Hand and wrist Examination

Question 1

Describe the following deformities

Answer 1

Bouchard’s nodes: occur at the proximal interphalangeal joints (PIPJ) and are associated with osteoarthritis.

Heberden’s nodes: occur at the distal interphalangeal joints (DIPJ) and are associated with osteoarthritis.

Question 2

Describe the following deformity

Answer 2

Swan neck deformity: occurs at the distal interphalangeal joint (DIPJ) with clinical features including DIPJ flexion with PIPJ hyperextension. Swan neck deformity is typically associated with rheumatoid arthritis.

Question 3

Describe the following deformity

Answer 3

Z-thumb: hyperextension of the interphalangeal joint, in addition to fixed flexion and subluxation of the metacarpophalangeal joint (MCPJ). Z-thumb is associated with rheumatoid arthritis.

Question 4

Describe the following deformity

Answer 4

Boutonnières deformity: PIPJ flexion with DIPJ hyperextension associated with rheumatoid arthritis.

Question 5

What is the following clinical sign and what does it indicate?

Answer 5

Skin thinning or bruising: can be associated with long-term steroid use (e.g. common in patients with active inflammatory arthritis).

Question 6

What is the following clinical sign and what does it indicate?

Answer 6

Psoriatic plaques: salmon coloured plaques with a silvery scale. Patients who have psoriasis are at significantly increased risk of developing psoriatic arthritis.

Question 7

What is the following clinical sign and what does it indicate?

Answer 7

Muscle wasting: can occur secondary to chronic joint pathology or lower motor neuron lesions (e.g. median nerve damage secondary to carpal tunnel syndrome).

Thenar/hypothenar wasting: isolated wasting of the thenar eminence is suggestive of median nerve damage (e.g. carpal tunnel syndrome).

Question 8

What is the following clinical sign and what does it indicate?

Answer 8

Splinter haemorrhages: a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.

Question 9

What is the following clinical sign and what does it indicate?

Answer 9

Nail pitting and onycholysis: associated with psoriasis and psoriatic arthritis.

Question 10

What is the following clinical sign and what does it indicate?

Answer 10

Dupuytren’s contracture involves thickening of the palmar fascia, resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb.

Question 11

What is the following clinical sign and what does it indicate?

Answer 11

Janeway lesions: non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and soles). Janeway lesions are typically associated with infective endocarditis.

Question 12

What is the following clinical sign and what does it indicate?

Answer 12

Osler’s nodes: red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. They are typically associated with infective endocarditis.

Question 13

What is OA?

Answer 13

Osteoarthritis (OA) is the most common form of arthritis and is characterised by joint pain worsened with activity, localised loss of cartilage, remodelling of adjacent bone and associated inflammation. Typical findings in the hands include swellings at the distal interphalangeal joints (Heberden’s nodes) and proximal interphalangeal joints (Bouchard’s nodes) which represent osteophyte formation. There is often associated crepitus and reduced range of joint movement.

Question 14

What is RA?

Answer 14

Rheumatoid arthritis (RA) is an autoimmune disease characterised by inflammation of the synovial joints, periarticular tissue destruction and a variety of extra-articular features (e.g. rheumatoid nodules, scleritis, nail fold infarcts and peripheral nerve entrapment). Patients typically experience joint pain (present even at rest), joint swelling and morning joint stiffness. Typical findings in the hands include symmetrical joint inflammation typically affecting the proximal interphalangeal joints, metacarpophalangeal joints and wrist joints. Other features of RA in the hands include muscle wasting, ulnar deviation, swan neck deformity, Boutonnière’s deformity and Z-thumb deformity.

Question 15

What is PA?

Answer 15

Psoriatic arthritis is 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).

Question 16

When squeezing across the metacarpophalangeal (MCP), discomfort and tenderness is suggestive of what?

Answer 16

active inflammatory arthropathy.

Question 17

Tenderness at the anatomical snuff box is indicative of what?

Answer 17

scaphoid fracture.

Question 18

What is the following clinical sign and what does it indicate?

Answer 18

Rheumatoid nodules

Question 19

What is a scaphoid fracture?

Answer 19

Scaphoid fracture

The scaphoid is the largest bone in the proximal row of carpal bones and is also the most commonly fractured. It often occurs due to a fall on an outstretched hand. As a result of the poor blood supply to the scaphoid, fractures can be slow to heal and avascular necrosis of the proximal fragment of the scaphoid can occur. Tenderness in the anatomical snuffbox is highly suggestive of a scaphoid fracture.

Question 20

Wrist and finger extension against resistance tests what nerve/muscle?

Answer 20

Wrist and finger extension against resistance

Nerve assessed: radial nerve

Muscles assessed: extensors of the wrist and fingers

Question 21

Index finger ABduction against resistance against resistance tests what nerve/muscle?

Answer 21

Nerve assessed: ulnar nerve

Muscles assessed: first dorsal interosseous (FDI)

Question 22

Thumb ABduction against resistance tests what nerve/muscle?

Answer 22

Thumb ABduction against resistance

Nerve assessed: median nerve

Muscle assessed: abductor pollicis brevis

Question 23

What is tinsels test?

Answer 23

Tinel’s test

Tinel’s test is 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.

Question 24

What is phalens test?

Answer 24

Phalen’s test

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).

Question 25

What is carpal tunnel syndrome?

Answer 25

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.

Question 26

What further further assessments and investigations would you do?

Answer 26

Further assessments and 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).