MSK - Hand Examination

Question 1

Answer 1

Osteoarthritis

Question 2

Answer 2

Rheumatoid arthritis

Question 3

Answer 3

Rheumatoid nodules

Question 4

Answer 4

Gouty tophi

Question 5

Answer 5

Pitting and onycholysis in psoriasis

Question 6

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

Answer 6

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

Question 7

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

Answer 7

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

Question 8

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

Answer 8

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

Question 9

What nail changes might be seen on hand examination?

Answer 9

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

Question 10

Answer 10

Nail fold vasculitis

Question 11

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

Answer 11

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).

Question 12

Describe Bouchard’s nodes

Answer 12

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

Question 13

Describe Heberden’s nodes

Answer 13

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

Question 14

Describe a swan neck deformity

Answer 14

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.

Question 15

Answer 15

Swan neck deformity

DIPJ flexion with PIPJ hyperextension

Rheumatoid arthritis

Question 16

Answer 16

Swan neck deformity

DIPJ flexion with PIPJ hyperextension

RA

Question 17

Describe Z-thumb

Answer 17

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

Question 18

Answer 18

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.

Question 19

Describe Boutonnieres deformity

Answer 19

PIPJ flexion with DIPJ hyperextension associated with rheumatoid arthritis.

Question 20

Answer 20

Splinter haemorrhage

Question 21

Answer 21

Janeway lesions

Question 22

Answer 22

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

Question 23

VIVA

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

Answer 23

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

Question 24

VIVA

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

Answer 24

• 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)

Question 25

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

Answer 25

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

Question 26

# VIVA What is Felty's syndrome?

Answer 26

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

Question 27

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

Answer 27

**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)

Question 28

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

Answer 28

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

Question 29

Answer 29

Thumb squaring in OA

Question 30

Answer 30

Ulnar deviation (RA)

Question 31

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

Answer 31

Curvature of the penis

Question 32

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

Answer 32

Callus under foot ± toe curling

Question 33

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

Answer 33

Dorsal knuckle pads

Question 34

What is the differential diagnosis of carpal tunnel syndrome?

Answer 34

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

Question 35

How is Phalen's test undertaken?

Answer 35

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

Question 36

How is Tinel's test undertaken?

Answer 36

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

Question 37

What is colour sequence of Raynaud's phenomenon?

Answer 37

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

Question 38

What is the pathophysiology in Scleroderma renal crisis?

Answer 38

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

Question 39

Please list three associations with psoriasis?

Answer 39

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

Question 40

What are some complications of psoriasis?

Answer 40

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

Question 41

What is Koebner phenomenon?

Answer 41

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

Question 42

What are the possible pathologies in the hands?

Answer 42

Question 43

RA statistics?

Answer 43

Question 44

Features of active RA?

Answer 44

Question 45

Extra-articular features of RA

Answer 45

Question 46

Aetiology of anaemia in RA?

Answer 46

Question 47

RA x-ray findings

Answer 47

Question 48

OA x-ray findings

Answer 48

Question 49

Psoriatic arthropathy features

Answer 49

Question 50

Presentations of psoriatic arthropathy?

Answer 50

Question 51

Sjögrens syndrome features

Answer 51

Question 52

DMARDs + key side effects

Answer 52

Question 53

How to test median nerve in hands?

Answer 53

Question 54

How to test ulnar nerve in hands?

Answer 54

Question 55

How to test radial nerve in hands?

Answer 55

Question 56

Sensory innervation of median nerve

Answer 56

Lateral palm Thumb & lateral 2½ fingers

Question 57

Motor innervation of median nerve

Answer 57

LOAF muscles of hand Lateral 2 lumbricals Opponens pollicis ABductor pollicis brevis Flexor pollicis brevis

Question 58

Features of median nerve palsy

Answer 58

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

Question 59

Sensory innervation of ulnar nerve

Answer 59

Medial hand (palm & dorsum) Medial 1½ fingers

Question 60

Motor innervation of ulnar nerve

Answer 60

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

Question 61

Mechanism of ulnar nerve injury

Answer 61

Elbow (funny bone) trauma Hand trauma (rare)

Question 62

Features of ulnar nerve palsy

Answer 62

Hypothenar eminence Interossei (1st most obvious) Partial claw hand Pain / sensory loss as above Weak finger ABduction Froment's sign

Question 63

Sensory innervation of radial nerve

Answer 63

Lateral dorsum of hand (no fingers)

Question 64

Motor innervation of the radial nerve

Answer 64

Extensors (fingers, wrist, elbow)

Question 65

Features of radial nerve palsy

Answer 65

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

Question 66

Mechanism of radial nerve injury

Answer 66

Humeral shaft # Saturday night palsy

Question 67

T1 lesion: aetiology + clinical features

Answer 67

Question 68

∆∆ carpal tunnel syndrome

Answer 68

Question 69

Outline the sensory innervation of the hand

Answer 69

Question 70

Describe Froment's sign

Answer 70