REMS: Hands and wrist Flashcards
Structure of the Hand examination
Look
Feel
Move
Look
Ask the patient to lay their hands on a pillow
Compare both sides and look for assymetry
Start by looking at the dorsal aspect of the hands
- Joint swelling
- erythema
- joint alignment
- Bony nodules
- Rhuematoid nodules
- Psoriatic skin rasges
- Psoriatic nail changes
- nail fold infarcts
- skin thinning/bruising
- surgical scars
- small muscle wasting
Palmar aspect
- dupuytrens nodules or contractures
- scars from carpal tunnel release surgery
Psoratic nail changes
- thimble pitting
- ridging
- discolouration
- oncholysis
What does this show
Thimble pitting - tiny pits on the surface of the nail, resembling those on a thimble (sewing) see in psoriasis
What does this show?
Horizontal ridging as seen in psoriasis
What does this show?
Separation of the nail from the nail bed
Difference between rhuematoid nodules and bony nodules
Rhuematoid - Fleshy, and firm nodules found on the extensor surface of the knuckles.
Bony nodules - Osteophyte formation is seen in osteoarthritis.
- Nodules at the DIP joints - Heberdens Nodes
- Nodules at the PIP joints - Bouchards Nodes
What to look for when examining joint alignment
- Ulnar deviation of the fingers
- Swan Neck deformity (hyperextension at PIP joints and flexion at DIP joint)
- Boutonniere deformity (fixed flexion at PIP joint and hyperextension at DIP joint)
When would you see nail fold infarcts and skin thinning/bruising
Nail fold infarcts- small brown black spots at the edges of the nails seen in rhuematoid vasculitis
Skin thinning/bruising - A side effect of long term steroid use
Small muscle wasting importance
Interossei and lumbricals
Muscle atrophy - through disuse associated with rhuematoid and osteoarthritis.
Note - can also be neurogenic in cause, thenar wasting, is seen in carpal tunnel syndrome
Feel
Compare both sides and look for asymmetry
- Joint warmth
- peripheral pulses - radial and ulnar
- feel for thenar and hypothenar muscle wasting
- tendon thickening
- Test sensation
- Ulnar nerve- Medial aspect of palm
- Median nerve: lateral aspect of palm
- radial nerve: Web-space between the index finger and thumb on the dorsal aspect of the hand
- metacarpal squeeze
- Palpation of each joint with bimanual technique
- carpal (wrist joints). Identify distal radius, ulna, distal radioulnar joint, carpal bone, anatomical snuffbox(scaphoid fracture) and thumb carpometacarpal joint
- MCP, PIP, DIP
- rhuematoid nodules and psoriatic plaques on forearms and elbow
Move
Perform active movements followed by passive movements for each joint and compare both sides
- wrist extension - put palms of your hands together “make a prayer sign”
- Wrist flexion - Put backs of your hands together
- Finger adduction/abduction - ask patient to spread fingers and then bring together again
- finger tuck- ask patient to close their hands into fists and then open again- movement performs flexion, extension, adduction and abduction together.
Motor function
- wrist/ finger extension - radial nerve
- finger abduction - ulnar nerve
- thumb abduction - median nerve
Function
- Test power grip - ask patient to grip index finger and middle fingers with their fist as tightly as they can. Try to pull fingers out
- Pincer grip - ask the patient to pick up and hold a pen
- Phalens test - Test is performed if carpal tunnel is suspected ask the patient to flex both wrists by pushing dorsums of hands together and ask to hold for 1 minute. If pain and paraesthesia in the median nerve distribution results, then carpal tunnel syndrome suspected
Conclusion
Thank patient
Wash hands
Summarise findings
Say you would…
- Perform a full neurovascular examination of upper limbs
- Examine the elbow joint
- Perform Tinels test – tap over carpal tunnel to elicit tingling – suggests median nerve compression
.
