Procedure
- The patient bares both arms up to the elbows, and removes jewellery/watches.
- The patient sits at an examination table and lifts the arms with stretched elbows and pronated lower arms (up to 90° anteflexion).
- This position of the hands is assessed to determine the presence of a peripheral nerve injury.
- Wrist drop (radial nerve lesion), claw hand (ulnar nerve lesion), preacher’s hand (median nerve lesion).
- The patient places the lower arms and palms on the table.
- Inspection from the proximal to the distal side is preferred.
- All bone structures are assessed for shape and position (individual position and position relative to the other bone structures and joints), whilst comparing left and right.
Dorsal Side
Inspect the shape and the position of the following structures [Figure 102].
Figure 102
1. Bones and Joints
- Distal part of the radius and ulna (fracture).
- Wrist joints (radiocarpal joint; ganglion, rheumatoid arthritis).
- Carpals (scaphoid bone, lunate bone, capitate bone, fractures).
- Metacarpals I through to V (acromegaly).
- Metacarpophalangeal joints = MCP II through to V (rheumatoid arthritis).
- Phalanges (acromegaly, amputations, drumstick fingers).
- Proximal interphalangeal joints = PIP II through to V (rheumatoid arthritis, Bouchard’s nodes with osteoarthritis, dislocation).
- Distal interphalangeal joints – DIP II through to V (Heberden’s nodes with osteoarthritis).
- Joints of the pollex (thumb):
- Carpometacarpal joint = CMC I (osteoarthritis).
- Metacarpophalangeal joint = MCP I (dislocation).
- Interphalangeal joint = IP.
2. Soft Tissue
- Skin (sclerodactyly, Sudeck atrophy, Raynaud’s syndrome) and nails (cyanosis, hourglass nails).
- Muscle contours of the:
- Extensors of the wrist.
- Interosseous muscles.
- Tendons and tendon sheaths (rheumatoid arthritis, De Quervain syndrome). Particularly, the anatomical snuff box (bordered by the tendons of the extensor pollicis longus, brevis muscles and the extensor retinaculum).
Palmar Side
Inspect the shape and position of the following structures [Figure 103].
Figure 103
1. Bones and Joints
- Pisiform bone (contour).
- Tubercle of the scaphoid bone (contour).
- Wrist joint (ganglion, rheumatoid arthritis).
2. Soft Tissue
- Skin (callous, sweat secretion, skin creases: Down’s syndrome).
- Muscle contours of the:
- Flexors of the wrist.
- Thenar eminence (eminence of the thumb).
- Hypothenar eminence (eminence of 5th digit).
- Tendons and tendon sheaths (rheumatoid arthritis).
- Palmar fascia (Dupuytren’s contracture).