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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: 
Phalen’s test‘Reverse prayer’ sign for 1 minute (pain/paraesthesia = carpal tunnel syndrome)
Tinel’s testTap over the carpal tunnel (paraesthesia = carpal tunnel syndrome)
Finkelstein’s testAsk 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

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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

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Test yourself with some questions

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