Hands and wrist examination

Question 1

In what general order do you examine the hands and wrists?

Answer 1

Look

Feel

Move

Resisted movements

Sensation

Special tests

Question 2

What medical paraphernalia should you look for before examining the hands and wrist?

Answer 2

Splint

Wrist brace

Compression glove

Prescriptions

Question 3

When looking at the hands, wrists and up to elbows, what 2 surfaces should you examine?

Answer 3

Dorsal/posterior

Palmar/anterior

Question 4

When examining the hands and wrist, where do you start looking and where do you finish?

Answer 4

Start at nails

Go down to elbow

Question 5

What kind of nail abnormalities do you look for, in the hand examination, which usually indicate PsA and maybe RA?

Answer 5

Pitting: Small pits/dents in nail

Onycholysis: Nail separates from skin

Ridging: Vertical raised lines on nails

Colour change to yellow or brown

Clubbing

Question 6

Apart from nail changes, what abnormality can appear near the nails?

Answer 6

Chondrocalcinosis: Hard white lumps that ooze chalky substance

Could be due to pseudogout

Question 7

What 2 types of abnormal nodes can you look for at the PIP and DIP joints of the hand, and what is the underlying pathology?

Answer 7

Bouchard’s nodes: Bony growths at PIP

Heberden’s nodes: Bony growths DIP

Both indicate OA

Question 8

What 3 fixed flexion deformities of the fingers can you look for, and what condition do they indicate?

Answer 8

Swan neck deformity: DIP flexion, PIP hyperextension which suggests RA

Boutonniere’s deformity: DIP hyperextension, PIP flexion which suggests RA

Dupuytren’s contracture: Fibrous cord crosses and contracts MCP then PIP

Question 9

What fixed flexion deformity of the thumb can you look for, and what condition does it indicate?

Answer 9

Z-thumb: interphalangeal joint hyperextension, fixed flexion and subluxation of metacarpophalangeal joint

Suggests RA

Question 10

What abnormality in the thumb can you look for, that suggests OA?

Answer 10

Squaring of base of thumb: Basal thumb arthritis

This is OA of thumb

Question 11

What skin abnormalities should you look for on the dorsal surface of the hand, wrist and elbow?

Answer 11

Psoriatic plaques: Psoriasis or PsA

Erythema: Infection eg. joint sepsis, cellulitis

Swelling, bruising, scarring

Question 12

What does skin thinning or bruising suggest, in terms of medications?

Answer 12

Long-term steroid use

Question 13

What is splinter haemorrhaging in the nail, and what conditions can cause this?

Answer 13

Vertical red-brown line under nail

suggests local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease

Question 14

What is Dupuytren’s contracture, and which fingers are most commonly affected?

Answer 14

Thickening of the plantar fibrous tissue forms fibrous cords, which cross MCP then PIP and cause them to contract

Question 15

What abnormalities should you look for on the plantar surface of the hand?

Answer 15

Dupuytren’s contracture

Hypothenar and thenar muscle wasting

Osler node: red-purple slightly raised tender lumps with pale centre on fingers, suggest infective endocarditis

Janeway lesion: non-tender haemorrhagic lesions on thenar and hypothenar eminences, suggest infective endocarditis

Question 16

Why should you make sure to look for scarring on the wrist?

Answer 16

This can indicate previous carpal tunnel surgery

Question 17

What abnormalities should you look for around the elbow, in the hand exam?

Answer 17

Rheumatoid nodules

Psoriatic plaques

Olecranon bursitis

Medial/lateral epicondylitis

Redness, swelling, bruising

Question 18

On which finger joints do rheumatoid nodules commonly occur?

Answer 18

MCP, PIP

Question 19

On which joints do psoriatic arthritis nodules commonly occur?

Answer 19

MCP, DIP

Question 20

On which surface of the hand should you palpate for temperature, and where else should you palpate?

Answer 20

Palpate palmar surface of hand, anterior aspect of across wrist joint and to elbow

Compare both arms to see if they have similar temperature

Question 21

On the dorsal surface of the hand, what should you do before palpating the hand joints?

Answer 21

MCP joint squeeze

Pain indicates active inflammatory arthritis

Question 22

After the MCP joint squeeze, what joints in the hand should you palpate?

Answer 22

Each MCP joint

Each interphalangeal joint

Question 23

After palpating the MCP joints and interphalangeal joints of the hand, what anatomical structure should you palpate and why?

Answer 23

Anatomical snuffbox

Pain indicates scaphoid fracture

Question 24

After palpating the anatomical snuffbox, what should you palpate in the hand and wrist examination?

Answer 24

Distal ends of radius and ulna

Wrist joint

Question 25

After palpating the wrist joint, what should you palpate on the palmar surface of the hand and wrist?

Answer 25

Thenar and hypothenar muscle bulk Dupuytren's contractures Radial and ulnar pulses

Question 26

What should you palpate on the elbow joint, in the hand examination?

Answer 26

Olecranon process Medial and lateral epicondyles

Question 27

What 4 active movements of the elbow should you test in the hand exam?

Answer 27

Elbow flexion Elbow extension Supination Pronation

Question 28

What 2 active movements of the wrist should you test in the hand examination?

Answer 28

Wrist flexion Wrist extension

Question 29

What 4 active movements of the fingers should you test in the hand examination?

Answer 29

Finger flexion Finger extension Finger abduction Finger adduction

Question 30

Which 5 active movements of the thumb should you test in the hand examination?

Answer 30

Thumb flexion Thumb extension Thumb abduction Thumb adduction Thumb opposition

Question 31

How do you test motor function of the median nerve?

Answer 31

Ask patient to abduct thumb, you try to push it down

Question 32

How do you test motor function of the radial nerve?

Answer 32

Ask patient to hold wrist extended, you try to push hand down

Question 33

How do you test motor function of the ulnar nerve?

Answer 33

Ask patient to abduct fingers, you try to push them together

Question 34

How do you test sensation of the radial nerve?

Answer 34

Establish normal sensation at cubital fossa Swipe cotton wool over 1st dorsal webspace, ask patient if it feels the same weaker or stronger

Question 35

How do you test sensation of the ulnar nerve?

Answer 35

Establish normal sensation at cubital fossa Swipe cotton wool over hypothenar eminence, ask patient if it feels the same weaker or stronger

Question 36

How do you test sensation of the median nerve?

Answer 36

Establish normal sensation at cubital fossa Swipe cotton wool over thenar eminence, ask patient if it feels the same weaker or stronger

Question 37

What special tests can you do to test for median nerve compression/carpal tunnel syndrome?

Answer 37

Reverse Phalen's test: Ask patient to hold dorsums of hands together for 30s-1min, positive if they feel pain, tingling, burning sensation Tinel's test: Tap hard over carpal tunnel for 30s-1min, positive if they feel pain, tingling, burning sensation

Question 38

How do you test power grip of the hand?

Answer 38

Ask patient to make fist around your fingers and squeeze as hard as possible

Question 39

How do you test pincer grip of the hand?

Answer 39

Ask patient to squeeze your finger between their thumb and index finger