Hand and Wrist Exam

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Hand and Wrist

Patient to be undressed to above elbow.

Patient to be resting hands comfortably in pronation on table or pillow

Bedside inspection ->

- Walking aids and frames

- Eating/ writing aids

- Obvious tremor

- Muscle wasting

- Medications

Check for symmetry throughout inspection

Joint Inspection->

1) Swellings:

- soft tissue (inflammatory)

- Bony hard nodes (osteophytes= at DIPS Heberdons nodes OA, at PIPs bouchards nodes OA)

- Firm subcutaneous mobile nodes (rheumatoid arthritis)

- Gouty tophi (translucent/ white

2) Deformities:

-Ulnar deviation (rheumatoid arthritis)

- Subluxation (rheumatoid arthritis)

- Swan neck deformity (rheumatoid arthritis- flexed DIP, extended PIP)

- Boutonniere deformity ( rheumatoid arthritis , flexed PIP, extended DIP)

- Z shaped deformity ( hyperextension of thumb IP, flexion and subluxation of MCP)

- Claw hand- ulnar nerve palsy

- Sign of trauma

Muscles Inspection ->

- In pronation, interossei for guttering consistent with instrinsic muscle wasting

- In supination- thenar and hypothenar wasting

Skin inspection ->

- Rashes- psoriatic plaques, gottrons papules

- Scars

- Colour - raynauds phenomenon, ischaemia, erythema, telangiectasia (systemic sclerosis)

- Texture - tight or shiny is systemic sclerosis, thinning or brusing prednisolone use

Nail Inspection->

- Clubbing (interstitial lung disease)

- Pitting onycholysis (psoriasis)

- Ragged nail folds (dermatomyositis)

- Nail fold infarcts, splinter haemorrhages (vasculitis)

Inspection of the elbows ->

- Psoriatic rash

- Gouty tophi

Feel ->

- Temperature of wrists and hands

Feel with the hands pronated ->

- The distal radius and radial styloid

- The distal ulna and the ulnar styloid

- The joint line of the wrist

- The MCP, PIP and DIP joints of each finger

Feel with the hands half supinated ->

- The CMC, MCP and IP joints of the thumb

Feel with the hands fully supinated ->

-Palmar fascia including Duputyren’s contracture

- Along the course of the flexor tendons

Active movements- Demonstate first ->

- Ask patient to flex and extend wrist (For subtle changes in range of movement at the wrist, ask patient to do ‘Prayer’

(extension) and ‘Reverse prayer’(flexion) signs. This is semi-active/ semi-passive

but allows easy comparison between left and right. At normal ranges the elbows and

forearms are in alignment)

-Ask patient to abduct (radial deviation) and adduct (ulnar deviation) wrists

-Ask patient to flex (make a fist) and extend the fingers (straighten)

- Ask patient to abduct and adduct fingers

-Ask patient to flex and extend the thumb, adduct and abduct it, and then oppose it to the

base of the little finger

Function ->

- Ask the patient to grip your fingers

- Ask the patient to oppose all digits in turn with thumb (demonstrate)

- Check pincer grip strength against your own

- Ask patient to either pick up varying sized coins from the table/ write a sentence/ do up

buttons etc

Motor ->

1) Median- Thumb opposition with little finger (opponens pollicis) test with your corresponding thumb/little finger opposition.

2) Ulnar- Finger abduction “spread your fingers apart, don’t let me push them together”,test little finger and index finger use both corresponding finger abductor

3) Wrist extension- make a fist, then cock your wrist back and stop me bending it down

Sensory ->

- Peripheral neuropathy screen- test the fingertips and the tip of the thumb

- Median- test thenar eminence

- Ulnar- test hypothenar eminence

- Radial- test anatomical snuff box

Vascular assessment ->

- Check radial pulse

- Check cap refill

( Reduction in blood supply to the hand in peripheral vascular disease in diabetics, thrombosis)

Special Tests->

- Tinnels (A positive test causes tingling intothe thumb, index, middle and lateral half of the ring finger. Note the distal point of thetingling - it represents the limit of regeneration of the sensory fibres)

- Phalens

Also test elbow