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Neurological hand examination

Clinical examination > Neurology

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/tremors/fasciculations: thenar (median) and hypothenar (ulnar) eminences; dorsal guttering (ulnar)
  • Scars (previous surgery/trauma)
  • Position: claw hand (ulnar), wrist drop (radial)

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’)
  • Finger opposition – touch finger tips and ‘Don’t let me break it’
    • Thumb and little finger
    • Thumb and index finger (‘OK sign’)

Ulnar

Commonest causes: compression at elbow/cubital tunnel syndrome, fractures, Guyon’s canal/ulnar tunnel syndrome

  • Finger abduction (spread fingers against resistance)
  • Ask patient to grip card between fingers with hands held vertically while you try to pull it away
    • Little and ring fingers
    • Thumb and index fingers (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

  • Extension
    • Thumb (with hand still vertical, point thumb to ceiling – ‘Don’t let me push it down’)
    • Wrist
    • Finger (all together at MCP joint)

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) 

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. write a sentence, turn key, undo buttons, hold cup)

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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Neurology