Examination of the Hand

Examination of the Hand

Look
Start examination by asking " Do you have RA?"

Patient seated

Hands on pillow

Dorsum

 Describe proximal to distal

o Skin
 Colour, scars, creases
 distal web skin limit is the midpoint of the proximal phalanx
 Creases on flexor surface are distal to the joint
 on the extensor surface they are proximal to the joint

o Wrist
 Ganglions, synovitis, prominent ulnar head
o Hand
 Swelling
 Tenosynovitis
 Carpal bossing: benign bony prominences that form on dorsum of
proximal ends of 2-3rd MC
 Atrophy
 of intrinsics
 NB: test peripheral nerves
 of first interosseus
 Radial border of 2nd MC
 Severe ulnar neuropathy
 MCPJ
 old Fracture’s, dropped knuckle
 Carpal bossing (benign prominences at the proximal end of the
2nd/3rd metacarpals)
o Digits
 Heberden’s nodes (DIP)
 Mucous cyst – DIP associated with degenerative changes of joints
 Bouchard’s nodes – (PIP)
o Fingernails: deformity, circulation
 Clubbing (respiratory & cardiac disease)
  Spoon nails (infection)
 Fragmentation & pitting (Psoriasis)
 Ridges (alcohol, vitamin deficiency)
 Splinter hemorrhages
 Onychogryposis –thick hook nails
 Paronychia

Radial surface

Palms together

 Thenar eminence
 Z deformity of thumb
 Dorsum of thumb
o Arthritis of basilar joint

Volar

Palms Up

 Creases
o Distal = proximal limit of the retinaculum
o Middle = Radio-carpal joint
o Proximal = proximal limit of synovial flexor sheath
 Swellings
o Ganglion
o Flexor synovitis
 Fingers
o Note the general resting posture, there should be increasing flexion from the index
to 5th. ? contracture, ? tendon injury (arcade of flexion)
o Swellings
 generalized finger swelling vrs localized (joint)
 Oslers nodes, small tender nodes in the finger pulp, from SBE
 ganglions (flexor creases)
 Phelon (pulp infection)
 Epidermal inclusion cyst
o Deformities
 rotational (previous fracture) get patient to flex the fingers, all should
point to scaphoid tubercle
 ulna drift (RA)
 swan neck
 follows an untreated mallet or DIPJ dislocation, or occurs
 primarily in RA
 After mallet/dislocation, the excessive extensor force causes
gradual attenuation of the PIPJ volar plate
  In RA, the synovitis erodes the volar plate & the hyperextension of
the PIPJ cause DIPJ flexion
 Boutonnière
 Central slip rupture
 acute (Trauma) or chronic (RA)
 claw fingers
 (loss of intrinsics or over-action of extrinsics)
 An extrinsic minus hand
 shown by extending the MCPJ, then able to flex the DIPJ & PIPJ
 Mallet finger extensor insertion dysfunction (mobile), if fixed may be
Osteoarthritis

Then bend elbows to look at ulnar surface

 elbow - scars or nodules

 benedectine
 ulnar clawing
 Best to see RA features, such as carpal subluxation & Caput ulnae

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Feel
 Feel area of interest
o go for most pathological finger is multiple regions
 In general palpate any swellings, scars or prominences & characterize any tender areas
 Feel for excessive warmth, sweating
 Proximal to distal, radial to ulnar
 Name each structure as you go
o Dorsal
 radial styloid
 Anatomical snuff box
 first dorsal compartment (De Quervain’s)
 Dorsal branch of radial artery
 Distal to this is trapezium
 Ganglion in 2nd dorsal compartment
 lister’s tubercle
 SL ligament distal to this
 DRUJ
 Ulnar styloid
 TFC
  (just distal to ulnar head in a small depression, continue palpating
during radial & ulnar deviation, feel a popping), L-T ligament is
just distal to the TFC, & extensor tendons (synovitis-RA)
 Remaining carpal bones & metacarpals
o Palmer
 Pulses
 scaphoid tubercle
 trapezium
 Lunate
 Scapho-trapezium joint
 Trapezio-metacarpal joint
 Pisiform & hook of hamate (end of FCU)
 Palmer fascia
 thenar & hypothenar eminencies (palpate eminencies whilst the patient
presses the tips of the thumb & 5th fingers together)
 flexor tendons (synovitis)
 To feel the Palmaris longus
 press tips of thumb & 5th together, wrist
 slightly flexed, palpate to the ulnar side of FCR. (Between PL &
FCR is median nerve)
 Fingers & thumbs
 Palpate swellings & joints

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Move
 Active & if any limited add passive
 Test passive & active movement, evaluate the end feel
 Wrist
o Whilst elbows are bent do
 Flexion (60-80°)
 Extension (70-90°)
o Brings hands down
 Radial (20°). & ulnar deviation(30-40°)
o Keep your elbows by yourside
 Supination
 Pronation
 Thumb
o Lateral abduction
o Palmar abduction
o Opposition
o Extension
 o Retropulsion
o thumb to LF base
o thumb to IF(tip to tip,pulp to side)
 Hand / Fingers
o Check arcade of flexion
o Extend fingers
 Fingers
o Flexion, extension, abduction (measure span between fingers) & adduction.
o tendon ruptures
 EPL post Colles
 EDC in RA (Vaughan-Jackson lesion)
 If finger PIPJ flexion limited, perform Bunnel test.
o Extension
 Passive MCPJ extension (70-80°) is always > active (0-20°)
 Can grossly assess flexion by distance of finger tips from the palm
 Note any triggering
o Thumb
 Opposition (distance between fingers)
 abduction (with reference to the palm)
 adduction
 radial abduction = opening up web.
o Stress
 Collateral ligaments of the fingers & thumbs
 IPJ’s in extension or 30°
 MCPJ’s in 90°

Functional Assessment / Grips

 Power Grip – squeeze my fingers

 Hook Grip – hook my hand
 Precision Grip hold pen
 Lateral Pinch Grip – key grip
 Tip Pinch – pick up coin

 Function
o Power grip
 extrinsic muscles 50% hand function
 hook (holding bag)
 cylinder & spherical
o Precision
 Intrinsic muscles, 45% hand function
 pinch grips e.g. holding a key, pen
o Paper weight
 Most basic function, 5%, requires limit strength & fine motor
o Also try doing up a button & tracing a diagram
o
 o 45% grasp
o 45% pinch
 side pinch (key pinch)
 tip pinch
 chuck pinch
o 5% hook
o 5% paper weight

Screening Series

ask patient to

 Neck side to side

 full abduction to over head position
 touch hands on head – check axilla & elbows for scars
 behind head
o flex elbows
o extend elbows
 behind lower back
 then pronation & supination with thumb up & elbows by side
 then make fist with thumb in & out
 spread fingers
 then wrist flexion & extension

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Special Tests
Nerve Palsy Examination

Deformities

 Ape Hand
o Thenar wasting, thumb held in line with fingers (extorens tendon pull)
o Median Nerve palsy
 Bishops Hand
o Also called Benediction hand
o Hypothenar wasting, intrinsic wasting, partial claw of the ulna side
o Ulnar nerve lesion
 Ulnar paradox
 o higher the lesion the less the claw
 Claw Hand
o Due to combined Median & Ulnar nerve palsy
o All fingers clawed
 Wrist Drop
o Radial Nerve lesion

Motor

 Posterior Interosseous
o ECU, EI, EDC, EPL, EPB, APL (radial thumb abduction)
 Radial
o ECRL, ECRB
 Median
o FCR, FDP2,3, FDS, FPL, APB (palmer thumb abduction)
o Opponens (press thumb/5th tips together, check strength & that the thumb is
opposing-rotating)
 Ulnar nerve
o FCU, FDP4,5, Intrinsics, Adductor policis

Sensation

 Median
o Palmer thumb & 1 • fingers & tips of fingers
o Palmer cutaneous nerve base of thumb
 Ulnar
o Ulnar 1 • fingers
 Radial
o Dorsal fingers/hand over median nerve fingers

Nerve tests

 Froment’s sign
o Grasp paper between index & thumb of both hands, pull out paper. If the thumb
IPJ flexes, then it is an isolated ulnar nerve palsy
 Phalan's test
o Hold the wrist flexed for 1 minute. Symptoms of median Nerve indicate CTS
 Tinnels test
o Tap over the median nerve, pins & needles indicates CTS
 Compression test
o press for 1 minute on median nerve at the distal palmer crease as it enters the CT,
pins & needles is positive
 Ulnar nerve compression test
o Guyon’s canal beneath the pisio-hamate ligament, through here runs the ulnar
nerve & artery. Compression just radial to the pisiform for 1 minute, positive test
is neurological symptoms
Flexor Tendon Tests

 General
o Anchor DIPJ’s to assess FDS
o Note index is unreliable to test for FDS, here check pinch grip gets
hyperextension of DIPJ, also flex & hold PIPJ at 90°, check DIPJ for contraction
 Finkelsteins test – De Quervain’s
o Make a fist with the thumb in the palm, Ulna deviate the wrist
o A positive test has pain over the abductor & EPB tendons
 Bunnel-Littler test – tight intrinsics
o Extend the MCPJ’s & try to passively flex the PIPJ
o If you are unable to do this, then this may mean a PIPJ contracture or tight
intrinsics.
o Thus flex the MCPJ (to relax the intrinsics), if this allows further flexion, then it
is intrinsic tightness.
o If flexing the MCPJ causes no change in PIPJ flexion, then it is a joint
contracture.
o If PIPJ flexion is ↓ with MCPJ flexion, then it is an extrinsic contracture of the
long finger extensor tendons.
o Tight retinacular ligament of Lansmere
o Extend PIPJ, if unable to passively flex the DIPJ then this is either a tight
ligament or joint contracture.
o Thus flex the PIPJ, if this allows flexion at the DIPJ then the oblique ligament is
tight.

Instability tests

 Shear test
o triquetrum is stabilized by applying palmer pressure over the pisiform & dorsal
pressure over the triquetrum. The lunate is the manipulated relative to the
triquetrum by gripping the lunate with the thumb & index finger of the other hand
over the dorsal & palmer poles of the lunate respectively.
o Discomfort or excessive translation as compared to the other side is positive.
o Assesses the L-T ligament.
 Kirk Watson test – S-L instability
o ref: Watson & Black "Instabilities of the Wrist" Hand Clin 3: 103, 1987.
o Distal pole/tubercle of scaphoid is stabilized with your thumb, to restrict its
palmer flexion, whilst the wrist is moved from ulnar deviation in extension to
radial deviation in flexion.
o If there is a S-L disruption, then the scaphoid will sublux dorsally when the wrist
is in radial deviation & flexion, & pain will result.
o A popping sensation may be felt as the scaphoid subluxes over the dorsal rim of
the radius.
o Releasing your thumb should allow the scaphoid to reduce & relieve pain.
 Midcarpal instability
o Axially load the wrist as you move it from radial to ulnar deviation.
 oJumping, catching or clunking is a positive result.
 DRUJ instability
o Translation of ulnar relative to radius in lateral plane
o Clicking, popping or pain may be produced.

Shuck test

 Test for thumb CMCJ subluxation/instability (usually Osteoarthritis).

 Grasp the thumb MC between your index & thumb, push & pull along the thumb axis.
 Grinding of this joint causing pain is usually from Osteoarthritis.

TFC injuries

 Press test
 Supposed to be 100% sensitive for TFC tear. Push up from chair with an extended wrist.
Pain at ulnar-carpal joint is indicative of a tear.

Compression test

 Axially load the wrist in maximal ulnar deviation, in neutral, pronation & supination.
 Production of pain distal to the ulnar is indicative of a tear
 Clicking & popping may be felt.

Circulation

Allen’s test

 Open & shut the hand a few times, then occlude both arteries. Next open the hand &
notice the blanched palm. Release one of the arteries (usually the ulnar) & look for the
return of colour.
 Allen test for digital arteries
 Tests the prescience of two vessels. Flex the finger & compress these, release one at a
time with the finger extended. Look for return of colour.

Capillary refill

 Press on nails & compare

 Check normal Arcade of Flexion

Avulsion of flexor digitorum profundus (Jersey finger)

o It occurs when the fingers of a football player are pulled into extension as he
attempts to grasp the jersey of an opponent
o Common in ring finger
o Leads to abnormal resting arcade
 Affected finger is in relatively extended position
Lacerations

o FDP
 Abnormal resting arcade
o FDS
 Only slight break in resting arcade because of pull of FDP
o FDP / FDS
 Loss of ability to flex DIP & PIPJ
 Affected finger is straight

Finger tips

o Felon: closed space infection of fingertip

Flexor tendon sheath infection

o 4 cardinal signs of Kanavel

 fusiform swelling extending along the middle & proximal phalanges into
the distal palm
 tender
 finger is held in flexed position at rest
 passive extension of finger exacerbates the patient’s pain

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Summary
" Do you have RA?"

Look

Patient seated

Hands on pillow
Dorsum

 Describe proximal to distal

o Skin
 Colour, scars, creases
 distal web skin limit is the midpoint of the proximal phalanx
 Creases on flexor surface are distal to the joint
 on the extensor surface they are proximal to the joint

o Wrist
 Ganglions, synovitis, prominent ulnar head
o Hand
 Swelling
 Tenosynovitis
 Carpal bossing: benign bony prominences that form on dorsum of
proximal ends of 2-3rd MC
 Atrophy
 of intrinsics
 NB: test peripheral nerves
 of first interosseus
 Radial border of 2nd MC
 Severe ulnar neuropathy
 MCPJ
 old Fracture’s, dropped knuckle
 Carpal bossing (benign prominences at the proximal end of the
2nd/3rd metacarpals)
o Digits
 Heberden’s nodes (DIP)
 Mucous cyst – DIP associated with degenerative changes of joints
 Bouchard’s nodes – (PIP)
o Fingernails: deformity, circulation
 Clubbing (respiratory & cardiac disease)
 Spoon nails (infection)
 Fragmentation & pitting (Psoriasis)
 Ridges (alcohol, vitamin deficiency)
 Splinter hemorrhages
 Onychogryposis –thick hook nails
 Paronychia

Radial surface

Palms together

 Thenar eminence
 Z deformity of thumb
 Dorsum of thumb
 o Arthritis of basilar joint

Volar

Palms Up

 Creases
o Distal = proximal limit of the retinaculum
o Middle = Radio-carpal joint
o Proximal = proximal limit of synovial flexor sheath
 Swellings
o Ganglion
o Flexor synovitis
 Fingers
o Note the general resting posture, there should be increasing flexion from the index
to 5th. ? contracture, ? tendon injury (arcade of flexion)
o Swellings
 generalized finger swelling vrs localized (joint)
 Oslers nodes, small tender nodes in the finger pulp, from SBE
 ganglions (flexor creases)
 Phelon (pulp infection)
 Epidermal inclusion cyst
o Deformities
 rotational (previous fracture) get patient to flex the fingers, all should
point to scaphoid tubercle
 ulna drift (RA)
 swan neck
 follows an untreated mallet or DIPJ dislocation, or occurs
 primarily in RA
 After mallet/dislocation, the excessive extensor force causes
gradual attenuation of the PIPJ volar plate
 In RA, the synovitis erodes the volar plate & the hyperextension of
the PIPJ cause DIPJ flexion
 Boutonnière
 Central slip rupture
 acute (Trauma) or chronic (RA)
 claw fingers
 (loss of intrinsics or over-action of extrinsics)
 An extrinsic minus hand
 shown by extending the MCPJ, then able to flex the DIPJ & PIPJ
 Mallet finger extensor insertion dysfunction (mobile), if fixed may be
Osteoarthritis

Then bend elbows to look at ulnar surface

 elbow - scars or nodules

  benedectine
 ulnar clawing
 Best to see RA features, such as carpal subluxation & Caput ulnae

Feel

 Feel – area of interest – go for most pathological finger is multiple regions

 In general palpate any swellings, scars or prominences & characterize any tender areas
 Feel for excessive warmth, sweating
 Proximal to distal, radial to ulnar
 Name each structure as you go
o Dorsal
 radial styloid
 Anatomical snuff box
 first dorsal compartment (De Quervain’s)
 Dorsal branch of radial artery
 Distal to this is trapezium
 Ganglion in 2nd dorsal compartment
 lister’s tubercle
 SL ligament distal to this
 DRUJ
 Ulnar styloid
 TFC
 (just distal to ulnar head in a small depression, continue palpating
during radial & ulnar deviation, feel a popping), L-T ligament is
just distal to the TFC, & extensor tendons (synovitis-RA)
 Remaining carpal bones & metacarpals
o Palmer
 Pulses
 scaphoid tubercle
 trapezium
 Lunate
 Scapho-trapezium joint
 Trapezio-metacarpal joint
 Pisiform & hook of hamate (end of FCU)
 Palmer fascia
 thenar & hypothenar eminencies (palpate eminencies whilst the patient
presses the tips of the thumb & 5th fingers together)
 flexor tendons (synovitis)
 To feel the Palmaris longus
 press tips of thumb & 5th together, wrist
 slightly flexed, palpate to the ulnar side of FCR. (Between PL &
FCR is median nerve)
 Fingers & thumbs
 Palpate swellings & joints
Move

 Active & if any limited add passive

 Test passive & active movement, evaluate the end feel
 Wrist
o Whilst elbows are bent do
 Flexion (60-80°)
 Extension (70-90°)
o Brings hands down
 Radial (20°). & ulnar deviation(30-40°)
o Keep your elbows by yourside
 Supination
 Pronation
 Thumb
o Lateral abduction
o Palmar abduction
o Opposition
o Extension
o Retropulsion
o thumb to LF base
o thumb to IF(tip to tip,pulp to side)
 Hand / Fingers
o Check arcade of flexion
o Extend fingers
 Fingers
o Flexion, extension, abduction (measure span between fingers) & adduction.
o tendon ruptures
 EPL post Colles
 EDC in RA (Vaughan-Jackson lesion)
 If finger PIPJ flexion limited, perform Bunnel test.
o Extension
 Passive MCPJ extension (70-80°) is always > active (0-20°)
 Can grossly assess flexion by distance of finger tips from the palm
 Note any triggering
o Thumb
 Opposition (distance between fingers)
 abduction (with reference to the palm)
 adduction
 radial abduction = opening up web.
o Stress
 Collateral ligaments of the fingers & thumbs
 IPJ’s in extension or 30°
 MCPJ’s in 90°

Functional Assessment / Grips

  Power Grip – squeeze my fingers
 Hook Grip – hook my hand
 Precision Grip hold pen
 Lateral Pinch Grip – key grip
 Tip Pinch – pick up coin

 Function
o Power grip
 extrinsic muscles 50% hand function
 hook (holding bag)
 cylinder & spherical
o Precision
 Intrinsic muscles, 45% hand function
 pinch grips e.g. holding a key, pen
o Paper weight
 Most basic function, 5%, requires limit strength & fine motor
o Also try doing up a button & tracing a diagram
o
o 45% grasp
o 45% pinch
 side pinch (key pinch)
 tip pinch
 chuck pinch
o 5% hook
o 5% paper weight

Screening Series

ask patient to

 Neck side to side

 full abduction to over head position
 touch hands on head – check axilla & elbows for scars
 behind head
o flex elbows
o extend elbows
 behind lower back
 then pronation & supination with thumb up & elbows by side
 then make fist with thumb in & out
 spread fingers
 then wrist flexion & extension

Special Tests

NERVE PALSY EXAMINATION

Deformities

 APE HAND
o Thenar wasting, thumb held in line with fingers (ext tendon pull)
o Median N palsy
 BISHOPS HAND
o Also called benediction hand
o Hypothenar wasting, intrinsic wasting, partial claw of the ulna side
o indicates ulnar nerve lesion
 Ulnar paradox
o higher the lesion the less the claw
 CLAW HAND
o Due to combined median & ulnar nerve palsy
o All fingers clawed
 WRIST DROP
o Radial Nerve lesion

Motor

 PosteriorInterosseous
o ECU, EI, EDC, EPL, EPB, APL (radial thumb abduction)
 Radial
o ECRL, ECRB
 Median
o FCR, FDP2,3, FDS, FPL, APB (palmer thumb abduction)
o Opponens (press thumb/5th tips together, check strength & that the thumb is
opposing-rotating)
 Ulnar nerve
o FCU, FDP4,5, Intrinsics, Adductor policis

Sensation

 Median
o Palmer thumb & 1 • fingers & tips of fingers
o Palmer cutaneous nerve base of thumb
 Ulnar
o Ulnar 1 • fingers
 Radial
o Dorsal fingers/hand over median nerve fingers

Nerve tests

Froment’s sign

 Grasp paper between index & thumb of both hands, pull out paper. If the thumb IPJ
flexes, then it is an isolated ulnar nerve palsy
Phalan's test

 Hold the wrist flexed for 1 minute. Symptoms of median Nerve indicate CTS

Tinnels test

 Tap over the median nerve, pins & needles indicates CTS

Compression test

 press for 1 minute on median nerve at the distal palmer crease as it enters the CT, pins &
needles is positive

Ulnar nerve compression test

 Guyon’s canal beneath the pisio-hamate ligament, through here runs the ulnar nerve &
artery. Compression just radial to the pisiform for 1 minute, positive test is neurological
symptoms

Flexor tendon tests

 Anchor DIPJ’s to assess FDS

 Note index is unreliable to test for FDS, here check pinch grip gets hyperextension of
DIPJ, also flex & hold PIPJ at 90°, check DIPJ for contraction

Finkelsteins test – De Quervain’s

 Make a fist with the thumb in the palm, Ulna deviate the wrist
 A positive test has pain over the abductor & EPB tendons

Bunnel-Littler test – tight intrinsics

 Extend the MCPJ’s & try to passively flex the PIPJ

 If you are unable to do this, then this may mean a PIPJ contracture or tight intrinsics.
 Thus flex the MCPJ (to relax the intrinsics), if this allows further flexion, then it is
intrinsic tightness.
 If flexing the MCPJ causes no change in PIPJ flexion, then it is a joint contracture.
 If PIPJ flexion is ↓ with MCPJ flexion, then it is an extrinsic contracture of the long
finger extensor tendons.
 Tight retinacular ligament of Lansmere
 Extend PIPJ, if unable to passively flex the DIPJ then this is either a tight ligament or
joint contracture.
 Thus flex the PIPJ, if this allows flexion at the DIPJ then the oblique ligament is tight.

Instability tests
Shear test

 triquetrum is stabilized by applying palmer pressure over the pisiform & dorsal pressure
over the triquetrum. The lunate is the manipulated relative to the triquetrum by gripping
the lunate with the thumb & index finger of the other hand over the dorsal & palmer
poles of the lunate respectively.
 Discomfort or excessive translation as compared to the other side is positive.
 Assesses the L-T ligament.

Kirk Watson test – S-L instability

 ref: Watson & Black "Instabilities of the Wrist" Hand Clin 3: 103, 1987.
 Distal pole/tubercle of scaphoid is stabilized with your thumb, to restrict its palmer
flexion, whilst the wrist is moved from ulnar deviation in extension to radial deviation in
flexion.
 If there is a S-L disruption, then the scaphoid will sublux dorsally when the wrist is in
radial deviation & flexion, & pain will result.
 A popping sensation may be felt as the scaphoid subluxes over the dorsal rim of the
radius.
 Releasing your thumb should allow the scaphoid to reduce & relieve pain.

Midcarpal instability

 Axially load the wrist as you move it from radial to ulnar deviation.
 Jumping, catching or clunking is a positive result.
 DRUJ instability
 Translation of ulnar relative to radius in lateral plane
 Clicking, popping or pain may be produced.

Shuck test

 Test for thumb CMCJ subluxation/instability (usually Osteoarthritis).

 Grasp the thumb MC between your index & thumb, push & pull along the thumb axis.
 Grinding of this joint causing pain is usually from Osteoarthritis.

TFC injuries

 Press test
 Supposed to be 100% sensitive for TFC tear. Push up from chair with an extended wrist.
Pain at ulnar-carpal joint is indicative of a tear.

Compression test

 Axially load the wrist in maximal ulnar deviation, in neutral, pronation & supination.
 Production of pain distal to the ulnar is indicative of a tear
 Clicking & popping may be felt.
Circulation

Allan’s test

 Open & shut the hand a few times, then occlude both arteries. Next open the hand &
notice the blanched palm. Release one of the arteries (usually the ulnar) & look for the
return of colour.
 Allen test for digital arteries
 Tests the prescience of two vessels. Flex the finger & compress these, release one at a
time with the finger extended. Look for return of colour.

Capillary refill

 Press on nails & compare

 Must assess the elbow =/- the shoulder as well
 Check normal Arcade of Flexion
 Avulsion of flexor digitorum profundus (Jersey finger)
o It occurs when the fingers of a football player are pulled into extension as he
attempts to grasp the jersey of an opponent
o Common in ring finger
o Leads to abnormal resting arcade
 Affected finger is in relatively extended position
 Lacerations
o FDP
 Abnormal resting arcade
o FDS
 Only slight break in resting arcade because of pull of FDP
o FDP / FDS
 Loss of ability to flex DIP & PIPJ
 Affected finger is straight
 Finger tips
o Felon: closed space infection of fingertip
 Flexor tendon sheath infection
o 4 cardinal signs of Kanavel
 fusiform swelling extending along the middle & proximal phalanges into
the distal palm
 tender
 finger is held in flexed position at rest
 passive extension of finger exacerbates the patient’s pain
 Epidermal inclusion cysts
 Ganglion of flexor tendon sheath

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SUMMARY …………………………………….