Hand OSCE Exam

Question 1

What are the first 5 things you should do in any examination?

Answer 1

Wash hands
Introduce yourself
Confirm pt details
Explain examination
Gain consent

Question 2

How would you position a pt for a hand examination?

Answer 2

Expose pt’s hands, wrists & elbows.

Position pt with hands on a pillow.

Question 3

What crucial question should you ask before you begin?

Answer 3

Ask if the pt currently has any pain.

Question 4

What routine would be good to adopt in a hand examination?

Answer 4

Look
Feel
Move

Question 5

What are the 2 positions in which you’d like to examine the hands?

Answer 5

Dorm (palms down)

Palms up

Question 6

When the hands are dorsum (palms down), what 7 things are you looking for?

Answer 6

1. Inspect hand posture (asymmetry/abnormalities)
2. Scars or swelling
3. Skin colour
4. Deformities
5. Skin changes
6. Muscle wasting
7. Nail changes
   * note if any of the above changes are symmetrical or asymmetrical.

Question 7

When the hands are in the dorsal position, what 2 things are you looking for with regards to skin colour?

Answer 7

Erythema eg. cellulitis (erythema) / palmar erythema

Pallor eg. peripheral vascular disease / anaemia

Question 8

When the hands are in the dorsal position, what 4 deformities are you looking for?

Answer 8

• 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

Question 9

What 2 skin changes are you looking for when the hands are in the dorsal position?

Answer 9

Skin thinning or bruising - long term steroid use

Rashes - eg. psoriatic plaques

Question 10

You find muscle wasting on examination of the hands in the dorsal position. What might this indicate?

Answer 10

Chronic joint pathology OR motor neurone lesions

Question 11

What 2 nail changes should you look for when the hands are in the dorsal position?

Answer 11

• Nailfold vasculitis: small areas of infarction

- Pitting and onycholysis: associated with psoriasis

Question 12

With the pt’s palms facing upwards, what 7 things are you looking at / assessing?

Answer 12

1. Inspect hand posture: asymmetry / abnormalities (eg. clawed hand)
2. Scars: carpal tunnel release surgery
3. Swelling
4. Skin colour
5. Deformity
6. Thenar / hypothenar wasting
7. Elbows

Question 13

With the pt’s palms facing upwards, what are you looking for with regards to skin colour?

Answer 13

Erythema: eg. cellulitis (erythema) / palmar erythema

Pallor: eg. peripheral vascular disease / anaemia

Question 14

What deformity are you looking for when pt’s palms are facing upwards?

Answer 14

Dupuytren’s contracture

Question 15

What does thenar / hypothenar wasting suggest?

Answer 15

Isolate wasting of the thenar eminence is suggestive of carpal tunnel syndrome.

Question 16

What are you looking for on the elbows?

Answer 16

Psoriatic plaques OR rheumatoid nodules.

Question 17

Patient’s palms are facing upwards. What 4 things should you feel for?

Answer 17

1. Temperature: wrist & MCP joint lines (warm joints in inflammatory / septic arthritis)
2. Radial & ulnar pulse: ensure adequate arterial supply to the hand
3. Thenar / hypothenar eminence bulk: wasting is noted in ulnar/median nerve lesions
4. Palmar thickening: Dupuytren’s contracture (familial / age related)

Question 18

How would you assess median nerve sensation?

Answer 18

Touch the thenar eminence / index finger

Question 19

How would you assess the ulnar nerve?

Answer 19

Touch the hypothenar eminence / little finger

Question 20

The pt’s palms are facing downwards. How would you assess radial nerve sensation?

Answer 20

Touch the 1st dorsal webspace.

Question 21

You need to assess & compare the temperature of the pt’s joints. How are you going to do this?

Answer 21

Use the back of your hand.

Assess the pt’s forearm, wrist & MCP joints

Question 22

You gently squeeze across the metacarpophalangeal (MCP) joints. What are you looking for?

Answer 22

Non-verbal signs of discomfort.

Tenderness may indicate inflammatory arthropathy.

Question 23

You bimanually palpate the joints of the hand.

Which joints are you feeling?

Answer 23

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).

Question 24

You bimanually palpate the joints of the hand. What are you assessing & comparing?

Answer 24

Assess & compare for:

• tenderness
• irregularities
• warmth

Question 25

You palpate the anatomical snuffbox & find tenderness. What does this suggest?

Answer 25

Scaphoid fracture

Question 26

What else must you bimanually palpate?

Answer 26

The pt's wrists

Question 27

Describe how you would palpate the pt's arm & elbow.

Answer 27

Palpate the pt's arm along the ulnar border to the elbow. | Note any rheumatoid nodules or psoriatic plaques (extensor surface).

Question 28

How should finger / hand / wrist movements be assessed?

Answer 28

``` Actively first (pt does the movements independently). Then assess movements passively, feeling for crepitus & noting any pain. ```

Question 29

What 4 movements should you instruct your patient to carry out?

Answer 29

1. Finger extension: "Open your fist & splay your fingers" 2. Finger flexion: "Make a fist." 3. Wrist extension: "Put palms of your hands together & extend wrists fully" (ROM = 90o) 4. Wrist flexion: "Put the backs of your hands together & flex wrists fully" - ROM = 90o

Question 30

What are the 3 major nerves of the hand?

Answer 30

Radial nerve Ulnar nerve Median nerve

Question 31

What is the purpose of the Motor assessment?

Answer 31

To quickly assess the 3 major nerves of the hand.

Question 32

How would you assess the radial nerve?

Answer 32

Wrist / finger extension (against resistance)

Question 33

How would you assess the ulnar nerve?

Answer 33

(Index) Finger abduction (against resistance)

Question 34

How would you assess the median nerve?

Answer 34

Thumb abduction (against resistance)

Question 35

What 3 tests assess 'function'?

Answer 35

Power grip Pincer grip Pick up small object / undo shirt button

Question 36

How would you assess 'Power grip'?

Answer 36

"Squeeze my fingers with your hands"

Question 37

How would you assess 'Pincer grip'?

Answer 37

"Place your thumb & index finger together & don't let me separate them".

Question 38

What are the 2 'special tests' required to assess the hand?

Answer 38

Tinel's test | Phalen's test

Question 39

What is Tinel's test used to identify?

Answer 39

Used to identify nerve irritation. Can be useful in the diagnosis of carpal tunnel syndrome.

Question 40

How would you conduct a Tinel's test?

Answer 40

- 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.

Question 41

What is Phalen's test used for?

Answer 41

If Hx or examination findings are suggestive of carpal tunnel syndrome, this test may be used to further support the diagnosis.

Question 42

How would you conduct a Phalen's test?

Answer 42

- 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

Question 43

What symptoms (of carpal tunnel syndrome) might be elicited on conducting Phalen's test?

Answer 43

Burning, tingling or numb sensation over the thumb, index, middle & ring fingers

Question 44

What 3 things are you going to do to complete the examination?

Answer 44

Thank pt Wash hands Summarise findings

Question 45

What further assessments & investigations might be appropriate?

Answer 45

- Perform a full neurovascular examination of the upper limbs - Examine the elbow joint