure: 
    • Stabilize the scapula by placing one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand on the spine of the scapula and the coracoid process.
    • Actively and passively carry the shoulder from 0 degrees to 180 degrees of abduction.
  • Positive result: shoulder pain Shoulder Pain Acute shoulder injuries are a common reason for visits to primary care physicians and EDs. Common acute shoulder injuries include acromioclavicular joint injuries, clavicle fractures, glenohumeral dislocations, proximal humerus fractures, and rotator cuff tears. Acute Shoulder Pain at 60–120 degrees
  • Test significance: suggests subacromial impingement

Neer test:

  • Positioning: seated
  • Procedure:
    • Stabilize the scapula by placing one hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand on the spine of the scapula and the coracoid process.
    • Adduct shoulder to 90 degrees and rotate internally. Extend elbow; forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm is pronated. 
    • Actively and passively raise the arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm (shoulder flexion).
  • Positive result: pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain at 90–120 degrees
  • Test significance: suggests subacromial impingement

Hawkins-Kennedy test:

  • Positioning: seated
  • Procedure:
    • Shoulder and elbow are flexed at 90 degrees.
    • Stabilize the elbow and passively rotate the shoulder joint internally.
  • Positive result: pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain on internal rotation
  • Test significance: suggests subacromial impingement 

Other provocative tests

Cross-body adduction test:

  • Positioning: seated
  • Procedure: 
    • Adduct the arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm(s) across the chest. 
    • Assess the acromioclavicular and sternoclavicular joints.
  • Positive result: pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with adduction
  • Test significance: acromioclavicular or sternoclavicular dysfunction

Yegason’s test:

  • Positioning: seated
  • Procedure:
    • The individual flexes the elbow to 90 degrees. 
    • The individual supinates the wrist and internally rotates the shoulder against the examiner’s resistance.
  • Positive result: pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in the bicipital groove or movement of the biceps tendon out of the bicipital groove
  • Test significance: tests for stability of the biceps tendon in the bicipital groove and bicipital tendinitis

Speed’s test:

  • Positioning: seated
  • Procedure:
    • The individual flexes the shoulder to 90 degrees with the elbow extended and the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm supinated.
    • The examiner applies a downward force as the individual resists.
  • Positive result: pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain elicited in the bicipital groove
  • Test significance: tests for bicipital tendinitis of the long head of the biceps 

Elbow Examination

Inspection

Inspect the following structures of the elbow bilaterally:

  • Bony structures:
    • Proximal radius
    • Proximal ulna
    • Distal humerus
  • Muscular structures:
    • Bicep
    • Tricep
    • Wrist flexors
    • Wrist extensors
    • Pronators
    • Supinators 
  • Normal valgus angle: 11–13 degrees (when elbow fully extended)

Note:

  • Asymmetry
  • Swelling
  • Deformity
  • Muscle atrophy or fasciculations
  • Abnormal positioning

Palpation

Palpate the various components of the elbow, including:

  • Olecranon process of the ulna
  • Radial head
  • Medial epicondyle of the humerus
  • Lateral epicondyle of the humerus

Note:

  • Swelling
  • Crepitus
  • Bony irregularities
  • Tenderness: Palpate tender areas last and compare with nontender areas.

Range of motion

  • Flexion:
    • Individual bends the elbow to touch the shoulder.
    • Normal range of motion: 0–145 degrees
  • Extension:
    • Individual straightens the arms as far out as possible.
    • Normal range of motion: 0 degrees
  • Pronation:
    • Individual turns the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm so that the palm is facing down.
    • Normal range of motion (proximal radioulnar joint): 0–85 degrees
  • Supination:
    • Individual turns the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm so that the palm is facing up.
    • Normal range of motion (proximal radioulnar joint): 0–90 degrees

Special tests

Tennis elbow (lateral epicondylitis):

  • Positioning: seated
  • Procedure:
    • Individual flexes the elbow to 90 degrees with wrist pronated and flexed completely.
    • Individual is asked to extend the wrist against the examiner’s resistance.
  • Positive test: pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain over the lateral epicondyle
  • Test significance: suggests lateral epicondylitis and/or wrist extensor tendinopathy 

Golfer’s elbow (medial epicondylitis):

  • Positioning: seated
  • Procedure: 
    • Individual flexes the elbow to 90 degrees with the wrist supinated and extended completely.
    • Individual is asked to make a fist and flex the wrist against the examiner’s resistance. 
  • Positive test: pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain over the medial epicondyle.
  • Test significance: suggests medial epicondylitis and/or wrist flexor tendinopathy

Wrist Examination

Inspection

Inspect the following structures of the wrist bilaterally:

  • Bony structures:
    • Distal radius
    • Distal ulna
    • Carpal bones
  • Muscular structures:
    • Wrist flexors
    • Wrist extensors
    • Pronators
    • Supinators 

Note:

  • Asymmetry
  • Swelling
  • Deformity
  • Muscle atrophy or fasciculations
  • Abnormal positioning

Ganglion cyst:

  • Synovial cysts that contain mucinous fluid.
  • Most commonly found on the dorsal aspect of the wrist
  • Believed to arise from repetitive microtrauma resulting in mucinous degeneration of connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue
  • Majority are asymptomatic.
  • May present with:
    • Pain and tenderness
    • Dissatisfaction with cosmetic appearance
A ganglion cyst

A ganglion cyst

Image: “Ueberbein2” by Kulzerwi. License: Public Domain

Palpation

Palpate the various components of the wrist, including:

  • Distal radius
  • Distal ulna
  • Carpal bones

Note:

  • Swelling
  • Crepitus
  • Bony irregularities
  • Tenderness: Palpate tender areas last and compare with nontender areas.

Range of motion

  • Flexion: 
    • Individual puts the backs of the hands together and flexes the wrist fully.
    • Normal range of motion: 0–90 degrees
  • Extension: 
    • Individual puts the backs of the hands together and extends the wrist fully.
    • Normal range of motion: 0–90 degrees
  • Adduction:
    • With palm facing down, individual brings the fingers toward the midline.
    • Normal range of motion: 0–30 degrees
  • Abduction: 
    • With palm facing down, individual brings the fingers away from the midline.
    • Normal range of motion: 0–30 degrees
  • Pronation:
    • Individual turns the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm so the palm is facing down. 
    • Normal range of motion (distal radioulnar joint): 0–150 degrees
  • Supination:
    • Individual turns the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm so that the palm is facing up.
    • Normal range of motion (distal radioulnar joint): 0–30 degrees

Special tests

Tinel test:

  • Positioning: seated
  • Procedure:
    • Individual flexes the elbow to 90 degrees with the wrist supinated and extended.
    • Examiner taps in the center of the transverse carpal ligament.
  • Positive test: pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain or paresthesia in the distribution of the median nerve
  • Test significance: suggests median nerve compression
Tinel test for carpal tunnel syndrome

Tinel test for carpal tunnel syndrome Carpal Tunnel Syndrome Carpal tunnel syndrome (CTS) is a complex of signs and symptoms caused by compression of the median nerve as it crosses the carpal tunnel. Presentation is with pain and paresthesia of the dermatomal target tissues innervated by the median nerve as well as weakness and atrophy of the nerve's myotomal targets. Carpal Tunnel Syndrome

Image by Lecturio.

Phalen test:

  • Positioning: seated
  • Procedure:
    • Individual flexes the elbow to 90 degrees with the dorsal aspect of the wrists pressed together in the completely flexed position.
    • Individual is asked to extend the wrist against the examiner’s resistance.
  • Positive test: pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, paresthesia, or numbness in the distribution of the median nerve
  • Test significance: suggests median nerve compression
Phalen test in carpal tunnel syndrome

Phalen test in carpal tunnel syndrome Carpal Tunnel Syndrome Carpal tunnel syndrome (CTS) is a complex of signs and symptoms caused by compression of the median nerve as it crosses the carpal tunnel. Presentation is with pain and paresthesia of the dermatomal target tissues innervated by the median nerve as well as weakness and atrophy of the nerve's myotomal targets. Carpal Tunnel Syndrome

Image by Lecturio.

Finkelstein test:

  • Positioning: seated
  • Procedure:
    • Individual adducts the thumb into the palm and closes a fist around it and then adducts the wrist.
    • Individual attempts to abduct the wrist and thumb against the examiner’s resistance.
  • Positive test: pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain over radial aspect of the wrist
  • Test significance: suggests tendinopathy of the extensor pollicis brevis and/or abductor pollicis longus tendons (de Quervain tenosynovitis)
Finkelstein test to aid in the diagnosis of de quervain tenosynovitis

Finkelstein test to aid in the diagnosis of de Quervain tenosynovitis

Image by Lecturio.

Hand Examination

Inspection

Inspect the following structures of the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand bilaterally:

  • Bony structures:
    • Metacarpals 
    • Proximal phalanges
    • Distal phalanges
  • Muscular structures:
    • Interosseus muscles
    • Thenar muscles
    • Hypothenar muscles
    • Finger flexors
    • Finger extensors 

Note:

  • Asymmetry
  • Swelling
  • Deformity
  • Muscle atrophy or fasciculations
  • Abnormal positioning

Common abnormalities

Deformity:

  • Rotational deformity due to phalangeal fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • Mallet finger:
    • Flexion at DIP
    • Can be passively reversed
  • Boutonnière deformity:
    • PIP: fixed flexion
    • DIP: hyperextension
  • Swan-neck deformity:
    • PIP: hyperextension
    • DIP: flexion
  • Dupuytren contracture:
    • Fixed flexion of the MCP and PIP joints 
    • Usually affects the little and ring finger

Swelling:

  • Swollen MCP → loss of hill–valley–hill 
  • Heberden node: nodules at the DIP
  • Bouchard node: nodules at the PIP
  • Ganglion cysts

Extra-articular signs:

  • Muscle wasting (thenar and hypothenar eminence)
  • Palmar erythema
  • Psoriatic patches
  • Thickening of the flexor tendons or flexion contractures in the fingers

Palpation

Palpate the various components of the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand, including:

  • CMC joints
  • PIP joints
  • DIP joints

Note:

  • Swelling
  • Crepitus
  • Bony irregularities
  • Tenderness (palpate tender areas last and compare with nontender areas)

Palms up:

  • Palpate the radial and ulnar pulses to confirm adequate blood supply to the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand.
  • Palpate the muscle bulk of the thenar and hypothenar eminences. Wasting is due to:
    • Disuse atrophy
    • Lower motor neuron lesions Lower motor neuron lesions Upper motor neurons (UMNs) and lower motor neurons (LMNs) combine to form a neuronal circuit for movement. LMN lesions affect the nerve fibers traveling from the anterior horn of the spinal cord to the peripheral muscle. Upper and Lower Motor Neuron Lesions in the ulnar and/or median nerves 
  • Palpate the palm to detect the typical bands of thickened palmar fascia associated with Dupuytren contracture. 
  • Assess median and ulnar nerve sensation:
    • Median nerve: over the thenar eminence and index finger
    • Ulnar nerve: over the hypothenar eminence and little finger

Palms down:

  • Assess radial nerve sensation over the 1st dorsal web space.
  • Gently squeeze across the MCP joints to elicit tenderness (suggestive of active inflammatory arthropathy).
  • Palpate the joints of the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand
    • MCP, PIP, DIP, and CMC joints
    • Assess and compare for:
      • Tenderness
      • Irregularities
      • Warmth 
  • Palpate the anatomical snuffbox for tenderness (suggestive of a scaphoid fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures).
  • Palpate the wrists bimanually for joint-line irregularities or tenderness.

Range of motion

  • Fingers:
    • Flexion: Individual makes a fist.
    • Extension: Individual opens the fist and splays the fingers.
    • Abduction: Individual spreads the fingers apart.
    • Adduction: Individual puts the fingers together.
  • Thumb:
    • Flexion: The individual moves the thumb across the palm and touches the base of the 5th finger.
    • Extension: Move the thumb back across the palm and away from the fingers. 
    • Abduction: With the fingers and thumb in a neutral position and palm up, the individual moves the thumb away from the palm.
    • Adduction: With the fingers and thumb in a neutral position and palm up, the individual moves the thumb back down.
    • Opposition: The individual touches the thumb to each of the other fingertips.

Clinical Relevance

  • Rotator cuff tears: Rotator cuff pathology is the most common condition of the shoulder for which individuals seek treatment. Rotator cuff tears are caused by degeneration, impingement, and overload. Presentation is with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and weakness at the shoulder joint. On examination, there may be a positive painful arc sign, positive drop arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm test, or weakness in external rotation. Physical examination findings are dependent on the muscles involved. Imaging studies such as musculoskeletal ultrasonography and MRI can be done to confirm the diagnosis. Management is with physical therapy or surgical repair.
  • Carpal tunnel syndrome: complex of signs and symptoms caused by compression of the median nerve as it crosses the carpal tunnel. Presentation may be with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, paresthesia, weakness, and atrophy over the median nerve dermatome and myotome distribution. On examination, a positive Tinel test and Phalen test are elicited. Management can be with splinting, physical therapy, or surgical correction. 
  • Rheumatoid arthritis: chronic, systemic, autoimmune, inflammatory disorder of unknown etiology that primarily involves synovial joints. The arthritis is usually symmetrical and leads to erosion of cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage and bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones, causing joint deformities. During the onset of disease, individuals present with joint pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, stiffness (especially morning stiffness), and swelling of many joints. On examination, joint tenderness and swelling may be noted on the small joints of the hands, wrist, and forefoot. Individuals with poorly controlled disease have significant joint deformities (e.g., swan-neck deformity). Management is with early use of disease-modifying antirheumatic drugs Disease-modifying antirheumatic drugs Disease-modifying antirheumatic drugs are antiinflammatory medications used to manage rheumatoid arthritis. The medications slow, but do not cure, the progression of the disease. The medications are classified as either synthetic or biologic agents and each has unique mechanisms of action and side effects. Disease-modifying Antirheumatic Drugs (DMARDs) and antiinflammatory agents. 
  • Elbow tendinopathy: Chronic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain at the lateral or medial epicondyle of the elbow is a relatively common condition, particularly among tennis players and golfers, respectively, and among manual laborers. On examination, there is localized tenderness over the lateral or medial epicondyle, with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain elicited during resisted wrist flexion or extension. The diagnosis is primarily clinical. Management may include activity modification, bracing, oral analgesics, or physical therapy. 
  • Ganglion cyst: one of the most common soft tissue swellings in the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand and the wrist. A ganglion cyst is a fluid-filled swelling overlying a joint or tendon sheath. These cysts are benign but may occasionally lead to pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, weakness, and loss of function. On examination, an obvious swelling that is firm, smooth, rounded, rubbery, and at times tender is noted. Management is with reassurance for asymptomatic cysts, aspiration, or surgical therapy. 

References

  1. Bickley, L.S. (2017). The musculoskeletal system. In: Bates’ Guide to Physical Examination and History Taking, 12th ed. Wolters Kluwer, pp. 645–666.
  2. Potter, L. (2021). Shoulder examination—OSCE guide. Geeky Medics. Retrieved November 12, 2021, from https://geekymedics.com/shoulder-examination/
  3. Potter, L. (2021). Elbow examination—OSCE guide. Geeky Medics. Retrieved November 12, 2021, from https://geekymedics.com/elbow-examination/
  4. Potter, L. (2021). Hand & Wrist examination—OSCE guide. Geeky Medics. Retrieved November 12, 2021, from https://geekymedics.com/hand-examination/
  5. Rothaermel, B.J. (2017). Shoulder examination. Medscape. Retrieved October 13, 2021, from https://emedicine.medscape.com/article/1909254

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