MSK: hand and wrists

Question 1

step 1

Answer 1

introduce your to the patient and obtain consent

Question 2

step 2: positioning &posture

Answer 2

Patient seated with hands placed palms down on a pillow. Expose the hands, wrists and elbows.

Question 3

step 3

Answer 3

hand hygiene

Question 4

step 4: screening

Answer 4

Ask the patient if he has any pain in his hands or wrists.

Question 5

step 5a: inspection (palms facing down)

Answer 5

1) look for abnormal hand posture, asymmetry
2) look for any obvious swelling deformity, muscle wasting and scars
3) look for thinning of skin, bruising (signs of long term steroid use), erythema, rashes and scars
4) look at the nails- for any pitting, onycholysis, any signs of vasculitis

Question 6

step 5b: inspection

Answer 6

Ask the patient to turn his/ her hands over, observe if the patient has any problems turning his/ her hands over (radioulnar involvement)

Question 7

step 5c: inspection (palms facing up)

Answer 7

1) Look for muscle wasting- hypothenar and thenar eminences
2) Look for palmar erythema
3) Look for scars at wrist (carpal tunnel release)

Question 8

step 6a: palpate (palms facing up)

Answer 8

• palpate bilateral radial pulses
• ask patient to close his eyes, test for light touch
• feel for muscle bulk of thenar and hypothenar eminences
• palpate across palm for tendon thickening or tenderness
• sensation testing
  1) median nerve- thenar eminence, thumb/ index finger
  2) ulnar nerve- hypothenar eminence and little finger

Question 9

step 6b: palpate (palms facing down)

Answer 9

• sensation testing: radial nerve (1st dorsal web space)
• feel for temperature with back of hand (comparing both sides)
• squeeze across MCPJ for tenderness (one side at a time)
• bimanual palpation of wrist, MPJ, PIPJ and DIPJ for tenderness and joint fluctuation

Question 10

step 6c: palpation (flex elbow)

Answer 10

• inspect for psoriasis and rheumatoid nodules

- palpate along the ulnar border

Question 11

step 7a: Move (active)

Answer 11

• wrist flexion (prayer)

- wrist extension (inverse prayer)

Question 12

step 7b: move (passive, palms facing down)

Answer 12

• finger abduction, against resistance

- finger extension, against resistance

Question 13

step 7c: move (passive, palms facing up)

Answer 13

thumbs abduction against resistance

Question 14

step 8: function

Answer 14

• power grip (make a fist)
• precision grip (pinch)
• picking up small object e.g. coin
• Tinel’s test: Tap for several seconds over the patient’s wrist (median nerve), ask patient if there is any tingling sensation or “pins and needle” felt over palm, thumb and fingers.
• Phalen’s test for carpal tunnel syndrome: ask the patient to hold their wrist in complete and forced flexion (pushing the dorsal surfaces of both hands together) for 60 seconds

Question 15

step 9

Answer 15

Thank the patient + hand hygiene

Question 16

step 10: closing

Answer 16

nform that you would like to complete the examination by checking other joints and a few neurological examination of the upper limbs