Table of Contents
- 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
- 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)
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)
- 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)
- 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)
‘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: 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
- 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
Test yourself with some questions
Which nerve impingement would lead to a wrist drop and what could cause it?
What examination findings in the hand and wrist would make you suspect rheumatoid arthritis?
Please list some extra-articular manifestations of rheumatoid arthritis
What is Felty’s syndrome?
How would you differentiate between osteoarthritis and rheumatoid arthritis based on x-ray findings?
A patient presents with trigger finger. Which conditions are associated with this finding?