OSCE Clinical skills - Examination of hand

This is a non-exhaustive list of some clinical signs helpful for pediatric clinical examination and OSCE station. The elicitation or identification of clinical signs is an important part of OSCE examination as well. This post focuses on clinical signs related to hands, palms, and nails.

Clinical signs of Nail - Clubbing

angle of clubbing — **Fig.1 - showing the change of nail bed angle in clubbing .**

Clubbing is a characteristic bulging of the distal finger and nail bed.

How to measure finger clubbing

The ratio of the anteroposterior diameter of a fingernail to that at the distal inter-phalangeal joint is a simple measure for diagnosing clubbing. This can be obtained by clippers.

If the ratio is more than one - clubbing is present.

Schamroth Sign

Schamroth sign is used for detecting any evidence of clubbing in the child. Asked the child or help him to place the nails of the right and left index fingers against each other.

Normally a diamond-shaped gap is seen between the margin of the nails. In an infant or a child with clubbing, this gap is not visible for the obvious reason as the nail beds are full.

Stages of clubbing are

Softening of the nail bed, causing a spongy feeling when the nail is pressed
Loss of the normal < 165° angle between nail bed and fold
Convex nail growth
Thickening of the distal part of the finger
Shine and striation of the nail and skin

Mechanism of clubbing

Normal pulmonary circulation disruption
Megakaryocytes not broken into fragments
Platelet growth factors released
The proliferation of muscle cells and fibroblasts
Clubbing

Causes

Neoplastic

Bronchogenic carcinoma
Lymphoma
Pleural tumors

Pulmonary

Cystic fibrosis
Asbestosis
Pulmonary fibrosis
Sarcoidosis
Hypertrophic pulmonary osteoarthropathy (HPOA)

Cardiac

Cyanotic heart disease
Endocarditis

Gastro-intestinal

Inflammatory bowel disease
Liver disease
Coeliac disease

Infection

Tuberculosis
Infective endocarditis
HIV

Endocrinology

Thyroid disease

Value

Clubbing is always pathological
Absence does not exclude underlying disease

Other Clinical signs of nail

pediatric clinical sign of nail — **Fig.4 - List of clinical signs observed in nails. See text below for diagnosis.**

Absent part of Nail - Anonychia congenital
Pitting nails - Psoriasis
Cutic Jeinvasion - Lichen planus
Dark brown pigmentation, ridging - Monilia
Dista Onycholysis - Tinea
Spoon nails - Iron deficiency
Discolored nails with an inverted edge - Ectodermal dysplasia
Clubbing in - toxins, malignancy and hypoxia
Short and overcut nails ( bitten) - anxiety
Splinter hemorrhage - Infective endocarditis.
yellow nail- Lymphoedema, Bronchiectasis, lymphoma
Half and half appearance - Hepatic cirrhosis
Ridging - Rheumatoid arthritis
Longitudinal brown Lines - Addison's disease, Breast cancer, Melanoma
White or pale nails - Anemia
Red nail – polycythemia, Systemic lupus
Horizontal white and pink bands - Nephrotic syndrome
Brittle Nail - Hypothyroidism

Clinical signs of palm

pediatric clinical sign in palm — **Fig.5 - List of clinical signs to be observed in the palm. See text below for diagnosis.**

Anemia - Pale or light-colored palm
Raynaud's phenomenon - Bluish palm especially in peripheries
Hepatitis / Jaundice- Yellow tinge to palm
Addison disease - Darkly pigmented creases over the palm can be seen
Hypothyroidism - Orange palm
Portal hypertension - Palmar erythema
Thyrotoxicosis - Hot and Sweaty
Down Syndrome - Transverse palmar crease
Lung cancer - Tripe (velvety rugose thickening)
Bladder Cancer - Palmar keratosis (papules or pits)
Ovarian cancer Palmar fascial thickening with lumpy areas
Dupuytren's Disease - Palm thickening and pink fingers bend forward
Psoriasis - Thick-red-scaly palm
Kindler Syndrome - Thick glaze palm with decreased palmar creases
Rheumatoid arthritis - Wrist and fingers deformities
Ulnar nerve injury - Clawing of the ring and little fingers
Median nerve injury - Adduction and hyperextension of thumb and index

Author

Ajay Agade | DNB(Pediatrics), FNB(Pediatric Intensive Care), Fellowship in Pediatric pulmonology and LTV

Ajay is a Paediatric Intensivist, currently working in Pediatric Pulmonology & LTV at Great Ormond Street Hospital NHS, London

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