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Phase 2b Sheffield Medicine > Hand and Wrist Examination > Flashcards

Hand and Wrist Examination Flashcards

1
Q

What position should the patient be in before commencing a hand and wrist examination?

A

● Adequately expose the patient’s hands, wrist and elbows.
● Position the patient seated with their hands on a pillow.
● Ask the patient if they have any pain before proceeding with the clinical examination.

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2
Q

What is the first step in a hand and wrist examination?

A

● General inspection looking for clinical signs and objects/equipment.

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3
Q

What clinical signs should you be aware of when performing a general inspection?

A

● Scars
● Wasting of muscles

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4
Q

What may scars be suggestive of when completing a general inspection during a hand and wrist exam?

A

● May provide clues regarding previous upper limb surgery.

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5
Q

What may wasting of muscles be suggestive of when completing a general inspection during a hand and wrist exam?

A

● Suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron lesion.

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6
Q

What objects or equipment may be seen when performing a general inspection during a hand and wrist exam?

A

● Aids and adaptations - e.g. splints
● Prescriptions

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7
Q

What areas of the hands should be inspected during a hand and wrist exam?

A

● Dorsal aspect of the hand
● Palmar aspect of the hand

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8
Q

List some clinical signs that may be observed on the dorsal aspect of the hand when completing a hand and wrist exam?

A

● Hand posture
● Scars
● Swelling
● Skin colour changes
● Bouchard’s nodes
● Heberden’s nodes
● Swan neck deformity
● Z-thumb
● Boutonnières deformity
● Skin thinning or bruising
● Psoriatic plaques
● Muscle wasting
● Splinter haemorrhages
● Nail pitting and onycholysis

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9
Q

What may an abnormal hand posture be suggestive of when completing a hand and wrist exam?

A

● May indicate underlying pathology (e.g. Dupuytren’s contracture, ulnar deviation secondary to rheumatoid arthritis).

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10
Q

What may scars be suggestive of when completing a hand and wrist exam?

A

● May indicate previous surgery or trauma.

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11
Q

What may Bouchard’s nodes be suggestive of when completing a hand and wrist exam?

A

● Occur at the proximal interphalangeal joints (PIPJ) and are associated with osteoarthritis.

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12
Q

What may Heberden’s nodes be suggestive of when completing a hand and wrist exam?

A

● Occur at the distal interphalangeal joints (DIPJ) and are associated with osteoarthritis.

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13
Q

What may swan neck deformity be suggestive of when completing a hand and wrist exam?

A

● 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.

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14
Q

What may Z-thumb be suggestive of when completing a hand and wrist exam?

A

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

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15
Q

What may Boutonnières deformity be suggestive of when completing a hand and wrist exam?

A

● PIPJ flexion with DIPJ hyperextension associated with rheumatoid arthritis.

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16
Q

What may skin thinning or bruising be suggestive of when completing a hand and wrist exam?

A

● Can be associated with long-term steroid use (e.g. common in patients with active inflammatory arthritis).

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17
Q

What may psoriatic plaques be suggestive of when completing a hand and wrist exam?

A

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

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18
Q

What may muscle wasting be suggestive of when completing a hand and wrist exam?

A

● Can occur secondary to chronic joint pathology or lower motor neuron lesions (e.g. median nerve damage secondary to carpal tunnel syndrome).

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19
Q

What may splinter haemorrhages be suggestive of when completing a hand and wrist exam?

A

● 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.

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20
Q

What may nail pitting and onycholysis be suggestive of when completing a hand and wrist exam?

A

● Associated with psoriasis and psoriatic arthritis.

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21
Q

What may skin colour changes be suggestive of when completing a hand and wrist exam?

A

● Erythema of the soft tissue may indicate cellulitis or joint sepsis

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22
Q

List some clinical signs that may be observed on the palmar aspect of the of the hand when completing a hand and wrist exam?

A

● Hand posture changes
● Scars
● Swelling
● Dupuytren’s contracture
● Thenar / hypothenar wasting
● Psoriatic plaques (elbow)
● Rheumatoid nodules (elbow)
● Janeway lesions
● Osler’s nodes

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23
Q

What may (hypo-)thenar wasting be suggestive of when completing a hand and wrist exam?

A

● Isolated wasting of the thenar eminence is suggestive of median nerve damage (e.g. carpal tunnel syndrome).

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24
Q

What may Janeway lesions be suggestive of when completing a hand and wrist exam?

A

● 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.

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25
What may Osler's nodes be suggestive of when completing a hand and wrist exam?
● 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.
26
What aspects of the hands should you feel when the palms are up in a hand and wrist exam?
● Temperature ● Radial and ulnar pulse ● Thenar and hypothenar eminence bulk ● Palmar thickening ● Median and ulnar nerve sensation
27
What aspects of the hands should you feel when the palms are down in a hand and wrist exam?
● Radial nerve sensation ● Temperature ● Metacarpophalangeal joint squeeze ● Bimanual joint palpation ● Anatomical snuffbox ● Bimanual wrist palpation
28
Describe how you would assess temperature during a hand and wrist exam?
● Assess and compare the temperature of the joints of the hand and elbow using the back of your hands. ● Assess and compare the temperature of the joints on the dorsal aspect of the hand (e.g. metacarpophalangeal joints) and elbow using the back of your hands.
29
What may increased temperature indicate during a hand and wrist exam?
● Increased temperature of a joint, particularly if also associated with swelling and tenderness may indicate septic arthritis or inflammatory arthritis.
30
Why should you palpate the radial and ulnar pulse during a hand and wrist exam?
● Palpate the radial and ulnar pulse to confirm adequate blood supply to the hand.
31
What may thenar and hypothenar eminence wasting be an indication of when performing a hand and wrist exam?
● Wasting can be caused by disuse atrophy as well as lower motor neuron lesions (e.g. ulnar and median nerve).
32
Describe how you would assess palmar thickening during a hand and wrist exam?
● Support the patient’s hand and palpate the palm to detect the typical bands of thickened palmar fascia associated with Dupuytren’s contracture.
33
How would you assess median nerve sensation in a hand and wrist exam?
● Assess median nerve sensation over the thenar eminence and index finger.
34
How would you assess ulnar nerve sensation in a hand and wrist exam?
● Assess ulnar nerve sensation over the hypothenar eminence and little finger.
35
How would you assess radial nerve sensation in a hand and wrist exam?
● Assess radial nerve sensation over the first dorsal webspace.
36
Describe how you would perform a metacarpophalangeal joint squeeze during a hand and wrist exam?
● Gently squeeze across the metacarpophalangeal (MCP) joints and observe for verbal and non-verbal signs of discomfort.
37
What is tenderness, during a MCP joint squeeze associated with?
● Tenderness is suggestive of active inflammatory arthropathy.
38
When performing bimanual joint palpation what should you compare for and what joints should you assess, during a hand and wrist exam?
● 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)
39
What is anatomical snuffbox tenderness suggestive of when performing a hand and wrist exam?
● Scaphoid fracture
40
Describe how you would palpate the elbow during a hand and wrist exam, what should you make note of?
● Palpate the patient’s arm along the ulnar border to the elbow and note any tenderness, rheumatoid nodules or psoriatic plaques.
41
Which hand should be assessed first in a hand and wrist exam?
● If the patient is known to have an issue with a particular hand, you should assess the ‘normal’ hand first for comparison
42
What is active movement?
● Active movement refers to a movement performed independently by the patient.
43
What is passive movement?
● Passive movement refers to a movement of the patient, controlled by the examiner.
44
What movements should you demonstrate to and ask the patient to perform in a hand and wrist exam for active movement?
● Finger extension ● Finger flexion ● Wrist extension ● Wrist flexion
45
How would you ask a patient to perform finger extension during a hand and wrist exam?
● “Open your fist and splay your fingers.”
46
How would you ask a patient to perform finger flexion during a hand and wrist exam?
● “Make a fist.”
47
How would you ask a patient to perform wrist extension during a hand and wrist exam?
● “Put the palms of your hands together and extend your wrists fully.”
48
What is the normal range of motion for wrist extension during a hand and wrist exam?
● 90º
49
How would you ask a patient to perform wrist flexion during a hand and wrist exam?
● “Put the backs of your hands together and flex your wrists fully.”
50
What is the normal range of motion for wrist flexion during a hand and wrist exam?
● 90º
51
What movements of the hand and wrist should you perform on the patient during a hand and wrist exam for passive movement?
● Finger extension ● Finger flexion ● Wrist extension ● Wrist flexion
52
What nerve does wrist and finger extension against resistance assess?
● Radial nerve
53
What muscles does wrist and finger extension against resistance assess?
● Extensors of the wrist and fingers
54
Describe how you would perform wrist and finger extension against resistance in a hand and wrist exam?
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.”
55
What nerve does index finger abduction against resistance assess?
● Ulnar nerve
56
What muscles does index finger abduction against resistance assess?
● First dorsal interosseous (FDI)
57
Describe how you would perform index finger abduction against resistance in a hand and wrist exam?
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.
58
What nerve does thumb abduction against resistance assess?
● Median nerve
59
What muscles does thumb abduction against resistance assess?
● Abductor pollicis brevis
60
Describe how you would perform thumb abduction against resistance in a hand and wrist exam?
1. 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. 2. 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.”
61
What fine motor screening tests would you perform to assess hand function in a hand and wrist exam?
● Power grip ● Pincer grip ● Pick up a small object
62
What instructions would you give to a patient to assess power grip during a hand and wrist exam?
● “Squeeze my fingers with your hands.”
63
What instructions would you give to a patient to assess pincer grip during a hand and wrist exam?
● “Squeeze my finger between your thumb and index finger.”
64
What instructions would you give to a patient when asking them to pick up and object during a hand and wrist exam?
● “Could you please pick up the coin off the table.”
65
What two special test can be performed at the end of a hand and wrist exam?
● Tinel's test ● Phalen's test
66
What is Tinel's test used for in a hand and wrist exam?
● Tinel’s test is used to identify median nerve compression and can be useful in the diagnosis of carpal tunnel syndrome.
67
How would you perform Tinel's test in a hand and wrist exam?
● To perform the test, simply tap over the carpal tunnel with your finger.
68
Describe how you would interpret a Tinel's test result during a hand and wrist exam?
● If the patient develops tingling in the thumb and radial two and a half fingers this is suggestive of median nerve compression.
69
What is Phalen's test used for in a hand and wrist exam?
● If the history or examination findings are suggestive of carpal tunnel syndrome, Phalen’s test may be used to further support the diagnosis.
70
How would you perform Phalen's test in a hand and wrist exam?
● Ask the patient to hold their wrist in maximum forced flexion (pushing the dorsal surfaces of both hands together) for 60 seconds.
71
Describe how you would interpret a Phalen's test result during a hand and wrist exam?
● 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).
72
What further assessments and investigations could be performed after a hand and wrist exam?
● Neurovascular examination of the upper limbs. ● Examination of the elbow joint and shoulder joint. ● Further imaging if indicated (e.g. X-ray and MRI).

Phase 2b Sheffield Medicine (17 decks)

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