MSK - Hand Examination Flashcards
Osteoarthritis
Rheumatoid arthritis
Rheumatoid nodules
Gouty tophi
Pitting and onycholysis in psoriasis
What are you looking for in the hands on general inspection?
clinical signs (scars, wasting – disuse atrophy/LMN), objects (aids/adaptations, prescriptions), posture
What are you looking for on the dorsal aspect of the hand?
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
What skin changes might be seen on the dorsal aspect of the hands?
skin thinning/bruising (long-term steroid use), rashes, erythema, psoriatic plaques
What nail changes might be seen on hand examination?
psoriatic changes (pitting, onycholysis), nail fold vasculitis, clubbing, splinter haemorrhages
Nail fold vasculitis
What does muscle wasting of the hand suggest (generally)?
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).
Describe Bouchard’s nodes
occur at the proximal interphalangeal joints (PIPJ) and are associated with osteoarthritis.
Describe Heberden’s nodes
occur at the distal interphalangeal joints (DIPJ) and are associated with osteoarthritis.
Describe a swan neck deformity
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.
Swan neck deformity
DIPJ flexion with PIPJ hyperextension
Rheumatoid arthritis
Swan neck deformity
DIPJ flexion with PIPJ hyperextension
RA
Describe Z-thumb
hyperextension of the interphalangeal joint, in addition to fixed flexion and subluxation of the metacarpophalangeal joint (MCPJ). Z-thumb is associated with rheumatoid arthritis.
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.
Describe Boutonnieres deformity
PIPJ flexion with DIPJ hyperextension associated with rheumatoid arthritis.
Splinter haemorrhage
Janeway lesions
Osler’s nodes (Painful - OWWWsler’s nodes)
VIVA
Which nerve impingement would lead to a wrist drop and what could cause it?
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
VIVA
What examination findings in the hand and wrist would make you suspect rheumatoid arthritis?
- 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)
VIVA
Please list some extra-articular manifestations of rheumatoid arthritis (8)
Episcleritis and scleritis
Atlantoaxial subluxation
Carpal tunnel syndrome
Pulmonary fibrosis
Pericarditis
Secondary Sjogren’s syndrome
Anaemia of chronic disease
Splenomegaly
VIVA
What is Felty’s syndrome?
Felty’s syndrome is a triad of: rheumatoid arthritis + splenomegaly + neutropenia. The underlying pathogenesis is unclear.
VIVA
How would you differentiate between osteoarthritis and rheumatoid arthritis based on x-ray findings?
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)
VIVA
A patient presents with trigger finger. Which conditions are associated with this finding?
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
Thumb squaring in OA
Ulnar deviation (RA)
Peyronie’s disease is associated with Dupuytren’s contracture. What is a characteristic features?
Curvature of the penis
Ledderhose disease is associated with Dupuytren’s contracture. What is a characteristic features?
Callus under foot ± toe curling
Garrod’s disease is associated with Dupuytren’s contracture. What is a characteristic features?
Dorsal knuckle pads
What is the differential diagnosis of carpal tunnel syndrome?
Thoracic outlet syndrome
– Pronator teres syndrome (compression of median nerve at elbow)
How is Phalen’s test undertaken?
– ‘Reverse prayer’ sign for 1 minute
– Pain/paraesthesia indicates carpal tunnel syndrome
How is Tinel’s test undertaken?
– Tap over the carpal tunnel
– Paraesthesia indicates carpal tunnel syndrome
What is colour sequence of Raynaud’s phenomenon?
Hands change colour in cold: White→Blue→Red
Remember as White Before Red!
What is the pathophysiology in Scleroderma renal crisis?
Scleroderma renal crisis is characterised by acute renal failure and malignant hypertension. Pathophysiology involves:
– Increased vascular permeability
– Activation of coagulation cascade
– Renin secretion
Please list three associations with psoriasis?
– Multiple HLA subtypes
– Post-streptococcal guttate psoriasis
– Medications (β-blockers, antimalarials, lithium)
– Alcohol
– Stress
– Trauma (Koebner phenomenon)
– HIV
What are some complications of psoriasis?
– Nail changes: pitting, subungual hyperkeratosis, onycholysis, Beau lines
– Psoriatic arthropathy
– Erythroderma
What is Koebner phenomenon?
New lesions of a patient’s skin condition appearing on areas of healthy skin after cutaneous skin injury.
What are the possible pathologies in the hands?
RA statistics?
Features of active RA?
Extra-articular features of RA
Aetiology of anaemia in RA?
RA x-ray findings
OA x-ray findings
Psoriatic arthropathy features
Presentations of psoriatic arthropathy?
Sjögrens syndrome features
DMARDs + key side effects
How to test median nerve in hands?
How to test ulnar nerve in hands?
How to test radial nerve in hands?
Sensory innervation of median nerve
Lateral palm
Thumb & lateral 2½ fingers
Motor innervation of median nerve
LOAF muscles of hand
Lateral 2 lumbricals
Opponens pollicis
ABductor pollicis brevis
Flexor pollicis brevis
Features of median nerve palsy
Wasting of thenar eminence
Pain/sensory loss
Weak thumb ABduction
Tinel/Phalen +ve
Sensory innervation of ulnar nerve
Medial hand (palm & dorsum) Medial 1½ fingers
Motor innervation of ulnar nerve
Small muscles of the hand with the exception of the LOAF muscles
Mechanism of ulnar nerve injury
Elbow (funny bone) trauma Hand trauma (rare)
Features of ulnar nerve palsy
Hypothenar eminence Interossei (1st most obvious)
Partial claw hand
Pain / sensory loss as above
Weak finger ABduction
Froment’s sign
Sensory innervation of radial nerve
Lateral dorsum of hand (no fingers)
Motor innervation of the radial nerve
Extensors (fingers, wrist, elbow)
Features of radial nerve palsy
Wrist drop
Pain / sensory loss as above Weak finger / wrist extension
Mechanism of radial nerve injury
Humeral shaft #
Saturday night palsy
T1 lesion: aetiology + clinical features
∆∆ carpal tunnel syndrome
Outline the sensory innervation of the hand
Describe Froment’s sign
