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Y6 PACES > MSK - Hand Examination > Flashcards

MSK - Hand Examination Flashcards

1
Q
A

Osteoarthritis

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2
Q
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Rheumatoid arthritis

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3
Q
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Rheumatoid nodules

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4
Q
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Gouty tophi

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5
Q
A

Pitting and onycholysis in psoriasis

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6
Q

What are you looking for in the hands on general inspection?

A

clinical signs (scars, wasting – disuse atrophy/LMN), objects (aids/adaptations, prescriptions), posture

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7
Q

What are you looking for on the dorsal aspect of the hand?

A

Posture
Heberden’s nodes (DIP - OA)
Bouchard’s (PIP - OA)
Swan neck deformity (PIP hyperextension + DIP flexion - RA)
Boutonniere (PIP flexion + DIP hyperextension – RA)
Z-shaped thumb (RA)
Dactylitis (seronegative spondyloarthropathy)

Then looks specifically at: skin changes, nail changes and muscle changes

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8
Q

What skin changes might be seen on the dorsal aspect of the hands?

A

skin thinning/bruising (long-term steroid use), rashes, erythema, psoriatic plaques

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9
Q

What nail changes might be seen on hand examination?

A

psoriatic changes (pitting, onycholysis), nail fold vasculitis, clubbing, splinter haemorrhages

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10
Q
A

Nail fold vasculitis

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11
Q

What does muscle wasting of the hand suggest (generally)?

A

Disuse atrophy secondary to joint pathology or a lower motor neuron lesion.

Isolated wasting of the thenar eminence is suggestive of median nerve damage (e.g. carpal tunnel syndrome).

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12
Q

Describe Bouchard’s nodes

A

occur at the proximal interphalangeal joints (PIPJ) and are associated with osteoarthritis.

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13
Q

Describe Heberden’s nodes

A

occur at the distal interphalangeal joints (DIPJ) and are associated with osteoarthritis.

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14
Q

Describe a swan neck deformity

A

Occurs at the distal interphalangeal joint (DIPJ) with clinical features including **DIPJ flexion with PIPJ hyperextension. **

Swan neck deformity is typically associated with rheumatoid arthritis.

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15
Q
A

Swan neck deformity

DIPJ flexion with PIPJ hyperextension

Rheumatoid arthritis

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16
Q
A

Swan neck deformity

DIPJ flexion with PIPJ hyperextension

RA

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17
Q

Describe Z-thumb

A

hyperextension of the interphalangeal joint, in addition to fixed flexion and subluxation of the metacarpophalangeal joint (MCPJ). Z-thumb is associated with rheumatoid arthritis.

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18
Q
A

Z-thumb deformity

hyperextension of the interphalangeal joint, in addition to fixed flexion and subluxation of the metacarpophalangeal joint (MCPJ). Z-thumb is associated with rheumatoid arthritis.

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19
Q

Describe Boutonnieres deformity

A

PIPJ flexion with DIPJ hyperextension associated with rheumatoid arthritis.

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20
Q
A

Splinter haemorrhage

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21
Q
A

Janeway lesions

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22
Q
A

Osler’s nodes (Painful - OWWWsler’s nodes)

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23
Q

VIVA

Which nerve impingement would lead to a wrist drop and what could cause it?

A

Radial nerve palsy

Trauma/compression at:
Axilla: crutches, sleeping over chair Saturday night palsy’, stabbing
Humeral shaft: fracture
Elbow: fracture, dislocation, ganglion

If there is a history of trauma an X-ray is required

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24
Q

VIVA

What examination findings in the hand and wrist would make you suspect rheumatoid arthritis?

A
  • Swelling of the MCP and PCP joints (small joint synovitis)
  • Positive MCP squeeze test
  • Rheumatoid nodules
  • Tendinopathy/tendon rupture
  • Ulnar deviation
  • Z-shaped deformity of the thumb
  • Swan neck deformity (hyperextended PIP with a flexed DIP)
  • Boutonnières deformity (hyperextended DIP with flexed PIP)
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25
Q

VIVA

Please list some extra-articular manifestations of rheumatoid arthritis (8)

A

Episcleritis and scleritis
Atlantoaxial subluxation
Carpal tunnel syndrome
Pulmonary fibrosis
Pericarditis
Secondary Sjogren’s syndrome
Anaemia of chronic disease
Splenomegaly

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26
Q

VIVA

What is Felty’s syndrome?

A

Felty’s syndrome is a triad of: rheumatoid arthritis + splenomegaly + neutropenia. The underlying pathogenesis is unclear.

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27
Q

VIVA

How would you differentiate between osteoarthritis and rheumatoid arthritis based on x-ray findings?

A

Osteoarthritis: ‘LOSS’
Loss of joint space
Osteophytes
Subchondral Sclerosis
Subchondral cysts

Rheumatoid arthritis: ‘LESS’
Loss of joint space
Erosions (juxta-articular/marginal)
Soft tissue swelling
Soft bones (periarticular osteopenia)

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28
Q

VIVA

A patient presents with trigger finger. Which conditions are associated with this finding?

A

Most commonly trigger finger (stenosing tenosynovitis) is idiopathic. However, there are some associations to be aware of:
* Diabetes
* Rheumatoid arthritis
* Hypothyroidism
* Gout
* De Quervain’s disease
* Amyloidosis
* Carpal tunnel syndrome
* Dupuytren’s contracture

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29
Q
A

Thumb squaring in OA

30
Q
A

Ulnar deviation (RA)

31
Q

Peyronie’s disease is associated with Dupuytren’s contracture. What is a characteristic features?

A

Curvature of the penis

32
Q

Ledderhose disease is associated with Dupuytren’s contracture. What is a characteristic features?

A

Callus under foot ± toe curling

33
Q

Garrod’s disease is associated with Dupuytren’s contracture. What is a characteristic features?

A

Dorsal knuckle pads

34
Q

What is the differential diagnosis of carpal tunnel syndrome?

A

Thoracic outlet syndrome
– Pronator teres syndrome (compression of median nerve at elbow)

35
Q

How is Phalen’s test undertaken?

A

– ‘Reverse prayer’ sign for 1 minute
– Pain/paraesthesia indicates carpal tunnel syndrome

36
Q

How is Tinel’s test undertaken?

A

– Tap over the carpal tunnel
– Paraesthesia indicates carpal tunnel syndrome

37
Q

What is colour sequence of Raynaud’s phenomenon?

A

Hands change colour in cold: White→Blue→Red
Remember as White Before Red!

38
Q

What is the pathophysiology in Scleroderma renal crisis?

A

Scleroderma renal crisis is characterised by acute renal failure and malignant hypertension. Pathophysiology involves:
– Increased vascular permeability
– Activation of coagulation cascade
– Renin secretion

39
Q

Please list three associations with psoriasis?

A

– Multiple HLA subtypes
– Post-streptococcal guttate psoriasis
– Medications (β-blockers, antimalarials, lithium)
– Alcohol
– Stress
– Trauma (Koebner phenomenon)
– HIV

40
Q

What are some complications of psoriasis?

A

– Nail changes: pitting, subungual hyperkeratosis, onycholysis, Beau lines
– Psoriatic arthropathy
– Erythroderma

41
Q

What is Koebner phenomenon?

A

New lesions of a patient’s skin condition appearing on areas of healthy skin after cutaneous skin injury.

42
Q

What are the possible pathologies in the hands?

A
43
Q

RA statistics?

A
44
Q

Features of active RA?

A
45
Q

Extra-articular features of RA

A
46
Q

Aetiology of anaemia in RA?

A
47
Q

RA x-ray findings

A
48
Q

OA x-ray findings

A
49
Q

Psoriatic arthropathy features

A
50
Q

Presentations of psoriatic arthropathy?

A
51
Q

Sjögrens syndrome features

A
52
Q

DMARDs + key side effects

A
53
Q

How to test median nerve in hands?

A
54
Q

How to test ulnar nerve in hands?

A
55
Q

How to test radial nerve in hands?

A
56
Q

Sensory innervation of median nerve

A

Lateral palm
Thumb & lateral 2½ fingers

57
Q

Motor innervation of median nerve

A

LOAF muscles of hand

Lateral 2 lumbricals
Opponens pollicis
ABductor pollicis brevis
Flexor pollicis brevis

58
Q

Features of median nerve palsy

A

Wasting of thenar eminence
Pain/sensory loss
Weak thumb ABduction
Tinel/Phalen +ve

59
Q

Sensory innervation of ulnar nerve

A

Medial hand (palm & dorsum) Medial 1½ fingers

60
Q

Motor innervation of ulnar nerve

A

Small muscles of the hand with the exception of the LOAF muscles

61
Q

Mechanism of ulnar nerve injury

A

Elbow (funny bone) trauma Hand trauma (rare)

62
Q

Features of ulnar nerve palsy

A

Hypothenar eminence Interossei (1st most obvious)

Partial claw hand

Pain / sensory loss as above

Weak finger ABduction

Froment’s sign

63
Q

Sensory innervation of radial nerve

A

Lateral dorsum of hand (no fingers)

64
Q

Motor innervation of the radial nerve

A

Extensors (fingers, wrist, elbow)

65
Q

Features of radial nerve palsy

A

Wrist drop
Pain / sensory loss as above Weak finger / wrist extension

66
Q

Mechanism of radial nerve injury

A

Humeral shaft #
Saturday night palsy

67
Q

T1 lesion: aetiology + clinical features

A
68
Q

∆∆ carpal tunnel syndrome

A
69
Q

Outline the sensory innervation of the hand

A
70
Q

Describe Froment’s sign

A

Y6 PACES (21 decks)

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