Edited by Carew Giberson-Chen and Jeffrey "Spud" Olson - 7/1/2021
Inspection/Palpation
Wounds/lacerations i.e. open fractures
Ecchymosis, erythema (demarcate)
Draining wounds, masses
Local swelling and joint effusions
Bony tenderness: snuffbox, scaphoid tubercle (scaphoid fx); 5th metacarpal (Boxer’s fx); thumb base (Bennett/Rolando), etc.
Muscle atrophy (especially in specific nerve distributions--thenar = median = carpal tunnel, interosseous/hypothenar = ulnar = guyon vs. cubital tunnel vs. cervical radiculopathy)
Deformity: asymmetry, angulation, rotation, cascade (when flexed, fingers should all converge towards scaphoid tubercle; an assessment of digital alignment)
Range of Motion
Fingers:
MCP: 0° extension to 85° of flexion
PIP: 0° extension to 110° of flexion
DIP: 0° extension to 65° of flexion
Wrist:
60° flexion
60° extension
50° radioulnar deviation arc
Neurovascular Exam
Sensation:
Radial: dorsal webspace between thumb and IF
Median: palmar aspect of distal IF
Palmar cutaneous branch
Ulnar: palmar aspect of distal SF
Dorsal cutaneous branch
Motor:
Median
Anterior interosseous nerve (FDL, 2nd FDS, 2nd FDP): OK sign (“make an OK sign”)
Recurrent motor branch (APB): thumb palmar abduction (”bring your thumb towards your forearm”)
Radial nerve proper: triceps (elbow extension), wrist extension (ECRL/ECRB)
PIN (EPL): thumb IP extension (“thumbs up”), EIP/EDQ (spider man “spidey” fingers)
Ulnar (interosseous): digit adduction/abduction (“cross your fingers”, “make a peace sign”, “spread your fingers out”); ADM (small finger abduction); adductor pollicus (thumb adduction - deep branch ulnar)
Vascular:
Palpate radial artery pulse
Palpate ulnar artery pulse
Doppler: radial/ulnar aa., superficial/deep arches, common/proper digital aa.
Pulse oximetry on each fingertip
Provocative maneuvers or special tests
Snuffbox tenderness: scaphoid fracture
To isolate FDP: hold MCP and PIP in extension, have patient flex just DIP
To isolate FDS: hold MCP, PIP, and DIP of other 3 digits in extension flat on table with palm up, have patient flex PIP of digit of concern
Tinel’s (carpal tunnel): percuss with two fingers over distal palmar wrist crease at midline, positive for carpal tunnel if patient reports paresthesias in median distribution
Phalen’s (carpal tunnel): passive flexion of both wrists to 90˚ with dorsal palms pressed together, positive for carpal tunnel if patient reports paresthesias in median distribution
Froment’s (ulnar nerve weakness): hold sheet of paper between thumb and radial side of IF, pull paper away, positive if thumb IP flexes to hold onto paper
Wartenberg’s (ulnar nerve weakness: hold all fingers fully adducted with MCP, PIP, and DIP joints fully extended, positive if small finger drifts away from others into abduction