3. Hand & Wrist

Question 1

Look

Answer 1

Patient sitting, hands resting on pillow

• Scars, wounds, thinning of skin (steroids), rashes
• Nails for clubbing, psoriatic changes, pitting, splinter haemorrhages, nail fold vasculitis
• Posture of hand and wrist
• Fingers (deformity)
• Muscle wasting, obvious deformity, Bouchard’s nodes, Heberden’s nodes
• Hard swellings (OA)
• Soft swellings (Synovitis)
• Dupuytren’s disease

Question 2

Feel

Answer 2

• Temperature of forearm, wrist and back of hand
• Assess radial pulse
• Feel for muscle bulk of thenar and hypothenar eminences
• Sensation of Median (index and thenar), Ulnar (little finger and hypothenar) and Radial nerves (first webspace on dorsum)
• Palpate for tenderness whilst watching face
• Bimanually palpate and swollen or painful joints for tenderness and fluctuation
• Palpate MCP and wrist joint with thumbs above, index fingers below

Question 3

Move

Answer 3

• Stretch fingers out and make a fist (check alignment)
• Passively assess if abnormality to assess if joint/tendon/nerve problem
• Wrist flexion/extension, prayer sign and reverse prayer sign
• Nerve power: Radial (resisted finger extension), Median (abductor pollicis brevis push thumb down), Ulnar (interossei spread fingers)

Question 4

Function

Answer 4

Power grip
Pincer grip

Examine elbow joint

Question 5

Special Tests

Answer 5

Tinel’s - tapping over median nerve as it passes through wrist

Phalen’s - wrist held in full flexion for 60 seconds