Percussion technique rationale

[PassionReborn]

I have actually had the chance to work/observe with a very senior Hepatologist in 1 of the top 4 medical teaching hospitals/med schools in the US. It was years ago but as far as I remember, he would cur his fingers of right hand and use the knuckles to percuss on the fingers of left hand.

In my school they condemn this practice and want us tow use any finger (index or middle preferred) as natural hammer to percuss. I would like to know if using the knuckles which makes far better sound IMO is medically or clinically or scientifically wrong in any way ?

Before someone possibly bashes the physician I am giving example of, please refrain from such comments as he is someone I have immense respect for. He is a strong reason I chose medicine as a profession, esp. when I saw his encounter with a rich guy (by rich, I mean this patient had NO CLUE what to do with his wealth), yet he broke up on the shoulder of this Doc. because all this $$$ was not going to help him where he was headed.

Anyways, any inputs ?

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[chief illiniwek]

I have actually had the chance to work/observe with a very senior Hepatologist in 1 of the top 4 medical teaching hospitals/med schools in the US. It was years ago but as far as I remember, he would cur his fingers of right hand and use the knuckles to percuss on the fingers of left hand.

In my school they condemn this practice and want us tow use any finger (index or middle preferred) as natural hammer to percuss. I would like to know if using the knuckles which makes far better sound IMO is medically or clinically or scientifically wrong in any way ?

Before someone possibly bashes the physician I am giving example of, please refrain from such comments as he is someone I have immense respect for. He is a strong reason I chose medicine as a profession, esp. when I saw his encounter with a rich guy (by rich, I mean this patient had NO CLUE what to do with his wealth), yet he broke up on the shoulder of this Doc. because all this $$$ was not going to help him where he was headed.

Anyways, any inputs ?

We were taught the same way you were...I've actually never seen or heard of the "knuckle" technique you're talking about. But, I think the most important thing is just having a reproducible method that gives consistent results.

 

[gravitywave]

serious question: has anyone seen someone under the age of 60 actually use percussion in a clinical setting? we learned it just last week and it seems profoundly obsolete in the modern era, CT scans being ubiquitous and all that.

 

[Forthegood]

I use percussion frequently in PEs for inital screening because it is fast and cheap. It is a good quick way to estimate sizes. On wards the imaging studies are the preferred method. But working at a free-health clinic we use our hands b/c we have no moolahhhh.

 

[Dr McSexy]

serious question: has anyone seen someone under the age of 60 actually use percussion in a clinical setting? we learned it just last week and it seems profoundly obsolete in the modern era, CT scans being ubiquitous and all that.

yup. Everytime I go for a physical exam, I'm usually percussed by the physician no matter their age.

 

[PassionReborn]

serious question: has anyone seen someone under the age of 60 actually use percussion in a clinical setting? we learned it just last week and it seems profoundly obsolete in the modern era, CT scans being ubiquitous and all that.

Its ROUTINELY used in clinical setting esp. to look for Ascites, Hepatomegaly or Splenomegaly. The physician I was talking about would do this on every patient while doing rounds, and meanwhile the Chief Resident would summarize the patient chart and current status.

Simple, Classical yet an elegant tool IMO. But I still found the knuckles being alot easier and Louder than the finger tips. I know for Pulse they say not to use the thumb because there of the Artery (princeps something) in the thumb of the person taking BP, which makes sense, BUT , this is percussion ! No sensation needed...

But I can understand the Reproducibility part, however again, shouldnt it be about sounds and now the metod.

 

[Bacchus]

Since we're talking about percussion, does anyone use a reflex hammer to strike the finger on the skin?

 

[Cruzinman]

For those who think that percussion is obsolete, try lugging a portable x-ray machine up four flights of stairs in a walk-up apartment building to examine a patient with suspected CHF, whose dyspnea keeps him in bed. It can't be done. You should know how to percuss the heart borders to at least know whether his SOB is cardiac or due to something else.

 

[turkeyjerky]

Since we're talking about percussion, does anyone use a reflex hammer to strike the finger on the skin?

I do this sometimes when eliciting difficult DTRs (like biceps). Most of the docs and residents I've worked with poo-poo percussion's use for pulmonary exams but endorse it for measuring liver span.

 

[beyondbethany]

Since we're talking about percussion, does anyone use a reflex hammer to strike the finger on the skin?

A general IM doc showed us this technique during a PE skills session a few weeks ago. I had never heard of or seen it done before. He said he encouraged students to use this technique because they typically do not strike hard enough with their hammer finger to elicit useful sounds. I tried it that day and really liked it.

 

[MossPoh]

Its ROUTINELY used in clinical setting esp. to look for Ascites, Hepatomegaly or Splenomegaly. The physician I was talking about would do this on every patient while doing rounds, and meanwhile the Chief Resident would summarize the patient chart and current status.

Simple, Classical yet an elegant tool IMO. But I still found the knuckles being alot easier and Louder than the finger tips. I know for Pulse they say not to use the thumb because there of the Artery (princeps something) in the thumb of the person taking BP, which makes sense, BUT , this is percussion ! No sensation needed...

But I can understand the Reproducibility part, however again, shouldnt it be about sounds and now the metod.

Loudness does not indicate correctness/quality.You want to use the best technique to allow for a reproduceable quality of sound. Once you practice it enough, you can have it pretty darn loud with the tip of your finger. Just messing with my knuckle over the standard finger technique, it kind of deadens the sound a bit since the upstroke is a little slower and you tend to hit with a slightly heavier hand.

I prefer to think of the technique as a very stacatto note. You'd recreate the wrist/hand motion by trying to dribble a ball against a wall and then pick whichever finger you prefer for the actual striking. Now, I was a percussionist and in drumline for quite some time, so my ears may be a little more exacting than most to that kind of deal. It also explains my explanation of the technique.

That guy probably had decades of practice using that technique, so while technically wrong he most likely developed a very consistent method and could hear the differences. Kind of like those QBs that have weird throwing motions but have been using that weird throwing motion so long that it is what they are best at.

 

[Simmy]

I have actually had the chance to work/observe with a very senior Hepatologist in 1 of the top 4 medical teaching hospitals/med schools in the US. It was years ago but as far as I remember, he would cur his fingers of right hand and use the knuckles to percuss on the fingers of left hand.

In my school they condemn this practice and want us tow use any finger (index or middle preferred) as natural hammer to percuss. I would like to know if using the knuckles which makes far better sound IMO is medically or clinically or scientifically wrong in any way ?

Before someone possibly bashes the physician I am giving example of, please refrain from such comments as he is someone I have immense respect for. He is a strong reason I chose medicine as a profession, esp. when I saw his encounter with a rich guy (by rich, I mean this patient had NO CLUE what to do with his wealth), yet he broke up on the shoulder of this Doc. because all this $$$ was not going to help him where he was headed.

Anyways, any inputs ?

At my uni. we use the same technique as you do. Don't think it really matters anyway as long as you get the result (right sound quality) you want... Pretty fast and efficient method to use on the initial exam of a patient that is admitted.. No hospital can afford to CT/MRI/X-ray every pt. that comes in just for a initial physical anyways.

 

[OveractiveBrain]

Extended middle finger of left (nonstriking) hand, flexed at the first knuckle, pad of middle finger in contact with the abdomen/thorax, full extension of the other digits to keep the fingers away from the percussed surface (contact with the hand or other fingers dampens the acoustics).

Striking with the middle and index finger together of the right (striking) hand on the middle phalange of the nonstriking hand. Short finger nails and a brisk strike creates a vibrant acoustic sound without any pain on the part of the examiner.

Using a reflex hammer to create the strike sounds like it could be painful. Not to mention you will often find yourself without a hammer. Unless you end up in afghanistan and are unfortunate enough to roll over an IUD, you will generally always have two hands.

The use of diagnostic imaging in place of a good physical exam marks the detriment of our craft. Any idiot with an ultrasound can see there's fluid. Diagnostics are expensive, time consuming, and some come with an uncessary radiation burden. Not to mention you can gain extra information from percussion (if you percuss an acute abdomen you can identify peritoneal signs without ranking on someone's abdomen). Finally, when the payment system shifts in the new health care bill, doing LESS procedures will bring about MORE profit, emotionally and financially rewarding people for learning good exam skills

Case in point: A hematologist I worked with was able to tap out a fluid level in a patient with ascites in less time than it would have taken me to leave the room and bring back an Ultrasound, even if I knew where the ultrasound machine was.

 

[gravitywave]

good thread. thanks for the responses, folks. I'll take percussion more seriously now