Hand Examination

Regional Examination of the Musculoskeletal System: (REMS)


REMS refers to more detailed examination that should be carried out once an abnormality has been detected either through the history or through the screening examination (GALS)
All REMS consist of is:

Look
Feel
Move
Function
Special Tests


Hand Examination:

In the OSCE you may be given a patient with a joint disease: if you know the diagnosis from inspecting the hand say it e.g RA , Dupuytrens (be wary of ulnar n. palsy)

Tailor the examination to the clinical history and the nature of the problem e.g patient with laceration of digits, assessments of the integrity of tendons, nerves and circulation will be necessary as full examination of function is lengthy
If a patient presents with stiffness, pain and swelling of the hands the examination should concentrate on establishing the pattern of joint and tendon involvement and testing the principal hand functions such as power grip and fine pinch.

If asked to examine ‘this patient’s hands’ ask if would like to examine the peripheral nervous system too

CONSENT
Ask the patient if they have any pain before touching them.

Inspection

Place the hands palm down, resting on a pillow:
• Hands and wrists: deformity? (Z thumb- RA, squaring of 1st CMC joint- OA) Swelling? Scars (joint replacements)? Interossei or any other muscle wasting (due to disuse of joints because of RA or OA rather than neurological cause)
• Decide which joints- if any are affected MCP, PIP, DIP
• Look at skin- thinning (in areas of steroid injection)
• Looks at nails- psoriatic changes (pitting) and onycholysis (loosening of the nails beginning at free border)-> psoriatic arthritis
• If any abnormalities- symmetrical? Asymmetrical?
• Using the back of your hand gently feel the patient’s arm wrist hand, MCP. PIP and DIP joints for any differences in temperature (joints should feel cooler as they a comparatively avascular compared to skin)

Ask the patient to turn the hands over so palm up (supinate)- if problems with this suggests radioulnar joint involvement
• Any scars- carpal tunnel release scar
• Wasting of they thenar or hypothenar eminence

Palpation

Turn the hand back over so palm down:
• Palpate each joint for tenderness: wrist, MCPs, PIPs and DIPs- any synovitis or deformity?
o Swelling between the furrows of the MC heads, red, warm, rubbery feel--> active synovitis
o Bimanually palpate each MCP, PIP and DIP joint
• May be tenderness over the styloid process in RA: symmetry of deformity suggests RA
• Hard, bony swellings? Heberdens- DIPs, Bouchard’s nodes- PIPs, both OA
• Palpate each joint while moving fingers passively- nodules? Crepitus?

With patient’s hand palm up:
• Quickly asses radial and ulnar pulses (just mention)
• Feel bulk of thenar and hypothenar eminences
• (Test median nerve- touch index finger/ thenar eminence)
• (Test ulnar nerve- touch little finger/ hypothenar eminence): sensation normal/equal?
• Test temperature on skin of patient’s forearm, wrist and MCP joints- differences?
• Squeeze MCP joints for tenderness – look at patient’s face


Finally feel and look along ulnar border up to elbow for rheumatic nodules or psoriatic plaques on extensor surfaces.


Move


• Ask the patient to straighten their fingers (against gravity ie palms down), fixed flexion deformity?
- if unable may be due to joint disease, extensor tendon rupture etc
• Ask the patient to make a fist
• Assess wrist flexion and extension: Prayer sign (limited extension of small hand joints prevents placing fingers together): actively and passively
o Arthrodesis = joint fusion
• If patient has a hx of carpel tunnel do Phalen’s Test (forced flexion of the wrist for 60secs produces patients symptoms- usually middle finger): Tinels: tapping on the flexor retinaculum reproduces patient’s symptoms: paraesthesia in fingers
• Testing ulnar n by adduction of thumb (Froment’s sign): hold card between palm and adducted thumb. If adductor is weak the thumb cannot be held straight and flexes at MCP and IP joint
• Test median n by abducting the thumb against resistance
• Finkelstein’s test: curl thumb in to fingers (in fist) mid supinate the wrist, then flex- causes pain: De Queviens synovitis

Function

• Ask patient to grip fingers (three fingers) --> power grip
• Ask the patient to perform fine pinch