Thread by @d_ramonfaur

Careful evaluation of the hands 🤲 is a fundamental part of the physical exam.

What to look for?

A high-yield mega thread 🧵

Splinter hemorrhages:

Micro-hemorrhage of the nail bed capillaries. Trauma is most common cause. Also associated with vasculitis, antiphospholipid sx, and endocarditis in ~20% of cases. Look for concomitant fever, new murmur, neurologic deficits. They are most common in Black males. [1]

Leukonychia:

Can be caused by trauma and cosmetic products. Can also be 2/2 drugs like cyclosporine, sulfas, tretinoin or arsenic (Mees’ lines). May reflect underlying CKD or malignancy like Hodkins or Leukemia. [2]

Left: manicure trauma Right: CKD

Onychomycosis:

Fungal infection of the nail. Up to 14% prevalence! Higher with older age. Presents as smelly, thickened discolored nails. Risk factors: nail injury, diabetes, immunodeficiency, venous insufficiency. Mostly caused by dermatophytes (Left) or candida (Right). If present in hands, always check feet too.[3,4]

Nail pitting:

Small, round depressions in the nails. Usually associated with autoimmune conditions, classically psoriasis but also eccema and alopecia areata. [5]

Nail clubbing:

Round deformation of the tips of the fingers. Not a nail problem, but nails are affected. The etiology is not well understood but theories are capillary dilation and platelet deposition. Associated with chronic hypoxemia i.e., low blood oxygen. It is seen in cardiac right to left shunting, pulmonary disease like ILD and CF, and can also be a paraneoplastic phenomenon. [5]

Koilonychia (AKA spoon nails):

Concave deformity of nails. Classic finding in iron deficiency anemia, although less than 5% of IDA patients have this finding and it is not well correlated to severity. The most common cause is traumatic and occupational (exposure to solvents). It may also be associated with lichen planus and hemochromatosis, and may even be familial (genetic). [6]

Heberden and Bouchard nodes:

Distal and proximal interphalangeal joint osteoarthritis, respectively. Extremely common in advanced age. Risk factors include injuries and joint overuse. Caused by bone to bone friction and associated inflammation. Symptoms include pain, stiffness, swelling. [7]

Dupuytren’s contracture:

Not a true contracture, but a painless thickening of the fascia under the skin. It causes fingers to curl towards palm. Associated with smoking, alcohol use, malnutrition, diabetes and use of vibrating tools. Affects 4th and 5th digits more commonly. [8]

Pinprick fingers:

Pinpoint dark lesions from repetitive capillary glucose tests (dextrose stick). Commonly found in diabetic patients who monitor glucose frequently.

Diabetic cheiroarthropathy:

Stiff hand syndrome. Limited extension of the metacarpophalangeal, proximal, and distal interphalangeal joints. Associated finding is preacher’s sign, an inability to approximate the palms (photo). It’s presence suggests microvascular complications. [9]

Carpal tunnel syndrome:

A narrowing of the carpal tunnel that results in damage to the median nerve. Associated with diabetes, amyloidosis, hypothyroidism, acromegaly, CKD, or simply occupational exposure (desk jobs). Usually presents with pain and numbness of first three digits but no loss of sensation. Symptoms are reproducible by tapping the lower palm/ wrist (Tinel’s test). In it’s late phase it can result in thenar eminence (photo) [10,11]

Raynaud’s phenomenon:

Transitory decrease in blood flow to the fingers 2/2 vasospasm (Left). Spasms happen in response to cold or stress. It may be primary (isolated) or occur as a manifestation of another rheumatologic condition (Lupus, Antiphospholipid syndrome, scleroderma, Rheumatoid arthritis, etc.) Primary is present in 10% of the population. If secondary Raynaud’s is left untreated it may progress to finger ischemia and necrosis (Right). [12,13]

Ulnar deviation (Ulnar drift): A deviation of the ringers towards the Ulna at the level of the MCP joints (knuckles) (Left). This is chiefly associated with longstanding rheumatoid arthritis. It may be due to a combination of inflammation, muscle tone imbalance, and gravitational pull. Frequently found in combination with “swan neck deformity”(Right) [14-16]

Grotton papules:

Hyperkeratotic, flat, red papules with central atrophy on the metacarpophalangeal and interphalangeal joints with skin hypertrophy and periungueal capillary dilatation. This is pathognomonic of dermatomyositis, and in up to 40% of patients this is the only manifestation. [27]

Porphyria cutanea tarda:

A deficiency of the uroporphyrinogen decarboxylase enzyme causing sub-epidermal bullae and thick hyalinized blood vessels. Symptoms include painful, blistering skin lesions that develop on sun-exposed skin. Most cases are acquired. Risk factos include genetic predisposition + Alcohol use, Hepatitis C, HIV, and hemochromatosis. [17-19]

Gout:

A form of inflammatory arthritis characterized by uric acid crystal deposition in the joints. Classically affects the 1st toe but can affect most joints and is common in the finger joints. It causes painful flareups associated with tenderness, and redness (Left) and also chrinic deposition (tophi) (Right). Anything that causes uric acid buildup in the blood can precipitate attacks; CKD, red meat and alcohol consumption, diabetes, etc. [20,21]

Janeway lesions:

Microabscesses in the dermis with thrombosis of small vessels. Caused by septic embolization of endocarditis lesions. They present as irregular non-tender macules on the palms (Left). Associated with Osler nodes, which are vasculitic reactions and not septic emboli lesions (Right). [22-24]

Syphilis rash:

Rough, red or brown spots on the palms of the hands. May also appear in soles of feet. It is associated with secondary syphilis, appears 2-12 weeks after primary syphilis, and only lasts a few weeks before it disappears regardless of treatment. The rash won’t be painful or itchy but may be accompanied by fever, swollen lymph glands and sore throat. [25,26]

Russell’s sign:

Also known as Bulimia hands. Characterized by callosities in the dorsal hands, frequently on the knuckles. Associated with repetitive attempts to induce vomit through the gag reflex. An frequently co-existing sign is parotid hypertrophy and enamel erosion. [28]

Scabies:

Infestation of the Sacroptes scabiei mite. Look for long tunnels under the skin. Frequently affects the palmar side of the wrist, and is associated with extreme itchiness particularly at night. It may also affect the armpits, waist, and any part of the body. It can be quickly spread from person-to-person contact. Commonly affects elderly, children, and healthcare workers. [29]

Bonus: treat it with Ivermectin!

Eczema of the hands:

A reddish, cracked, scaly and crusting skin that can be painful. Caused by genetic predisposition and contact with irritating substances. Often affects people who work in cleaning, catering, hairdressing, healthcare and mechanical jobs where they may come into contact with chemicals and other irritants. It is different than atopic dermatitis but may sometimes be allergic. [30]

Senile purpura:

Purple lesion caused by hemorrhage in older adults. As people age, their soft tissues become friable and prone to bleeding. In addition, many elderly individuals are on anticoagulant medications which can exacerbate the findings. These lesions are characteristically in the dorsal aspect of hands and forearms. They usually do not require treatment of further workup. [31]

What other high yield findings can be present on the hands?

All photos and references were obtained from open access sources.

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[6] .

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[18]

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[20]

[21]

[22] .

[23]

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[25]

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[27]

[28]

[29]

[30]

[31] my.clevelandclinic.org/health/disease…
ncbi.nlm.nih.gov/pmc/articles/P…
aafp.org/pubs/afp/issue…
mayoclinic.org/diseases-condi…
mayoclinic.org/healthy-lifest…
ncbi.nlm.nih.gov/books/NBK55931…
my.clevelandclinic.org/health/symptom…