MSK - Hand and Wrist Flashcards
What position should the patient be in for hand examination?
Patient sitting and hands resting on a pillow
What do you look for on the hands? (6)
1) Palm and dorsum of hand for scars, wounds, or thinning of skin (steroid use) or rashes
2) Nails for signs of clubbing, psoriatic changes, splinter haemorrhages, nail fold vasculitis
3) Look for posture of hand and wrist. Is there a fracture, or any deformity?
4) Look at fingers. Is there any evidence of deformity?
5) Look for muscle wasting, obvious swelling and deformity
6) Look at palm for fascial thickening - Dupuytren’s disease.
Where would you find such as Bouchard’s nodes and Heberden’s nodes?
Bouchard’s nodes - PIP joint
Heberden’s nodes - DIP joint
Deformities of fingers
What may hand swellings suggest?
Bony outgrowths suggest OA
What do soft swellings suggest?
Soft swellings suggest synovitis.
What do you feel for? (7)
1) Compare temperature of forearm with wrist and back of hands
2) Assess radial pulse
3) Feel for muscle bulk of the thenar and hyopthenar eminences.
4) Palpate distal radius, distal ulnar, all carpals and metacarpals for tenderness (one place at a time) whilst watching patient’s face.
5) Palpate fingers, using thumb and index finger of both your hands to encircle the joint.
6) Palpate the MCP joints and wrist joint with thumbs above and index fingers below.
[7) Bimanually palpate any joints that are swollen or painful for tenderness and fluctuation.]
What ACTIVE movements do you ask the patient to do? (2)
1) Ask patient to straighten fingers fully (check alignment of fingers)
2) Ask then to make a fist
2) Wrist flexion. Assess full flexion by asking patient to make the prayer sign.
3) Wrist extension. Assess full extension by asking patient to make the reverse prayer sign.
What PASSIVE movements do you carry out? (4)
1) Passively assess flexion and extension of fingers at MCPJ, PIPJ and DIPJ
2) Perform Phalen’s test and/or Tinel’s test
What should you do if you find an issue at an MCPJ, PIPJ or DIPJ?
Determine if tendon, joint or nerve problem
How to test function? (3)
1) Power grip: Ask patient to grip your two fingers
2) Pincer grip: Ask patient to pick up a small object
3) Examine elbow joint.
What are you testing in the neurological examination?
Sensation and power of radial, ulnar and median nerves (RUM)
How do you test the sensation of these 3 nerves?
RUM
1) Radial - touch the first web space on dorsum of hand (between thumb and index finger.)
2) Ulnar - touch volar tip of little finger and hypothenar eminence.
3) Median - touch volar tip of index finger and thenar eminence.
N.B. volar = anterior/palm
How do you test the power of these 3 nerves?
RUM
1) Radial nerve - testing resisted finger extension.
2) Ulnar nerve - testing the interossei by asking patient to spread fingers wide and keep them there whilst you try to squeeze them together.
3) Median nerve: testing abductor pollicis brevis. Place hand flat with palm to ceiling. Ask patient to point thumb to ceiling and hold it there whilst you try to push it down.
What are the tests for Carpel Tunnel Syndrome?
Phalen’s Test and Tinel’s Test
Describe Phalen’s Test
The wrist is held in full flexion for 60 seconds. The test is positive if patient’s symptoms are elicited by this manoeuvre.
