The Hand Exam
- A rapid hand exam can be performed in the following manner:
- Ask the patient make an “OKAY” sign with thumb and first finger (median nerve). Spread the fingers apart maximally (ulnar nerve). Dorsiflex the wrist fully (radial nerve). These can be combined into an OKAY sign with remaining fingers spread apart and the wrist dorsiflexed to get an all-in-one motor exam.
- Check sensation of the median and ulnar nerve by testing two-point discrimination at the index and small finger pads respectively. Radial nerve sensation can be tested over the dorsum of the thumb.
- For carpal tunnel syndrome, perform Tinel’s and Phalen’s tests. Remember, a positive test occurs when the patient reports paresthesias in median nerve distribution.
- Acute compartment syndrome must go to the OR within 8 hours of onset.
- Kanavel’s Signs are key physical exam findings for flexor tenosynovitis: finger held in flexion, pain with passive extension, pain with palpation of the flexor tendon sheath, and fusiform swelling.
- Beware of high-pressure injection injuries. They look more benign than they truly are, and warrant a careful physical examination of the hand and consultation.
- When considering when to remove sutures in the hand, leave sutures that are over areas of tension (i.e. over a joint) for longer (at least 12 days) so they heal completely.
- If controlling bleeding is an issue, do NOT clamp any digital arteries, as the digital nerve is very nearby and hard to visualize. Use pressure, limited tourniquet and elevation to control bleeding safely.
- Prophylactic antibiotics are indicated for for all animal bites to the hand, and for certain complex injuries (crush wounds, wounds over a joint, or for immune compromised patients).
- If referring a hand abscess to a clinic, consider swabbing the drained fluid so MRSA status can be determined.
- Immobilizing the PIP joint in extension can stiffen the collateral ligaments causing permanent disability, so don’t splint PIP joint for greater than 1–2 weeks unless necessary, and if splinting, ensure an early referral time. (within 1–2 weeks).