Begin the examination with the upper extremities. Instruct the patient to open both hands while you inspect the dorsal surface for any obvious deformity or visible swelling. Now inspect the palmar surface and note any atrophy of the thenar or hypothenar eminences. Turn the hands over once again with the palms down. Assess finger extension by asking the patient to spread the fingers. Note whether each finger's DIP (distal interphalangeal), PIP (proximal interphalangeal), and MCP (metacarpophalangeal) joints extend fully (Figs. 2–4 through 2–6). Extension of the MCP joints beyond neutral is normal. Assess finger flexion by observing the patient make a fist with each hand. Inspect both the dorsal and palmar surfaces of each fist to visualize the adequacy of finger flexion (Fig. 2–7A,B). Making a fist is a complex maneuver, involving nearly maximal flexion of all DIP, PIP, and MCP joints (see Figs. 2–4 through 2–6). This permits the tips of digits 2 to 5 to be buried in the palm at the level of the distal palmar crease. Thumb opposition, with partial thumb MCP and IP (interphalangeal) joint flexion, completes the normal fist (Fig. 2–7B). Next, inspect the wrists looking for deformity or visible swelling. Ask the patient to turn both hands over with the palms up. This maneuver permits assessment of both forearm supination and visual inspection of the wrist flexor surface. Then, ask the patient to turn both palms face down. This maneuver permits simultaneous assessment of forearm pronation and visual inspection of the wrist extensor surface. Now, extend and flex each wrist (Fig. 2–8). Take the patient's hand in your dominant hand, as though you were going to “kiss the hand” (Fig.2–9). This allows you to comfortably move the patient's wrist into full extension using pressure with your index finger against the distal palm (at the level of the metacarpal heads), avoiding unnecessarily squeezing the patient's fingers (Fig. 2–10A). Then, downward pressure with your thumb on the patient's second or third metacarpal allows you to bring the wrist gently into full flexion (Fig. 2–10B). Full wrist extension and flexion should be symmetrical and bring the hand nearly perpendicular to the forearm on each side.