Rheumatology Hand Examination

Question 1

INSPECTION aspect of rheumatological hand examination?

Answer 1

Start on the dorsum of the hand
Inspect nail plates
DIPJs
PIPJs
Metalcarpal pharangeal joint
LOOK OUT FOR: Rash Atrophy Swelling/scars Hyperemia(redness)
Synovitis of small hand joints will be visable (spindly appearance)

Inspect dorsum of hand

1. Swelling? Look at bases of fingers - flexor tenosynovitis
2. Thenar eminance - full?
3. Hypothenar eminance - full?
4. Wrist scars - carpal tunnle surgery

Inspect elbows - chronic plaque psoriasis, gouty tophi, rheumatoid nodules

Ask patient to make a fist - mountain sign?

Question 2

What does hypothenar eminance wasting suggest?

Answer 2

Ulnar nerve lesion

Question 3

What does thenar eminance wasting suggest?

Answer 3

Median nerve damage
Carpal tunnel syndrome
Base thumb arthritis
Trauma to forarm wrist or thumb
Mass or tumour
ALS

Question 4

FEEL ASPECT OF HAND EXAMINATION

Answer 4

Four finger technique:

Squeeze PIPJs, DIPJs, MCPs, wrist, elbows

Question 5

MOVE aspect of hand examination (active movements)?

Answer 5

Make a fist, open it up, and fan out hand, repeat
Bend fist down (flexing wrist)
Bend first up (extending the wirst)
Move first side to side
Roll fist around
Bend elbows 
Straigten out 
'Screw light bulbs)

Question 6

MOVE ASPECT of hand examination (passive)

Answer 6

Wrist dorsiflexion
Wrist flexion
Move wrist from side to side
Roll wrist (clockwise and anticlockwise)

Question 7

MOVE aspect of hand examination (function)?

Answer 7

Ask pt to grip your hand
Ask pt to do hand to mouth
Ask patient to write name with dominant hand and then non dominant hand -opportunity for intention tremor, macrography and movements of hand
Check pincer grip (pick up coin)
Check pincer against each finger

Question 8

Neurovascular aspect of hand examination?

Answer 8

Check radial pulse (compare both sides)
SENSORY:
Ulnar: dorsum of little finger - outer boarder with cotton wall (sensation present and equal on both sides)
Median: Inner boarder of index finger
Radial: First webspace
MOTOR:
Radial: Ask pt to dorsiflex wrist against resistance (hold down arm)
Ulnar: Ask patient to fann out fingers and oppose index and little finger adduction (use same finger you are testing on pt)
Median: Palms up, thumb up, ask pt to resist as you push it out and then in

Question 9

Special tests in rheumatology examination?

Answer 9

Phalens - prayer sign for 60s burning, tingling or numb sensation in the thumb, index, middle and ring fingers
Tinnels - tap over the carpal tunnel for ten seconds (tingling in radial two and a half digits)

Question 10

What might erythema of the joint in a hand examination indicate?

Answer 10

Cellulitis, joint swelling, gout

Question 11

Bouchard’s nodes?

Answer 11

• occur at PROXIMAL interpharangeal joints

OA

Question 12

Heberden’s nodes?

Answer 12

Occur at DISTAL interpharangeal joints

OA

Question 13

What might skin thinning indicate?

Answer 13

Long term steroid use (inflamatory arthritis)

Question 14

Swan neck deformity

Answer 14

DISTAL interpharangeal joint FLEXION
PROXIMAL interpharangeal joint HYPEREXTENSION
RA

Question 15

Z-thumb

Answer 15

HYPEREXTENSION of the interphalangeal joint of the thumb
Fixxed flexion and subluxation of the MCP
RA

Question 16

Ulnar devitation?

Answer 16

Away from thumb

RA

Question 17

Signs of late stage RA?

Answer 17

Ulnar deviation
Z thumb
Swan neck deformity
MCP subluxation

Question 18

Which joints are spare in RA (hand)

Answer 18

DIPs

Question 19

Dactylitis

Answer 19

Swelling of entire digit

Question 20

What does weakness of thumb ABduction against resistance indicate?

Answer 20

Median nerve motor function impairment

Question 21

Hand examination - further assesments and investigations?

Answer 21

Neurovascular examination of the upper limbs.
Examination of the elbow joint and shoulder joint.
Further imaging if indicated (e.g. X-ray and MRI)
?CRP, ESR, rheumatology screen?