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 ands and forearms and rest hands on pillow
• General inspection: patient, e.g. age, pain/discomfort, signs of trauma; around bed, e.g. mobility aids, splint

Look

• Dorsum
  • Deformities of joint/bones/alignment (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), clubbing
• Palmar surface
  • Look for: scars (e.g. carpal tunnel release scar), swellings (e.g. ganglions – local small fluctuant swellings), muscle wasting of thenar eminence (carpal tunnel syndrome) and hypothenar eminence(ulnar nerve lesion)
• Extensor surface of arm
  • Feel up border: psoriatic plaques, rheumatoid nodules, gouty tophi

Osteoarthritis

Rheumatoid arthritis

Rheumatoid nodules

Gouty tophi

Pitting and onycholysis in psoriasis

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)
  • Palpate 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) 

Move

• Wrist movements actively and passively (feel for crepitus): extension 70˚ and flexion 80˚ (‘prayer’ sign and ‘reverse prayer’ sign respectively); pronation 75˚ and supination 85˚; 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 test

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

Finkelstein’s test

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; attempt a tasks, e.g. pick up a pen
• Basic neurological hand exam: quickly do the motor and sensory parts of the neurological hand exam

Basic neurological hand examination

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A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

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

Test yourself with some questions

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

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

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Please list some extra-articular manifestations of rheumatoid arthritis

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What is Felty’s syndrome?

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

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

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We have some great hand & wrist OSCE stations for you

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