Hand and wrist examination

Question 1

How do you explain hand examination to the patient?

Answer 1

Today I’m going to examine the bones of your hands and wrists. The examination will involve me first looking at the hands, then feeling the joints and finally asking you to do some movements.

Question 2

What is the exposure for hand examination?

Answer 2

Expose the hands, wrists and elbow

Question 3

What do you check for on inspection of the hands?

Answer 3

Scars 
Swelling 
Deformities 
Skin/nail changes 
Muscle wasting

Question 4

What are the typical findings in the hands in osteoarthritis? (3)

Answer 4

1. Swellings at:
   a) distal interphalangeal joints (DIP)
   b) proximal interphalangeal joints (PIP)
2. Creptius
3. Reduced ROM

Question 5

What are the typical findings in the hands in rheumatoid arthritis? (6)

Answer 5

1. Symmetrical joint inflammation affecting:
   a) proximal interphalangeal joints (PIP)
   b) metacarpophalangeal joints (MCP)
   c) wrist joints
2. Muscle wasting
3. Ulnar deviation
4. swan neck deformity
5. Boutonniere’s deformity
6. Z-thumb deformity

Question 6

What are the extra articular features of rheumatoid arthritis?

Answer 6

1. rheumatoid nodules
2. scleritis
3. nail fold infarcts
4. peripheral nerve entrapment

Question 7

When do patients with RA experience pain?

Answer 7

At rest

It is STIFFNESS which is in the morning + gets better as the day goes on

Question 8

What are Bouchard’s and Heberden’s nodes and which condition are they associated with?

Answer 8

Osteoarthritis:
Bouchard’s node = PIP joint swellings
Heberden’s nodes = DIP joint swellings
note: H is later on in the alphabet therefore distal

Question 9

What deformities are associated with RA and describe each?

Answer 9

Swan neck deformity = DIPJ flexion with PIPJ hyperextension

Boutonniere’s deformity = PIPJ flexion with DIPJ hyperextension

Question 10

What is Z-thumb deformity?

Answer 10

Hyperextension of the interphalangeal joint of the thumb

Question 11

What nail changes are associated with psoriatic arthritis?

Answer 11

Nail pitting and onycholysis

Question 12

What can muscle wasting in the hand be a cause of?

Answer 12

lower motor neuron lesions e.g. median nerve damage secondary to carpel tunnel syndrome (thenar eminence wasting)

Question 13

What are you looking for on inspection of the elbows?

Answer 13

1. Psoriatic plaques

2. rheumatoid nodules

Question 14

If a joint feels warm, what may this indicate?

Answer 14

1. septic arthritis

2. inflammatory arthritis

Question 15

Why do you feel radial and ulnar pulses in hand examination?

Answer 15

To confirm adequate blood supply

Question 16

MCP joint squeeze - tenderness suggests what?

Answer 16

Inflammatory arthropathy

RA has MCP J tenderness

Question 17

What type of fall causes a scaphoid fracture?

Answer 17

fall on outstretched hand

Question 18

What movements are you assessing for in the hand?

Answer 18

finger flexion and
and extention
wrist flexion and extension

Question 19

How you test the motor function of the radial nerve and which muscles are involved ?

Answer 19

Wrist and finger extension against resistance

Muscles: extensors of the wrist and fingers

Question 20

How you test the motor function of the ulnar nerve and which muscles are involved?

Answer 20

Index finger ABduction against resistance

Muscle: first dorsal interosseous

Question 21

How you test the motor function of the median nerve and which muscles are involved?

Answer 21

Thumb ABduction against resistance

muscle: abductor pollicis brevis

Question 22

How do you check function in the hands?

Answer 22

Power grip
Pincer grip
Pick up a small object

Question 23

What are the special tests for Hand examination?

Answer 23

Tinel’s test
Phalen’s test
Finkelstein test

Question 24

How long should the patient test Phalen’s test?

Answer 24

60 seconds

Question 25

What are the further investigations for a hand exam?

Answer 25

1. Neurovascular examination of the upper limb

2. Elbow joint examination