Hands and wrist examination Flashcards
In what general order do you examine the hands and wrists?
Look
Feel
Move
Resisted movements
Sensation
Special tests
What medical paraphernalia should you look for before examining the hands and wrist?
Splint
Wrist brace
Compression glove
Prescriptions
When looking at the hands, wrists and up to elbows, what 2 surfaces should you examine?
Dorsal/posterior
Palmar/anterior
When examining the hands and wrist, where do you start looking and where do you finish?
Start at nails
Go down to elbow
What kind of nail abnormalities do you look for, in the hand examination, which usually indicate PsA and maybe RA?
Pitting: Small pits/dents in nail
Onycholysis: Nail separates from skin
Ridging: Vertical raised lines on nails
Colour change to yellow or brown
Clubbing
Apart from nail changes, what abnormality can appear near the nails?
Chondrocalcinosis: Hard white lumps that ooze chalky substance
Could be due to pseudogout
What 2 types of abnormal nodes can you look for at the PIP and DIP joints of the hand, and what is the underlying pathology?
Bouchard’s nodes: Bony growths at PIP
Heberden’s nodes: Bony growths DIP
Both indicate OA
What 3 fixed flexion deformities of the fingers can you look for, and what condition do they indicate?
Swan neck deformity: DIP flexion, PIP hyperextension which suggests RA
Boutonniere’s deformity: DIP hyperextension, PIP flexion which suggests RA
Dupuytren’s contracture: Fibrous cord crosses and contracts MCP then PIP
What fixed flexion deformity of the thumb can you look for, and what condition does it indicate?
Z-thumb: interphalangeal joint hyperextension, fixed flexion and subluxation of metacarpophalangeal joint
Suggests RA
What abnormality in the thumb can you look for, that suggests OA?
Squaring of base of thumb: Basal thumb arthritis
This is OA of thumb
What skin abnormalities should you look for on the dorsal surface of the hand, wrist and elbow?
Psoriatic plaques: Psoriasis or PsA
Erythema: Infection eg. joint sepsis, cellulitis
Swelling, bruising, scarring
What does skin thinning or bruising suggest, in terms of medications?
Long-term steroid use
What is splinter haemorrhaging in the nail, and what conditions can cause this?
Vertical red-brown line under nail
suggests local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease
What is Dupuytren’s contracture, and which fingers are most commonly affected?
Thickening of the plantar fibrous tissue forms fibrous cords, which cross MCP then PIP and cause them to contract
What abnormalities should you look for on the plantar surface of the hand?
Dupuytren’s contracture
Hypothenar and thenar muscle wasting
Osler node: red-purple slightly raised tender lumps with pale centre on fingers, suggest infective endocarditis
Janeway lesion: non-tender haemorrhagic lesions on thenar and hypothenar eminences, suggest infective endocarditis
Why should you make sure to look for scarring on the wrist?
This can indicate previous carpal tunnel surgery
What abnormalities should you look for around the elbow, in the hand exam?
Rheumatoid nodules
Psoriatic plaques
Olecranon bursitis
Medial/lateral epicondylitis
Redness, swelling, bruising
On which finger joints do rheumatoid nodules commonly occur?
MCP, PIP
On which joints do psoriatic arthritis nodules commonly occur?
MCP, DIP
On which surface of the hand should you palpate for temperature, and where else should you palpate?
Palpate palmar surface of hand, anterior aspect of across wrist joint and to elbow
Compare both arms to see if they have similar temperature
On the dorsal surface of the hand, what should you do before palpating the hand joints?
MCP joint squeeze
Pain indicates active inflammatory arthritis
After the MCP joint squeeze, what joints in the hand should you palpate?
Each MCP joint
Each interphalangeal joint
After palpating the MCP joints and interphalangeal joints of the hand, what anatomical structure should you palpate and why?
Anatomical snuffbox
Pain indicates scaphoid fracture
After palpating the anatomical snuffbox, what should you palpate in the hand and wrist examination?
Distal ends of radius and ulna
Wrist joint
After palpating the wrist joint, what should you palpate on the palmar surface of the hand and wrist?
Thenar and hypothenar muscle bulk
Dupuytren’s contractures
Radial and ulnar pulses
What should you palpate on the elbow joint, in the hand examination?
Olecranon process
Medial and lateral epicondyles
What 4 active movements of the elbow should you test in the hand exam?
Elbow flexion
Elbow extension
Supination
Pronation
What 2 active movements of the wrist should you test in the hand examination?
Wrist flexion
Wrist extension
What 4 active movements of the fingers should you test in the hand examination?
Finger flexion
Finger extension
Finger abduction
Finger adduction
Which 5 active movements of the thumb should you test in the hand examination?
Thumb flexion
Thumb extension
Thumb abduction
Thumb adduction
Thumb opposition
How do you test motor function of the median nerve?
Ask patient to abduct thumb, you try to push it down
How do you test motor function of the radial nerve?
Ask patient to hold wrist extended, you try to push hand down
How do you test motor function of the ulnar nerve?
Ask patient to abduct fingers, you try to push them together
How do you test sensation of the radial nerve?
Establish normal sensation at cubital fossa
Swipe cotton wool over 1st dorsal webspace, ask patient if it feels the same weaker or stronger
How do you test sensation of the ulnar nerve?
Establish normal sensation at cubital fossa
Swipe cotton wool over hypothenar eminence, ask patient if it feels the same weaker or stronger
How do you test sensation of the median nerve?
Establish normal sensation at cubital fossa
Swipe cotton wool over thenar eminence, ask patient if it feels the same weaker or stronger
What special tests can you do to test for median nerve compression/carpal tunnel syndrome?
Reverse Phalen’s test: Ask patient to hold dorsums of hands together for 30s-1min, positive if they feel pain, tingling, burning sensation
Tinel’s test: Tap hard over carpal tunnel for 30s-1min, positive if they feel pain, tingling, burning sensation
How do you test power grip of the hand?
Ask patient to make fist around your fingers and squeeze as hard as possible
How do you test pincer grip of the hand?
Ask patient to squeeze your finger between their thumb and index finger
