MSK - Hand and wrist exam

Question 1

How would you explain and MSK hand and wrist exam to the patient?

Answer 1

I’ve been asked to examine your hand and wrist - this will involve having a look, feel and move of your hand. You will have to be exposed from the elbow down and the examiner will act as a chaperone today - Is this ok?
Are you in any pain in your hands or anywhere else. Pleas let me know if you do experience an pain at any point throughout this procedure.

Question 2

what is the general layout of the MSK hand and wrist exam?

Answer 2

1) General inspection (patient and bedside)
2) close inspection of back of hand
3) close inspection of palm
4) feel of back of hand
5) feel of palm
6) movements
7) function tests

Question 3

What do you look for on general inspection of the patient and bedside in an MSK hand and wrist exam?

Answer 3

1) Bedside : analgesia, hand splints

2) patient : comfortable and well, cushingoid disease.

Question 4

What do you look for on close inspection of the dorsal (back) aspect of the hand?

Answer 4

1) Symmetrical?
2) swelling - bouchard’s (PIPJs), Herberden’s (DIPJs)
3) Deformities:
- Ulnar deviation at MCP
- swan neck
- boutonniere’s
- mallet finger
- Z shaped thumb
- tophi

4) Muscle wasting, scars
5) Skin thinning, bruising, psoriasis
6) Nails
- psoriatic changes (pitting, onycholysis)
- clubbing
- splinter haemorrhages

Question 5

What do you look for on the palmar aspect of the hand (MSK exam?)

Answer 5

• problem with turning hand over
• Palmar erythema
• dupuytren’s contracture
• Scars (carpal tunnel release)
• Muscle wasting (thenar / hypothenar)

Question 6

What do you feel for on the palmar aspect of the hand (MSK exam)?

Answer 6

1) Temperature
2) Radial pulse (15s)
3) Muscle bulk of thenar , hypothenar eminences
4) Tendon nodules - dupuytren’s contracture
5) Sensation - median (thenar), ulnar (hypothenar) and radial (back of hand thumb web)
6) Tinel’s test - percuss over carpal tunnel - any numbness or tingling in median distribution.

Question 7

What do you feel for on the dorsal aspect of the hand (back of hand) -msk exam?

Answer 7

1) Temperature
2) Ask if pain in hands - squeeze MCPs - tender?
3) Bimanual palpation of MCPs, DIPs, PIPs
4) feel arms and elbows for RA nodules / psoriatic plaques
5) look for psoriasis on elbow

Question 8

how would you assess the movement of the joints in the hand (MSK exam)

Answer 8

1) straighten (extend fingers)
2) make fist ( flex fingers)
3) Spread out fingers (abduct fingers) and stop from closing
4) adduct and squeeze fingers
5) Thumb adduction, abduction, flexion and extension against resistance.
6) Pincer movement (opposition)
7) Wrist –> prayer, reverse prayer (flexion and extension) *** if held in reverse prayer for 60s this is phalen’s test for carpal tunnel
8) passive flexion and extension
9) supination and pronation

Question 9

How would you assess the function of the hand?

Answer 9

• power grip
• pincer grip
• pick up small object
• flex and extend elbows
• hands behind head
• hands over spine

Question 10

What are the end pieces to a hand exam?

Answer 10

• tinnel’s test (tap of carpal tunnel —> numbness tingling in median nerve distribution = carpal tunnel syndrome)
• Phalen’s test ( hold wrist in reverse prayer position —> numbness tingling in median nerve distribution —> carpal tunnel)
• assess tendons