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Name:
Comprehensive Hand Examination
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Comprehensive Hand Examination
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Transcript:
Language: EN.
Segment:0 .
VINAY KUMAR SINGH: So viewers today, I'm going to take you through hand examination. Now, hand is a very important part of the body and it provides a lot of useful function for our day to day activities. Now, even a slight loss of function can pose a lot of challenge when we do our day to day activities. So for me, hand is one of the most important part of the body, and a thorough assessment is extremely important
VINAY KUMAR SINGH: so that you are able to diagnose under those conditions properly and treat them appropriately so that you don't have any disability in future. Now, for me, hand is an organ because hand does a lot of useful things. For example, it is used for grasping things. If I want to grasp the stamp or if I want to hold a pen, I think hand is the most important part of the body in doing these functions.
VINAY KUMAR SINGH: Now it is also a sensory organ because even if I have my eyes closed. And I can tell even when my eyes are closed that what I'm holding in my hand, for example, whether I'm holding a coin, I'm holding a pen, I'm holding a paper. So you can tell actually, even without opening your eyes. So that provides a lot of sensory and tactile feedback for our day to day activities.
VINAY KUMAR SINGH: Now it is also used as an organ of expression, you know, in your day to day activities when, say, for example, you're upset and your kid is misbehaving. And if any point this that means you're angry or if you point a fist, that means you convey your expression, sometimes through hand as well. So that is why, for me, it is an organ. So today my aim is to take you through thoroughly through hand examination.
VINAY KUMAR SINGH: So that you feel confident in diagnosing common conditions and you can treat them appropriately so that there is no functional disability. So history plays a very important role in most of the examinations, so I talk about taking a thorough history. Now hand, is quite special to me. So if certain things which should be part and parcel of the history is first thing is the age.
VINAY KUMAR SINGH: Now, age plays a very important role. The reason I talk about age is that the same injury in an elderly would be treated separately or differently to a person who is young. So hand, we try not to operate unless we have to. So slight loss of functional function in an elderly may be acceptable, but may not be acceptable in a young patient. Occupation is also important, so you should always ask, what does the patient do?
VINAY KUMAR SINGH: So the same injury could be treated differently in a computer operator. Then if somebody is a labouror because a small loss of function for a labouror man might not be disabling or might not matter a lot, but the same loss of function may matter a lot for a computer operator or a musician who needs a fine finger movements. Now, hobbies is also becoming extremely important these days.
VINAY KUMAR SINGH: People love to do their hobbies after the injury, so you, it can also influence the treatment. Now hand dominance, whether somebody is right handed or left handed, you should always ask. Again, the reason is sometimes if the injury is affecting a non-dominant hand and especially if the patient is elderly, then I tend to treat them less aggressively. Now, once you have moved on, then the most common time the reason the patient will present is pain.
VINAY KUMAR SINGH: Now pain, you should drill the pain quite well. First of all, you should ask the duration of pain. You know, all those headings of the pain that where is the pain? What makes the pain better? What makes the pain worse? So drill pain thoroughly because that will help you reach your differential diagnosis and eventually your final diagnosis as well.
VINAY KUMAR SINGH: The other common thing that you will see in hand is swelling. So again, nature of the swelling. Where is the swelling? Does it get big or small? If it changes size, you will see ganglion is a typical swelling that can change size. So once it becomes big and sometimes you will see the patient will say that it's becoming smaller. So if you have swelling found out where the swelling is.
VINAY KUMAR SINGH: And that will help you reach your diagnosis as well. The other common things that will affect hand is the nerve pathologies. So whether it's proximal or pathologies or C spine problem or this talar pathologies such as carpal tunnel will manifest in the form of pins and needles or tingling. So ask about the numbness. Where is the tingling, whether they have neck pain in order to localize where the problem is, and you will be able to come to a diagnosis when you do an examination, whether it's a carpal tunnel or a cubital tunnel, or whether it's a c-spine lesion or it's a combination of lesion.
VINAY KUMAR SINGH: Now sometimes patients will report color changes or hot and cold feeling that can point towards a vascular cause. So drill history appropriately. Occasionally, a patient will report deformities and catching. So if the patient reports catching when they're opening or closing the fist, that's a typical history that you will see in a trigger finger.
VINAY KUMAR SINGH: And deformities could be due to nerve injuries or could be due to burns or could be due to the patrons. So drill, take a lot of time in taking a proper history because a lot of times only the history when you take a thorough history will come to a diagnosis. So take a thorough history when you are doing a hand examination. So once you have done your hand examination now, the first thing that I talk about is, you know, how much exposure do you need for doing a proper hand examination?
VINAY KUMAR SINGH: So for me, if I'm examining the hand, I should be able to see the hand completely. I should be able to see the forearm completely and I should be able to see the elbow completely. So like if you look at my hand, this is the bare minimum that I would like to see when I'm doing my hand examination. So I should be able to see the elbow. I should be able to see the forearm and I should be able to see the hand.
VINAY KUMAR SINGH: If you have any jewelry or any rings, which is coming in your way when you're examining it, you can ask the patients to remove it so that your examination is not hampered because by the presence. So once you have done taking a thorough history and if you have exposed the patient well, then next thing you move on is for, look, that will be the first part of your examination.
VINAY KUMAR SINGH: But before you do the look, what I like to do is what we call is a screening of the hand. So let's if the patient is coming to ask them to put your hands like this. And first thing I want you to notice is the natural cascade of the fingers, if you see here, this is the normal resting position of a normal hand. So if you see my little finger, this is more flexed than the ring finger.
VINAY KUMAR SINGH: Ring finger is more flexed than the long finger, and the long finger is more flexed than the index finger. So there is a natural cascade. And this is normal, so you want to appreciate whether this cascade is present or not. If there is any disruption in cascade, say, for example, if the middle finger is in this position now, this tells me that the cascade is disturbed. Now this finger is more extended than these fingers so that if somebody has got a laceration here, then that will tell me that there's a very good chance that the flexor tendon injury is there.
VINAY KUMAR SINGH: And because the senses are overpowering, then there is a loss of cascade. Similarly, if there are two fingers, which are like this, then if you have a big laceration that will tell you that there might be injury to flex attendants of both the hands. Now, on the other hand, if the finger was more flexed like this, if I try to show it like this. Now if you see the middle finger is more flexed.
VINAY KUMAR SINGH: So again, there is disruption of the natural cascade, but it is opposite to what we saw a few minutes ago. And what it tells me. Now, the flexors are more overpowering now if somebody has got a laceration here or here across the extensor tendon. Then there is a very highly likelihood chance that there is an extensor tendon injury. And that is the reason the cascade of the finger is disturbed.
VINAY KUMAR SINGH: Now, once you have looked at the cascade of the fingers, the second thing you want to do is to ask the rough screening. So ask a patient to open and close hand so open and close hand. If they are able to do this, then functionally they should be able to do something. If there is an interruption in this, then it can point towards a particular differential diagnosis.
VINAY KUMAR SINGH: So this is what I do. Once you have done the screening, you have looked at the cascade you have asked to flex and extend. Then you move on to the skin, so you want to see the skin in the front and in the back. And what you are looking for is looking for any scars, whether there is any old heal scar, whether there is a new lacerated wound or if there is any wound in front or back.
VINAY KUMAR SINGH: If there is any erythema or there is loss of shiny or skin is shiny. All these things are extremely important, whether there is any skin changes, you know, or if one hand is looking paler than the other hand or if there is a lot of redness. These are the things that you look to start with. When you're examining the skin. You also look for the nails.
VINAY KUMAR SINGH: Nails are extremely important because sometimes real diagnosis, such as gliomas, tumor and I have seen two or three in my lifetime. You will see a ridging of the nail or nail being deformed. And if a patient is complaining of pain there and there is deformity, then think of gliomas tumor. If there is pitting of the nail, and if the patient has got pain in the large joints on the small joints, that can point towards the psoriatic arthroplasty.
VINAY KUMAR SINGH: Now the second thing you move on is. Swelling, so notice for any swelling now, the common swelling that you will see in hand or ganglion so ganglion can present across the wrist, which I have covered in the wrist examination video you can have ganglion in the back as well. Now the other uncommon swelling are you can have giant cell tumor of the tendon sheet.
VINAY KUMAR SINGH: They can also present as swelling in the hand. Now, nodules of sometimes if you see swelling in the hand across the palm and pitting those swelling or nodules are usually related to Putin's disease. You can have sometimes inclusion cyst, which can present across the fingers or retinaculum cyst. They can present there. Not uncommon swelling can be lipoma, or fibro, but they are not very common in hands.
VINAY KUMAR SINGH: Now, the other swelling that you will see are usually related to arthritis. So if you notice swelling of the distinctive l'engle joint, then it is a habitant node. And if you notice a swelling across the proximal deferential joint, then it is the Bush nodes. So see the swelling when you are inspecting. So these are the commonest swellings that you will see. Now, once you have looked at the skin you have seen for any swelling, then I move on to any muscle wasting.
VINAY KUMAR SINGH: The muscle wasting that you need to look for is this thenar muscles, which are supplied by nerve. These hypertine muscles, which are supplied by median nerve. Also the small muscles of the hand, especially the first dorsal interossei, which is also supplied by the nerve. Now, if there is any wasting of thenar muscles. Especially abductor policies, brevis here and the wasting, you appreciate more when you look at this, so develop a habit of looking at the swelling in this form.
VINAY KUMAR SINGH: And in this form. So in this way, you will be able to appreciate minor wasting and that can point towards uh, the median nerve pathology. A lot of times you will see wasting of muscles if somebody has got severe degenerative changes at base of thumb, and that is because of the lack of use. So these are,
VINAY KUMAR SINGH: so you look for the wasting of our muscles. Similarly, you look for wasting for hypertension muscles, and that can point towards the ulnar pathology, as I said before. So when you have wasting of hypertension muscle, and if somebody has what wasting of some forearm muscles and has got positive signal at the elbow that can suggest towards the pathology. The other thing that you also need to look when you are looking for ulnar pathology is wasting of the first dorsal intro.
VINAY KUMAR SINGH: So if you look at both my hands, if I attached my thumbs together, you will see this is my dominant hand. So that is why this is more prominent here. It is less prominent, but there is no wasting. If I show you in this profile, this muscle is first dorsal interrossei. If you see any wasting of this muscle, then that indicates towards a learner involvement.
VINAY KUMAR SINGH: Also, in advanced stages, you will see guttering. So if you have guttering of these metacarpals or in between metacarpals, then that also indicates towards the learner pathology. Now, so these are the things that I would look for wasting in terms of thinner and hyper-thinning muscles, which will give me an indication towards any other problems. But once you have looked at the atrophy of the muscles for looking for any cause of nerve involvement or other causes that may lead to the wasting of these muscles, then you move on to the deformity. Now deformity, the three commonest deformity that I would like to talk about.
VINAY KUMAR SINGH: First is this swan neck deformity, the sore ampo deformity and the maller deformity now. So swan neck deformity. If I show, try to show it on my finger, I'm not that flexible. But swan neck deformity usually has got hyperextension of the proximal interferon joint and flexion at the joint, and this is usually seen in somebody who has got a wooden plate injury. So swan neck deformity I will is hyperextension at approximately helensville joint and flexion at the distant joint.
VINAY KUMAR SINGH: Now, the second deformity is called continuous deformity, so it will present something like this where there is flexion of the approximate differential joint, an extension or typekit extension at the distance joints. If I show you in this profile, this is how it will manifest. Now, central slip is a commonly injured but uncommonly appreciated. Now, when I was a trainee resident, I missed once a center slip injury and I treated her with a body strapping.
VINAY KUMAR SINGH: And three weeks later, that girl came with her Petito's deformity. And that was the last time I missed a central slip injury. So I've uploaded a separate video on lucentis. So do learn what lucentis, and I will cover in this video as well. So any injury in this area? Don't take it lightly. It might be central slip injury.
VINAY KUMAR SINGH: So this is the buttonless deformity. Now, the last thing, the last deformity that a common deformity is what we call a mala deformity. So minor deformity will present something like this if I show you in this profile. So there is only flexion, at least in the fillings and joints of flexion could be mild. It could be a bit more or it could be quite a lot. So this is my deformity.
VINAY KUMAR SINGH: This is usually due to either rupture of extensor tendon or stretching of extensor tendon, or sometimes a bony mallet due to a small bony evolution in the back. So these three deformities are extremely common, and I have shown you what to see in these deformities. Now, the other common deformity that you might see is what we call a clawing, and I will cover that later in this video as well.
VINAY KUMAR SINGH: So clawing will present something like this. So if in this there will be extension of the metacarpophalangeal joint and the reflection of proximal, as well as the distinctive l'engle joint. Now, other causes may also lead to deformity such as the uterus, such as burns, such as post traumatic contraction. I will cover that later in my video in the detail. Now the last thing if somebody has got history of trauma and is complaining of pain across the metacarpals, what I do is what I would advise you is to see your metacarpal in a tangential profile.
VINAY KUMAR SINGH: So if you see my hand metacarpal in tangential profile, you can see that I want you to focus on my ring finger. So if you see metacarpal head on, my left hand is far more prominent than this side, so focus here. This is flat, and on this side, you can see that it is not that flat. And the reason is because I broke this metacarpal while playing cricket, and this is healed by slight shortening.
VINAY KUMAR SINGH: So any shortening of the metacarpal will manifest itself in form of flattening of the knuckles. So if you can ask somebody to just do this and look at it tangentially, you will be easily able to diagnose boxer's fracture or fracture of the metacarpals. And if you can pair it with the normal side, you will see flattening. So this is the last thing I will do.
VINAY KUMAR SINGH: Before I move on to the palpation. So you have done your inspection, then you move on to the field part of the examination. So the first thing you can do is look for any local temperature. If there is any raise inlocal temperature, that could suggest inflammatory or infective pathology. Now, a lot of pathologies of the hand sorry of the wrist are covered in my wrist examination video so I am not covering those areas.
VINAY KUMAR SINGH: But in terms of palpation, it's always a good practice to ask the patient where is the pain and come to the painful area in the end. But in essence, you look for palpation of each individual bones and look for any tenderness. So you look for metacarpal proximal differential joint list and fill in the joint and you do it, do it very systematically so that you don't miss out anything.
VINAY KUMAR SINGH: Same for thumb, you can examine the base of thumb IPG proximal. Failings in the engine joint and the steel filings, so go systematically, sometimes if a patient gives history of a triggering, then you can feel the individual even pully and see if the patient is complaining of any tenderness there, and you can always sometimes feel nodule. And part of the palpation good practice to feel for both radial as well as a ulna artery.
VINAY KUMAR SINGH: Now, because I am already feeling for radial as well as ulnar artery, if at all, I have any doubts about any vascular cause. I would do an alan's test at this point of time. So let me tell you what alan test is. So if you're doing an alan test as a part of feel, you feel for radial pulse, you feel for a nerve pulse, you keep the hand subordinated. And once you feel for both radial and ulna pulse, just obliterate them and ask the patient to open and close and a few times.
VINAY KUMAR SINGH: And once. And the hand is completely white, then you release at the time, I have at least radial artery, so you can see the hand is becoming red. That tells me that the radial artery is functioning very well. Same way. I will repeat it and then I will release my ulnar artery and then hand will go pink.
VINAY KUMAR SINGH: So this will tell me about patterns of both radial as well as a large artery, usually in the majority of the patients ulnar artery is the main artery to the hand. At this point of time, I will also check for sensation at the tip of the index finger for median nerve tip of the little finger for ulnar nerve and first web space for any radial nerve involvement. In part of palpation, you can also feel for any obvious cause which can be present in decroutements such as spiral coordinated record or commercial record, which is seen in between the index and the thumb.
VINAY KUMAR SINGH: So that would be my palpation complete. So once you have done the palpation or feel part of the examination, then we move on to the movements. So let's first focus the metric up of l'engle joints. If you see metacarpal interphalangeal joint is bending roughly up to 90 degrees, so this is the maximum flexion. So it's measured bending up to 90 degrees. But it hyper extends so finger can go backwards if you can see this is hyperextension.
VINAY KUMAR SINGH: So even if the finger can be extended up to neutral, that also means that we have lost some extension. So metacarpal interphalangeal joint is from almost minus 40 to roughly 90 degrees of flexion. So now let's focus on proximity to phalangeal joints, if you see I can extend. So the movement of proximity for phalangeal joint is from 0 to you can see this, this is 90.
VINAY KUMAR SINGH: This is going past 90, so roughly around 100 degrees of flexion. So if I show you the moment of the dipg, so IPG again can extend up to zero degrees, but if you talk about flexion, it flexes. If I show you in this profile, some fingers will bend up to 90 degrees. Some fingers will bend up to 80 to 90 degrees. So 80 to 90 degrees of flexion is normal range of motion of distant differential joint.
VINAY KUMAR SINGH: So now if I talk about movement at metacarpal angle joint of thumb, so it takes hyperextend slightly, maybe around minus 10 degrees. And then if you flex it, it flexes if this is the profile. So if this is metacarpal, if you can see it's flexing to roughly around 45 to 55 degrees of flexion. And if you look at the interval, you'll join in into filling joint, in my case, hyper. But it's not always the case.
VINAY KUMAR SINGH: Some people, it will be just about neutral. Some people it will extend in some people. It will extend more than others. So always compare the other side if the other side is uninjured. And in terms of flexion, again, you can see you can flex it up to around 80 to 90 degrees. So in terms of movements of the hand, the fingers usually flex and extend, they also abduct and attack so you can check these movements.
VINAY KUMAR SINGH: Now, in terms of movement of. Often the moment is slightly more complex, so finger flexion is this finger extension, is this finger abduction? Is this and finger eight action? Is this? Now, in terms of movement of the thumb finger flexion, is this finger extension, is this finger reduction or is this finger abduction?
VINAY KUMAR SINGH: Is this opposition is again, touching the other fingers. And if you move? You can circumduct. So these are the movements of the thumb. So once you have done this basic examination, now I will move on to the specific pathologies as how to identify these specific pathologies. So when we talk about specific pathologies, let's talk first about the flexors of the hand.
VINAY KUMAR SINGH: So when we talk about the tendons or the muscles, which are involved in movement of the hand, now, they are usually of two types. So there will be muscles which will come from approximately will cross across the wrist. And they will be inserted onto the various parts of the hand. These muscles are called extrinsic muscles. Now there are other muscles which will take origin within the hand and will be inserted within the hand.
VINAY KUMAR SINGH: These are called intrinsic muscles of the hand. So the first muscle or first muscle that I would like to cover. Let's cover the extrinsic muscle and we will start with flexor digitorum profundus, not flexibly. Now flexor digitorum profundus originates and comes as individual muscle belly, and then it crosses the wrist. Then it crosses the metacarpal phalangeal joint. It crosses the proximer phalangeal joint and then subsequently it crosses their distinctive joint and is inserted at the base of the distal filings.
VINAY KUMAR SINGH: Now, if you talk about the function, the primary function of this FDP or flex funders is to bend the distinctive joint. But because it is crossing all these joints when it functions, it would also function as flexor of approximately interphalangeal joint. Subsequently of metacarpal interference, the joint and subsequently of the wrist as well. So it is also a wrist flexor, but a very weak one.
VINAY KUMAR SINGH: So if somebody has got injury to its flexor distal and profondes, so how should we diagnose? So if somebody has got injury to the FDP, then how shall we diagnose it? So if you want to diagnose the deep injury, what you have to do is to immobilize. I usually put my hand my index finger over the proximal phalanx and distal or the middle finger over the middle phalanx, and I ask the patient to bend.
VINAY KUMAR SINGH: So if you can see this patient is able to bend this. Just at the tip, that means the FDP of the long finger is pretty good. Same way. Ring finger. Same way. Index finger and same way ring finger, now analogous to FDP and thumb is to flex their policies longer. So if you ask them to bend the tip, this means the flexible longest in thumb is working well.
VINAY KUMAR SINGH: So the second tendon that I would like to cover is FDS. That is flexor superficially. So if you ask somebody to bend the finger, then you cannot be sure whether FDS is intact or not. The function of FDS is to bend the middle or the proximal joint. However, because as I said, FTP also crosses this joint. It acts as a secondary flexor for this. So what we need to do is we need to eliminate the function of ADP, so I'll show you how to do it.
VINAY KUMAR SINGH: So what you want to do is because they work together, so you want to eliminate FDP or FDP. So what you do is that you hyperextend the disdain differential joint like this. So that any function of FDP is completely eliminated. So you hyper extend, if at all. If you do not hyperextended, you can at least put it and then ask the patient to bend. If I show you in a volunteer, if you can, if I'm testing the middle finger in the middle finger, that means the PhDs to this finger is working fine if I want to check the ring finger.
VINAY KUMAR SINGH: So that's fine. If I want to check the index finger, that's fine. And lastly, this. So now he's not able to bend his little finger proximity to interphalangeal joint. And this is. And this can be normal because 15% of the patient will have either absent or a rudimentary. As to the little finger.
VINAY KUMAR SINGH: So if I show you my hand, I'm able to bend it. However, my volunteer was not able to bend because of presence of a rudimentary or absent PHDS, so this is extremely important. Don't be. This can. What I want to say is that if there is no flexion at approximately falintil joint, it can be normal in 15% of the patients if it is just the little finger.
VINAY KUMAR SINGH: So once you have assessed your flexor funders and flexor superficialis and flexible, as long as I think to extend the muscles, which are important is flex capillaries on the other side and flex by less on the radial side. Now, as I said before, because FTP and PhD as they both cross the rejoint and they can be a weak flex of the wrists if they are able to do some reflection.
VINAY KUMAR SINGH: And that doesn't mean that they have to flex the carpet and radial is as intact. So in order to assess this, how do you assess? It's extremely easy, you ask patient to palmer flex if you just ask patient to palmer flex. And then you feel FCU, you will feel bow stringing there, and it will also feel bow stringing there. So this bowstringing is next to the radial artery and this big thick tendon that you can see is a flexor didgitalis.
VINAY KUMAR SINGH: And this one you cannot see it is like polaris, not flex. This is attached to the base of fifth meta carpal, radial is attached on second and third. So the other option is to just put your hand on second and third metacarpal and ask them to bend. This becomes more prominent and same here. Put your hand on fifth metacarpal and ask them if you can feel this bow stringing and
VINAY KUMAR SINGH: that means these tendons are intact. So the last tendon, which is also an extensive muscle, is palmer extendus, as long as usually it's not of great functional importance, but it can be extremely useful tendon in tendon transfers. The easiest way because it attaches onto the palmer fascia. If you ask the patient to cup, you will see this tendon, which is predominant.
VINAY KUMAR SINGH: This is palmaris longus. Now it is absent in around 10% to 15% of normal population. So my subject today is one of the junior residents here. If I ask him to cup, you can see that nothing is coming up. So he's the same student in which the base of the little finger was also absent and his palmaris longus is also absent. So we have now examined the extrinsic that is all the flexors, extrinsic of the hand.
VINAY KUMAR SINGH: Now we move on to intrinsic. Now intrinsic, most people will think in usually involves your interossei both dorsal and palmar and lumbricals. However, as I said before in my description that all muscles which originate and insert within the hand are intrinsic so that will include muscles of thenar and hyper thenar muscles. So we'll cover as how to examine them. So now, lumbricals, they originate from FTP from the radial side.
VINAY KUMAR SINGH: And similarly dorsal in palmar interossei, they originate from the metacarpals and they all attach on this extensive hood. So as the function of these two intrinsics is, what they do is they flex the metacarpophalangeal joint and they extend the interphalangeal joints. This is so this function. If I show you like this, this function is being done by intrinsic.
VINAY KUMAR SINGH: Now we also know that intrinsic are also responsible for abduction, as well as a reduction of the fingers. So how to test them? Now, whenever you want to test the intrinsic, you always should put your hand flat on a flat surface. And the reason I say this is because all long flexes, which are extrinsics.
VINAY KUMAR SINGH: They are hayreductors, so they are reductors. And the reason they are if I show you, if I ask you to make a fist. With finger abducted, you will see that you are struggling. As you close it. You, as you are abduct and close, you are able to close it much more easily. So the long, extensive flexors are abductors, so that is why you cannot make a fist with finger abducted.
VINAY KUMAR SINGH: Cannot make a fist with finger abducted. Similarly, when you extend the fingers, the extensive on the back, those are expenses. They are abductors. So secondarily, as you will extend, fingers will automatically abduct. But if you want to extend your fingers with fingers together, you will have to work hard. I'm really struggling.
VINAY KUMAR SINGH: I will ask you to just try it on your own, so extend the expenses or abductors. So just to eliminate these functions of long flexes of expenses, as well as long extensor, which are extensive, is to ask the patient to spread the. Um, hand put the hand on the flat surface and abduct and abduct, you can do it actively, you can do it against the resistance.
VINAY KUMAR SINGH: One thing you will see is as you abduct and abduct, everything is moving except for the middle finger. So to check the middle finger. You ask middle finger to be moved separately. And this is how you examine the intrinsic of the hand. Now, the other intrinsic which are left are the muscles of the thenar muscles and hyperthenar muscles. Now the hypothenar muscles and thenar muscles, they have an abductor, they have a flexor and they have one small muscle for a position, each of them.
VINAY KUMAR SINGH: Now, to check the muscle on the thenar side, usually what you are assessing is assessing the function of the motor branch and motor branch, which originates. So usually if you bend your index finger, sorry ring finger, where it touches the thenar muscles usually is a site where you will find the motar branches originating, or you can draw a vertical line from your first or sorry second inter-web space.
VINAY KUMAR SINGH: So it starts giving supply to the opponents and then flexors and then abductor see if the patient can abduct against resistance, and if patient can abduct, that means the abductor is functioning well and that tells that you're. These three muscles are functioning well, because if the abductor is functioning well, the chances are that the two are functioning well as well.
VINAY KUMAR SINGH: And the same thing in hyper-thenar muscles. So you should check all these muscles and once you check, you have now checked all the exstentics as well as intrensics of the hand. So now, once you have examined the flexors and I'll move on to the extensors, the extensor tendon is extensor digitorum in-communis, so it start as a common muscle belly and then divides into force.
VINAY KUMAR SINGH: It crosses the metal club of the rejoint carpometacarpal joint. And then later on, it does go over the proximity of a join in form of central slip and then subsequently attaches towards the base of the distal filings. Now how to examine the extensor bisram communis. Now in order to check the function of the sensors or to extend, of course, the wrist, the and carpo-phalangeal joint and inter-phaleangel joint.
VINAY KUMAR SINGH: Now, the extension function is extremely important because if you have to grab something until unless you can extend, you will not be able to grasp. So for grasping purpose, extension is extremely important. Now, if you want to assess the extensive disturb communists now, as I said, it will extend the metacarpophalangeal joint, but it will also extend the approximate differential as well as the strength of joint.
VINAY KUMAR SINGH: But as you would have heard a few minutes ago, when I was talking about our intrinsic of the hand there, they can also cause extension of the proximity of joint. and the phyllangeal full engine joint, so how do you differentiate it? The only difference is that when you have intrinsic with flex, the metacarpal phyllangael joint, what our extensors will extend. So if you keep the hand extended onto the flat surface, you are eliminating actions of the intrinsic.
VINAY KUMAR SINGH: So if I want to check my extensor disturb communists, all I need to ask is to lift the finger up. As I said, the movement is almost 40 degrees of hyper extension, so if I show here. So this is the flat surface. You can see I'm able to extend this action can only be done by extensor this term communist, so this is how you would test it.
VINAY KUMAR SINGH: But as you know, nature always poses challenges, so things are not so straightforward, because now you have got separate extensors for index finger and separate extensor for little finger as well. So you have extensor indices, appropriées and extensor district districtwide, which are independent muscles and are responsible for extension of the index, as well as little finger. So how do we assess the movement of these two thing to separate muscles, which are independent?
VINAY KUMAR SINGH: Now, if you want to test them separately, then the only way to do it is to eliminate the action of ADC. So how do you do it? So make a fist. And then extend the resort now you are holding the EDC, so EDC cannot move. So if I now ask you to lift the index finger, you will still be able to do it. And that tells that extensor industries proprios or extensor indicis for this index finger is still working.
VINAY KUMAR SINGH: So if somebody can extend despite holding all these three fingers together flexed, that means it is working. And similarly, for little finger, you can still do it. However, if I hold everything. So if a patient is able to do this, that means these two tendons, which are separate are also functioning well. Now, there are three other important extrinsic extensor tendons, which are important, which I have not covered and they form the anatomical snuff box is one is the extensor pollicis longus and the other two are abductor policies, brevis and sorry objective policies, longus and extensor pollicis.
VINAY KUMAR SINGH: Previous now these two tendons, how do you assess these three? See if I can just ask you to just hitchhike, just put up and then feel the bow stringing. You will feel two tendons here and one tendon here. That means that these two are functioning well because one of them attaches at the base of the metacarpal and attaches at the metacarpophalangeal joint. So hitchhike, do this feel for these two tendons?
VINAY KUMAR SINGH: Define now how do you test extensor pollicis longus now? Extensor pollicis longus is the only muscle which is responsible for rate propulsion. So that propulsion means if I'm able to lift my thumb up from a flat surface, see, just keep your focus here. You will see this tendon becoming prominent. So if I'm able to retro pulse, then you will see this intact tendon. So that will cover the extensors of the hand.
VINAY KUMAR SINGH: So now we have covered how to test the flexors and sensors of the hand. We also talked about the small muscles or the intrinsic of the hand. Now the next condition that I would like to move on, which is also related to one of these muscles or group of muscles, is called intrinsic tightness. So what is intrinsic tightness and how do you diagnose intrinsic tightness?
VINAY KUMAR SINGH: No intrinsic tightness, as the word itself means that your intrinsic are tight. That means they will be functioning more than their usual. And as you know, previously I said the function of intrinsic is this. So what intrinsic does is the cause flexion at the metacarpophalangeal joint and extension at these small joints now due to neurological injury or due to scarring after trauma, your intrinsic can become tight.
VINAY KUMAR SINGH: Now, if you look at the flexion of proximal to the joint, if I show you flexion of the proximal phyllangeal joint in different degrees of metacarpal phyllangeal joint flexion. If you see here. It seem it is not affected by position of metacarpal phyllingeal joints, so the deflection remains same irrespective of what is the position of metacarpal phyllingeal joint.
VINAY KUMAR SINGH: Now this is normal. So in a normal patient flexion at intervals, the joint will remain same irrespective of flexion. What is present at a couple of joint? So now the test that we use to diagnose intrinsic tightness is called bunnell's test. Now what we do in bunnell's test is we check for flexion of inter-phyllingeal joint with MCP flexed when MCP is flexed and intrinsic tightness.
VINAY KUMAR SINGH: You will be able to flex the fingers at inter-phyllngeal joint. However, finger deflection is checked after extension, because once we extend, it is becoming more tighter when you flex proximity of phyllingeal joint, it will not flex and it will flex much less. So this is a positive test that is suggestive of a tight intrinsic. So just to repeat again, when you flex it, you will be able to bend IPG easily or it will bend more when you extend metacarpal phyllingeal joint, you will struggle.
VINAY KUMAR SINGH: Now, opposite of intrinsic tightness is extrinsic tightness. If there is scarring or shortening of the long extensors, then it will just be opposite to what you see. So now just imagine these extensors are tight. If these extensors are tight. And then if you are extending the metacarpal phyllingeal joint.
VINAY KUMAR SINGH: And what it is doing it, it is just relaxing the extensor slightly. So when it is extended, relaxing the extensor slightly in this position, the IPG in this situation will bend more. However, if the extensor is already tight and if I'm flexing the metacarpal phyllingeal joint, what it does is it is tightening this even more. And in this position, I will not be able to flex the proximal phyllingeal joints, so it is just opposite.
VINAY KUMAR SINGH: So if an extensive tightness in extension of metacarpophalangeal joint, you will have more flexion as you flex it, you will have less flexion at proximal differential joints. So this is extrinsic tightness. So now the other uncommon or relatively rare condition I would like to discuss, which is called a lumbrilicus finger shall talk about what is lumbrilicus finger and what you will see clinically and how will you diagnose it clinically?
VINAY KUMAR SINGH: So lumbrilicus is a clinical condition, which is usually due to disruption of flexor fundus and distal to the origin of lumbrilicals. So the disruption of FTP tendon will happen once the lumbrilicals have originated and as we talked before, they originate from the radial side. So any disruption secondary or later after the origin will lead to lumbrilicus finger. And this can be seen in distal transaction of FDP, whether there is any evolution.
VINAY KUMAR SINGH: You can see it in this inter-phyllangeal joint amputation. What amputation through the middle phalanx, or sometimes if you have put a graft and the graft is too long. So in these conditions, you will see lumbrilculus plus. So what you will see clinically in lumbriculus plus finger. So lumbriculus plus finger is a rare diagnosis, and I must confess that in my long orthopedic career of roughly 20 years, I have not seen a patient of lumbriculus plus finger.
VINAY KUMAR SINGH: However, what you will see is that once you try to flex the inter-phyllingeal joint, there will be paradoxical extension of the inter-phyllingeal joint of the extended finger. So if I'm trying to flex my finger, this will paradoxically extend. So when I'm trying to flex it, say, for example, there is a tendon cut in the middle finger, I try to flex my hand.
VINAY KUMAR SINGH: But this will go in paradoxical extension. And this is because the vehicle will pull the lateral bands. And what it does is as they pull the lateral bands, it causes the paradoxical extension of the inter-phyllingeal joint proximity to the joint. And because of the un, there is no action of flex performed as distally. So paradoxical extension when you're trying to bend, the IPG is characterized in lumbriculus plus finger.
VINAY KUMAR SINGH: Now, moving on to our next condition in continuity with the various pathologies that are already talked to make it more complex, we'll talk about intrinsic minus hand or in layman's terms, you can also call it as a claw hand. And this is usually due to weakness of intrinsic. So as it is intrinsic, minus means you are intrinsic so weak or have got strong extrinsic. So if you've got strong extensor, that will lead to a clinical condition, which is called claw hand.
VINAY KUMAR SINGH: Now you will see these conditions, especially if there is involvement of a learner. You can see also involvement of median nerve or sometimes involvement of both other conditions that you will see is if there is any issue with the brain, sometimes in people with stroke. If there is a balance between extrinsic and intrinsic and if intrinsic becomes weak, this leads to a claw hand or intrinsic minus hand.
VINAY KUMAR SINGH: So if you see here an intrinsic minus hand, we talked about the deformities, so if you see an intrinsic minus hand, extrinsic, so strong. So there is extension at metacarpophalangeal joint. So there is extension of carpometacarpal phalangeal joint now intrinsic are responsible for keeping these two joint straight, now because intrinsics are weak and extensors are overpowering. Then what it does is there is a reflection of both proximal as well as this general angle joint.
VINAY KUMAR SINGH: So this leads to a clinical condition which you will see clawing. So this is a position of a typical intrinsic minus hand. So now let's move on to our next condition. I think most of the orthopedic surgeons would have heard an effect, which is called quadriga effect. So now let's talk about quadriga effect. Now, quadriga effect is usually because, as we said before, that FTP has a common muscle belly.
VINAY KUMAR SINGH: So they work as a team, so if one of the team members is affected, the other will be affected as well. So if FTP is stuck down or there is an addition or there is a decrease excursion of FTP, then it will lead to quadriga effect and to talk about it, I will show you in my hand. So they said quadriga effect is usually seen due to scarring or addition of the FTP tendon. Also, if there is greater than 1 centimeter advancement of typekit tendon in case it is injured.
VINAY KUMAR SINGH: Now, as I said, they all work as a team, so if one is affected, then others will be affected too. Now, for any reason, say, for example, if the FTP of the middle finger is there is rotation and it is not able to bend properly. Now, the excursion of the rest of the tendon is pretty much dependent upon the excursion of the fingers, which has got the shortest excursions. If one finger has reached its maximum excursion, then that will act as a limiting factor for other fingers.
VINAY KUMAR SINGH: So what I mean by that is because of scarring if I'm able to bend because as you know, it crosses MCP, IPG as well as. The IPG for any reason, if I'm able to bend my middle finger detrusor due to scarring, then for me to bend the rest of the finger completely is next to impossible. So this is quadriga effect, and this leads to the weakness of the hand grip, and that is the reason we talk so much about being aggressive with physiotherapy to get the full range of movement.
VINAY KUMAR SINGH: Because if one finger gets stuck. And if one finger doesn't have a full range of movement. And because of it, there is excursion a decrease in excursion of the other fingers, then it leads to weakness. So just talk about again, if for any reason, if I'm able to bend this finger due to scarring irritation only this much, there is no way I will be able to make a full grip.
VINAY KUMAR SINGH: You can try it. You can try it until unless this comes completely within or reaches its maximum excursion. The rest of the fingers are also limited. This is quadriga effect. So now we have covered a lot of areas, which confuses surgeons and other, practicing doctors and physiotherapists, I have tried to cover that earlier so that you can eliminate your confusion.
VINAY KUMAR SINGH: It brings some clarity to your thought. Now let's cover some easy topics, and the first one I would like to talk about is trigger finger. Now, as the name suggests, you will notice triggering. So the patient will report catching, clicking or sometimes a patient will be able to bend the finger. And as it extends, you will hear they will report clicking. When it gets worse
VINAY KUMAR SINGH: sometimes they are able to bend it, but when extending, they have to use the other hand to extend it in later stages. This can remain flexed and even if you try, it doesn't extend. So how to diagnose trigger finger? It's extremely easy. If I show you in my hand. So trigger finger you will diagnose purely on history and the patient reports as a typical history of clicking, and it can affect anything, all the fingers can be affected.
VINAY KUMAR SINGH: And it's usually more common in diabetics and diabetics you will see it to be affecting more than one digit and sometimes bilateral as well. Now how do you locate even fully, even fully if you draw a distance from here to here? And the same distance from here to here, it's usually where they even police, if you feel safe, for example, if the patient has got triggering of the middle finger as you press across this region, he will or she will report pain and discomfort.
VINAY KUMAR SINGH: Also, you will feel its thicker and you can have a nodular feeling in that region. And if you put your hand there and ask them to extend, sometimes when you ask them to flex or extend if you see catching, that is a giveaway sign. So in earlier stages, just pain and tenderness in this region can be is more than enough for you to diagnose a trigger finger. Similarly, in thumb, if you have pain and tenderness across the metacarpophalangeal joint, that is where the police and you will feel tenderness and in order feeling, and that would suggest that the patient might have triggered some.
VINAY KUMAR SINGH: So now let's move on to another easy clinical condition to diagnose, which is called Duputren's disease. So Deputren's disease is a fibrous proliferative disorder, which which involves the palm of fascia. Now, the history is quite typical. A patient will usually give a long history of swelling and pitting of the skin, which is associated with deformities of the fingers. Now they can be unilateral, they can be bilateral, and they can affect other parts of body, such as feet or a penis in males.
VINAY KUMAR SINGH: So you should be mindful and you should look for other sites as well. Now how to diagnose it, it's very easy. And let's cover that now. So now the characteristic finding that you would see when you look on the palmus side, is you will see nodules. You will see pitting if you see small holes that is because skin is being pulled by the palma fascia, which is being contracted.
VINAY KUMAR SINGH: So if you see pitting and swelling and you will see cords, if you can see these cords in this region, then that is give away a sign for Depuytren's disease. Now you have to feel for the different cords that you see, like spinal cord here in between fingers. If you feel here, sometimes you will feel it. It records, which is responsible for addiction deformity, rarely in aggressive disease.
VINAY KUMAR SINGH: If you put your hand in this area, if you feel something like a bow string that is commercial cord and that suggest if there is radial involvement usually suggests the disease is more aggressive in these patients. So if you have cords, if you have swelling and simultaneously, of course, you will have deformity. The deformity can usually involves metacarpal phyllangeal joint.
VINAY KUMAR SINGH: And any later stages can involve approximate phllyngeal joint. In certain group of patients and approximate phyllangael joint can also be affected at an early stage. Now, in back of the hand, you will see Garrett's spots. If you see it spot, then that is also suggestive of the Duputren's disease. So as I said, you will have deformity in volume, metacarpal phyllangeal joint and proximite phyllangeal joint. Now how do you assess the deformity?
VINAY KUMAR SINGH: Now a lot of people find it quite difficulty in assessing the deformity. Now see, for example, if there was a deformity of there was a flexion deformity of proximal phyllingeal joint. Now, if I want to assess the deformity of proximal phyllingeal joint, what you need to do is you just need to flex them at a couple of joints and you will see a lot of times as you flex it.
VINAY KUMAR SINGH: This will become straight. That tells that there is no flexion deformity of the approximate phyllingeal joint. However, if you flex it and still it remains like this, then that will tell that yes, there is flexion deformity. But I can guarantee you a lot of times when you flex it, you will see this is becoming straight suggestive that it is not involving the proximal phyllingeal joint. Now how do I assess the deformity at the metacarpal phyllangeal joint?
VINAY KUMAR SINGH: So when, as I said, when you are assessing pip, you need to flex the MCP when you are trying to assess the deformity of CPG. You need to flex the pipe. So now I have flexed it and then I will take it front and back because this is a normal patient. You will be able to extend up to 90 degrees. So you can see this is almost 90 degrees in early part of the carrier.
VINAY KUMAR SINGH: A lot of trainee doctors and doctors who are training, they will be able to extend it up to here and they will say, OK, now it is extending up to around minus 30 degrees. So there is no deformity. No, that's not true. You can extend this up to 90 degrees. So even if even after passive extension, if you are coming up to here, that means still there is a loss of 70 degrees in this particular joint, so you will individually assess each joints, which are affected.
VINAY KUMAR SINGH: Now, the one common thing that patient will ask or which patient, which might help you in making a decision whether to operate or not, is called a tabletop test. So in Tabletop test is a very simple test. You ask the patient to put hand flat if the patient can put hand flat on the table. That means the deformity is little and it is correctable. And in those cases, you don't need to operate.
VINAY KUMAR SINGH: So again, if I can put my hand flat on the table and. That would suggest it's a negative test. That means you can treat it with non operative methods, but do want the patient that if deformity worsens to come back and revisit you. Now, one common thing that might confuse you is how to differentiate between somebody who has got footprints or somebody who has got close hand now in your hand.
VINAY KUMAR SINGH: As I said, it's an intrinsic minus condition. So there will be extension of metacarpophalangeal joint and flexion of proximity flange will join. And Dupuytren's disease there is always selection of metacarpal, phyllingeal joint and associated flexion of to phyllingeal joint if there is deformity of proximate phyllingeal joint. So this is the only way to differentiate. So MCTDH extended and intrinsic minus or claw hand and FPGA flexed in other conditions, which are not claw hand and Dupuytren's are one of them.
VINAY KUMAR SINGH: So let's not talk about keeping onto the team of contractors, the contractor of approximately phyllingeal joint, leading to a flexion deformity of approximate phyllingeal joint after trauma. Now hand, as I said, is such a versatile organ that you use it for your day to day activities and that makes it more prone for injuries. So if there is any injury to the proximate phyllingeal joint and if there is contraction of the ligaments and the waller plate, that would lead to flexion deformity of proximal phyllingeal joint.
VINAY KUMAR SINGH: Now the characteristic finding of a pip contraction due to injury is that there will be restriction of both active and passive movement. So it's not just that patient cannot move it. Even if you want to move it, there'll be no change in range of movement. So that is the first give away. That active and passive movement are pretty same. And also the second thing is that the pip movement is not related in any way to the position of MCAJ.
VINAY KUMAR SINGH: In normal hand, you can flex it to any degrees irrespective of position of CPG in a contracture as well, irrespective of position of CPG. The range of movement in the proximal interphalangeal joint will remain the same, so the range is remaining the same. Then it is suggestive of post traumatic contraction of pipe. So now let's move on to the ligament injury, which is called gamekeepers thumb now gamekeepers thumb is injury to the ulnar collateral ligament of metacarpophalangeal eye joint of thumb.
VINAY KUMAR SINGH: Now I have made a separate video, which is purely based on what to examine and how to diagnose this on a patient which had injury. So let's talk about it in brief. So you have two sets of ligaments. One is the accessory collateral ligament and one is the proper ulnar collateral ligament. And then you have boilerplate as well. Now if?
VINAY KUMAR SINGH: If you want to do an examination for a gamekeeper, some which is usually acute due to trauma, occasionally it can be chronic nature. What you need to do is you need to assess the thumb both in extension as well as in 30 degree of flexion. So now there are two sets of collateral ligament, as I said, as accessory collateral ligament. It provides some stability with metacarpophalangeal joint in extension, the proper ulnar collateral ligament in 30 degree of flexion.
VINAY KUMAR SINGH: Now, if there is injury to only proper collateral ligament, the thumb the pinch can still be a stable pinch. Despite injuring the ulnar collateral ligament. However, if you do a valgus force and this is opening even in extension, then that is a really bad news because that tells that not even the proper collateral ligament, but also accessory. Also, possibly the boilerplate is also gone. But if you want to assess or examine the ulnar collateral ligament, then if I show in my thumb, you need to bend it around 30 degrees.
VINAY KUMAR SINGH: Once you bend the MCP joint to 30 degree, what it does is it unlocks the joint and then you apply. I'm a valgus force, and if there is pain or there is tenderness or if there is opening, that would suggest that ulnar collateral ligament is gone and that would be suggestive of a game. Skip your thumb. So now let's move on and talk about the deformities, I think the three deformities that I would like to talk about as the swan neck deformity that I showed you earlier in the video, the boutonniere deformity and the mallet deformity.
VINAY KUMAR SINGH: So let's talk about the boutonniere deformity first. Now, as I said, usually boutonniere deformity after trauma is seen due to injury to the central slip. Now, a lot of Orthopedic Surgeons take injury to the soft tissue injury across the proximity phyllingeal joint quite lightly, and I've seen that body strapping or some form of immobilization is the usual prescription. However, occasionally you will get your hands bound and a patient with central slip injury will later on come and manifest itself in the form of a continuous deformity.
VINAY KUMAR SINGH: Now, I have already uploaded a separate video purely focusing on Elson test as how to interpret it, but just to make this video, complete will cover it again briefly. So now Elson test is an extremely useful test for diagnosing central slip injury. So for you to do the health and test put hand flat on the edge of the table so that proximity phyllingeal joint can be bent up to 90 degrees.
VINAY KUMAR SINGH: So once the fingers are bent before doing this test, if you have swelling or bruising on the door, some that will suggest that there may be injury to the central slip. So for Elson test, you put a finger across the middle phalanx and you ask the patient to extend if the patient can extend. Because that is the function of the central slip and the distant familial joint is floppy, then that is a negative test, suggesting that your central slip is intact.
VINAY KUMAR SINGH: However, if the center slip is gone, what will happen is as the extensor there will be weakness and there will be paradoxical extension of differential joint, I think, to refer to the separate video that I have uploaded, if this is not clear here. So the second deformity that we talked about, swan neck deformity, was where there was extension of the proximite phyllingealjoint and there was flexion of this phyllingeal joint, and this is purely usually due to injury to the wooler plate.
VINAY KUMAR SINGH: So wooler plate, it is a very important structure which is present across the wooller aspect, and it is responsible for providing stability and preventing hyperextension at the proximal inter phyllingeal joint. So if this is weak or this is gone, what happens is the extentor, that they over-power, and there is compensatory extension of the proximal interphalangeal joint and flexion of this joint.
VINAY KUMAR SINGH: So now in terms of management, I forgot to talk about the management of the Dupuytren's deformity. If you are treating a particular deformity, then if you think the center slip is gone. And if you have any doubts, then put them in, put in your splint. So put in your splint is something. It's a splint which keeps the hand and keeps the finger in extended position, and this is a position in which it will heal.
VINAY KUMAR SINGH: So Google put in a splint and you will see this is how the position. I will usually keep it for around six weeks if it is a soft tissue and then progressively get it mobilizing. So nobody's trapping, putting a splint. If you are talking about swan neck deformity and if you're worried about a wooler plate injury, whether it's a bony boilerplate or whether it's soft tissue boilerplate, what you do is an extension block splint so patients can flex but cannot extend.
VINAY KUMAR SINGH: So keep it immobilized for roughly around three weeks. And after that, get it going. You don't want to be immobilized in more than three weeks because then that leads to capsular contracture and then you will have paraplegic contraction, which I talked in this video a while ago. So that's deformity that I would talk about is a deformity again, as I said. There is a flexion deformity of the distant phyllingeal joint, and this is due to either extensor tendon being injured or becoming stressed, or there is a bony evolution.
VINAY KUMAR SINGH: These are usually three common things that will happen, and it's very easy to diagnose. There is a typical history and a deformity, which in initial stages is possibly correctable. So all I do for soft tissue mallet injury, I will keep the finger in mallet splint for around six weeks. 24/7 That is, you are wearing it day and night, and after six weeks, I will keep them for nighttime only for four to six weeks.
VINAY KUMAR SINGH: If it's a bone injury, it heals quite quick. So I'll keep them in my splint for roughly around three weeks and after three weeks, I'll get them going. So now let's move on to some now pathologies such as carpal tunnel or cubital tunnel. So carpal tunnel how there is compression of median nerve at the wrist and patient will typically give history of pins and needles, especially during the night times.
VINAY KUMAR SINGH: Patient might wake up in the morning with numb fingers, and any repeated activity during the day can lead to numbness in later stages. When they start to experience weakness, then they will report dropping things so they think they are holding something, but they'll start dropping things. Now, how to diagnose it, I think majority of the times it is very straightforward.
VINAY KUMAR SINGH: If the patient is not having any neck pain and has got these typical night symptoms, then it's usually carpal tunnel. Now how, how to diagnose it. There are two or three things, and let's talk, talk it about now. So if you want to diagnose carpal tunnel, then first thing use, as you would do for any.
VINAY KUMAR SINGH: Look, I look for any particular wasting, so the first thing that gets wasted is abductor pollicis brevis. So this is the area that will start to become hollow now. Occasionally, mild weakness or mild wasting is very hard to detect. However, if you put your hand in this position and then a mild wasting of even thenar muscles could be appreciated. So if there is any wasting that will suggest that it is, maybe it is carpal tunnel.
VINAY KUMAR SINGH: Now you also check the sensation on the median of distributions. If you feel for sensation of the thumb index finger, middle finger and the radial side of the ring finger. These are the 3 and 1/2 fingers where patients usually complain of hypoxia. If you have hypoxia in this area, that is also complain, that is also indicative that it might be carpal tunnel. Now I will take this opportunity to talk about if somebody has got a say, for example, C5 C6 disk.
VINAY KUMAR SINGH: And how do you differentiate it from carpal tunnel? And occasionally, you can have double crush. It can be quite difficult. Now, hypoxia in carpal tunnel will only affect the tip of the fingers. This area across the tenaa eminence, which is supplied by palma cutaneous branch, which originates and goes on top of the carpal tunnel, will be normal. So however, you know, outer aspect of the forearm is.
VINAY KUMAR SINGH: So if there is a problem with the whole c-6 region, you will have hypoxia not only here or in the fingers, but approximately as well, and same way. You will have wasting approximately as well. If you are wasting approximately mayfair altered sensation proximally, then think of cervical spine, not carpal tunnel. So the one muscle that I would like to test in somebody with carpal tunnel is to check the power of abductor pulsas brevis.
VINAY KUMAR SINGH: So I we have talked about how to test it before, so I will ask the patient to bring his thumb to the index finger and push against it. And this is fighting very well. It's a good strength. Checking the power of objective pulses brevis is of extreme importance in patients with carpal tunnel. Now to do that in sign as there is median nerve is a compressive neuropathy of carpal tunnel.
VINAY KUMAR SINGH: We just do some gentle taps. And if the patient reports the electric sensation or reproduction of the patient symptoms, then that is a positive sign which is suggestive of carpal tunnel syndrome. Now, the one test that I would like to talk about is a phalen's test, and I'll show you how I do it. So now the typically phalen's test is being described that you keep your hands in this particular position and you wait for around 30 seconds for see if the patient has got a production of symptoms.
VINAY KUMAR SINGH: Now the sooner the hands starts to tingle, I think more severe the carpal tunnel is. However, I do my test slightly differently. So what I do is I just ask keep the elbow extended and then I flex the wrist like this and I'll wait for around 30 seconds and I'll do it in both the hands. So one hand acts as a control, or if a patient has got bilateral symptoms, then it will see the patient is having a reproduction of symptoms in typically involving the radial three fingers.
VINAY KUMAR SINGH: However, there are occasions you may have atypical findings that some patients will report. Some altered sensation is little and ring finger. They may have a simultaneous ulnar pathology, or most likely, it is due to abnormal connections in between the median and ulnar what we call Martin Gruber osmosis. So don't get thrown away. And if certain patients were just typical symptoms of carpal tunnel are there.
VINAY KUMAR SINGH: But if they have atypical distribution, that can be due to Martin Gruber osmosis. So I have already covered cubital tunnel syndrome in my elbow examination, it is very rare for ulanar to become compressed and across the wrist. However, if it is, then you will have wasting of hyper-thenar muscles and it will have altered sensations in the little and other aspect of the ring finger.
VINAY KUMAR SINGH: Now, if you have got wasting of hyper-thenar muscles, if you are wasting your first dose on interoceanic, if you have got guttering off in between the metacarpals and if you have got a positive tingle, as I have shown you, that is because of capita tunnel. So you may have problem in the elbow, but you may have manifestation in the hand, so be mindful of it. So now let's talk about some hand infection, so infection of the hand is uncommon, but can happen after penetrating injury, and sometimes it is not associated with penetrating injury.
VINAY KUMAR SINGH: So let's first talk about if you have synovial sheet infection of the fingers, how to diagnose them and how do they manifest? Sure so if there is a patient who comes to you with some pain, swelling and redness and difficulty in moving the fingers, then you should think of infection of the flexor sheet. Now, if you talk about the individual fingers, then you will normally see what we call.
VINAY KUMAR SINGH: Look for the signs of Carnival. That is, you will the finger will become more swollen. You will have a fusiform swelling. Also, finger will be in slightly flexed position because that's it. That is the position of comfort. And if you try to do passive extension, the patient will not like it and will complain of a lot of pain. A percussion across the flexor sheet, if it even gentle percussion will be extremely painful.
VINAY KUMAR SINGH: So if you have got these three or four signs, then you should think of a flexor sheet infection. And it is an emergency form if you are few of the very rare orthopedic emergencies which should be dealt even in midnight. So that uncommon infection that you will see will be infection of the thenar space, hyper-thenar space or the miss palma space. I would not go into the deep into anatomy that which sheet is connected with which space.
VINAY KUMAR SINGH: But in a sense, if you have got redness, if you have got swelling, if you have got pain, if patient is a pyrexia, a patient is unable to move on the hand and there is a lot of swelling tenderness, then that is give away a sign for infection. It's not a difficult condition to diagnose. So these are typical red flag for any other infection or also present in the hand.
VINAY KUMAR SINGH: So if you are, keep that in mind, you will be. We will be easily able to diagnose these and infections. And again, as I said on this for me, is an emergency and should be addressed as soon as. So the last part covering infection, I would talk about botanical infections, so that is infection. You will see across an nail fold, it will present a swelling and pain and are very easy to diagnose.
VINAY KUMAR SINGH: Occasionally, you will have infection of the pulse phase. So if this is too swollen and if you lose these ridges, which are present in the finger and if it is very tender to touch an extremely swollen. And that can suggest that it is infection of the pulse space. And again, it may require surgical intervention. So the last thing I think, which I have not covered are the deformities of the hand, which are present in rheumatoid.
VINAY KUMAR SINGH: I think that itself is a very vast topic and it will take me at least half an hour to cover that, which will make this video very long. But if I have a patient of rheumatoid, I will probably talk just about rheumatoid hand. In a separate video, which was this was an extremely elaborate video on how to do a hand examination. I have made an attempt to make it as comprehensive as possible and as easy as possible to remove any confusion that you have.
VINAY KUMAR SINGH: I hope after watching this video, it will make you more confident in doing hand examination. Like this video, give us a thumbs up, to subscribe and to share our channel. Thank you.
Segment:0 .
VINAY KUMAR SINGH: So viewers today, I'm going to take you through hand examination. Now, hand is a very important part of the body and it provides a lot of useful function for our day to day activities. Now, even a slight loss of function can pose a lot of challenge when we do our day to day activities. So for me, hand is one of the most important part of the body, and a thorough assessment is extremely important
VINAY KUMAR SINGH: so that you are able to diagnose under those conditions properly and treat them appropriately so that you don't have any disability in future. Now, for me, hand is an organ because hand does a lot of useful things. For example, it is used for grasping things. If I want to grasp the stamp or if I want to hold a pen, I think hand is the most important part of the body in doing these functions.
VINAY KUMAR SINGH: Now it is also a sensory organ because even if I have my eyes closed. And I can tell even when my eyes are closed that what I'm holding in my hand, for example, whether I'm holding a coin, I'm holding a pen, I'm holding a paper. So you can tell actually, even without opening your eyes. So that provides a lot of sensory and tactile feedback for our day to day activities.
VINAY KUMAR SINGH: Now it is also used as an organ of expression, you know, in your day to day activities when, say, for example, you're upset and your kid is misbehaving. And if any point this that means you're angry or if you point a fist, that means you convey your expression, sometimes through hand as well. So that is why, for me, it is an organ. So today my aim is to take you through thoroughly through hand examination.
VINAY KUMAR SINGH: So that you feel confident in diagnosing common conditions and you can treat them appropriately so that there is no functional disability. So history plays a very important role in most of the examinations, so I talk about taking a thorough history. Now hand, is quite special to me. So if certain things which should be part and parcel of the history is first thing is the age.
VINAY KUMAR SINGH: Now, age plays a very important role. The reason I talk about age is that the same injury in an elderly would be treated separately or differently to a person who is young. So hand, we try not to operate unless we have to. So slight loss of functional function in an elderly may be acceptable, but may not be acceptable in a young patient. Occupation is also important, so you should always ask, what does the patient do?
VINAY KUMAR SINGH: So the same injury could be treated differently in a computer operator. Then if somebody is a labouror because a small loss of function for a labouror man might not be disabling or might not matter a lot, but the same loss of function may matter a lot for a computer operator or a musician who needs a fine finger movements. Now, hobbies is also becoming extremely important these days.
VINAY KUMAR SINGH: People love to do their hobbies after the injury, so you, it can also influence the treatment. Now hand dominance, whether somebody is right handed or left handed, you should always ask. Again, the reason is sometimes if the injury is affecting a non-dominant hand and especially if the patient is elderly, then I tend to treat them less aggressively. Now, once you have moved on, then the most common time the reason the patient will present is pain.
VINAY KUMAR SINGH: Now pain, you should drill the pain quite well. First of all, you should ask the duration of pain. You know, all those headings of the pain that where is the pain? What makes the pain better? What makes the pain worse? So drill pain thoroughly because that will help you reach your differential diagnosis and eventually your final diagnosis as well.
VINAY KUMAR SINGH: The other common thing that you will see in hand is swelling. So again, nature of the swelling. Where is the swelling? Does it get big or small? If it changes size, you will see ganglion is a typical swelling that can change size. So once it becomes big and sometimes you will see the patient will say that it's becoming smaller. So if you have swelling found out where the swelling is.
VINAY KUMAR SINGH: And that will help you reach your diagnosis as well. The other common things that will affect hand is the nerve pathologies. So whether it's proximal or pathologies or C spine problem or this talar pathologies such as carpal tunnel will manifest in the form of pins and needles or tingling. So ask about the numbness. Where is the tingling, whether they have neck pain in order to localize where the problem is, and you will be able to come to a diagnosis when you do an examination, whether it's a carpal tunnel or a cubital tunnel, or whether it's a c-spine lesion or it's a combination of lesion.
VINAY KUMAR SINGH: Now sometimes patients will report color changes or hot and cold feeling that can point towards a vascular cause. So drill history appropriately. Occasionally, a patient will report deformities and catching. So if the patient reports catching when they're opening or closing the fist, that's a typical history that you will see in a trigger finger.
VINAY KUMAR SINGH: And deformities could be due to nerve injuries or could be due to burns or could be due to the patrons. So drill, take a lot of time in taking a proper history because a lot of times only the history when you take a thorough history will come to a diagnosis. So take a thorough history when you are doing a hand examination. So once you have done your hand examination now, the first thing that I talk about is, you know, how much exposure do you need for doing a proper hand examination?
VINAY KUMAR SINGH: So for me, if I'm examining the hand, I should be able to see the hand completely. I should be able to see the forearm completely and I should be able to see the elbow completely. So like if you look at my hand, this is the bare minimum that I would like to see when I'm doing my hand examination. So I should be able to see the elbow. I should be able to see the forearm and I should be able to see the hand.
VINAY KUMAR SINGH: If you have any jewelry or any rings, which is coming in your way when you're examining it, you can ask the patients to remove it so that your examination is not hampered because by the presence. So once you have done taking a thorough history and if you have exposed the patient well, then next thing you move on is for, look, that will be the first part of your examination.
VINAY KUMAR SINGH: But before you do the look, what I like to do is what we call is a screening of the hand. So let's if the patient is coming to ask them to put your hands like this. And first thing I want you to notice is the natural cascade of the fingers, if you see here, this is the normal resting position of a normal hand. So if you see my little finger, this is more flexed than the ring finger.
VINAY KUMAR SINGH: Ring finger is more flexed than the long finger, and the long finger is more flexed than the index finger. So there is a natural cascade. And this is normal, so you want to appreciate whether this cascade is present or not. If there is any disruption in cascade, say, for example, if the middle finger is in this position now, this tells me that the cascade is disturbed. Now this finger is more extended than these fingers so that if somebody has got a laceration here, then that will tell me that there's a very good chance that the flexor tendon injury is there.
VINAY KUMAR SINGH: And because the senses are overpowering, then there is a loss of cascade. Similarly, if there are two fingers, which are like this, then if you have a big laceration that will tell you that there might be injury to flex attendants of both the hands. Now, on the other hand, if the finger was more flexed like this, if I try to show it like this. Now if you see the middle finger is more flexed.
VINAY KUMAR SINGH: So again, there is disruption of the natural cascade, but it is opposite to what we saw a few minutes ago. And what it tells me. Now, the flexors are more overpowering now if somebody has got a laceration here or here across the extensor tendon. Then there is a very highly likelihood chance that there is an extensor tendon injury. And that is the reason the cascade of the finger is disturbed.
VINAY KUMAR SINGH: Now, once you have looked at the cascade of the fingers, the second thing you want to do is to ask the rough screening. So ask a patient to open and close hand so open and close hand. If they are able to do this, then functionally they should be able to do something. If there is an interruption in this, then it can point towards a particular differential diagnosis.
VINAY KUMAR SINGH: So this is what I do. Once you have done the screening, you have looked at the cascade you have asked to flex and extend. Then you move on to the skin, so you want to see the skin in the front and in the back. And what you are looking for is looking for any scars, whether there is any old heal scar, whether there is a new lacerated wound or if there is any wound in front or back.
VINAY KUMAR SINGH: If there is any erythema or there is loss of shiny or skin is shiny. All these things are extremely important, whether there is any skin changes, you know, or if one hand is looking paler than the other hand or if there is a lot of redness. These are the things that you look to start with. When you're examining the skin. You also look for the nails.
VINAY KUMAR SINGH: Nails are extremely important because sometimes real diagnosis, such as gliomas, tumor and I have seen two or three in my lifetime. You will see a ridging of the nail or nail being deformed. And if a patient is complaining of pain there and there is deformity, then think of gliomas tumor. If there is pitting of the nail, and if the patient has got pain in the large joints on the small joints, that can point towards the psoriatic arthroplasty.
VINAY KUMAR SINGH: Now the second thing you move on is. Swelling, so notice for any swelling now, the common swelling that you will see in hand or ganglion so ganglion can present across the wrist, which I have covered in the wrist examination video you can have ganglion in the back as well. Now the other uncommon swelling are you can have giant cell tumor of the tendon sheet.
VINAY KUMAR SINGH: They can also present as swelling in the hand. Now, nodules of sometimes if you see swelling in the hand across the palm and pitting those swelling or nodules are usually related to Putin's disease. You can have sometimes inclusion cyst, which can present across the fingers or retinaculum cyst. They can present there. Not uncommon swelling can be lipoma, or fibro, but they are not very common in hands.
VINAY KUMAR SINGH: Now, the other swelling that you will see are usually related to arthritis. So if you notice swelling of the distinctive l'engle joint, then it is a habitant node. And if you notice a swelling across the proximal deferential joint, then it is the Bush nodes. So see the swelling when you are inspecting. So these are the commonest swellings that you will see. Now, once you have looked at the skin you have seen for any swelling, then I move on to any muscle wasting.
VINAY KUMAR SINGH: The muscle wasting that you need to look for is this thenar muscles, which are supplied by nerve. These hypertine muscles, which are supplied by median nerve. Also the small muscles of the hand, especially the first dorsal interossei, which is also supplied by the nerve. Now, if there is any wasting of thenar muscles. Especially abductor policies, brevis here and the wasting, you appreciate more when you look at this, so develop a habit of looking at the swelling in this form.
VINAY KUMAR SINGH: And in this form. So in this way, you will be able to appreciate minor wasting and that can point towards uh, the median nerve pathology. A lot of times you will see wasting of muscles if somebody has got severe degenerative changes at base of thumb, and that is because of the lack of use. So these are,
VINAY KUMAR SINGH: so you look for the wasting of our muscles. Similarly, you look for wasting for hypertension muscles, and that can point towards the ulnar pathology, as I said before. So when you have wasting of hypertension muscle, and if somebody has what wasting of some forearm muscles and has got positive signal at the elbow that can suggest towards the pathology. The other thing that you also need to look when you are looking for ulnar pathology is wasting of the first dorsal intro.
VINAY KUMAR SINGH: So if you look at both my hands, if I attached my thumbs together, you will see this is my dominant hand. So that is why this is more prominent here. It is less prominent, but there is no wasting. If I show you in this profile, this muscle is first dorsal interrossei. If you see any wasting of this muscle, then that indicates towards a learner involvement.
VINAY KUMAR SINGH: Also, in advanced stages, you will see guttering. So if you have guttering of these metacarpals or in between metacarpals, then that also indicates towards the learner pathology. Now, so these are the things that I would look for wasting in terms of thinner and hyper-thinning muscles, which will give me an indication towards any other problems. But once you have looked at the atrophy of the muscles for looking for any cause of nerve involvement or other causes that may lead to the wasting of these muscles, then you move on to the deformity. Now deformity, the three commonest deformity that I would like to talk about.
VINAY KUMAR SINGH: First is this swan neck deformity, the sore ampo deformity and the maller deformity now. So swan neck deformity. If I show, try to show it on my finger, I'm not that flexible. But swan neck deformity usually has got hyperextension of the proximal interferon joint and flexion at the joint, and this is usually seen in somebody who has got a wooden plate injury. So swan neck deformity I will is hyperextension at approximately helensville joint and flexion at the distant joint.
VINAY KUMAR SINGH: Now, the second deformity is called continuous deformity, so it will present something like this where there is flexion of the approximate differential joint, an extension or typekit extension at the distance joints. If I show you in this profile, this is how it will manifest. Now, central slip is a commonly injured but uncommonly appreciated. Now, when I was a trainee resident, I missed once a center slip injury and I treated her with a body strapping.
VINAY KUMAR SINGH: And three weeks later, that girl came with her Petito's deformity. And that was the last time I missed a central slip injury. So I've uploaded a separate video on lucentis. So do learn what lucentis, and I will cover in this video as well. So any injury in this area? Don't take it lightly. It might be central slip injury.
VINAY KUMAR SINGH: So this is the buttonless deformity. Now, the last thing, the last deformity that a common deformity is what we call a mala deformity. So minor deformity will present something like this if I show you in this profile. So there is only flexion, at least in the fillings and joints of flexion could be mild. It could be a bit more or it could be quite a lot. So this is my deformity.
VINAY KUMAR SINGH: This is usually due to either rupture of extensor tendon or stretching of extensor tendon, or sometimes a bony mallet due to a small bony evolution in the back. So these three deformities are extremely common, and I have shown you what to see in these deformities. Now, the other common deformity that you might see is what we call a clawing, and I will cover that later in this video as well.
VINAY KUMAR SINGH: So clawing will present something like this. So if in this there will be extension of the metacarpophalangeal joint and the reflection of proximal, as well as the distinctive l'engle joint. Now, other causes may also lead to deformity such as the uterus, such as burns, such as post traumatic contraction. I will cover that later in my video in the detail. Now the last thing if somebody has got history of trauma and is complaining of pain across the metacarpals, what I do is what I would advise you is to see your metacarpal in a tangential profile.
VINAY KUMAR SINGH: So if you see my hand metacarpal in tangential profile, you can see that I want you to focus on my ring finger. So if you see metacarpal head on, my left hand is far more prominent than this side, so focus here. This is flat, and on this side, you can see that it is not that flat. And the reason is because I broke this metacarpal while playing cricket, and this is healed by slight shortening.
VINAY KUMAR SINGH: So any shortening of the metacarpal will manifest itself in form of flattening of the knuckles. So if you can ask somebody to just do this and look at it tangentially, you will be easily able to diagnose boxer's fracture or fracture of the metacarpals. And if you can pair it with the normal side, you will see flattening. So this is the last thing I will do.
VINAY KUMAR SINGH: Before I move on to the palpation. So you have done your inspection, then you move on to the field part of the examination. So the first thing you can do is look for any local temperature. If there is any raise inlocal temperature, that could suggest inflammatory or infective pathology. Now, a lot of pathologies of the hand sorry of the wrist are covered in my wrist examination video so I am not covering those areas.
VINAY KUMAR SINGH: But in terms of palpation, it's always a good practice to ask the patient where is the pain and come to the painful area in the end. But in essence, you look for palpation of each individual bones and look for any tenderness. So you look for metacarpal proximal differential joint list and fill in the joint and you do it, do it very systematically so that you don't miss out anything.
VINAY KUMAR SINGH: Same for thumb, you can examine the base of thumb IPG proximal. Failings in the engine joint and the steel filings, so go systematically, sometimes if a patient gives history of a triggering, then you can feel the individual even pully and see if the patient is complaining of any tenderness there, and you can always sometimes feel nodule. And part of the palpation good practice to feel for both radial as well as a ulna artery.
VINAY KUMAR SINGH: Now, because I am already feeling for radial as well as ulnar artery, if at all, I have any doubts about any vascular cause. I would do an alan's test at this point of time. So let me tell you what alan test is. So if you're doing an alan test as a part of feel, you feel for radial pulse, you feel for a nerve pulse, you keep the hand subordinated. And once you feel for both radial and ulna pulse, just obliterate them and ask the patient to open and close and a few times.
VINAY KUMAR SINGH: And once. And the hand is completely white, then you release at the time, I have at least radial artery, so you can see the hand is becoming red. That tells me that the radial artery is functioning very well. Same way. I will repeat it and then I will release my ulnar artery and then hand will go pink.
VINAY KUMAR SINGH: So this will tell me about patterns of both radial as well as a large artery, usually in the majority of the patients ulnar artery is the main artery to the hand. At this point of time, I will also check for sensation at the tip of the index finger for median nerve tip of the little finger for ulnar nerve and first web space for any radial nerve involvement. In part of palpation, you can also feel for any obvious cause which can be present in decroutements such as spiral coordinated record or commercial record, which is seen in between the index and the thumb.
VINAY KUMAR SINGH: So that would be my palpation complete. So once you have done the palpation or feel part of the examination, then we move on to the movements. So let's first focus the metric up of l'engle joints. If you see metacarpal interphalangeal joint is bending roughly up to 90 degrees, so this is the maximum flexion. So it's measured bending up to 90 degrees. But it hyper extends so finger can go backwards if you can see this is hyperextension.
VINAY KUMAR SINGH: So even if the finger can be extended up to neutral, that also means that we have lost some extension. So metacarpal interphalangeal joint is from almost minus 40 to roughly 90 degrees of flexion. So now let's focus on proximity to phalangeal joints, if you see I can extend. So the movement of proximity for phalangeal joint is from 0 to you can see this, this is 90.
VINAY KUMAR SINGH: This is going past 90, so roughly around 100 degrees of flexion. So if I show you the moment of the dipg, so IPG again can extend up to zero degrees, but if you talk about flexion, it flexes. If I show you in this profile, some fingers will bend up to 90 degrees. Some fingers will bend up to 80 to 90 degrees. So 80 to 90 degrees of flexion is normal range of motion of distant differential joint.
VINAY KUMAR SINGH: So now if I talk about movement at metacarpal angle joint of thumb, so it takes hyperextend slightly, maybe around minus 10 degrees. And then if you flex it, it flexes if this is the profile. So if this is metacarpal, if you can see it's flexing to roughly around 45 to 55 degrees of flexion. And if you look at the interval, you'll join in into filling joint, in my case, hyper. But it's not always the case.
VINAY KUMAR SINGH: Some people, it will be just about neutral. Some people it will extend in some people. It will extend more than others. So always compare the other side if the other side is uninjured. And in terms of flexion, again, you can see you can flex it up to around 80 to 90 degrees. So in terms of movements of the hand, the fingers usually flex and extend, they also abduct and attack so you can check these movements.
VINAY KUMAR SINGH: Now, in terms of movement of. Often the moment is slightly more complex, so finger flexion is this finger extension, is this finger abduction? Is this and finger eight action? Is this? Now, in terms of movement of the thumb finger flexion, is this finger extension, is this finger reduction or is this finger abduction?
VINAY KUMAR SINGH: Is this opposition is again, touching the other fingers. And if you move? You can circumduct. So these are the movements of the thumb. So once you have done this basic examination, now I will move on to the specific pathologies as how to identify these specific pathologies. So when we talk about specific pathologies, let's talk first about the flexors of the hand.
VINAY KUMAR SINGH: So when we talk about the tendons or the muscles, which are involved in movement of the hand, now, they are usually of two types. So there will be muscles which will come from approximately will cross across the wrist. And they will be inserted onto the various parts of the hand. These muscles are called extrinsic muscles. Now there are other muscles which will take origin within the hand and will be inserted within the hand.
VINAY KUMAR SINGH: These are called intrinsic muscles of the hand. So the first muscle or first muscle that I would like to cover. Let's cover the extrinsic muscle and we will start with flexor digitorum profundus, not flexibly. Now flexor digitorum profundus originates and comes as individual muscle belly, and then it crosses the wrist. Then it crosses the metacarpal phalangeal joint. It crosses the proximer phalangeal joint and then subsequently it crosses their distinctive joint and is inserted at the base of the distal filings.
VINAY KUMAR SINGH: Now, if you talk about the function, the primary function of this FDP or flex funders is to bend the distinctive joint. But because it is crossing all these joints when it functions, it would also function as flexor of approximately interphalangeal joint. Subsequently of metacarpal interference, the joint and subsequently of the wrist as well. So it is also a wrist flexor, but a very weak one.
VINAY KUMAR SINGH: So if somebody has got injury to its flexor distal and profondes, so how should we diagnose? So if somebody has got injury to the FDP, then how shall we diagnose it? So if you want to diagnose the deep injury, what you have to do is to immobilize. I usually put my hand my index finger over the proximal phalanx and distal or the middle finger over the middle phalanx, and I ask the patient to bend.
VINAY KUMAR SINGH: So if you can see this patient is able to bend this. Just at the tip, that means the FDP of the long finger is pretty good. Same way. Ring finger. Same way. Index finger and same way ring finger, now analogous to FDP and thumb is to flex their policies longer. So if you ask them to bend the tip, this means the flexible longest in thumb is working well.
VINAY KUMAR SINGH: So the second tendon that I would like to cover is FDS. That is flexor superficially. So if you ask somebody to bend the finger, then you cannot be sure whether FDS is intact or not. The function of FDS is to bend the middle or the proximal joint. However, because as I said, FTP also crosses this joint. It acts as a secondary flexor for this. So what we need to do is we need to eliminate the function of ADP, so I'll show you how to do it.
VINAY KUMAR SINGH: So what you want to do is because they work together, so you want to eliminate FDP or FDP. So what you do is that you hyperextend the disdain differential joint like this. So that any function of FDP is completely eliminated. So you hyper extend, if at all. If you do not hyperextended, you can at least put it and then ask the patient to bend. If I show you in a volunteer, if you can, if I'm testing the middle finger in the middle finger, that means the PhDs to this finger is working fine if I want to check the ring finger.
VINAY KUMAR SINGH: So that's fine. If I want to check the index finger, that's fine. And lastly, this. So now he's not able to bend his little finger proximity to interphalangeal joint. And this is. And this can be normal because 15% of the patient will have either absent or a rudimentary. As to the little finger.
VINAY KUMAR SINGH: So if I show you my hand, I'm able to bend it. However, my volunteer was not able to bend because of presence of a rudimentary or absent PHDS, so this is extremely important. Don't be. This can. What I want to say is that if there is no flexion at approximately falintil joint, it can be normal in 15% of the patients if it is just the little finger.
VINAY KUMAR SINGH: So once you have assessed your flexor funders and flexor superficialis and flexible, as long as I think to extend the muscles, which are important is flex capillaries on the other side and flex by less on the radial side. Now, as I said before, because FTP and PhD as they both cross the rejoint and they can be a weak flex of the wrists if they are able to do some reflection.
VINAY KUMAR SINGH: And that doesn't mean that they have to flex the carpet and radial is as intact. So in order to assess this, how do you assess? It's extremely easy, you ask patient to palmer flex if you just ask patient to palmer flex. And then you feel FCU, you will feel bow stringing there, and it will also feel bow stringing there. So this bowstringing is next to the radial artery and this big thick tendon that you can see is a flexor didgitalis.
VINAY KUMAR SINGH: And this one you cannot see it is like polaris, not flex. This is attached to the base of fifth meta carpal, radial is attached on second and third. So the other option is to just put your hand on second and third metacarpal and ask them to bend. This becomes more prominent and same here. Put your hand on fifth metacarpal and ask them if you can feel this bow stringing and
VINAY KUMAR SINGH: that means these tendons are intact. So the last tendon, which is also an extensive muscle, is palmer extendus, as long as usually it's not of great functional importance, but it can be extremely useful tendon in tendon transfers. The easiest way because it attaches onto the palmer fascia. If you ask the patient to cup, you will see this tendon, which is predominant.
VINAY KUMAR SINGH: This is palmaris longus. Now it is absent in around 10% to 15% of normal population. So my subject today is one of the junior residents here. If I ask him to cup, you can see that nothing is coming up. So he's the same student in which the base of the little finger was also absent and his palmaris longus is also absent. So we have now examined the extrinsic that is all the flexors, extrinsic of the hand.
VINAY KUMAR SINGH: Now we move on to intrinsic. Now intrinsic, most people will think in usually involves your interossei both dorsal and palmar and lumbricals. However, as I said before in my description that all muscles which originate and insert within the hand are intrinsic so that will include muscles of thenar and hyper thenar muscles. So we'll cover as how to examine them. So now, lumbricals, they originate from FTP from the radial side.
VINAY KUMAR SINGH: And similarly dorsal in palmar interossei, they originate from the metacarpals and they all attach on this extensive hood. So as the function of these two intrinsics is, what they do is they flex the metacarpophalangeal joint and they extend the interphalangeal joints. This is so this function. If I show you like this, this function is being done by intrinsic.
VINAY KUMAR SINGH: Now we also know that intrinsic are also responsible for abduction, as well as a reduction of the fingers. So how to test them? Now, whenever you want to test the intrinsic, you always should put your hand flat on a flat surface. And the reason I say this is because all long flexes, which are extrinsics.
VINAY KUMAR SINGH: They are hayreductors, so they are reductors. And the reason they are if I show you, if I ask you to make a fist. With finger abducted, you will see that you are struggling. As you close it. You, as you are abduct and close, you are able to close it much more easily. So the long, extensive flexors are abductors, so that is why you cannot make a fist with finger abducted.
VINAY KUMAR SINGH: Cannot make a fist with finger abducted. Similarly, when you extend the fingers, the extensive on the back, those are expenses. They are abductors. So secondarily, as you will extend, fingers will automatically abduct. But if you want to extend your fingers with fingers together, you will have to work hard. I'm really struggling.
VINAY KUMAR SINGH: I will ask you to just try it on your own, so extend the expenses or abductors. So just to eliminate these functions of long flexes of expenses, as well as long extensor, which are extensive, is to ask the patient to spread the. Um, hand put the hand on the flat surface and abduct and abduct, you can do it actively, you can do it against the resistance.
VINAY KUMAR SINGH: One thing you will see is as you abduct and abduct, everything is moving except for the middle finger. So to check the middle finger. You ask middle finger to be moved separately. And this is how you examine the intrinsic of the hand. Now, the other intrinsic which are left are the muscles of the thenar muscles and hyperthenar muscles. Now the hypothenar muscles and thenar muscles, they have an abductor, they have a flexor and they have one small muscle for a position, each of them.
VINAY KUMAR SINGH: Now, to check the muscle on the thenar side, usually what you are assessing is assessing the function of the motor branch and motor branch, which originates. So usually if you bend your index finger, sorry ring finger, where it touches the thenar muscles usually is a site where you will find the motar branches originating, or you can draw a vertical line from your first or sorry second inter-web space.
VINAY KUMAR SINGH: So it starts giving supply to the opponents and then flexors and then abductor see if the patient can abduct against resistance, and if patient can abduct, that means the abductor is functioning well and that tells that you're. These three muscles are functioning well, because if the abductor is functioning well, the chances are that the two are functioning well as well.
VINAY KUMAR SINGH: And the same thing in hyper-thenar muscles. So you should check all these muscles and once you check, you have now checked all the exstentics as well as intrensics of the hand. So now, once you have examined the flexors and I'll move on to the extensors, the extensor tendon is extensor digitorum in-communis, so it start as a common muscle belly and then divides into force.
VINAY KUMAR SINGH: It crosses the metal club of the rejoint carpometacarpal joint. And then later on, it does go over the proximity of a join in form of central slip and then subsequently attaches towards the base of the distal filings. Now how to examine the extensor bisram communis. Now in order to check the function of the sensors or to extend, of course, the wrist, the and carpo-phalangeal joint and inter-phaleangel joint.
VINAY KUMAR SINGH: Now, the extension function is extremely important because if you have to grab something until unless you can extend, you will not be able to grasp. So for grasping purpose, extension is extremely important. Now, if you want to assess the extensive disturb communists now, as I said, it will extend the metacarpophalangeal joint, but it will also extend the approximate differential as well as the strength of joint.
VINAY KUMAR SINGH: But as you would have heard a few minutes ago, when I was talking about our intrinsic of the hand there, they can also cause extension of the proximity of joint. and the phyllangeal full engine joint, so how do you differentiate it? The only difference is that when you have intrinsic with flex, the metacarpal phyllangael joint, what our extensors will extend. So if you keep the hand extended onto the flat surface, you are eliminating actions of the intrinsic.
VINAY KUMAR SINGH: So if I want to check my extensor disturb communists, all I need to ask is to lift the finger up. As I said, the movement is almost 40 degrees of hyper extension, so if I show here. So this is the flat surface. You can see I'm able to extend this action can only be done by extensor this term communist, so this is how you would test it.
VINAY KUMAR SINGH: But as you know, nature always poses challenges, so things are not so straightforward, because now you have got separate extensors for index finger and separate extensor for little finger as well. So you have extensor indices, appropriées and extensor district districtwide, which are independent muscles and are responsible for extension of the index, as well as little finger. So how do we assess the movement of these two thing to separate muscles, which are independent?
VINAY KUMAR SINGH: Now, if you want to test them separately, then the only way to do it is to eliminate the action of ADC. So how do you do it? So make a fist. And then extend the resort now you are holding the EDC, so EDC cannot move. So if I now ask you to lift the index finger, you will still be able to do it. And that tells that extensor industries proprios or extensor indicis for this index finger is still working.
VINAY KUMAR SINGH: So if somebody can extend despite holding all these three fingers together flexed, that means it is working. And similarly, for little finger, you can still do it. However, if I hold everything. So if a patient is able to do this, that means these two tendons, which are separate are also functioning well. Now, there are three other important extrinsic extensor tendons, which are important, which I have not covered and they form the anatomical snuff box is one is the extensor pollicis longus and the other two are abductor policies, brevis and sorry objective policies, longus and extensor pollicis.
VINAY KUMAR SINGH: Previous now these two tendons, how do you assess these three? See if I can just ask you to just hitchhike, just put up and then feel the bow stringing. You will feel two tendons here and one tendon here. That means that these two are functioning well because one of them attaches at the base of the metacarpal and attaches at the metacarpophalangeal joint. So hitchhike, do this feel for these two tendons?
VINAY KUMAR SINGH: Define now how do you test extensor pollicis longus now? Extensor pollicis longus is the only muscle which is responsible for rate propulsion. So that propulsion means if I'm able to lift my thumb up from a flat surface, see, just keep your focus here. You will see this tendon becoming prominent. So if I'm able to retro pulse, then you will see this intact tendon. So that will cover the extensors of the hand.
VINAY KUMAR SINGH: So now we have covered how to test the flexors and sensors of the hand. We also talked about the small muscles or the intrinsic of the hand. Now the next condition that I would like to move on, which is also related to one of these muscles or group of muscles, is called intrinsic tightness. So what is intrinsic tightness and how do you diagnose intrinsic tightness?
VINAY KUMAR SINGH: No intrinsic tightness, as the word itself means that your intrinsic are tight. That means they will be functioning more than their usual. And as you know, previously I said the function of intrinsic is this. So what intrinsic does is the cause flexion at the metacarpophalangeal joint and extension at these small joints now due to neurological injury or due to scarring after trauma, your intrinsic can become tight.
VINAY KUMAR SINGH: Now, if you look at the flexion of proximal to the joint, if I show you flexion of the proximal phyllangeal joint in different degrees of metacarpal phyllangeal joint flexion. If you see here. It seem it is not affected by position of metacarpal phyllingeal joints, so the deflection remains same irrespective of what is the position of metacarpal phyllingeal joint.
VINAY KUMAR SINGH: Now this is normal. So in a normal patient flexion at intervals, the joint will remain same irrespective of flexion. What is present at a couple of joint? So now the test that we use to diagnose intrinsic tightness is called bunnell's test. Now what we do in bunnell's test is we check for flexion of inter-phyllingeal joint with MCP flexed when MCP is flexed and intrinsic tightness.
VINAY KUMAR SINGH: You will be able to flex the fingers at inter-phyllngeal joint. However, finger deflection is checked after extension, because once we extend, it is becoming more tighter when you flex proximity of phyllingeal joint, it will not flex and it will flex much less. So this is a positive test that is suggestive of a tight intrinsic. So just to repeat again, when you flex it, you will be able to bend IPG easily or it will bend more when you extend metacarpal phyllingeal joint, you will struggle.
VINAY KUMAR SINGH: Now, opposite of intrinsic tightness is extrinsic tightness. If there is scarring or shortening of the long extensors, then it will just be opposite to what you see. So now just imagine these extensors are tight. If these extensors are tight. And then if you are extending the metacarpal phyllingeal joint.
VINAY KUMAR SINGH: And what it is doing it, it is just relaxing the extensor slightly. So when it is extended, relaxing the extensor slightly in this position, the IPG in this situation will bend more. However, if the extensor is already tight and if I'm flexing the metacarpal phyllingeal joint, what it does is it is tightening this even more. And in this position, I will not be able to flex the proximal phyllingeal joints, so it is just opposite.
VINAY KUMAR SINGH: So if an extensive tightness in extension of metacarpophalangeal joint, you will have more flexion as you flex it, you will have less flexion at proximal differential joints. So this is extrinsic tightness. So now the other uncommon or relatively rare condition I would like to discuss, which is called a lumbrilicus finger shall talk about what is lumbrilicus finger and what you will see clinically and how will you diagnose it clinically?
VINAY KUMAR SINGH: So lumbrilicus is a clinical condition, which is usually due to disruption of flexor fundus and distal to the origin of lumbrilicals. So the disruption of FTP tendon will happen once the lumbrilicals have originated and as we talked before, they originate from the radial side. So any disruption secondary or later after the origin will lead to lumbrilicus finger. And this can be seen in distal transaction of FDP, whether there is any evolution.
VINAY KUMAR SINGH: You can see it in this inter-phyllangeal joint amputation. What amputation through the middle phalanx, or sometimes if you have put a graft and the graft is too long. So in these conditions, you will see lumbrilculus plus. So what you will see clinically in lumbriculus plus finger. So lumbriculus plus finger is a rare diagnosis, and I must confess that in my long orthopedic career of roughly 20 years, I have not seen a patient of lumbriculus plus finger.
VINAY KUMAR SINGH: However, what you will see is that once you try to flex the inter-phyllingeal joint, there will be paradoxical extension of the inter-phyllingeal joint of the extended finger. So if I'm trying to flex my finger, this will paradoxically extend. So when I'm trying to flex it, say, for example, there is a tendon cut in the middle finger, I try to flex my hand.
VINAY KUMAR SINGH: But this will go in paradoxical extension. And this is because the vehicle will pull the lateral bands. And what it does is as they pull the lateral bands, it causes the paradoxical extension of the inter-phyllingeal joint proximity to the joint. And because of the un, there is no action of flex performed as distally. So paradoxical extension when you're trying to bend, the IPG is characterized in lumbriculus plus finger.
VINAY KUMAR SINGH: Now, moving on to our next condition in continuity with the various pathologies that are already talked to make it more complex, we'll talk about intrinsic minus hand or in layman's terms, you can also call it as a claw hand. And this is usually due to weakness of intrinsic. So as it is intrinsic, minus means you are intrinsic so weak or have got strong extrinsic. So if you've got strong extensor, that will lead to a clinical condition, which is called claw hand.
VINAY KUMAR SINGH: Now you will see these conditions, especially if there is involvement of a learner. You can see also involvement of median nerve or sometimes involvement of both other conditions that you will see is if there is any issue with the brain, sometimes in people with stroke. If there is a balance between extrinsic and intrinsic and if intrinsic becomes weak, this leads to a claw hand or intrinsic minus hand.
VINAY KUMAR SINGH: So if you see here an intrinsic minus hand, we talked about the deformities, so if you see an intrinsic minus hand, extrinsic, so strong. So there is extension at metacarpophalangeal joint. So there is extension of carpometacarpal phalangeal joint now intrinsic are responsible for keeping these two joint straight, now because intrinsics are weak and extensors are overpowering. Then what it does is there is a reflection of both proximal as well as this general angle joint.
VINAY KUMAR SINGH: So this leads to a clinical condition which you will see clawing. So this is a position of a typical intrinsic minus hand. So now let's move on to our next condition. I think most of the orthopedic surgeons would have heard an effect, which is called quadriga effect. So now let's talk about quadriga effect. Now, quadriga effect is usually because, as we said before, that FTP has a common muscle belly.
VINAY KUMAR SINGH: So they work as a team, so if one of the team members is affected, the other will be affected as well. So if FTP is stuck down or there is an addition or there is a decrease excursion of FTP, then it will lead to quadriga effect and to talk about it, I will show you in my hand. So they said quadriga effect is usually seen due to scarring or addition of the FTP tendon. Also, if there is greater than 1 centimeter advancement of typekit tendon in case it is injured.
VINAY KUMAR SINGH: Now, as I said, they all work as a team, so if one is affected, then others will be affected too. Now, for any reason, say, for example, if the FTP of the middle finger is there is rotation and it is not able to bend properly. Now, the excursion of the rest of the tendon is pretty much dependent upon the excursion of the fingers, which has got the shortest excursions. If one finger has reached its maximum excursion, then that will act as a limiting factor for other fingers.
VINAY KUMAR SINGH: So what I mean by that is because of scarring if I'm able to bend because as you know, it crosses MCP, IPG as well as. The IPG for any reason, if I'm able to bend my middle finger detrusor due to scarring, then for me to bend the rest of the finger completely is next to impossible. So this is quadriga effect, and this leads to the weakness of the hand grip, and that is the reason we talk so much about being aggressive with physiotherapy to get the full range of movement.
VINAY KUMAR SINGH: Because if one finger gets stuck. And if one finger doesn't have a full range of movement. And because of it, there is excursion a decrease in excursion of the other fingers, then it leads to weakness. So just talk about again, if for any reason, if I'm able to bend this finger due to scarring irritation only this much, there is no way I will be able to make a full grip.
VINAY KUMAR SINGH: You can try it. You can try it until unless this comes completely within or reaches its maximum excursion. The rest of the fingers are also limited. This is quadriga effect. So now we have covered a lot of areas, which confuses surgeons and other, practicing doctors and physiotherapists, I have tried to cover that earlier so that you can eliminate your confusion.
VINAY KUMAR SINGH: It brings some clarity to your thought. Now let's cover some easy topics, and the first one I would like to talk about is trigger finger. Now, as the name suggests, you will notice triggering. So the patient will report catching, clicking or sometimes a patient will be able to bend the finger. And as it extends, you will hear they will report clicking. When it gets worse
VINAY KUMAR SINGH: sometimes they are able to bend it, but when extending, they have to use the other hand to extend it in later stages. This can remain flexed and even if you try, it doesn't extend. So how to diagnose trigger finger? It's extremely easy. If I show you in my hand. So trigger finger you will diagnose purely on history and the patient reports as a typical history of clicking, and it can affect anything, all the fingers can be affected.
VINAY KUMAR SINGH: And it's usually more common in diabetics and diabetics you will see it to be affecting more than one digit and sometimes bilateral as well. Now how do you locate even fully, even fully if you draw a distance from here to here? And the same distance from here to here, it's usually where they even police, if you feel safe, for example, if the patient has got triggering of the middle finger as you press across this region, he will or she will report pain and discomfort.
VINAY KUMAR SINGH: Also, you will feel its thicker and you can have a nodular feeling in that region. And if you put your hand there and ask them to extend, sometimes when you ask them to flex or extend if you see catching, that is a giveaway sign. So in earlier stages, just pain and tenderness in this region can be is more than enough for you to diagnose a trigger finger. Similarly, in thumb, if you have pain and tenderness across the metacarpophalangeal joint, that is where the police and you will feel tenderness and in order feeling, and that would suggest that the patient might have triggered some.
VINAY KUMAR SINGH: So now let's move on to another easy clinical condition to diagnose, which is called Duputren's disease. So Deputren's disease is a fibrous proliferative disorder, which which involves the palm of fascia. Now, the history is quite typical. A patient will usually give a long history of swelling and pitting of the skin, which is associated with deformities of the fingers. Now they can be unilateral, they can be bilateral, and they can affect other parts of body, such as feet or a penis in males.
VINAY KUMAR SINGH: So you should be mindful and you should look for other sites as well. Now how to diagnose it, it's very easy. And let's cover that now. So now the characteristic finding that you would see when you look on the palmus side, is you will see nodules. You will see pitting if you see small holes that is because skin is being pulled by the palma fascia, which is being contracted.
VINAY KUMAR SINGH: So if you see pitting and swelling and you will see cords, if you can see these cords in this region, then that is give away a sign for Depuytren's disease. Now you have to feel for the different cords that you see, like spinal cord here in between fingers. If you feel here, sometimes you will feel it. It records, which is responsible for addiction deformity, rarely in aggressive disease.
VINAY KUMAR SINGH: If you put your hand in this area, if you feel something like a bow string that is commercial cord and that suggest if there is radial involvement usually suggests the disease is more aggressive in these patients. So if you have cords, if you have swelling and simultaneously, of course, you will have deformity. The deformity can usually involves metacarpal phyllangeal joint.
VINAY KUMAR SINGH: And any later stages can involve approximate phllyngeal joint. In certain group of patients and approximate phyllangael joint can also be affected at an early stage. Now, in back of the hand, you will see Garrett's spots. If you see it spot, then that is also suggestive of the Duputren's disease. So as I said, you will have deformity in volume, metacarpal phyllangeal joint and proximite phyllangeal joint. Now how do you assess the deformity?
VINAY KUMAR SINGH: Now a lot of people find it quite difficulty in assessing the deformity. Now see, for example, if there was a deformity of there was a flexion deformity of proximal phyllingeal joint. Now, if I want to assess the deformity of proximal phyllingeal joint, what you need to do is you just need to flex them at a couple of joints and you will see a lot of times as you flex it.
VINAY KUMAR SINGH: This will become straight. That tells that there is no flexion deformity of the approximate phyllingeal joint. However, if you flex it and still it remains like this, then that will tell that yes, there is flexion deformity. But I can guarantee you a lot of times when you flex it, you will see this is becoming straight suggestive that it is not involving the proximal phyllingeal joint. Now how do I assess the deformity at the metacarpal phyllangeal joint?
VINAY KUMAR SINGH: So when, as I said, when you are assessing pip, you need to flex the MCP when you are trying to assess the deformity of CPG. You need to flex the pipe. So now I have flexed it and then I will take it front and back because this is a normal patient. You will be able to extend up to 90 degrees. So you can see this is almost 90 degrees in early part of the carrier.
VINAY KUMAR SINGH: A lot of trainee doctors and doctors who are training, they will be able to extend it up to here and they will say, OK, now it is extending up to around minus 30 degrees. So there is no deformity. No, that's not true. You can extend this up to 90 degrees. So even if even after passive extension, if you are coming up to here, that means still there is a loss of 70 degrees in this particular joint, so you will individually assess each joints, which are affected.
VINAY KUMAR SINGH: Now, the one common thing that patient will ask or which patient, which might help you in making a decision whether to operate or not, is called a tabletop test. So in Tabletop test is a very simple test. You ask the patient to put hand flat if the patient can put hand flat on the table. That means the deformity is little and it is correctable. And in those cases, you don't need to operate.
VINAY KUMAR SINGH: So again, if I can put my hand flat on the table and. That would suggest it's a negative test. That means you can treat it with non operative methods, but do want the patient that if deformity worsens to come back and revisit you. Now, one common thing that might confuse you is how to differentiate between somebody who has got footprints or somebody who has got close hand now in your hand.
VINAY KUMAR SINGH: As I said, it's an intrinsic minus condition. So there will be extension of metacarpophalangeal joint and flexion of proximity flange will join. And Dupuytren's disease there is always selection of metacarpal, phyllingeal joint and associated flexion of to phyllingeal joint if there is deformity of proximate phyllingeal joint. So this is the only way to differentiate. So MCTDH extended and intrinsic minus or claw hand and FPGA flexed in other conditions, which are not claw hand and Dupuytren's are one of them.
VINAY KUMAR SINGH: So let's not talk about keeping onto the team of contractors, the contractor of approximately phyllingeal joint, leading to a flexion deformity of approximate phyllingeal joint after trauma. Now hand, as I said, is such a versatile organ that you use it for your day to day activities and that makes it more prone for injuries. So if there is any injury to the proximate phyllingeal joint and if there is contraction of the ligaments and the waller plate, that would lead to flexion deformity of proximal phyllingeal joint.
VINAY KUMAR SINGH: Now the characteristic finding of a pip contraction due to injury is that there will be restriction of both active and passive movement. So it's not just that patient cannot move it. Even if you want to move it, there'll be no change in range of movement. So that is the first give away. That active and passive movement are pretty same. And also the second thing is that the pip movement is not related in any way to the position of MCAJ.
VINAY KUMAR SINGH: In normal hand, you can flex it to any degrees irrespective of position of CPG in a contracture as well, irrespective of position of CPG. The range of movement in the proximal interphalangeal joint will remain the same, so the range is remaining the same. Then it is suggestive of post traumatic contraction of pipe. So now let's move on to the ligament injury, which is called gamekeepers thumb now gamekeepers thumb is injury to the ulnar collateral ligament of metacarpophalangeal eye joint of thumb.
VINAY KUMAR SINGH: Now I have made a separate video, which is purely based on what to examine and how to diagnose this on a patient which had injury. So let's talk about it in brief. So you have two sets of ligaments. One is the accessory collateral ligament and one is the proper ulnar collateral ligament. And then you have boilerplate as well. Now if?
VINAY KUMAR SINGH: If you want to do an examination for a gamekeeper, some which is usually acute due to trauma, occasionally it can be chronic nature. What you need to do is you need to assess the thumb both in extension as well as in 30 degree of flexion. So now there are two sets of collateral ligament, as I said, as accessory collateral ligament. It provides some stability with metacarpophalangeal joint in extension, the proper ulnar collateral ligament in 30 degree of flexion.
VINAY KUMAR SINGH: Now, if there is injury to only proper collateral ligament, the thumb the pinch can still be a stable pinch. Despite injuring the ulnar collateral ligament. However, if you do a valgus force and this is opening even in extension, then that is a really bad news because that tells that not even the proper collateral ligament, but also accessory. Also, possibly the boilerplate is also gone. But if you want to assess or examine the ulnar collateral ligament, then if I show in my thumb, you need to bend it around 30 degrees.
VINAY KUMAR SINGH: Once you bend the MCP joint to 30 degree, what it does is it unlocks the joint and then you apply. I'm a valgus force, and if there is pain or there is tenderness or if there is opening, that would suggest that ulnar collateral ligament is gone and that would be suggestive of a game. Skip your thumb. So now let's move on and talk about the deformities, I think the three deformities that I would like to talk about as the swan neck deformity that I showed you earlier in the video, the boutonniere deformity and the mallet deformity.
VINAY KUMAR SINGH: So let's talk about the boutonniere deformity first. Now, as I said, usually boutonniere deformity after trauma is seen due to injury to the central slip. Now, a lot of Orthopedic Surgeons take injury to the soft tissue injury across the proximity phyllingeal joint quite lightly, and I've seen that body strapping or some form of immobilization is the usual prescription. However, occasionally you will get your hands bound and a patient with central slip injury will later on come and manifest itself in the form of a continuous deformity.
VINAY KUMAR SINGH: Now, I have already uploaded a separate video purely focusing on Elson test as how to interpret it, but just to make this video, complete will cover it again briefly. So now Elson test is an extremely useful test for diagnosing central slip injury. So for you to do the health and test put hand flat on the edge of the table so that proximity phyllingeal joint can be bent up to 90 degrees.
VINAY KUMAR SINGH: So once the fingers are bent before doing this test, if you have swelling or bruising on the door, some that will suggest that there may be injury to the central slip. So for Elson test, you put a finger across the middle phalanx and you ask the patient to extend if the patient can extend. Because that is the function of the central slip and the distant familial joint is floppy, then that is a negative test, suggesting that your central slip is intact.
VINAY KUMAR SINGH: However, if the center slip is gone, what will happen is as the extensor there will be weakness and there will be paradoxical extension of differential joint, I think, to refer to the separate video that I have uploaded, if this is not clear here. So the second deformity that we talked about, swan neck deformity, was where there was extension of the proximite phyllingealjoint and there was flexion of this phyllingeal joint, and this is purely usually due to injury to the wooler plate.
VINAY KUMAR SINGH: So wooler plate, it is a very important structure which is present across the wooller aspect, and it is responsible for providing stability and preventing hyperextension at the proximal inter phyllingeal joint. So if this is weak or this is gone, what happens is the extentor, that they over-power, and there is compensatory extension of the proximal interphalangeal joint and flexion of this joint.
VINAY KUMAR SINGH: So now in terms of management, I forgot to talk about the management of the Dupuytren's deformity. If you are treating a particular deformity, then if you think the center slip is gone. And if you have any doubts, then put them in, put in your splint. So put in your splint is something. It's a splint which keeps the hand and keeps the finger in extended position, and this is a position in which it will heal.
VINAY KUMAR SINGH: So Google put in a splint and you will see this is how the position. I will usually keep it for around six weeks if it is a soft tissue and then progressively get it mobilizing. So nobody's trapping, putting a splint. If you are talking about swan neck deformity and if you're worried about a wooler plate injury, whether it's a bony boilerplate or whether it's soft tissue boilerplate, what you do is an extension block splint so patients can flex but cannot extend.
VINAY KUMAR SINGH: So keep it immobilized for roughly around three weeks. And after that, get it going. You don't want to be immobilized in more than three weeks because then that leads to capsular contracture and then you will have paraplegic contraction, which I talked in this video a while ago. So that's deformity that I would talk about is a deformity again, as I said. There is a flexion deformity of the distant phyllingeal joint, and this is due to either extensor tendon being injured or becoming stressed, or there is a bony evolution.
VINAY KUMAR SINGH: These are usually three common things that will happen, and it's very easy to diagnose. There is a typical history and a deformity, which in initial stages is possibly correctable. So all I do for soft tissue mallet injury, I will keep the finger in mallet splint for around six weeks. 24/7 That is, you are wearing it day and night, and after six weeks, I will keep them for nighttime only for four to six weeks.
VINAY KUMAR SINGH: If it's a bone injury, it heals quite quick. So I'll keep them in my splint for roughly around three weeks and after three weeks, I'll get them going. So now let's move on to some now pathologies such as carpal tunnel or cubital tunnel. So carpal tunnel how there is compression of median nerve at the wrist and patient will typically give history of pins and needles, especially during the night times.
VINAY KUMAR SINGH: Patient might wake up in the morning with numb fingers, and any repeated activity during the day can lead to numbness in later stages. When they start to experience weakness, then they will report dropping things so they think they are holding something, but they'll start dropping things. Now, how to diagnose it, I think majority of the times it is very straightforward.
VINAY KUMAR SINGH: If the patient is not having any neck pain and has got these typical night symptoms, then it's usually carpal tunnel. Now how, how to diagnose it. There are two or three things, and let's talk, talk it about now. So if you want to diagnose carpal tunnel, then first thing use, as you would do for any.
VINAY KUMAR SINGH: Look, I look for any particular wasting, so the first thing that gets wasted is abductor pollicis brevis. So this is the area that will start to become hollow now. Occasionally, mild weakness or mild wasting is very hard to detect. However, if you put your hand in this position and then a mild wasting of even thenar muscles could be appreciated. So if there is any wasting that will suggest that it is, maybe it is carpal tunnel.
VINAY KUMAR SINGH: Now you also check the sensation on the median of distributions. If you feel for sensation of the thumb index finger, middle finger and the radial side of the ring finger. These are the 3 and 1/2 fingers where patients usually complain of hypoxia. If you have hypoxia in this area, that is also complain, that is also indicative that it might be carpal tunnel. Now I will take this opportunity to talk about if somebody has got a say, for example, C5 C6 disk.
VINAY KUMAR SINGH: And how do you differentiate it from carpal tunnel? And occasionally, you can have double crush. It can be quite difficult. Now, hypoxia in carpal tunnel will only affect the tip of the fingers. This area across the tenaa eminence, which is supplied by palma cutaneous branch, which originates and goes on top of the carpal tunnel, will be normal. So however, you know, outer aspect of the forearm is.
VINAY KUMAR SINGH: So if there is a problem with the whole c-6 region, you will have hypoxia not only here or in the fingers, but approximately as well, and same way. You will have wasting approximately as well. If you are wasting approximately mayfair altered sensation proximally, then think of cervical spine, not carpal tunnel. So the one muscle that I would like to test in somebody with carpal tunnel is to check the power of abductor pulsas brevis.
VINAY KUMAR SINGH: So I we have talked about how to test it before, so I will ask the patient to bring his thumb to the index finger and push against it. And this is fighting very well. It's a good strength. Checking the power of objective pulses brevis is of extreme importance in patients with carpal tunnel. Now to do that in sign as there is median nerve is a compressive neuropathy of carpal tunnel.
VINAY KUMAR SINGH: We just do some gentle taps. And if the patient reports the electric sensation or reproduction of the patient symptoms, then that is a positive sign which is suggestive of carpal tunnel syndrome. Now, the one test that I would like to talk about is a phalen's test, and I'll show you how I do it. So now the typically phalen's test is being described that you keep your hands in this particular position and you wait for around 30 seconds for see if the patient has got a production of symptoms.
VINAY KUMAR SINGH: Now the sooner the hands starts to tingle, I think more severe the carpal tunnel is. However, I do my test slightly differently. So what I do is I just ask keep the elbow extended and then I flex the wrist like this and I'll wait for around 30 seconds and I'll do it in both the hands. So one hand acts as a control, or if a patient has got bilateral symptoms, then it will see the patient is having a reproduction of symptoms in typically involving the radial three fingers.
VINAY KUMAR SINGH: However, there are occasions you may have atypical findings that some patients will report. Some altered sensation is little and ring finger. They may have a simultaneous ulnar pathology, or most likely, it is due to abnormal connections in between the median and ulnar what we call Martin Gruber osmosis. So don't get thrown away. And if certain patients were just typical symptoms of carpal tunnel are there.
VINAY KUMAR SINGH: But if they have atypical distribution, that can be due to Martin Gruber osmosis. So I have already covered cubital tunnel syndrome in my elbow examination, it is very rare for ulanar to become compressed and across the wrist. However, if it is, then you will have wasting of hyper-thenar muscles and it will have altered sensations in the little and other aspect of the ring finger.
VINAY KUMAR SINGH: Now, if you have got wasting of hyper-thenar muscles, if you are wasting your first dose on interoceanic, if you have got guttering off in between the metacarpals and if you have got a positive tingle, as I have shown you, that is because of capita tunnel. So you may have problem in the elbow, but you may have manifestation in the hand, so be mindful of it. So now let's talk about some hand infection, so infection of the hand is uncommon, but can happen after penetrating injury, and sometimes it is not associated with penetrating injury.
VINAY KUMAR SINGH: So let's first talk about if you have synovial sheet infection of the fingers, how to diagnose them and how do they manifest? Sure so if there is a patient who comes to you with some pain, swelling and redness and difficulty in moving the fingers, then you should think of infection of the flexor sheet. Now, if you talk about the individual fingers, then you will normally see what we call.
VINAY KUMAR SINGH: Look for the signs of Carnival. That is, you will the finger will become more swollen. You will have a fusiform swelling. Also, finger will be in slightly flexed position because that's it. That is the position of comfort. And if you try to do passive extension, the patient will not like it and will complain of a lot of pain. A percussion across the flexor sheet, if it even gentle percussion will be extremely painful.
VINAY KUMAR SINGH: So if you have got these three or four signs, then you should think of a flexor sheet infection. And it is an emergency form if you are few of the very rare orthopedic emergencies which should be dealt even in midnight. So that uncommon infection that you will see will be infection of the thenar space, hyper-thenar space or the miss palma space. I would not go into the deep into anatomy that which sheet is connected with which space.
VINAY KUMAR SINGH: But in a sense, if you have got redness, if you have got swelling, if you have got pain, if patient is a pyrexia, a patient is unable to move on the hand and there is a lot of swelling tenderness, then that is give away a sign for infection. It's not a difficult condition to diagnose. So these are typical red flag for any other infection or also present in the hand.
VINAY KUMAR SINGH: So if you are, keep that in mind, you will be. We will be easily able to diagnose these and infections. And again, as I said on this for me, is an emergency and should be addressed as soon as. So the last part covering infection, I would talk about botanical infections, so that is infection. You will see across an nail fold, it will present a swelling and pain and are very easy to diagnose.
VINAY KUMAR SINGH: Occasionally, you will have infection of the pulse phase. So if this is too swollen and if you lose these ridges, which are present in the finger and if it is very tender to touch an extremely swollen. And that can suggest that it is infection of the pulse space. And again, it may require surgical intervention. So the last thing I think, which I have not covered are the deformities of the hand, which are present in rheumatoid.
VINAY KUMAR SINGH: I think that itself is a very vast topic and it will take me at least half an hour to cover that, which will make this video very long. But if I have a patient of rheumatoid, I will probably talk just about rheumatoid hand. In a separate video, which was this was an extremely elaborate video on how to do a hand examination. I have made an attempt to make it as comprehensive as possible and as easy as possible to remove any confusion that you have.
VINAY KUMAR SINGH: I hope after watching this video, it will make you more confident in doing hand examination. Like this video, give us a thumbs up, to subscribe and to share our channel. Thank you.
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