Hand Practical Skills

Tubercle of scaphoid palpation

Sitting with hand supported on a table and pillow
Palpate distally within the floor of the anatomical snuffbox to identify the scaphoid bone
Now slide your finger around onto the palmar aspect of the hand maintaining the same level and palpate through the soft tissue to identify a bony ridge which is the tubercle of scaphoid

Pisiform palpation

Sitting with hand supported on a table and pillow
With the model’s arm in supination, palpate over the anteromedial aspect of the hand and the level of the wrist creases and identify a pea shaped bony prominence

Head of metacarpal palpation

Sitting with hand supported on a table and pillow
Ask model to make a fist and then palpate over the relevant bony prominence or knuckle on the dorsal aspect then ask model to open palm and palpate through the soft tissues to identify the relevant metacarpal head on the palmar aspect

First carpometacarpal joint line palpation

Synovial, biaxial, saddle, simple
Sitting with hand supported on a table and pillow
Identify tubercle of scaphoid on the palmar aspect of the hand and then slide finger distally and slightly laterally onto another bony prominence - maintain this position with one hand
With other hand, grip proximal end of model’s thumb at the level of the base of the first metacarpal and gently passively move the bone - mark the joint line by palpating through the soft tissues just distal to the crest of the trapezium as this passive movement is being performed

Metacarpophalangeal joint line palpation

Synovial, simple, biaxial, condyloid
Sitting with hand supported on a table and pillow
Joint line represented by curved line (concave distally) drawn from the tip of the metacarpal head
Posterior surface - identify appropriate metacarpal head (knuckle) with one hand whilst passively moving the corresponding proximal phalanx by gripping it firmly at its bae with your other hand, this will make identification of the posterior joint space a little easier
Anterior surface - identify appropriate metacarpal head and then draw a curved line (convex distally) approx. 1cm proximal to the finger web on the palmar aspect of the hand

Interphalangeal joint line palpation

Synovial, simple, uniaxial, hinge
Sitting with hand supported on table and pillow
Joint line represented by the skin creases over the palmar and dorsal aspects of the appropriate joint

Flexion at thumb CMC

0-50
Sitting with arm supported on a table, forearm held in supinated position
Axis on anterior surface joint line - trapezium bone
Stationary arm aligned with long axis of radius
Moving arm aligned with first metacarpal shaft
Keep wrist and fingers still, move your thumb across your palm

Flexion at thumb CMC limiting factors

Posterior oblique ligament
Tension in extensor muscles
Size and bulk of thenar eminence

Extension of thumb CMC

0-80
Sitting with arm supported on a table, forearm held in supinated position
Axis on anterior surface joint line - trapezium bone
Stationary arm aligned with long axis of radius
Moving arm aligned with first metacarpal shaft
Keep wrist and fingers still and move thumb away from palm

Extension of thumb CMC limiting factors

Anterior oblique ligament
Tension in flexor muscles

Abduction of thumb CMC

0-80
Sitting with arm supported on table, forearm held in pronated or mid-pronated position
Axis on lateral surface of joint line (trapezium bone)
Stationary arm along the line of shaft of second MC
Moving arm along line of the shaft of the first metacarpal
Keep your wrists and fingers still, take thumb away from index finger as far as you can

Abduction of thumb CMC limiting factors

Tension in thumb space
Tension in adductor muscles

Adduction of thumb CMC

0
Sitting with arm supported on table with forearm held in pronated or mid-pronated position
Axis on lateral surface of joint line (trapezium bone)
Stationary arm along line of the shaft of second metacarpal
Moving arm along line of the shaft of first metacarpal
Keep wrist straight and fingers still, bring thumb to meet the front of the index finger

Adduction of thumb CMC limiting factors

Approximation of first digit

CMC joint of thumb opposition - Kapandji score

1 - radial side of the proximal phalanx of the index finger
2 - radial side of the middle phalanx of the index finger
3 - tip of index finger
4 - tip of middle finger
5 - tip of ring finger
6 - tip of little finger
7 - distal interphalangeal joint crease of little finger
8 - proximal interphalangeal joint crease of little finger
9 - metacarpophalangeal joint crease of little finger
10 - distal palmar crease

MCP/IPJ flexion

0-90
Sitting with arm supported on table, forearm held in pronated position
Axis on lateral or medial aspect of joint line over the joint crease
Stationary arm along the more proximal bone
Moving arm along the more distal bone
Keep your wrist still, bend your fingers at the knuckle as far as you can

MCP/IPJ flexion limiting factors

Collateral ligaments
Tension in extensor ligaments

MCP/IPJ extension

0-50 or 0-10
Sitting with arm supported on table with forearm held in pronated position
Axis on lateral or medial aspect of joint line over joint crease
Stationary arm along more proximal bone
Moving arm along more distal bone
Keep your wrist still and straighten your fingers at your knuckle as far as you can

MCP/IPJ extension limiting factors

Palmar ligament
Tension in flexor tendons

MCP abduction

0-30
Sitting with arm supported on table, forearm held in pronated position
Axis on dorsal aspect centre of MT head
Stationary arm along more proximal bone
Moving arm along more distal bone
Keep wrist still, fan fingers out as far as you can away from each other

MCP abduction limiting factors

Skin web spaces in hand
Collateral ligament - depending on direction - opposite side

MCP adduction

0
Sitting with arm supported on table, forearm held in pronated position
Axis on dorsal aspect centre of MT head
Stationary arm along more proximal bone
Moving arm along more distal bone
Keep your wrist still and bring fingers as close as you can to each other

MCP adduction limiting factor

Contact with next digit

AP on CMCJ of thumb

Patient supine lying with abduction at shoulder - plinth fairly high
Standing on inside of arm being assessed, fix the thumb and trapezium with the hand closet to patient’s head - grip the head of the first metacarpal with the index finger and thumb of your other hand
Glide the first metacarpal in an AP direction
Mimics thumb extension and finger extension

PA on CMCJ of thumb

Supine lying with arm by side - plinth fairly high
Standing on outside of arm being assessed, fix thumb and trapezium with the hand closest to patient’s head - grip head of the first metacarpal with the index finger and thumb of other hand
Glide first metacarpal in PA direction
Mimics thumb flexion and finger flexion

PA on MCPJ (proximal phalanx)

Supine lying with arm by side - plinth fairly high
Standing on the outside of the arm being assessed, fix distal aspect of metacarpal with the hand closest to the patient’s head - grip the proximal phalanx with the index finger and thumb of the other hand
Glide proximal phalanx in a PA direction
Mimics thumb flexion and finger flexion

AP on MCPJ (proximal phalanx)

Supine lying with arm in abduction at the shoulder - plinth fairly high
Standing on the inside of the arm being assessed, fix the distal aspect of the metacarpal with the hand closet to the patient’s head - grip the proximal phalanx with the index finger and thumb of your other hand
Glide proximal phalanx in an AP direction\
Mimics thumb extension and finger extension

PA on IP of thumb - distal phalanx

Patient supine lying with arm by side - plinth fairly high
Standing on outside of arm being assessed, fix the proximal phalanx with the hand closest to the patients head - grip the distal phalanx with the index finger and thumb of your other hand
Glide distal phalanx in a PA direction
Mimics thumb flexion and finger flexion

AP on IP of thumb - distal phalanx

Supine lying with arm in abduction at the shoulder - plinth fairly high
Standing on inside of arm being assessed, fix the proximal phalanx with the hand closest to the patients head - grip distal phalanx with index finger and thumb of your other hand
Glide the distal phalanx in an AP direction
Mimics thumb extension and finger extension