Hand physical examination

Question 1

What do you look for on inspection of the dorsal aspect of the hands?

Answer 1

Swelling of joints, comparing hands and wrists

Deformities = Swan neck, Z deformities, Boutonniere

Evidence of psoriasis in nails (onycholysis, psoriatic plaques)

Muscle wasting (interossei)

Presence of scars (suggestive of corrective surgery)

Question 2

What do you look for on inspection of the palmar aspect of the hands?

Answer 2

Muscle wasting = thenar and hypothenar muscles

Presence of scars (suggestive of corrective surgery)

Palmar erythema (present in liver disease and RA)

Pallor of palmar creases = Anaemia (normochromic normocytic anaemia can occur in RA)

Question 3

What is involved in palpation of the hands?

Answer 3

Palpate radiocarpal (wrist), carpo-metacarpal, metacarpo-phalangeal, and interphalangeal joints
Check for: tenderness, synovial effusion and warmth bilaterally
(Use 2 thumb method for the wrist and MCP, Use four finger method for PIPs and DIPs)

Palpate flexor tendons for fibrosis/adhesions
(Tendon involvement in RA, Trigger finger associated with RA)

Question 4

What movements (passive and active) are tested in examination of the hands?

Answer 4

Wrist
Dorsiflexion
Palmar flexion
Lateral flexion (radial and ulnar)

Thumbs
Thumb flexion, extension, abduction, adduction and opposition
Thumb interphalangeal flexion and extension

MCP, DIP and PIP of all digits
Hand closure and opening

Question 5

What function tests are done in the hand examination?

Answer 5

Tinel and Phalen

Power grip

Precision grip

Question 6

How would you assess for sensory innervation of the hand (i.e. median, ulnar, and radial nerve function)?

Answer 6

Assess median nerve sensation over the thenar eminence and index finger

Assess ulnar nerve sensation over the hypothenar eminence and little finger

Assess radial nerve sensation over the first dorsal webspace

Question 7

What non-hand/extraarticular tests or examinations would you consider for a patient with RA?

Answer 7

Elbows for subcutaneous nodules and psoriatic rash (subcutaneous rheumatoid nodules or gouty tophi or psoriatic rash on extensor surface).

Signs of systemic disease and general inspection - mention only:
Respiratory examination for extraarticular manifestations of RA
Examination of eyes for scleritis (in RA)