Share your insights

Help us by sharing what content you've recieved in your exams


Hand and wrist examination

Introduction

  • Wash hands
  • Introduce self
  • Ask Patient’s name, DOB and what they like to be called
  • Explain examination and obtain consent
  • Expose arms to above elbows and place pillow on their lap to rest hands on
  • General inspection: patient, e.g. age, pain/discomfort, signs of trauma; around bed, e.g. mobility aids, splint

Look

  • Dorsum
    • General: posture, obvious deformities, scars
    • Bone/joint swelling and deformity
      • Osteoarthritis: Heberden’s nodes (DIP joints), Bouchard’s nodes (PIP joints)
      • RA: loss of knuckle guttering, ‘swan neck’ deformity (PIP joint hyperextension + DIP joint flexion), boutonnière deformity (PIP joint flexion + DIP joint hyperextension), Z-shaped thumb (IP joint hyperextension + MCP joint flexion), ulnar deviation at wrist, palmar subluxation of MCP joints
      • Seronegative spondyloarthropathy: dactylitis (‘sausage digit’ – inflammation of entire digit) NB: there is no DIP joint involvement in RA but there may be in OA or seronegative spondyloarthropathies.
    • Skin: scars, thinning/bruising (steroid use), rashes, erythema
    • Muscles: guttering (ulnar nerve lesion, tendon ruptures, peripheral neuropathy)
    • Nails: psoriatic changes (e.g. pitting, onycholysis), nail fold vasculitis, clubbing
  • Palmar surface
    • Look for: posture abnormalities, muscle wasting of thenar eminence (carpal tunnel syndrome) and hypothenar eminence (ulnar nerve lesion), palmar erythema, carpal tunnel release scar, swellings (e.g. ganglions – local small fluctuant swellings)
  • Extensor surface of arm
    • Feel up border: psoriatic plaques, rheumatoid nodules, gouty tophi (whitish nodules of crystallised uric acid under skin around fingers/elbows)

Feel

Ask about any pain before examining.

  • Palmar surface
    • Bulk of thenar/hypothenar eminences
    • Tendon thickening: palpate palmar flexor tendons (palmar tendon thickening with fixed flexion deformity = Dupuytren’s contracture); flex and extend fingers individually while palpating flexor tendons near MCP joints (tendon thickening/bump near MCP joint with triggering = trigger finger)
  • Dorsum
    • Temperature (forearm, wrist and MCP joints)
    • Squeeze joints for tenderness and feel for bony swellings, effusions, synovitis, deformities
      • Distal radio-ulnar joint
      • Radial and ulnar styloids
      • Anatomical snuffbox (tenderness = scaphoid fracture)
      • Carpals (bimanual palpation)
      • MCP joints (squeeze along row then bimanual palpation if any pain elicited) and base of thumb (squaring = osteoarthritis)
      • IP joints (bimanual palpation of each joint; Heberden’s/Bouchard’s nodes = osteoarthritis)
    • Tendon tenderness
      • Around radial styloid, i.e. 1st extensor compartment (tenderness = de Quervain’s tenosynovitis)
      • Around ulnar styloid (tenderness = extensor carpi ulnaris tendinopathy

Move

  • Wrist movements actively and passively (feel for crepitus): extension 70˚ and flexion 80˚ (‘prayer’ sign and ‘reverse prayer’ sign respectively); pronation 70˚ and supination 80˚; radial deviation 20˚ and ulnar deviation 40˚ 
  • Finger movements: straighten fingers fully against gravity (difficulty = joint disease, extensor tendon rupture or neurological damage; triggering of a finger = trigger finger); make fist (cannot tuck fingers in = tendon/small joint involvement); move each MCP and IP joint passively (assess for limited movement and crepitus)
  • Thumb movements: extension (stretch thumb out laterally); resisted abduction (point thumb to ceiling with wrist supinated); opposition (touch thumb to little finger tip); flexion (thumb to palm); adduction (point thumb to floor with wrist supinated)

Special tests

‘Reverse prayer’ sign for 1 minute (pain/paraesthesia = carpal tunnel syndrome)

Tap over the carpal tunnel (paraesthesia = carpal tunnel syndrome)

Ask patient to adduct their thumb to their palm and close fist around it; then tilt their wrist into ulnar deviation (pain = de Quervain’s tenosynovitis)

Function

  • Function: test pincer grip; carry out everyday tasks, e.g. undo buttons, write sentence, hold cup, turn key
  • Basic neurological hand exam: quickly do the motor and sensory parts of the neurological hand exam

Basic neurological hand examination

Oops! This section is restricted to members. Click here to signup!

To complete

  • Thank patient
  • ‘To complete my examination, I would examine the elbows and perform a distal neurovascular examination.’ 
  • Summarise and suggest further investigations you would consider after a full history

Common hand and wrist pathology

Oops! This section is restricted to members. Click here to signup!

Test yourself with some questions

Which nerve impingement would lead to a wrist drop and what could cause it?

Oops! This section is restricted to members. Click here to signup!

What examination findings in the hand and wrist would make you suspect rheumatoid arthritis?

Oops! This section is restricted to members. Click here to signup!

Please list some extra-articular manifestations of rheumatoid arthritis

Oops! This section is restricted to members. Click here to signup!

What is Felty’s syndrome?

Oops! This section is restricted to members. Click here to signup!

How would you differentiate between osteoarthritis and rheumatoid arthritis based on x-ray findings?

 

Oops! This section is restricted to members. Click here to signup!

A patient presents with trigger finger. Which conditions are associated with this finding?

Oops! This section is restricted to members. Click here to signup!

We have some great hand & wrist OSCE stations for you

  1. Try a normal exam first
  2. Gout
  3. Rheumatoid arthritis
  4. More here!

No comments yet 😉

Leave a Reply