The Stanford 25

An Initiative to Revive the Culture of Bedside Medicine

The Hand in Diagnosis

Introduction: Examination of the hand can reveal several physical findings helpful for diagnosis.

Goals: We particularly want you to pick up CLUBBING, CYANOSIS and be well versed in what that means. We want you to be able to test for and recognize median nerve and ulnar nerve disease. In addition there are a host of abnormalities that are evident in the hand, and we hope you will keep adding to your personal list.

Technique:

[Stanford 25 video forthcoming]

Consider beginning all physical examinations by reaching for the patient’s right hand with both of yours. Inspect it and then move to the radial pulse. This is a nice way to ease into the examination; you are beginning with a  the equivalent of a handshake.

Findings: (Graphics not generated by Stanford, click on the pictures for credit and source.)

Handshake:

  • Moist and warm hands (think nervousness, thyrotoxicosis, look for tremor, eye signs).
  • Inability to let go your hand (think myotonia, not to be confused with the grasp reflex in frontal lobe disease. Look for other signs of myotonic dystrophy: hatchet face, cataracts, baldness, myopathic facies).

Nails

Paronychia: inflammation of the nail folds–red, swollen, often tender. Frequent immersion in water a risk factor for chronic paronychia. See UCSF Dermatology Glossary’s entry on on paronychia for more detail and images.

Herpetic Whitlow: Occupational hazard for respiratory therapists and housestaff who work around oral secretions.

Credit: howstuffworks.com

Terry’s (aka Half-and-half) Nails: proximal paleness extending halfway up the nail, often eliminating the lunela.  Darker distal band. Seen in states of stress (e.g. advanced age, liver disease, chemotherapy, CHF, DM2).

Credit sixwise.com

Mee’s Lines (Transverse white lines): similar curves as lunela. Evolve with acute illness, often grow out during recovery.

Beau’s Lines: similar to Mee’s Lines but with depressions. Also 2/2 acute illness. Both Mee’s and Beau’s lines may allow physician to estimate time of acute illness.

Acral lentiginous melanoma: May also be seen on palms, soles, and in the mouth.

Credit: Ispub.com

Pitting: Non-specific sign for psoriasis (additional signs include onycholysis, thickening, and ‘oilspot’ lesions).

Splinter Hemorrhages:nonspecific finding associated with trauma, subacute bacterial endocarditis, scleroderma, and other conditions.

Quitter’s Nail: nicotine stained distally, but not proximally with clear line of demarcation. You can estimate when they quit if you remember the nail grows  approx. 1mm/week. See also our article in Chest and NEJM clinical image. May also appear when pt switches to “lower tar” tobacco: false positive quitter’s nail.

Quitter's Nail. Credit: NEJM

Shape of Nails and Fingers

Clubbing: Angle between nail plate and proximal nail fold greater than 180 degrees.

Image credit: merck.com

Credit: WebMD.com

Important causes of clubbing in the adult:

  • Lungs
    • LUNG CANCER (clubbing is in general an ominous sign for this, and remember “beware of the yellow clubbed digit”. (Yellow from nicotine, and clubbed from cancer).
    • PUS in the lung (bronchiectasis as in CF, but also lung abscess and empyema.
    • FIBROSIS (but has to be considerable fibrosis to do this).
    • COPD IS NOT A CAUSE OF CLUBBING (even though some textbooks say so–if it were clubbing would be a pretty useless sign, and many VA patients would have clubbing. They don’t.
  • Heart
    • R to L shunts.
    • Endocarditis.
    • Pericarditis.
  • There are other causes of clubbing, outside the heart and lungs, but these are the important ones.
  • If a patient has painful wrists, painful ankles and comes to see you and you miss that they also have clubbing, you will go down the wrong path looking for RA etc, when what they have is Hypertrophic Pulmonary Osteoarthropathy which you can think of as “5+ clubbing”.  The causes of HPOA are the same as those of clubbing.

Pseudoclubbing: distinguished from clubbing by the preservation of the nail-fold angle and bony erosion of the terminal phalanges on radiography.

Mechanical Function of Hand (full review of anatomy & function here.)

  • Median nerve: The 1st & 2nd lumbricals, three thenar muscles (abductor pollicis brevis, flexor pollicis brevis, and via a distal branch the opponens pollicis)
    • Proximal median nerve dysfunction: thenar atrophy, inability to flex 1st & 2nd fingers at PIP (aka Pope’s Hand or Hand of Benediction).

      Pope's Hand. Credit: netterimages.com

      • Ask patient to use both hands to make and “Okay” sign by forming a circle with thumb and index finger. Median nerve palsy may make one hand produce a pinched circle.

        Credit: Simmonsortho.com

    • Distal median nerve dysfunction: inability to oppose thumb (aka Ape Hand).
  • Ulnar nerve: The 3rd & 4th lumbricals, the three hypothenar muscles, the dorsal & palmar interossei, and the palmaris brevis.
    • Ulnar nerve damage may cause hypothenar atrophy and inability to flex 4th & 5th digits at the PIP (aka Claw Hand).

      Credit: nlm.nih.gov

      • Froment’s Sign: Ask patient to hold a piece of paper between thumb and index finger. If the examiner can pull paper away (a positive Froment’s sign), it suggests that an ulnar palsy has weakened the thumbs strength of opposition.
  • Radial nerve: No intrinsic muscles but important wrist extensors.
    • Radial nerve damage commonly causes wrist drop.

 

Boutonniere deformity: flexion of PIP and extension of DIP, seen in chronic rheumatoid arthritis.

Swan neck deformity: extension of the PIP, flexion of DIP, seen in chronic rheumatoid arthritis.

Credit: eorthopod.com

Some interesting systemic conditions which are reflected in the hand.

  • “fingerization” of the thumb. Image credit: circ.ahajournals.org.

    “Fingerization” of the thumb:  Holt-Ohram syndrome—absent radius, single atrium, autosomal dominant.

  • Hypermobility of hand joints: Ehlers Danlos, many types. Syndrome may include skin hyperextensible, fragile,  “cigarette paper burn” scars, spontaneous rupture of eye, arteries, intestine, —hip dislocations, —Marfanoid habitus, kyphoscoliosis, —prominent hernia, mitral valve prolapse, coronary dissection.
  • Short extremities and polydactyly: Ellis Van Creveld Syndrom–dwarfism, short extremities and polydactyly, dysplastic teeth and nails, multiple frenula binding the upper lip to the alveolar ridge, ASD or a single atrium.
  • Arachnodactyly: long “spider-like” digits, thumb can often extend beyond palm. Characteristic of Marfan’s Syndrome–tall stature, thoracic deformity,joint laxity, ectopia lentis and myopia, aortic dilation and dissection, mitral valve prolapse, autosomal dominant, spontaneous pneumothorax, chordae tendineae rupture.
  • Tripe hand. Image credit: handresearch.com

    Tripe (or ‘velvet’) hand: Thickened, velvety texture of hand. Often sign of visceral malignancy. See also NEMJ “Velvet Palms” in Images in Clinical Medicine.

  • Down’s syndrome; single palmar crease and associated with endocardial cushion defects.
  • Osler’s nodes, splinter hemorrhages, Janeway lesions and other signs of endocarditis.
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Written by stanford25admin

June 7, 2010 at 3:44 pm

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