Physical findings on hands in cardiovascular disease

Examination of hands may give a lot of important findings in cardiovascular disease. Cold clammy hands in cardiogenic shock is well known. Body’s protective mechanisms reduce blood flow to extremities and divert blood flow to vital organs like brain and heart. That makes the skin cool. ‘Clammy’ indicates that the skin is moist to touch like a clam! Cyanosis and clubbing occurring in congenital heart disease was discussed in a previous post. They are valuable indicators of cyanotic congenital heart disease.

Simian thumb which is in the same plane as the other fingers is also called a ‘fingerized’ thumb. That is characteristic of Holt-Oram syndrome which has other skeletal abnormalities on the radial side of the upper limb and associated cardiovascular abnormalities. Atrial septal defect is the commonest association of Holt-Oram syndrome described by Mary Holt and Samuel Oram way back in 1960. Ellis-van Creveld syndrome can manifest with polydactyly and single atrium, a cyanotic congenital heart disease.

Arachnodactyly in Marfan syndrome is well known. The slender long fingers resembles the long legs of spider which is an arachnid and hence the name. Aortic root dilatation with possibility for aortic regurgitation and dissection is associated with Marfan syndrome. Another common association of Marfan syndrome is mitral valve prolapse and mitral regurgitation. Quincke sign with alternating reddening and blanching of nail beds can occur in severe aortic regurgitation.

Short, broad hands, a single transverse palmar crease which is known as a simian crease, and clinodactyly which is inward curvature of little finger are important findings in Down syndrome. Down syndrome due to trisomy 21 can be associated with significant congenital heart diseases known in general as endocardial cushion defects, though other complex defects like Tetralogy of Fallot can also occur.

Slightly raised non tender hemorrhagic lesions on palms characterise Janeway lesions in infective endocarditis. Tender, raised lesions on pads of fingers are the Osler’s nodes in infective endocarditis. Linear hemorrhages in the nail bed in infective endocarditis are known as splinter hemorrhages. Splinter hemorrhages can also occur after a local trauma. Vasculitic ulcers may also occur on finger tips in various disorders.