Examination of The H a n d - - A t h o l Parkes
Some thoughts on EXAMINATION OF THE HAND
A T H O L PARKES, Glasgow The Honorary Secretary of the Society probably did not realise the risk he was taking when he invited me to contribute to this Instructional Course. For him to have made available to an Old Age Pensioner who has been completely out of touch with hand surgery for almost a year a captive audience is sheer madness; it risks turning a serious scientific meeting into a platform for mere anecdotage! At least I can assure you that any stories I may tell are basically true and that they have a moral which should be useful to budding hand surgeons. I propose to talk about examination of the hands of patients referred to a Hand Clinic rather than of those arriving at, say, a Casualty Department fresh from injury, though the principles are, of course, essentially the same and are based mainly on applied anatomy. The first stage of the e x a m i n a t i o n - - I N S P E C T I O N - - c a n usefully start the moment the patient enters the consulting room. I generally ask the patient to remove his coat and jacket and to roll up both sleeves before he sits down. This gives one the opportunity to observe any disability. A severe bilaterial Dupuytren's Contracture is, for instance, usually immediately obvious; so are some typical nerve lesions. Wrist drop, the tendency to " p a w " at an object before grasping it and a grasp hampered by the wrist going into palmarflexion are all fairly typical of radial nerve palsy. The patient with a median nerve lesion tends not to use the thumb, index or middle finger, but to hold things with the ring and little fingers only. In contrast, the patient with an ulnar nerve palsy makes excessive use of the pincers action not as a "key grip" but with the tip of the thumb contacting the tips of index and long fingers; moreover, the typical paralytic clawing of ring and little fingers and wasting, especially of the first dorsal interosseous, may also be obvious from a distance. The effects of division of one or more long flexor or long extensor tendons may also be obvious at this stage. Although making such "spot diagnoses" purely from inspection is a fascinating exercise in observation--and they surprisingly often prove to be c o r r e c t - it is nevertheless important to take time to listen to what the patient has to say. Some years ago I was involved (at a late stage) in a tragic case which reminded one very forcibly of what happened to t h e principle character in Evelyn Waugh's novel "Decline and Fall". The victim was an unintelligent but solid citizen aged about fifty from the North of England. He had been employed at a steel works where his job was to feed steel plates into an hydraulic press and to remove them after they had been stamped. One day one of the plates got stuck in the machine. While the patient was attempting to free it the press closed on all his eight fingers and immediately re-opened. Fortunately the patient was wearing thick leather gloves at the time. He quickly removed the gloves and inspected the fingers. The skin was intact but his verbal reaction was "Eee, ba goom they look a bit flat!". By squeezing the fingers he managed to improve their shape and, finding that he could move them fairly well, he managed to finish the shift with some help from his mates. The next morning, not surprisingly, all eight proximal interphalangeal joints were painful, swollen and a bit stiff to move; so he decided to see the Works Medical Officer. A receptionist wrote down the history briefly on a card, but the doctor was too busy to read it. He said something like "Having trouble with your hands, are you? Well, come 104
The H a n d - - V o l . 7
No. 2
1975
E x a m i n a t i o n of T h e I t a n d - - A t h o l Parlces
on man, let's see them". Observing the symmetrical swelling of all the joints, he added " H ' m , looks like some sort of rheumatic condition. We'll have the hands X-rayed". He wrote on the X-ray card, "Swollen joints--? rheumatism", and went off, possibly for coffee. The hands were X-rayed and, in due course, the Radiologist's Report was sent to the man's G.P. (whom he had not seen). It read "Peri-articular soft tissue swelling around all P.I.P. joints of all fingers; possibly some narrowing of joint spaces. Could be early R.A.". Unfortunately there were no fractures! The G.P. then arranged an appointment with a Consultant Physician at the local hospital but sent him only the X-ray Report. Meantime the patient continued at his work with gradual improvement in finger function. At the consultation with the physician a week or two later the patient assumed that the Consultant had been told about the accident and did not mention it. Despite negative blood tests and the observation that no other joints were yet affected, the diagnosis made was rheumatoid arthritis. The patient was advised to stop working and R E S T the affected joints which, under this treatment, gradually became permanently stiff. The patient was registered as a Disabled Person and for seven years received treatment for rheumatoid arthritis including physiotherapy, gold injections, steroid t h e r a p y - - t h e lot! Only when the man's G.P. died and a new man took over was the diagnosis questioned. The man was then referred to the Rheumatic Clinic in Edinburgh where the true story was elicited and no evidence of R.A. found. But the poor fellow was left with permanently stiff finger joints and little chance of getting a job. The final insult was that he was accused by his former employers of malingering! The moral? N E V E R F A I L T O L I S T E N T O W H A T T H E P A T I E N T HAS T O SAY. P A L P A T I O N is an examination technique which tends to be neglected. It is, of course, always used to detect fractures and dislocations, but few clinicians realise to what linear extent nerves can be felt especially in a thin individual. Palpation of a neuroma or of a ganglion pressing on a nerve can often clarify the diagnosis. Palpation of tendons should, of course, always be employed when testing voluntary power, but the extent over which tendons are palpably A B S E N T after division or rupture can often be determined especially within the digital flexor sheaths. Perhaps the really important part of the clinical examination of most hand conditions is concerned with detecting M O T O R D E F E C T S including joint stiffness, muscle contractures, tendon adhesions and loss o f voluntary power. I propose to deal with this by showing a short movie at the end of my talk; I have also provided some notes for your perusal. Examination for SENSORY D E F E C T S is equally important in some cases. I need not describe the areas of sensory loss found in typical nerve lesions, but would mention in passing the slow pain response which, when present, is pathognomonic of ischaemic nerve lesions. A "glove" type of anaesthesia is nearly always due either to ischaemia or hysteria. Careful sensory testing requires considerable concentration on the part of the patient; quiet surroundings and plenty of time are essential. D I A G N O S I S is seldom a problem after adequate clinical examination. Most of the difficulties that do arise are those of sorting out organic from functional conditions. Sometimes it may be fairly obvious that a condition is hysterical, but the treatment of such a case may have its problems. Mrs. X had been off work for about two months when she was first referred to our Hand Clinic. She was quite positive about the cause of her complaint; she had been scrubbing a stone floor with a pad of steel wool when a piece of steel entered her right thenar eminence which had been extremely tender ever The Hand--Vol.
7
No. 2
1975
105
Examination of The H a n d - - A t h o l Parkes
since. Apart from the tenderness, examination was completely negative. There was no sign of a scar and radiography revealed no foreign body. She continued to attend week after week and we were quite unable to convince her that there was N O T a piece of steel wool in the tissues. Eventually I gave in and admitted that she could be right. "Come up to-morrow morning and I shall perform a small operation and try to find it," said I. She was positively eager to have this done. Under local anaesthesia I made a small incision over the tender area and immediately closed it with a single stitch. Having raided the ward kitchen, we produced a small piece of steel wool on a swab and gave it to the patient with our compliments and congratulations. She was completely cured and returned to work the following week with full function. I, too, was delighted and could not resist indulging in some private self-congratulation. After all, the cure had been much quicker and easier than referring the patient to a psycho-therapist! About a month later I received a letter from a lawyer acting for Mrs. X to say that she was bringing an action agains.t her employers for loss of wages etc. and he proposed to cite me as an Expert Witness to prove that a piece of steel wool had been removed from her thumb. One can be too clever! But now back to the Motor Defects. In the film you are about to see I am examining a normal limb. But no matter! It is the m e t h o d that I feel is important because it requires the minimum of co-operation by the patient. All that the patient has to d o - - a n d this should be explained beforehand--is to comply with two simple alternating requests by the examiner:-1. "Leave it quite loose and let m e move it." 2. "Keep it in that position; D O N ' T let me move it." At least this should minimise language difficulties in Common Market Hand Surgery! Even I can manage these two phrases in French and German! In only ONE of the tests shown do I ask the patient to perform a movement. The examination is divided into T H R E E sections:-1. Tests for Joint Stiffness. 2. Tests for Muscle Contractures. 3. Tests for Voluntary Power. With two exceptions the muscles are tested for voluntary power in groups according to their nerve supply. At the end of the film the examination is repeated to show that the whole procedure can be carried out in under two minutes provided that no abnormalities are found. And even the N E G A T I V E findings:-" N O joint stiffness" " N O muscle contractures" " N O muscle weakness" are surely worth two minutes of your examination time?
106
The Hand--Vol. 7
No. 2
1975
Some thoughts on EXAMINATION OF THE HAND
A T H O L PARKES, Glasgow The Honorary Secretary of the Society probably did not realise the risk he was taking when he invited me to contribute to this Instructional Course. For him to have made available to an Old Age Pensioner who has been completely out of touch with hand surgery for almost a year a captive audience is sheer madness; it risks turning a serious scientific meeting into a platform for mere anecdotage! At least I can assure you that any stories I may tell are basically true and that they have a moral which should be useful to budding hand surgeons. I propose to talk about examination of the hands of patients referred to a Hand Clinic rather than of those arriving at, say, a Casualty Department fresh from injury, though the principles are, of course, essentially the same and are based mainly on applied anatomy. The first stage of the e x a m i n a t i o n - - I N S P E C T I O N - - c a n usefully start the moment the patient enters the consulting room. I generally ask the patient to remove his coat and jacket and to roll up both sleeves before he sits down. This gives one the opportunity to observe any disability. A severe bilaterial Dupuytren's Contracture is, for instance, usually immediately obvious; so are some typical nerve lesions. Wrist drop, the tendency to " p a w " at an object before grasping it and a grasp hampered by the wrist going into palmarflexion are all fairly typical of radial nerve palsy. The patient with a median nerve lesion tends not to use the thumb, index or middle finger, but to hold things with the ring and little fingers only. In contrast, the patient with an ulnar nerve palsy makes excessive use of the pincers action not as a "key grip" but with the tip of the thumb contacting the tips of index and long fingers; moreover, the typical paralytic clawing of ring and little fingers and wasting, especially of the first dorsal interosseous, may also be obvious from a distance. The effects of division of one or more long flexor or long extensor tendons may also be obvious at this stage. Although making such "spot diagnoses" purely from inspection is a fascinating exercise in observation--and they surprisingly often prove to be c o r r e c t - it is nevertheless important to take time to listen to what the patient has to say. Some years ago I was involved (at a late stage) in a tragic case which reminded one very forcibly of what happened to t h e principle character in Evelyn Waugh's novel "Decline and Fall". The victim was an unintelligent but solid citizen aged about fifty from the North of England. He had been employed at a steel works where his job was to feed steel plates into an hydraulic press and to remove them after they had been stamped. One day one of the plates got stuck in the machine. While the patient was attempting to free it the press closed on all his eight fingers and immediately re-opened. Fortunately the patient was wearing thick leather gloves at the time. He quickly removed the gloves and inspected the fingers. The skin was intact but his verbal reaction was "Eee, ba goom they look a bit flat!". By squeezing the fingers he managed to improve their shape and, finding that he could move them fairly well, he managed to finish the shift with some help from his mates. The next morning, not surprisingly, all eight proximal interphalangeal joints were painful, swollen and a bit stiff to move; so he decided to see the Works Medical Officer. A receptionist wrote down the history briefly on a card, but the doctor was too busy to read it. He said something like "Having trouble with your hands, are you? Well, come 104
The H a n d - - V o l . 7
No. 2
1975
E x a m i n a t i o n of T h e I t a n d - - A t h o l Parlces
on man, let's see them". Observing the symmetrical swelling of all the joints, he added " H ' m , looks like some sort of rheumatic condition. We'll have the hands X-rayed". He wrote on the X-ray card, "Swollen joints--? rheumatism", and went off, possibly for coffee. The hands were X-rayed and, in due course, the Radiologist's Report was sent to the man's G.P. (whom he had not seen). It read "Peri-articular soft tissue swelling around all P.I.P. joints of all fingers; possibly some narrowing of joint spaces. Could be early R.A.". Unfortunately there were no fractures! The G.P. then arranged an appointment with a Consultant Physician at the local hospital but sent him only the X-ray Report. Meantime the patient continued at his work with gradual improvement in finger function. At the consultation with the physician a week or two later the patient assumed that the Consultant had been told about the accident and did not mention it. Despite negative blood tests and the observation that no other joints were yet affected, the diagnosis made was rheumatoid arthritis. The patient was advised to stop working and R E S T the affected joints which, under this treatment, gradually became permanently stiff. The patient was registered as a Disabled Person and for seven years received treatment for rheumatoid arthritis including physiotherapy, gold injections, steroid t h e r a p y - - t h e lot! Only when the man's G.P. died and a new man took over was the diagnosis questioned. The man was then referred to the Rheumatic Clinic in Edinburgh where the true story was elicited and no evidence of R.A. found. But the poor fellow was left with permanently stiff finger joints and little chance of getting a job. The final insult was that he was accused by his former employers of malingering! The moral? N E V E R F A I L T O L I S T E N T O W H A T T H E P A T I E N T HAS T O SAY. P A L P A T I O N is an examination technique which tends to be neglected. It is, of course, always used to detect fractures and dislocations, but few clinicians realise to what linear extent nerves can be felt especially in a thin individual. Palpation of a neuroma or of a ganglion pressing on a nerve can often clarify the diagnosis. Palpation of tendons should, of course, always be employed when testing voluntary power, but the extent over which tendons are palpably A B S E N T after division or rupture can often be determined especially within the digital flexor sheaths. Perhaps the really important part of the clinical examination of most hand conditions is concerned with detecting M O T O R D E F E C T S including joint stiffness, muscle contractures, tendon adhesions and loss o f voluntary power. I propose to deal with this by showing a short movie at the end of my talk; I have also provided some notes for your perusal. Examination for SENSORY D E F E C T S is equally important in some cases. I need not describe the areas of sensory loss found in typical nerve lesions, but would mention in passing the slow pain response which, when present, is pathognomonic of ischaemic nerve lesions. A "glove" type of anaesthesia is nearly always due either to ischaemia or hysteria. Careful sensory testing requires considerable concentration on the part of the patient; quiet surroundings and plenty of time are essential. D I A G N O S I S is seldom a problem after adequate clinical examination. Most of the difficulties that do arise are those of sorting out organic from functional conditions. Sometimes it may be fairly obvious that a condition is hysterical, but the treatment of such a case may have its problems. Mrs. X had been off work for about two months when she was first referred to our Hand Clinic. She was quite positive about the cause of her complaint; she had been scrubbing a stone floor with a pad of steel wool when a piece of steel entered her right thenar eminence which had been extremely tender ever The Hand--Vol.
7
No. 2
1975
105
Examination of The H a n d - - A t h o l Parkes
since. Apart from the tenderness, examination was completely negative. There was no sign of a scar and radiography revealed no foreign body. She continued to attend week after week and we were quite unable to convince her that there was N O T a piece of steel wool in the tissues. Eventually I gave in and admitted that she could be right. "Come up to-morrow morning and I shall perform a small operation and try to find it," said I. She was positively eager to have this done. Under local anaesthesia I made a small incision over the tender area and immediately closed it with a single stitch. Having raided the ward kitchen, we produced a small piece of steel wool on a swab and gave it to the patient with our compliments and congratulations. She was completely cured and returned to work the following week with full function. I, too, was delighted and could not resist indulging in some private self-congratulation. After all, the cure had been much quicker and easier than referring the patient to a psycho-therapist! About a month later I received a letter from a lawyer acting for Mrs. X to say that she was bringing an action agains.t her employers for loss of wages etc. and he proposed to cite me as an Expert Witness to prove that a piece of steel wool had been removed from her thumb. One can be too clever! But now back to the Motor Defects. In the film you are about to see I am examining a normal limb. But no matter! It is the m e t h o d that I feel is important because it requires the minimum of co-operation by the patient. All that the patient has to d o - - a n d this should be explained beforehand--is to comply with two simple alternating requests by the examiner:-1. "Leave it quite loose and let m e move it." 2. "Keep it in that position; D O N ' T let me move it." At least this should minimise language difficulties in Common Market Hand Surgery! Even I can manage these two phrases in French and German! In only ONE of the tests shown do I ask the patient to perform a movement. The examination is divided into T H R E E sections:-1. Tests for Joint Stiffness. 2. Tests for Muscle Contractures. 3. Tests for Voluntary Power. With two exceptions the muscles are tested for voluntary power in groups according to their nerve supply. At the end of the film the examination is repeated to show that the whole procedure can be carried out in under two minutes provided that no abnormalities are found. And even the N E G A T I V E findings:-" N O joint stiffness" " N O muscle contractures" " N O muscle weakness" are surely worth two minutes of your examination time?
106
The Hand--Vol. 7
No. 2
1975
