Hand OSCE Exam Flashcards
What are the first 5 things you should do in any examination?
Wash hands Introduce yourself Confirm pt details Explain examination Gain consent
How would you position a pt for a hand examination?
Expose pt’s hands, wrists & elbows.
Position pt with hands on a pillow.
What crucial question should you ask before you begin?
Ask if the pt currently has any pain.
What routine would be good to adopt in a hand examination?
Look
Feel
Move
What are the 2 positions in which you’d like to examine the hands?
Dorm (palms down)
Palms up
When the hands are dorsum (palms down), what 7 things are you looking for?
- Inspect hand posture (asymmetry/abnormalities)
- Scars or swelling
- Skin colour
- Deformities
- Skin changes
- Muscle wasting
- Nail changes
* note if any of the above changes are symmetrical or asymmetrical.
When the hands are in the dorsal position, what 2 things are you looking for with regards to skin colour?
Erythema eg. cellulitis (erythema) / palmar erythema
Pallor eg. peripheral vascular disease / anaemia
When the hands are in the dorsal position, what 4 deformities are you looking for?
- Bouchard’s nodes (PIP) / Heberden’s nodes (DIP) - OA
- Swan neck deformity (DIP) joint hyperflecion with PIP joint hyperextension - RA
- Z-thumb: hyperextension of the interphalangeal joint, in addition to fixed flexion and subluxation of the MCP joint - RA
- Boutonniere’s deformity - PIP flexion with DIP hyperextension - RA
What 2 skin changes are you looking for when the hands are in the dorsal position?
Skin thinning or bruising - long term steroid use
Rashes - eg. psoriatic plaques
You find muscle wasting on examination of the hands in the dorsal position. What might this indicate?
Chronic joint pathology OR motor neurone lesions
What 2 nail changes should you look for when the hands are in the dorsal position?
- Nailfold vasculitis: small areas of infarction
- Pitting and onycholysis: associated with psoriasis
With the pt’s palms facing upwards, what 7 things are you looking at / assessing?
- Inspect hand posture: asymmetry / abnormalities (eg. clawed hand)
- Scars: carpal tunnel release surgery
- Swelling
- Skin colour
- Deformity
- Thenar / hypothenar wasting
- Elbows
With the pt’s palms facing upwards, what are you looking for with regards to skin colour?
Erythema: eg. cellulitis (erythema) / palmar erythema
Pallor: eg. peripheral vascular disease / anaemia
What deformity are you looking for when pt’s palms are facing upwards?
Dupuytren’s contracture
What does thenar / hypothenar wasting suggest?
Isolate wasting of the thenar eminence is suggestive of carpal tunnel syndrome.
What are you looking for on the elbows?
Psoriatic plaques OR rheumatoid nodules.
Patient’s palms are facing upwards. What 4 things should you feel for?
- Temperature: wrist & MCP joint lines (warm joints in inflammatory / septic arthritis)
- Radial & ulnar pulse: ensure adequate arterial supply to the hand
- Thenar / hypothenar eminence bulk: wasting is noted in ulnar/median nerve lesions
- Palmar thickening: Dupuytren’s contracture (familial / age related)
How would you assess median nerve sensation?
Touch the thenar eminence / index finger
How would you assess the ulnar nerve?
Touch the hypothenar eminence / little finger
The pt’s palms are facing downwards. How would you assess radial nerve sensation?
Touch the 1st dorsal webspace.
You need to assess & compare the temperature of the pt’s joints. How are you going to do this?
Use the back of your hand.
Assess the pt’s forearm, wrist & MCP joints
You gently squeeze across the metacarpophalangeal (MCP) joints. What are you looking for?
Non-verbal signs of discomfort.
Tenderness may indicate inflammatory arthropathy.
You bimanually palpate the joints of the hand.
Which joints are you feeling?
MCP: Metacarpophalangeal joint
PIP: Proximal interphalangeal joint
DIP: Distal interphalangeal joint
CMC: Carpometacarpal joint of the thumb (squaring of the joint is associated with OA).
You bimanually palpate the joints of the hand. What are you assessing & comparing?
Assess & compare for:
- tenderness
- irregularities
- warmth
You palpate the anatomical snuffbox & find tenderness. What does this suggest?
Scaphoid fracture
What else must you bimanually palpate?
The pt’s wrists
Describe how you would palpate the pt’s arm & elbow.
Palpate the pt’s arm along the ulnar border to the elbow.
Note any rheumatoid nodules or psoriatic plaques (extensor surface).
How should finger / hand / wrist movements be assessed?
Actively first (pt does the movements independently). Then assess movements passively, feeling for crepitus & noting any pain.
What 4 movements should you instruct your patient to carry out?
- Finger extension: “Open your fist & splay your fingers”
- Finger flexion: “Make a fist.”
- Wrist extension: “Put palms of your hands together & extend wrists fully” (ROM = 90o)
- Wrist flexion: “Put the backs of your hands together & flex wrists fully” - ROM = 90o
What are the 3 major nerves of the hand?
Radial nerve
Ulnar nerve
Median nerve
What is the purpose of the Motor assessment?
To quickly assess the 3 major nerves of the hand.
How would you assess the radial nerve?
Wrist / finger extension (against resistance)
How would you assess the ulnar nerve?
(Index) Finger abduction (against resistance)
How would you assess the median nerve?
Thumb abduction (against resistance)
What 3 tests assess ‘function’?
Power grip
Pincer grip
Pick up small object / undo shirt button
How would you assess ‘Power grip’?
“Squeeze my fingers with your hands”
How would you assess ‘Pincer grip’?
“Place your thumb & index finger together & don’t let me separate them”.
What are the 2 ‘special tests’ required to assess the hand?
Tinel’s test
Phalen’s test
What is Tinel’s test used to identify?
Used to identify nerve irritation. Can be useful in the diagnosis of carpal tunnel syndrome.
How would you conduct a Tinel’s test?
- Tap over the carpal tunnel
- If the pt develops tingling in the thumb and radial two and a half fingers, this is suggestive of median nerve irritation & compression.
What is Phalen’s test used for?
If Hx or examination findings are suggestive of carpal tunnel syndrome, this test may be used to further support the diagnosis.
How would you conduct a Phalen’s test?
- Ask the pt to hold their wrist in complete & forced flexion (pushing the dorsal surfaces of both hands together) for 60secs.
- If pt’s symptoms of carpal tunnel syndrome are reproduced, then the test is positive
What symptoms (of carpal tunnel syndrome) might be elicited on conducting Phalen’s test?
Burning, tingling or numb sensation over the thumb, index, middle & ring fingers
What 3 things are you going to do to complete the examination?
Thank pt
Wash hands
Summarise findings
What further assessments & investigations might be appropriate?
- Perform a full neurovascular examination of the upper limbs
- Examine the elbow joint
