Hand & wrist examination

Question 1

In the hand & wrist examination, what do we GENERALLY INSPECT for?

Answer 1

Surrounding area:
Walking aids
Splints

Patient:
Body habitus
Signs of pain
Systemically well

Question 2

In the hand & wrist examination, what do we INSPECT?

Answer 2

Nails:
Nail pitting and onycholysis - psoriatic arthritis
Nail fold infarct - vasculitis

Skin changes:
Thinning and bruising - steroid use
Palmar erythema - RA
Scars

Muscle wasting:
1st dorsal interossei
Thenar and hypothenar eminences

Swelling:
Heberden’s nodes and Bouchards nodes - osteoarthritis
Bogey swelling - synovitis in RA
Cystic swelling - ganglion cyst

Deformity:
Swan neck, Boutonnaires, z-thumb, ulnar deviation, subluxation of MCPJ - signs of RA
Dupuytren’s contracture

Wrist:
Deformity - subluxation, deviation
Swelling - RA nodules, ganglion cyst, gouty tophi
Scars - carpal tunnel release?

Elbow:
Psoriatic plaques
RA nodules
Gouty tophi

Question 3

In the hand & wrist examination, what do we FEEL?

Answer 3

Temperature

Hands:
Muscle wasting in thenar and hypothenar eminence
Thickening in flexor tendons - Dupuytren’s contracture
Tenderness in anatomical snuff box - fractured scaphoid

Pharengeal joints:
Squeeze MCP joints - if pain, bimanually palpate each joint
PIPJ
DIPJ
Base of thumb and IPJ of thumb

Wrists:
Ulnar border
Tenderness in ulnar head? - extensor carpi ulnaris tendonitis in RA
Tenderness in radial styloid process? - de Quervain’s tenosynovitis

Question 4

In the hand & wrist examination, what MOVEMENTS do we assess?

Answer 4

Functionality:
Grip strength
Thumbs to tip of all fingers
Do button or pick up something small

Finger flexion, extension and abduction

Thumb abduction, adduction, extension, flexion and opposition

Question 5

In the hand & wrist examination, what JOINT ABOVE do we assess?

Answer 5

Wrist:
Wrist extension - prayer sign
Wrist flexion - reverse prayer sign
Radial and ulnar deviation of wrist
Supination and pronation of wrist

Question 6

In the hand & wrist examination, what SPECIAL TESTS do we perform?

Answer 6

Phalen’s test:
Reverse prayer sign for 60secs - if tingling, numbness, pain, then positive for carpal tunnel syndrome

Froment’s test:
Positive is able to pull paper from thumb and index finger grip. Positive for ulnar nerve palsy

Question 7

In the hand & wrist examination, what NEUROVASCULATURE do we test?

Answer 7

Power:
Resisted finger abduction - ulnar nerve
Resisted thumb opposition - median nerve
Resisted wrist extension - radial nerve

Sensation:
Cotton wool or finger on dorsum and plantar surface hand

Vascular:
Capillary refill time
Radial pulse
Ulnar pulse (or Allen’s test)