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Neurological hand examination

Introduction

  • Wash hands
  • Introduce self
  • Ask Patient’s name, DOB and what they like to be called
  • Explain examination and obtain consent
  • Expose arms to above elbows; place pillow on their lap to rest hands on
  • General inspection: mobility aids; posture; carpal tunnel syndrome risk factors (age, pregnancy, hypothyroidism, obesity, trauma, acromegaly)

Hand inspection

  • Muscle wasting: thenar (median) and hypothenar (ulnar) eminences; dorsal guttering (ulnar)
  • Scars of previous surgery or trauma
  • Position: claw hand (ulnar), wrist drop (radial)
  • Tremors, fasciculations

Motor power

  • Median (commonest causes: carpal tunnel syndrome, distal radial fracture, penetrating forearm injury, pronator teres syndrome)
    • Thumb abduction (patient should lay hand flat on pillow with palm up and then point thumb towards ceiling – ‘Don’t let me push it down’)
    • Pincer grip/thumb opposition (patient should touch tip of thumb to tip of little finger – ‘Don’t let me break it’)
    • ‘OK sign’ (patient should touch tip of thumb to tip of index finger) – anterior interosseous nerve
  • Ulnar (commonest causes: compression at elbow/cubital tunnel syndrome, fractures, Guyon’s canal/ulnar tunnel syndrome)
    • Finger abduction (spread fingers against resistance)
    • Grip card between little and ring fingers with hands held vertically. Examiner tries to pull card away. (Tests adduction of little finger.)
    • Grip card between thumb and index fingers with hands held vertically. Examiner tries to pull card away. (If adductor pollicis is weak, patient will flex their thumb to grip the card – ‘Froment’s sign’.)
  • Radial (commonest causes: humeral shaft fracture, compression over spiral groove/Saturday night palsy)
    • Wrist extension
    • Finger extension (all together at MCP joint) – posterior interosseous nerve
    • Thumb extension (with hand vertical, point thumb to ceiling – ‘Don’t let me push it down’)

Sensory (light touch)

  • Palm facing up
    • Over DIP joint of index finger (median nerve)
    • Over DIP joint of little finger (ulnar nerve)
  • Palm facing down
    • Anatomical snuffbox (radial nerve) 
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Special tests for carpal tunnel syndrome

Phalen’s test

Test: reverse prayer sign for 1 minute

Positive test: causes pain and paraesthesia in median nerve distribution.

Tinel’s test

Test: tap median nerve at its course in wrist

Positive test: worsening paraesthesia

Function

  • Function: test pincer grip; prayer sign; carry out everyday tasks (e.g. undo buttons, write a sentence, hold cup, turn key)

To complete 

  • Thank patient 
  • Summarise and suggest further investigations you would consider after a full history

You need to know which muscles are supplied by which nerve

Which hand muscles does the median nerve supply?

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Which hand muscles does the ulnar nerve supply?

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Which hand muscles does the radial nerve supply?

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Here’s a couple more questions

What can cause damage to the ulnar nerve and how would this present?

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What are the different management options for carpal tunnel syndrome?

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