REMS: Hand Examination (geekymedics) Flashcards
(A1) What 6 aspects should you look for on the dorsum of the hand?
> Inspect hand posture - asymmetry / abnormalities
> Scars or swelling
> Skin colour
> Deformities
> Skin changes
> Muscle wasting - may indicate chronic joint pathology or motor neurone lesions
> Nail changes
(A2) What two skin colour changes may you see?
- Erythema - cellulitis (erythema) / palmar erythema
* Pallor - peripheral vascular disease / anaemia
(A3) What 4 hand deformities may you see?
- Bouchard’s nodes (PIP) / Herberden’s nodes (DIP) - OA
- Swan neck deformity - DIP joint hyperflexion with PIP joint hyperextension - RA
- Z-thumb - hyperextension of interphalangeal joint, in addition to fixed flexion and subluxation of the MCP joint - RA
- Boutonnieres deformity - PIP flexion with DIP hyperextension - RA
(A4) What 2 skin changes may you see?
- skin thinning or bruising - long term steroid use
* rashes - e.g. psoriatic plaques
(A5) What 2 nail changes may you see?
- Nailfold vasculitis - small areas of infarction
* Pitting and onycholysis - associated with psoriasis
(A6) What 7 aspects should you look for on the palm of the hand? What other joint should you inspect at this stage?
> Insect hand posture - asymmetry / abnormalities (e.g. clawed hand)
> Scars - e.g. carpel tunnel release surgery
> Swelling
> Skin colour
•Erythema - e.g. cellulitis (erythema) / palmar erythema
•Pallor - e.g. peripheral vascular disease / anaemia
> Deformity - Dupuytren’s contracture
> Thenar / hypothenar wasting - isolated wasting of the thenar eminence is suggestive of carpel tunnel syndrome
> Elbows - psoriatic plaques or rheumatoid nodules
(A7) What 5 aspects should you feel for on the palm of the hand?
> Temperature - wrist and MCP joint lines - warm joints inflammatory / septic arthritis
> Radial and ulnar pulse - palpate to ensure adequate supply to the hand
> Thenar / Hypothenar eminence bulk - wasting is noted in ulnar / median nerve lesions
> Palmar thickening - Dupuytren’s contracture - family / age related
> Asses median and ulnar nerve sensation by touching the following areas:
• Thenar eminence / index finger - median nerve
•Hypothenar eminence / index finger - ulnar nerve
(A8) What 6 aspects should you feel for on the dorsum of the hand?
> Asses radial nerve sensation by touching: first dorsal webspace
> Assess and compare temperature using the back of your hand: • forearm • wrist • MCP joints
> Gently squeeze across the MCP joints - observe for non-verbal signs of discomfort - tenderness may indicate inflammatory arthropathy
> Bimanually palpate the joints of the hand: •MCP •PIP • DIP •CMC (Carpometacarpal)
> Palpate the anatomical snuffbox - tenderness may suggest scaphoid fracture
> Bimanually palpate the patient’s wrist
(A9) How should you palpate the elbow of the patient?
> Palpate the patient’s arm along the ulnar border to the elbow: note any rheumatoid nodules or psoriatic plaques
(B1) Should you assess active or passive movement first?
> Assess active movement first
> Then assess movements passively - feeling for crepitus and noting any pain
(B2) Describe the four hand movements assessed.
> finger extension - open your fist and splay your fingers - an inability to perform could indicate: joint disease / extensor tendon rupture / neurological damage
> finger flexion - make a fist - an inability to perform could indicate: tendon or small joint involvement. Move the fingers passively to assess whether the problem is with the tendon or nerves, or in the joint.
> wrist extension - put the palms of your hands together and extend wrists fully - ROM 90
> wrist flexion - put back of your hands together and flex wrists fully - ROM 90
(B3) What are 3 motor assessments?
> wrist / finger extension - radial nerve
> finger abduction - index finger - ulnar nerve
> thumb abduction - median nerve
> ALL DONE AGAINST RESISTANCE
(B4) What are the 4 function tests?
> power grip - squeeze your fingers with my hand
> pincer grip - place your thumb and index finger together and don’t let me separate them
> dexterity - pick up small object or undo a shirt button - this assesses pincer grip and function.
(B5) What are the 2 special tests?
> Tinel’s test - used to identify nerve irritation - useful diagnosis in carpel tunnel syndrome
> Phalen’s test
(B6) What further assessments and investigations would you carry out?
> Perform a full neurovascular examination of the upper limbs
> Examine the elbow joint
