Flashcards in Hand OSCE Exam Deck (45)
What are the first 5 things you should do in any examination?
Confirm pt details
How would you position a pt for a hand examination?
Expose pt's hands, wrists & elbows.
Position pt with hands on a pillow.
What crucial question should you ask before you begin?
Ask if the pt currently has any pain.
What routine would be good to adopt in a hand examination?
What are the 2 positions in which you'd like to examine the hands?
Dorm (palms down)
When the hands are dorsum (palms down), what 7 things are you looking for?
1. Inspect hand posture (asymmetry/abnormalities)
2. Scars or swelling
3. Skin colour
5. Skin changes
6. Muscle wasting
7. Nail changes
*note if any of the above changes are symmetrical or asymmetrical.
When the hands are in the dorsal position, what 2 things are you looking for with regards to skin colour?
Erythema eg. cellulitis (erythema) / palmar erythema
Pallor eg. peripheral vascular disease / anaemia
When the hands are in the dorsal position, what 4 deformities are you looking for?
- Bouchard's nodes (PIP) / Heberden's nodes (DIP) - OA
- Swan neck deformity (DIP) joint hyperflecion with PIP joint hyperextension - RA
- Z-thumb: hyperextension of the interphalangeal joint, in addition to fixed flexion and subluxation of the MCP joint - RA
- Boutonniere's deformity - PIP flexion with DIP hyperextension - RA
What 2 skin changes are you looking for when the hands are in the dorsal position?
Skin thinning or bruising - long term steroid use
Rashes - eg. psoriatic plaques
You find muscle wasting on examination of the hands in the dorsal position. What might this indicate?
Chronic joint pathology OR motor neurone lesions
What 2 nail changes should you look for when the hands are in the dorsal position?
- Nailfold vasculitis: small areas of infarction
- Pitting and onycholysis: associated with psoriasis
With the pt's palms facing upwards, what 7 things are you looking at / assessing?
1. Inspect hand posture: asymmetry / abnormalities (eg. clawed hand)
2. Scars: carpal tunnel release surgery
4. Skin colour
6. Thenar / hypothenar wasting
With the pt's palms facing upwards, what are you looking for with regards to skin colour?
Erythema: eg. cellulitis (erythema) / palmar erythema
Pallor: eg. peripheral vascular disease / anaemia
What deformity are you looking for when pt's palms are facing upwards?
What does thenar / hypothenar wasting suggest?
Isolate wasting of the thenar eminence is suggestive of carpal tunnel syndrome.
What are you looking for on the elbows?
Psoriatic plaques OR rheumatoid nodules.
Patient's palms are facing upwards. What 4 things should you feel for?
1. Temperature: wrist & MCP joint lines (warm joints in inflammatory / septic arthritis)
2. Radial & ulnar pulse: ensure adequate arterial supply to the hand
3. Thenar / hypothenar eminence bulk: wasting is noted in ulnar/median nerve lesions
4. Palmar thickening: Dupuytren's contracture (familial / age related)
How would you assess median nerve sensation?
Touch the thenar eminence / index finger
How would you assess the ulnar nerve?
Touch the hypothenar eminence / little finger
The pt's palms are facing downwards. How would you assess radial nerve sensation?
Touch the 1st dorsal webspace.
You need to assess & compare the temperature of the pt's joints. How are you going to do this?
Use the back of your hand.
Assess the pt's forearm, wrist & MCP joints
You gently squeeze across the metacarpophalangeal (MCP) joints. What are you looking for?
Non-verbal signs of discomfort.
Tenderness may indicate inflammatory arthropathy.
You bimanually palpate the joints of the hand.
Which joints are you feeling?
MCP: Metacarpophalangeal joint
PIP: Proximal interphalangeal joint
DIP: Distal interphalangeal joint
CMC: Carpometacarpal joint of the thumb (squaring of the joint is associated with OA).
You bimanually palpate the joints of the hand. What are you assessing & comparing?
Assess & compare for:
You palpate the anatomical snuffbox & find tenderness. What does this suggest?
What else must you bimanually palpate?
The pt's wrists
Describe how you would palpate the pt's arm & elbow.
Palpate the pt's arm along the ulnar border to the elbow.
Note any rheumatoid nodules or psoriatic plaques (extensor surface).
How should finger / hand / wrist movements be assessed?
Actively first (pt does the movements independently).
Then assess movements passively, feeling for crepitus & noting any pain.
What 4 movements should you instruct your patient to carry out?
1. Finger extension: "Open your fist & splay your fingers"
2. Finger flexion: "Make a fist."
3. Wrist extension: "Put palms of your hands together & extend wrists fully" (ROM = 90o)
4. Wrist flexion: "Put the backs of your hands together & flex wrists fully" - ROM = 90o