The Physical Exam: Up to Snuff

It\’s time we get away from all of that serious nonsense, and back to something I am far more comfortable with: taking otherwise useful information and twisting it into utter nonsense.  Yes, it\’s time to journey back to the wonderful world of the physical exam. My ongoing mission is to explore the human body from my unique (albeit moderately unstable) perspective. For an overview of my previous posts on the physical exam see this post which features Dick Chaney on a Segway (reason enough to click on the link).  Please visit a psychiatry blog to aid in recovery once you have done so.
My most recent post in this fine series covered the topic of psychics and about the examination of the hand.  It was mainly about psychics examining the hand, but I did slip in a little doctor stuff to keep the cops off of me.  But then I got a call from the department of homeland security and they said that if I didn\’t shape up, I\’d no longer be able to use the picture of Dick Cheney on the Segway.  It\’s hard to resist such harsh tactics.

Today I\’ll take the high road.  The really high road.

You see, the hand is not only celebrated by doctors on blogs, it is also a subject of divine consequence.  The above picture is, of course, a representation of the most famous utterance of the words: \”pull my finger.\”

OK, I guess I can\’t stay on the high road for long.  I don\’t think many of you would read this blog in the first place if I did.

Now that we\’ve gotten that out of the way, let\’s get back to the subject at hand (har, har): the physical exam.  As I said previously, the hand exam is done usually in response to complaints about the hand.  There are a few common hand problems I am able to diagnose through the physical exam.

The Snuff Box

As a medical student, you are taught a whole lot of information that you wonder if you will ever use.  Why, for example, did we have to use up valuable grey mater to learn about the Kreb\’s cycle, that the spot where you most commonly hurt with appendicitis is called McBurney\’s Point, that chickens have something called the Bursa of Fabricius (from which the B-Cell is named), and about the spot on the base of the thumb called the anatomical snuff box. Considering the amount of time spent on the anatomical snuff box, you would think it was a window to the soul or a portal to the demonic realm.  I was skeptical about its significance.  But my neurons were relieved to find out that the anatomical snuff box had significance (other than as a place powdered tobacco could be put before snorting it into the nose).

Photographic evidence of the usefulness of the snuff box by Dutch men in hats (credit).

So what exactly is the anatomical snuff box?  It\’s a depression just above the wrist and right below the thumb that is formed by the space between two thumb tendons.

Technically it\’s not a box, but the term anatomical snuff depression wouldn\’t fly with anatomy profs (although I don\’t think Dutch guys would mind).  The significance of the snuff box for me (I swear, I didn\’t inhale) is that two conditions make the bones under it hurt.  (Note that the above picture uses the term \”snuffbox\” instead of \”snuff box,\” which shows which side of the healthcare debate it supports).

Scaphoid Fracture

The first is a fracture of the scaphoid bone.

In this illustration, the scaphoid bone is pink, and has the letter \”A\” on it.  Scientists are not certain of the significance of the big letters, but some have claimed this as evidence of an intelligent creator.  Opponents of this theory point out that the giant number \”3\” is actually pointing at 5 bones, which makes the intelligence of this so-called creator suspect.  The debate rages on.

The scaphoid bone can be fractured when a person falls on an outstretched hand.  I broke mine when I was running backwards and was tripped by some microorganisms who jumped up and grabbed my ankles.  I swear that\’s how it happened.  Normal wrist x-rays can miss a scaphoid fracture, but the astute clinician suspects it when the patient jumps, screams in pain, and threatens a curse on the doctor\’s descendants when the doctor presses on the anatomical snuff box.

Day-Something Teno-Something

The second condition involving the anatomical snuff box is called De Quervain\’s Tenosinovitis.  This condition was first described by a Swiss doctor who was unfortunate enough to be named Fritz De Quervain, a name that has baffled doctors and patients ever since Fritz did his discovering.  How do you pronounce the dang name?  Is it \”Dee-Kwer-Vain,\” as it appears, is it \”Duh-Kare-Vahs,\” as the Mayo Clinic suggests, or is it \”Deh-Ker-Vehs,\” as Miriam Webster suggests?  I suggest it be pronounced \”Dang-my-thumb-hurts,\” but this pronunciation hasn\’t gained widespread acceptance.

The basic problem happens when the tendons (tough fibrous tissue that connects muscle to bone, allowing the muscle to move the bone from a remote location) that straighten out the thumb become inflamed due to repetitive use of said thumb.

Fritz noticed the orange irregular outline, and decided to investigate.  The rest is history. (Credit)

On exam, the person hurts at or near our old pal, the anatomical snuff box, when it is pressed while the person moves the thumb across the palm.  This condition is treated by cortisone injection and a period of torture by a physical therapist.

There is another way to diagnose this condition – a maneuver called the \”Finkelstein Test.\”  The test is named after De Quervain\’s arch rival, the evil Baron Von Finkelstein.  This test is performed by making a fist with the thumb tucked under the other fingers and the wrist is flexed toward the pinkie.


When this procedure is performed, two things happen: the wrist hurts in the region of the snuff box, and it glows an eerie red.  There are three reasons I don\’t perform this test:

  1. Neither the patients nor me want anything to do with the evil Baron Von Finkelstein.
  2. The eerie red light freaks people out.
  3. The patient is simultaneously in pain and making a fist – a situation most doctors try to avoid.

Well now I have burdened your neurons with more information about the anatomical snuff box than you could ever wish to know.  But there is one more thing I would like to mention about this critical part of the body.

These amazing pictures from the wonderful world of reflexology show that the snuff box is really a mirror to the top of the right leg.  Now that\’s information you\’d never get on Kevin, MD!  I\’d better keep quiet about that, however, because he may just flip me the spleen.

14 thoughts on “The Physical Exam: Up to Snuff”

  1. That face on the anterior of your hand, is that Dr. Kevin? Or Muhammed Ali? You did, after all, mention Dr. Kevin. On mouseover, I see that the picture comes from a Korean chart, so I guess it's not likely the face of a Vietnamese-American Physician or African-American boxer. Of course, the mouseover doesn't say whether it's North or South Korean, so who knows?

  2. I tried to contact the North Koreans about this and they shot at me, so I couldn't get accurate information. It does look like Ali, but I didn't want to get punched, so I didn't ask.

  3. So, silly me I had to try the test and it hurt like a b*tch. (You know. A batch? Of cookies? When you eat them all at once and your tummy hurts? Yes, this save works on five-year olds and grandmas).

    No red light, however, and I was quite disappointed. (For viewers at home, I have RA, so if that HADN'T hurt then I would have been utterly surprised and possibly would have had the Vatican declare this blog a miracle cure. Sadly, we both missed out on that chance. Oh well, there's always next time.)

  4. The Vatican has declared this blog, but it wasn't altogether complimentary. You see why Baron Von Finkelstein is evil.

  5. This post is almost as therapeutic as your link to Cake Wrecks! Two daily 15 minute viewings of Cake Wrecks is better at altering my mood than any SSRI! I believe that means you have cured depression or at least made significant progress towards doing so.
    (under neat that)
    Dr Rob

  6. So, if he has cured your depression, does that mean you no longer have a snuff box? How does that work?


    You people are hilarious! Just shared this with my OT friends on twitter.

  8. i dunno about your old prof, but MY anatomy prof calls it the anatomic snuff box!!!
    but interestingly enough, she doesn't like the mnemonic Oh oh oh to touch and feel a girl's vagina… ahhh heaven. i can't understand it, since she's helping me become a junkie, yet i can't talk about vaginas.

  9. anatomic vs. anatomical? Now that's a debate that has caused great bloodshed. Makes the Hatfiields and McCoys seem like BFF's.

  10. I still have that depression, unless I get the urge to fill it with frosting from an overdose of Cake Wrecks!

  11. Dr Rob; You failed to mention the acronym from gross anatomy (do they still teach this?). NLTPMMCH (Never Lower Tilly's Pants, Mother Might Come Home. ie, Navicular Lunate Triangulate, etc. Even Google lists this eponym. ” Male medical students once identified the eight wrist bones (navicular, lunate, triquetrum, pisiform, multangular greater, multangular lesser, capitate, hamate) by snickering: ''Never lower Tillie's pants. Mother might come home.''
    I think this would date me….

  12. I learned it using “scaphoid” instead of “navicular” so it was (SLTPTTCH) – Some Lovers Try Positions That They Can't Handle

  13. I learned that one in Occupational Therapy school too- don't forget that we torture, I mean, rehabilitate hand injuries as well 🙂

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