Terrys Nails

Half and half nails en Terry's nailsmore

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The Hand in Diagnosis

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

Handshake:

Moist and warm hands (think nervousness, thyrotoxicosis, look for tremor, eye
signs).

Inability to let go your of hand (think myotonia, not to be confused with the grasp
reflex in frontal lobe disease. Look for other signs of myotonic dystrophy: hatchet
face, cataracts, baldness, myopathic facies).

Nails

Terry's Nails

Lindsay's Nails (Half-and-half Nails)

Beau's Lines

Muehrcke's Lines (Leukonychia striata)

Mees' Lines

Acral Lentiginous Melanoma

Splinter Hemorrhages

Nail Pitting

Quitter's Nail

Paronychia

Clubbing

Mechanical Dysfunction of the Hand

Pope's Hand (Hand of Benediction)

Ape Hand

Claw Hand

Boutonniere Deformity & Swan Neck Deformity

Misc. Hand Findings

Herpetic Whitlow

Bouchard's and Heberden's Nodes

"Fingerization" of the Thumb

Tripe Hand

Down's Syndrome (Simian Crease)

Janeway Lesions vs. Osler Nodes

Nails
Terry's Nails
Proximal paleness extending halfway up the nail, often eliminating the lunula. Darker
distal band. Seen in states of stress (e.g. advanced age, liver disease/cirrhosis, CHF,

DM2). (Image Credit)

<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p

anel_0/panel_builder/panel_0/image.img.620.high.png' alt='Terry&#39;s Nails'>

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Lindsay's Nails (Half-and-half Nails)

Distal brown transverse band seen in kidney disease. Caused by increased pigment
deposition.
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder/panel_0/image_407792230.img.620.high.jpg' alt='Lindsay&#39;s

Nails'>

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Beau's Lines
Transverse depressed ridges seen in severe infection, MI, hypotension/shock,
hypocalcemia, post-surgical, malnutrition and with certain chemotherapy.
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder/panel_0/image_1020978563.img.620.high.jpg' alt='Beau&#39;s

Nails'>

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Muehrcke's Lines (Leukonychia striata)

Narrow while transverse lines (Not depressed, compared to Beau's lines). Usually 2 or
more lines on one nail. Seen in states of decreased protein synthesis or increase protein
loss such as with hypoalbunemia (usually less than < 2.2 g/dL), certain chemotherapy
and nephrotic syndrome. (Image Credit)
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p

anel_0/panel_builder/panel_0/image_31075038.img.620.high.jpg' alt='Muehrcke&#39;s

Lines'>
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Mees' Lines
Transverse while lines (usually one per nail, no depressions) that often can will
disappear if pressure is placed over the line. It is strongly associated with arsenic
poisoning, thallium poisoning and to a lesser extent other heavy metal poisoning.
(Image Credit)
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder/panel_0/image_739715717.img.620.high.jpg' alt='Mees&#39;

Lines'>
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Acral Lentiginous Melanoma (involving nail)

While acral lentinginous melanoma is often seen anywhere on the palms, soles, and
even in the mouth, when it occurs within the nail, a clue that this is melanoma is
involvement of the periungal regions as seen in this picture.
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder/panel_0/image_1150556380.img.620.high.jpg' alt='acral
lentinginous melanoma'>

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Splinter Hemorrhages
Nonspecific finding associated with trauma most commonly but also seen in subacute
bacterial endocarditis and scleroderma. (Image Credit)
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p

anel_0/panel_builder/panel_0/image_371440011.img.620.high.jpg' alt='Splinter

Hemorrhages'>
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Nail Pitting
Non-specific sign for psoriasis (additional signs include onycholysis, thickening, and
'oilspot' lesions which are yellow patches on the nail). (Image Credit)
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p

anel_0/panel_builder/panel_0/image_217248029.img.620.high.jpg' alt='Nail Pitting'>

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Quitter's Nail
Nicotine stained distally, but not proximally with clear line of demarcation. See also our
article in Chest and NEJM clinical image. May also appear when pt switches to "lower
tar" tobacco.
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder/panel_0/image_639930993.img.620.high.jpg' alt='Quitter&#39;s
Nail'>

<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder/panel_0/panel_builder_194622025/panel_0/image.img.620.high.pn

g' alt='clinical corner'>

Finger nails grow at a rate of about 0.8-1.0 mm per week. Using this,
you can approximate when the clinical scenario causing the nail
finding occurred. For example, approximating when someone has
stopped smoking who has quitter's nails.

<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder/panel_0/panel_builder_194622025/panel_2/image.img.620.high.pn

g' alt='clinical corner'>

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Paronychia
Inflammation of the nail folds - red, swollen, often tender. Frequent immersion in water a
risk factor for chronic paronychia. (Image Credit)
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p

anel_0/panel_builder/panel_0/image_2124083612.img.620.high.jpg' alt='Paronychia'>

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Clubbing
Angle between nail plate and proximal nail fold greater than 180 degrees.
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder/panel_0/image_668112240.img.620.high.jpg' alt='Clubbing

figure'>

Important causes of clubbing in the adult:

1. Lungs
1. Lung Cancer (clubbing is in general an ominous sign for this, and
remember "beware of the yellow clubbed digit". (Yellow from nicotine, and
clubbed from cancer).
2. Pus in the lung (bronchiectasis as in CF, but also lung abscess and
empyema)

3. Pulmonary Fibrosis
4. COPD IS NOT A CAUSE OF CLUBBING (if you seen clubbing in a COPD
patient, think lung cancer)
2. Heart
1. R to L shunts
2. Endocarditis
3. Pericarditis

There are other causes of clubbing, outside the heart and lungs, but these are
the important ones.

If a patient has painful wrists, painful ankles and comes to see you and you miss
that they also have clubbing, you will go down the wrong path looking for RA etc.,
when what they have is Hypertrophic Pulmonary Osteoarthropathy. The
causes of HPOA are the same as those of clubbing.

Pseudoclubbing: distinguished from clubbing by the preservation of the nail-fold angle

and bony erosion of the terminal phalanges on radiography. Pseudoclubbing is also
more likely to be asymmetric.
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Mechanical Dysfunction of the Hand

Pope's Hand (Hand of Benediction)
The pope's hand is seen with median nerve dysfunction when asking the patient to
make a fist due to inability to flex 1st & 2nd fingers at PIP. The median nerve controls
the 1st & 2nd lumbricals, three thenar muscles (abductor pollicis brevis, flexor pollicis
brevis, and via a distal branch the opponens pollicis).Additionally there may be thenar
atrophy. (Image Credit)
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder_3/panel_0/image.img.620.high.jpg' alt='pope&#39;s hands'>

https://www.netterimages.com/hand-of-benediction-unlabeledorthopaedics-john-a-craig-7639.html
Ask patient to use both hands to make and "Okay" sign by forming a circle with thumb
and index finger. Median nerve palsy may make one hand produce a pinched circle
(right hand in image). (Image Credit)
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p

anel_0/panel_builder_3/panel_0/image_1947381427.img.620.high.jpg' alt='median

nerve'>
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Ape Hand
Distal median nerve dysfunction: Inability to oppose thumb from distal median nerve
dysfunction.

clawhand
The image below is a simulated claw hand. Note that due to ulnar damage, the 3rd &
4th lumbricals are unable to extend the PIP & DIP joints at the 4th & 5th digits.
The ulnar nerve controls the 3rd & 4th lumbricals, the three hypothenar muscles, the
dorsal & palmar interossei, the palmaris brevis and the adductor pollicis. Ulnar nerve
damage may also cause hypothenar atrophy.
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p

anel_0/panel_builder_3/panel_0/image_567372593.img.620.high.jpg' alt='claw'>

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Froment's Sign
Ask patient to hold a piece of paper between thumb and index finger. If the examiner
can pull paper away (a positive Froment's sign), it suggests that an ulnar palsy has
weakened the thumbs strength of opposition.

Radial nerve damage

No intrinsic muscles but important wrist extensors. Radial nerve damage commonly
causes wrist drop.

Boutonniere Deformity & Swan Neck Deformity

Flexion of PIP and extension of DIP, seen in chronic rheumatoid arthritis.
Swan neck deformity: extension of the PIP, flexion of DIP, seen in chronic rheumatoid
arthritis. (Image Credit)
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder_3/panel_0/image_2139419388.img.620.high.jpg'

alt='boutonniere.swanNeck (2)'>

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Misc. Hand Findings

Herpetic Whitlow
Occupational hazard for respiratory therapists and house staff who work around oral
secretions. (Image Credit)
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder_1/panel_0/image.img.620.high.jpg' alt='herpetic'>

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Bouchard's and Heberden's Nodes

Bouchard nodes (found at the PIP) and Heberden's nodes (found at DIP) are bony
outgrowths seen in osteoarthritis (DJD) of the hand. These outgrowths are formed by
calcific spurs within the respective articular joint.
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder_1/panel_0/image_925686283.img.620.high.jpg' alt='Bouchard and
Heberden&#39;s'>

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"Fingerization" of the Thumb

Holt-Ohram syndrome - absent radius, single atrium, autosomal dominant. (Image
Credit)
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder_1/panel_0/image_692577879.img.620.high.jpg'

alt='fingerization.small'>

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Hypermobility of hand joints

Ehlers Danlos, many types. Syndrome may include skin hyperextensible, fragile,
"cigarette paper burn" scars, spontaneous rupture of eye, arteries, intestine, hip
dislocations, Marfanoid habitus, kyphoscoliosis, prominent hernia, mitral valve prolapse,
coronary dissection.

Short extremities and polydactyly

Ellis Van Creveld Syndrome - dwarfism, short extremities and polydactyly, dysplastic
teeth and nails, multiple frenula binding the upper lip to the alveolar ridge, ASD or a
single atrium.

Arachnodactyly
Long "spider-like" digits, thumb can often extend beyond palm. Characteristic of
Marfan's Syndrome - tall stature, thoracic deformity, joint laxity, ectopia lentis and
myopia, aortic dilation and dissection, mitral valve prolapse, autosomal dominant,
spontaneous pneumothorax, chordae tendineae rupture.

Tripe Hand

Thickened, velvety texture of hand. Often sign of visceral malignancy. See also NEMJ
"Velvet Palms" in Images in Clinical Medicine. (Image Credit)
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder_1/panel_0/image_2051773766.img.620.high.jpg'
alt='TripeHand.smal'>

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Down's syndrome
Single palmar crease (Simian crease). The fifth digit is abnormally short (only reaches
the second crease of the 4th digit). Remember to look for endocardial cushion defects
(ASD, VSD and mitral/tricuspid abnormalities).
<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder_1/panel_0/image_755936749.img.620.high.jpg'

alt='Down&#39;s'>

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Janeway Lesions vs. Osler Nodes

Both found in bacterial endocarditis.

Osler Nodes:

Painful, palpable red lesions usually on fingers/toes. They are caused

by immune complexes. (Image Credit)

Janeway Lesions

Non-painful, macular lesions, usually on palms/soles. They are caused

by septic emboli, more common in Staph aureus endocarditis. (Image Credit)

(See Splinter Hemorrhages and Roth Spots)

<img
src='//stanfordmedicine25.stanford.edu/the25/hand/_jcr_content/main/panel_builder_0/p
anel_0/panel_builder_1/panel_0/image_431336122.img.620.high.png' alt='Janeway and
Osler'>

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Gait Abnormalities
Observation of gait is an important aspect of diagnosis that may provide information
about several musculoskeletal and neurological conditions. In particular, there are eight
basic pathological gaits that can be attributed to neurological conditions: hemiplegic,
spastic Diplegic, neuropathic, myopathic, Parkinsonian, choreiform, ataxic (cerebellar)
and sensory.
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Stanford Medicine 25 Gaits

http://stanfordmedicine25.stanford.edu/the25/gait.html

Hemiplegic Gait
The patient stands with unilateral weakness on the affected side, arm flexed, adducted
and internally rotated. Leg on same side is in extension with plantar flexion of the foot
and toes. When walking, the patient will hold his or her arm to one side and drags his or
her affected leg in a semicircle (circumduction) due to weakness of distal muscles (foot
drop) and extensor hypertonia in lower limb. This is most commonly seen in stroke. With
mild hemiparesis, loss of normal arm swing and slight circumduction may be the only
abnormalities.

Diplegic Gait
Patients have involvement on both sides with spasticity in lower extremities worse than
upper extremities. The patient walks with an abnormally narrow base, dragging both
legs and scraping the toes. This gait is seen in bilateral periventricular lesions, such as
those seen in cerebral palsy. There is also characteristic extreme tightness of hip
adductors which can cause legs to cross the midline referred to as a scissors gait. In
countries with adequate medical care, patients with cerebral palsy may have hip
adductor release surgery to minimize scissoring.

Neuropathic Gait
(Steppage Gait, Equine Gait)
Seen in patients with foot drop (weakness of foot dorsiflexion), the cause of this gait is
due to an attempt to lift the leg high enough during walking so that the foot does not
drag on the floor. If unilateral, causes include peroneal nerve palsy and L5

radiculopathy. If bilateral, causes include amyotrophic lateral sclerosis, Charcot-MarieTooth disease and other peripheral neuropathies including those associated with
uncontrolled diabetes.

Myopathic Gait
<img
src='//stanfordmedicine25.stanford.edu/the25/gait/_jcr_content/main/panel_builder_0/pa
nel_0/panel_builder_3/panel_0/panel_builder/panel_0/image.img.620.high.png'

alt='trendelenburg'>
Hip girdle muscles are responsible for keeping the pelvis level when walking. If you have
weakness on one side, this will lead to a drop in the pelvis on the contralateral side of
the pelvis while walking (Trendelenburg sign). With bilateral weakness, you will have
dropping of the pelvis on both sides during walking leading to waddling. This gait is
seen in patient with myopathies, such as muscular dystrophy.

Choreiform Gait
(Hyperkinetic Gait)
This gait is seen with certain basal ganglia disorders including Sydenham's chorea,
Huntington's disease and other forms of chorea, athetosis or dystonia. The patient will
display irregular, jerky, involuntary movements in all extremities. Walking may
accentuate their baseline movement disorder.

Ataxic Gait
(Cerebellar)
Most commonly seen in cerebellar disease, this gait is described as clumsy, staggering
movements with a wide-based gait. While standing still, the patient's body may swagger
back and forth and from side to side, known as titubation. Patients will not be able to
walk from heel to toe or in a straight line. The gait of acute alcohol intoxication will
resemble the gait of cerebellar disease. Patients with more truncal instability are more
likely to have midline cerebellar disease at the vermis.

Parkinsonian Gait
In this gait, the patient will have rigidity and bradykinesia. He or she will be stooped
with the head and neck forward, with flexion at the knees. The whole upper extremity is
also in flexion with the fingers usually extended. The patient walks with slow little steps
known at Marche a petits pas (walk of little steps). Patient may also have difficulty
initiating steps. The patient may show an involuntary inclination to take accelerating
steps, known as festination. This gait is seen in Parkinson's disease or any other
condition causing Parkinsonism, such as side effects from drugs.

Sensory Gait
As our feet touch the ground, we receive propioreceptive information to tell us their
location. The sensory ataxic gait occurs when there is loss of this propioreceptive input.
In an effort to know when the feet land and their location, the patient will slam the foot
hard onto the ground in order to sense it. A key to this gait involves its exacerbation
when patients cannot see their feet (i.e. in the dark). This gait is also sometimes
referred to as a stomping gait since patients may lift their legs very high to hit the
ground hard. This gait can be seen in disorders of the dorsal columns (B12 deficiency or
tabes dorsalis) or in diseases affecting the peripheral nerves (uncontrolled diabetes). In
its severe form, this gait can cause an ataxia that resembles the cerebellar ataxic gait.

Key Learning Points

Review the following eight gaits and be able to observe the unique characteristics of
each.

Related to Gait Abnormalities

Gait Abnormalities

Cerebellar Exam

Deep Tendon Reflexes

Internal Capsule Stroke

Involuntary Movements

The Stanford Medicine 25

Ankle Brachial Index

Ascites & Venous Patterns

BP & Pulsus Paradoxus

Bedside Ultrasound

Cardiac Second Sounds

Cerebellar Exam

Deep Tendon Reflexes

Dermatology Exam: Acne vs. Rosacea

Dermatology Exam: Learning the Language

Dermatology Exam: Nevi (Mole) Exam

Examination of the Liver

Examination of the Spleen

Fundoscopic Exam

Gait Abnormalities

Internal Capsule Stroke

Involuntary Movements

Knee Exam

Liver Disease, Head to Foot

Lymph Node Exam

Neck Veins & Wave Forms

Precordial Movements

Pulmonary Exam: Percussion & Inspection

Pupillary Responses

Rectal Exam

Shoulder Exam

The Hand in Diagnosis

The Tongue in Diagnosis

Thyroid Exam

Visit the 25

The Stanford Medicine 25

Ankle Brachial Index

Ascites & Venous Patterns

BP & Pulsus Paradoxus

Bedside Ultrasound

Cardiac Second Sounds

Cerebellar Exam

Deep Tendon Reflexes

Examination of the Liver

Examination of the Spleen

Fundoscopic Exam

Gait Abnormalities

Internal Capsule Stroke

Involuntary Movements

Knee Exam

Liver Disease, Head to Foot

Lymph Node Exam

Neck Veins & Wave Forms

Precordial Movements

Pulmonary Exam: Percussion & Inspection

Pupillary Responses

Rectal Exam

Shoulder Exam

The Hand in Diagnosis

The Tongue in Diagnosis

Thyroid Exam

http://stanfordmedicine25.stanford.edu/the25/gait.html