Hand and Wrist Exam Flashcards
What is the overall layout of the hand and wrist exam
WIPERQQ
Inspection
Look
Feel
Move
Function
Special tests
Finish exam
What should you look for in the inspection part of the hand exam
General: scars, wasting, aids, prescriptions
Dorsum: hand posture, scars, swelling, skin colour, nodes, deformities, skin bruising/thinning, psoriatic plaques, nail changes (splinter haemorrhages, pitting and onycholysis)
Palm: posture, swelling, Dupuytren’s contracture, wasting, Janeway lesions/ Osler’s nodes
ELBOWS! - inspect for evidence of psoriatic plaques or rheumatoid nodules.
Which hand deformities are associated with RA (5)
muscle wasting,
ulnar deviation,
swan neck deformity,
Boutonnière’s deformity
Z-thumb deformity.
What is psoriatic arthritis
How does it present on the hands
an autoimmune disease associated with psoriasis that is characterised by inflammation of the joints and the surrounding tendons.
Typical clinical features in the hands include joint swelling, joint pain and dactylitis (swelling of whole digits).
What do you do during the Feel section of the hand exam
2 sections: 5 things in palm up, 7 things in palm down
Palm up - temperature, pulses, hypo/thenar eminences, palmar thickening, sensation
Palm down - radial nerve sensation, temp, MCP squeeze, bimanual joint palpation, anatomical snuffbox, bimanual wrist palpation, elbow palpation
Which nerves do you assess sensation of in the palm up section of palpating the hand in the hand exam
Palm down?
- Assess median nerve sensation over the thenar eminence and index finger.
- Assess ulnar nerve sensation over the hypothenar eminence and little finger.
- radial nerve - first dorsal webspace
a) What does bimanual joint palpation of the hand involve in the hand exam ?
b) What about bimanual wrist palpation?
a) Bimanually palpate the joints of the hand, assessing and comparing for tenderness, irregularities and warmth:
Metacarpophalangeal joint (MCPJ)
Proximal interphalangeal joint (PIPJ)
Distal interphalangeal joint (DIPJ)
Carpometacarpal joint (CMCJ) of the thumb (squaring of the joint is associated with OA
b) Palpate the wrists for evidence of joint line irregularities or tenderness.
How do you do elbow palpation in the hand and wrist exam
Palpate the patient’s arm along the ulnar border to the elbow and note any tenderness, rheumatoid nodules or psoriatic plaques.
Which active movements should you get the patient to do in a Hand and Wrist exam? (4)
Give instructions for each
What do you do after this? Repeat each movement passively
Finger extension
Instructions: “Open your fist and splay your fingers.”
Finger flexion
Instructions: “Make a fist.”
Wrist extension
Normal range of movement: 90º
Instructions: “Put the palms of your hands together and extend your wrists fully.”
Wrist flexion
Normal range of movement: 90º
Instructions: “Put the backs of your hands together and flex your wrists fully.”
What does the motor assessment part of the the Hand exam entail
Test the following:
-Wrist and finger extension against resistance
-Index finger ABduction against resistance
- Thumb ABduction against resistance
Which nerves and muscles does -Wrist and finger extension against resistance assess
radial nerve, extensors of the wrist and fingers
(Instructions:
1. Ask the patient to hold their arms out in front of them with their palms facing downwards –“Hold your arms out in front of you, with your palms facing the ground.”
2. Ask the patient to extend their fingers and wrist joints, keeping their hands in this position whilst you apply resistance – “Extend your fingers out in front of you, cock your wrists back and don’t let me pull them downwards.”)
What does Index finger ABduction against resistance motor test assess
ulnar nerve; first dorsal interosseous (FDI)
(Instructions:
1. Ask the patient to splay their fingers and stop you from pushing their fingers together – “Splay your fingers outwards and don’t let me push them together.”
2. Apply resistance to the patient’s index finger using your own index finger to assess abduction)
What does thumb ABduction against resistance motor test assess
median nerve; abductor pollicis brevis
(Instructions: Ask the patient to turn their hand over so their palm is facing upwards and to position their thumb over the midline of the palm. Advise them to keep it in this position whilst you apply downward resistance with your own thumb – “Point your thumbs to the ceiling and don’t let me push them down.)
How do you assess hand function in the Hand exam
Power grip
(Instructions: “Squeeze my fingers with your hands.”)
Pincer grip
(Instructions: “Squeeze my finger between your thumb and index finger.”)
Pick up a small object
(Instructions: “Could you please pick up the coin off the table.”)
What special tests should you do in a hand exam?
Finkelstein
Phalen
Tinel
Describe Tinel’s test and its interpretation
used to identify median nerve compression and can be useful in the diagnosis of carpal tunnel syndrome.
To perform the test, simply tap over the carpal tunnel with your finger.
Interpretation
If the patient develops tingling in the thumb and radial two and a half fingers this is suggestive of median nerve compression.
Describe Phalen’s test and its interpretation
If the history or examination findings are suggestive of carpal tunnel syndrome, Phalen’s test may be used to further support the diagnosis.
Ask the patient to hold their wrist in maximum forced flexion (pushing the dorsal surfaces of both hands together) for 60 seconds.
Interpretation
If the patient’s symptoms of carpal tunnel syndrome are reproduced then the test is positive (e.g burning, tingling or numb sensation in the thumb, index, middle and ring fingers)
What is carpal tunnel syndrome
Carpal tunnel syndrome occurs as a result of compression of the median nerve as it traverses through the wrist via the carpal tunnel. Typical clinical features include pain and paraesthesia in the distribution of the median nerve (index finger, thumb and lateral half of the ring finger). Grip weakness can also develop secondary to wasting of the thenar muscles which receive motor innervation from the median nerve.
What do you do after the special tests in the Hand exam
thank patient etc,
summarise,
further investigations (Neurovascular examination of the upper limbs.
Examination of the elbow joint and shoulder joint.
Further imaging if indicated (e.g. X-ray and MRI).)
