Musculoskeletal (Hand) Flashcards
What do you look for on inspection of the nails?
Make sure patient has hands supported on pillow
Pitting/ridges (ie psoriasis)
Onycholysis (ie psoriasis, fungal, hyperthyroidism)
Splinter haemorrhages (ie nail fold infarcts from vasculitis)
Clubbing
What do you look for on inspection of the fingers?
Colour - pink/white/blue?
Scars/skin changes
Trophic changes ie ulcers
Fusiform or focal swelling ie dactylitis (PsA, AS, IBD)
Nodular deformities in OA - Bouchards = PIP, Heberdens = DIP
Squaring off of the hand at 1st MCP in OA
Other deformities in RA - swan neck, Boutonniere’s, ulnar deviation, Z thumb
Abnormal posturing suggestive of peripheral nerve injury ie ulnar claw
What do you look for on inspection of the palm and dorsum of the hand?
Skin conditions (ie psoriasis)
Scars
Wasting of the interossei (dorsum) and thenar/hypothenar (palm) muscles
Dupuytren’s contracture
What do you look for on inspection of the wrist?
Swelling? (synovitis)
What do you look for on inspection of the elbow?
Rheumatoid nodules and psoriatic plaques
What do you look for on palpation?
Temperature, perfusion, inflammation, tenderness, deformity of dorsal and palmar sides of wrist, hand and fingers
Perform a squeeze test at the MCP joints - if painful, locate source by palpating each joint individually (your thumb on the dorsum and fingers on metacarpal heads in the palm)
Palpate along the radial and ulnar aspects of the phalanges
Perform a neurovascular examination - ulnar+radial pulse/Allen’s test/sensation of C6-8 and median+ulnar+radial distributions
How do you assess the range of movement?
Test active first then passive if limited.
Ask patient to make a fist - if can’t be done, test individual flexion of MCP, PIP and DIP joints
Ask patient to extend and spread their fingers (test power of dorsal interossei by applying resistance)
Test individual movements of thumb (abd/add/flex/ext/opp)
Ask patient to perform prayer and reverse prayer signs to test range of dosri+palmarflexion in the wrists
How do you assess the function?
Assess grip strength by getting them to hold a pen or your finger in their closed fist whilst you try to remove it
Assess lateral pinch grip (key grip) ie by asking them to hold a pen or key
Assess precision by getting a patient to undo and do-up buttons or hold a needle between the tip of their thumb and index finger
(or asking whether they have trouble with it normally)
What tests can you perform to assess for Carpal tunnel syndrome?
Tinsel’s test - tapping strongly over median nerve as it crosses under flexor retinaculum, will produce pain/numbness/tingling in distribution of median nerve
Phalen’s test - hold both of patients wrists in palmar flexion for one minute (simultaneously apply carpal compression using thumbs over median nerve at flexor retinaculum), see results above
How can you test median nerve function?
Test palmar abduction against resistance - supinate hand and point thumb up at ceiling then push back towards the palm with your thumb
Test opposition against resistance - oppose thumb and little finger making a ring, interlock your hand in the same way and attempt to pull apart
Test sensation in the median nerve distribution
How can you test ulnar nerve function?
Ask patient to cross index and middle fingers
Ask patient to grip a piece of paper between thumb and index finger without flexing their thumb IP joint (Froment’s sign)
Test sensation in the ulnar nerve distribution
How can you test the function in the radial nerve distribution?
Test wrist dorsiflexion against resistance
Test sensation in the anatomical snuff box
How do you conclude the examination?
IF the patient has pain or restricted movement at the wrist joint, you should also fully examine the ipsilateral elbow (or state that you would do so)
Thank patient and wash hands
