DrE: Ortho Hands

Question 1

Hand examination: inspection

Answer 1

Start: patient opposite, hands resting on table/pillow, expose above elbows bilaterally, look for aids e.g. splints

• NAILS - onycholysis - nail seperation from nail bed e.g. psoriasis
• scars - trauma, post op e.g. carpal tunnel/tendon repair
• swelling - soft tissue/bony mass
  
  • 6Ss - site, size, shape, surface, symmetry, scars
• deformity - dupuytren’s contracture, nerve lesion, OA, RA
• erythema - infammation/infection
• sinus - post op/infective
• muscle wasting - thenar/hypothenar eminences, dorsal intermetacarpal wasting
• other:
  
  • raynaud’s phenomenon
  • gangrene
  • Elbow - psoriatic plaques/rheumatoid nodules

Question 2

Hand examination: feel

Answer 2

• temperature discrepency
• CRT - press for 5 secs, white to pink, normal 2-3secs
• Dupuytren’s - palmar fascia thickening, assoc garrod’s pads
• rheumatoid nodules - subcutaneous lesions on extensor surfaces
• tenderness -
  
  • each joint seperately and systematically
  • anatomical snuffbox - scaphoid #
• Nerve injury screen - fine touch
  
  • radial nerve - 1st dorsal webspace
  • median nerve - thenar eminence
  • ulnar nerve - palmar aspect of little finger

Question 3

Hand examination: move

Answer 3

• global functional assessment:
  
  • flex thumb
  • make a fist -> fan out fingers
  • abduct->adduct fingers
  • opposition
  • power grip
• ROM: active and passive
  
  • prayer signs - nroaml = 70
  • reverse prayer sign = 90
  • radial deviation = 20
  • ulnar deviation = 50
  • pronation/supination = 85/80
• Digital tendons:
  
  • thumb:
    
    • abductor pollicis brevis (against resistance)
    • flexor pollicis longus (against resistance)
    • extensor pollicis longus (palmar surface flat on table & lift thumb)
  • digital flexors
    
    • flexor digitorum profundus (against resistance)
    • flexor digitorum superficialis (against resistance)
  • digital extensors
    
    • extensor digitorum communis (against resistance)
    • extensor indicis & extensor digiti minimi - ask pt to make a fist and extend their index & little fingers ‘bullhorns’

Question 4

Hand examination: special tests

Answer 4

• Tinnels’ test - fap forearm, poximal to distal along the course of the median nerve (warn the patient) - tingling - CTS
• Phalen’s test - hold hands in reverse prayer for 1 minute - tingling - CTS
• Finkelstein’s - flex thumb, form a fist, ulnar deviate - pain/ inflammation of extensor pol brevis, abd poll longus reproduced - de quervian’s tenosynovitis
• fine function assessment - pick up a key (pincer grip), unbutton a shirt, pick up a pen and write a short sentence
• two point discrimination
  
  • normal <6mm
  • fair 6-10mm
  • poor 11-16mm
  • protective 1 point percieves
  • anaesthetic - no points percieved

Question 5

Hand examination: completion

Answer 5

• lymphadenopathy
• joints - wrist and elbow
• upper limb NV staus - pulses/dermatomes/myotomes
• QoL impingement & sleep
• help pt dress
• radiographs - soft tissue/bony abnormalities

Question 6

Features of osteoarthritis in the hands

Answer 6

• Heberden’s nodes - bony DIPJ swelling
• Bouchard’s nodes - bony PIPJ swlling
• Thumb squaring - 1st CMCJ subluxation

Question 7

features of rheumatoid arthritis in hands

Answer 7

• rheymatoid nodules - 25% on pt with RA
• Boutonier’s deformity - PIPJ flexion DIPJ hyperextension
• Swan neck deformity - PIPJ hyperextension & DIPJ flexion
• Z thumb - MCPJ extension IPJ flexion
• Radial deviation of wrist
• ulnar deviation of digits - capsular loosening & ligamentous laxity of MCPJ