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Hand and wrist examination frequently appears in OSCEs, often involving patients with osteoarthritis (OA) or rheumatoid arthritis (RA). You’ll be expected to pick up the relevant clinical signs using your examination skills. This hand examination OSCE guide provides a clear step by step approach to examining the hand, with an included video demonstration.

Check out the hand examination mark scheme here.

See the bones of the hand guide here.

 


Introduction

  • Wash hands
  • Introduce yourself
  • Confirm the patient’s details (e.g. name and date of birth)

 

  • Explain the examination:
    • “Today I’m going to examine the bones of your hands and wrists. The examination will involve me first looking at the hands, then feeling the joints and finally asking you to do some movements.”
  • Gain consent:
    • “Does everything I’ve said make sense?”
    • “Do you have any questions?”
    • “Are you happy for me to go ahead with the examination?”
  • Expose the patient’s hands, wrists and elbows
  • Position the patient with their hands on a pillow
  • Ask if the patient currently has any pain

 


Look

Dorsum (palms down)

Hand posture

  • Inspect hand posture and note any abnormal posture (e.g. contracture)

 

Scars or swelling

  • Inspect for evidence of scars suggestive of previous surgery
  • Note any obvious areas of swelling, comparing the hands and wrists

 

Skin colour

  • Erythema of the soft tissue may indicate cellulitis or joint sepsis
  • Pallor of the hands may indicate the presence of peripheral vascular disease and/or anaemia

 

Deformities

  • Bouchard’s nodes:
    • Occur at the proximal interphalangeal joints (PIPJ)
    • Associated with osteoarthritis (OA)

 

  • Heberden’s nodes:
    • Occur at the distal interphalangeal joints (DIPJ)
    • Associated with OA

 

  • Swan neck deformity:
    • Occur at the distal interphalangeal joint (DIPJ)
    • Features include DIPJ flexion with PIPJ hyperextension
    • Associated with rheumatoid arthritis

 

  • Z-thumb:
    • Hyperextension of the interphalangeal joint, in addition to fixed flexion and subluxation of the metacarpophalangeal joint (MCPJ)
    • Associated with rheumatoid arthritis

 

  • Boutonnières deformity:
    • PIPJ flexion with DIPJ hyperextension
    • Associated with rheumatoid arthritis

 

Skin changes

  • Skin thinning or bruising can be associated with long-term steroid use (e.g. common in patients with active inflammatory arthritis)
  • Psoriatic plaques (salmon coloured plaques with silvery scale) are important to recognise as psoriasis and psoriatic arthritis are closely associated

 

Muscle wasting

  • Muscle wasting can occur secondary to chronic joint pathology
  • Consider lower motor neurone lesions (e.g. carpal tunnel syndrome)

 

Nail changes

  • Nailfold vasculitis is a feature of rheumatoid arthritis (small vessel vasculitis)
  • Nail pitting and onycholysis are associated with psoriasis (and psoriatic arthritis)

 

If you identify any clinical signs, note if they are symmetrical (e.g. affecting both limbs) or not.

Palms up

Inspect hand posture

  • Note any asymmetry of the hands
  • Note any evidence of abnormal hand posture (e.g. clawed hand secondary to Dupuytren’s contracture)

 

Scars or swelling

  • Inspect for evidence of scars suggestive of previous surgery
  • Note any obvious areas of swelling, comparing the hands and wrists

 

Skin colour

  • Erythema of the soft tissue may indicate cellulitis or joint sepsis
  • Pallor of the hands may indicate the presence of peripheral vascular disease and/or anaemia

 

Deformity

  • Dupuytren’s contracture presents as a thickening or painless nodule in the palm
  • The most common finger to be affected is the ring finger; the thumb and index finger are much less often affected
  • In advanced disease, there is a loss of range of motion in the affected fingers

 

Thenar/hypothenar wasting

  • Isolated wasting of the thenar eminence is suggestive of carpal tunnel syndrome

 

Elbows

  • Inspect for evidence of psoriatic plaques or rheumatoid nodules

 

  • Inspect dorsum of the hand
    Inspect the dorsum of the hands

 


Feel

Palms up

Temperature

  • Assess and compare the temperature of the wrists and small joints of the hand
  • Increased warmth in a joint is suggestive of inflammatory arthritis or joint sepsis

 

Radial and ulnar pulse

  • Palpate the radial and ulnar pulse to confirm there is adequate blood supply to the hand

 

Thenar/hypothenar eminence bulk

  • Assess the muscle bulk of the thenar and hypothenar eminences
  • Wasting of these areas is often noted in ulnar/median nerve lesions

 

Palmar thickening

  • Palpate the palms for evidence of palmar thickening
  • Palmar thickening can be caused by Dupuytren’s contracture

 

Assess median and ulnar nerve sensation

  • Assess median nerve sensation over the thenar eminence and index finger
  • Assess ulnar nerve sensation over the hypothenar eminence and little finger

 

  • Assess and compare joint temperature
    Assess and compare joint temperature

 

 

Dorsum (palms down)

Assess radial nerve sensation

  • Assess radial nerve sensation over the first dorsal web space

 

Assess and compare temperature using the back of your hand

  • Forearm
  • Wrist
  • MCP joints

 

Gently squeeze across the metacarpophalangeal (MCP) joints

  • Observe for non-verbal signs of discomfort
  • Tenderness may indicate active inflammatory arthropathy

 

Bimanually palpate the joints of the hand (MCPJ/PIPJ/DIPJ/CMCJ)

Assess and compare joints for tenderness, irregularities and warmth:

  • Metacarpophalangeal joint (MCPJ)
  • Proximal interphalangeal joint (PIPJ)
  • Distal interphalangeal joint (DIPJ)
  • Carpometacarpal joint (CMCJ) of the thumb (squaring of the joint is associated with OA)

 

Palpate the anatomical snuffbox

  • Tenderness may suggest scaphoid fracture 

 

Bimanually palpate the patient’s wrists

  • Palpate the wrists for evidence of joint line irregularities or tenderness

Elbows

Palpate the elbow

  • Palpate the patient’s arm along the ulnar border to the elbow
  • Note any rheumatoid nodules or psoriatic plaques (extensor surface)
  • Assess radial nerve sensation
    Assess radial nerve sensation

 

 


Move

Assess each of the following movements actively first (the patient does the movements independently). Then assess movements passively, feeling for crepitus and noting any pain: 

  • Finger extension – “Open your fist and splay your fingers”
  • Finger flexion – “Make a fist”
  • Wrist extension – “Put the palms of your hands together and extend your wrists fully” – ROM 90º
  • Wrist flexion – “Put the backs of your hands together and flex  your wrists fully” – ROM 90º

 

 

  • Active finger flexion
    Active finger flexion

Motor assessment

The following screening test will allow you to quickly assess the motor function of the radial, ulnar and median nerve.

Ask the patient to carry out the following movements against resistance:

  • Wrist/finger extension – radial nerve
  • Finger ABduction of the index finger – ulnar nerve
  • Thumb ABduction – median nerve

 

  • Finger extension against resistance (radial nerve)
    Finger extension against resistance (radial nerve)

 


Function

Assess the patient’s hand function using the following screening tests:

  • Power grip – “Squeeze my fingers with your hands”
  • Pincer grip – “Squeeze my finger between your thumb and index finger “
  • Pick up a small object or undo a shirt button – “Can you pick up this small coin out of my hand?”

 

  • Power grip
    Power grip

 


Special tests

Tinel’s test

Tinel’s test is used to identify nerve irritation and can be useful in the diagnosis of carpal tunnel syndrome.

The test involves the following:

  • Tap over the carpal tunnel with your finger
  • If the patient develops tingling in the thumb and radial two and a half fingers this is suggestive of median nerve irritation and compression
  • Tinel's test
    Tinel's test

Phalen’s test

If the history or examination findings are suggestive of carpal tunnel syndrome, Phalen’s test may be used to further support the diagnosis:

  • Ask the patient to hold their wrist in complete and forced flexion (pushing the dorsal surfaces of both hands together) for 60 seconds
  • If the patient’s symptoms of carpal tunnel syndrome are reproduced then the test is positive (e.g burning, tingling or numb sensation in the thumb, index, middle and ring fingers)
  • Phalen's test
    Phalen's test

 


To complete the examination

  • Thank the patient
  • Wash your hands
  • Summarise your findings

 

Suggest further assessments and investigations

 


Further reading

Arthritis Research UK provides some excellent free guides to musculoskeletal examination and history taking [Available here]


 

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