Introduction
This a very good examination to score full marks in, if you remember an ordered system. The template examination below isbased upon the principles of 'Look, Feel, Move' and the order of 'Skin, Soft-tissue, Bones' (commonly used in Orthopaedic examinations).
Before you begin: Wash your hands, introduce yourself, and ask permission (consent) to examine. It is also essential to ask if the patient has any pain in their hands or arms. If they do have any discomfort, then remember to be gentle and keepan eye on the patient's face to determine whether your actions are causing any pain.
Position: Expose to above the elbow joint. Get the patient to flex at the elbow and medially rotate their forearms. Inspect the elbows. Once you have done this, gently place the patient's forearms onto a pillow (pronated).
Inspection
In the elbows, look for:
Before you place the arms on the pillow, look at the elbows (rheumatoid nodules / psoriatic plaques - these are silvery/white and well demarcated)
In the wrist & hand, look for:
SKIN:
- Colour (erythema / inflammation)
- Scars (including carpal tunnel scars)
- Rashes (any signs of vasculitis)
- Sclerodactyly (long tapered fingers - found in CREST syndrome)
- Thin skin (from steroid use)
SOFT TISSUE:
- Wasting / swelling
BONES:
- Nails (pitting / ridges are found in psoriasis)
Deformities:
Rheumatoid arthritis (RA):
- Z-thumb
- Swan-necking - hyper-flexed proximal interphalangeal joint (PIP)
- Boutonniere -'button-holing', hyper-flexed distal interphalangeal joint (DIP)<
- Ulnar deviation of the fingers
- Radial deviation of wrist
Osteoarthritis (OA):
- Heberden's nodes (found on DIP)
- Bouchard's nodes (found on PIP)
- Square-shaped thumbs
Movements and Neurology
Active movements(the patient moves the joint):
- Make a fist
- Wrist extension
- Raise (extend) the little finger (the extensor digiti minimi tends to loose function 1st in RA)
- Raise (extension) of all of the little fingers
- Pincer grip (thumb & 1st finger - a useful functional test, as many day-to-day tasks employ this action eg. writing and using keys)
- ?Prayer? sign (see if the patient can put their hands together as if they are praying, ie. by touching the palmar surfaces of the interphalangeal joints together with the fingers spread - if unable to, the test is positive and is classically considered a sign of diabetic joint disease or 'cheiroarthropathy').
Passive movements(you move the joint):
- Test each joint to its full extent in its plane of movement to determine the full range of motion. Always look at the patient's face to determine if any particular movement is painful.
Neurology (sensorimotor function):
- You can perform a quick 'screening' neurological examination of the wrist/hand here - you don't need to perform it all as you have already tested some of these movements.
- The aim is to test the individual nerves against resistance:
- Ulnar nerve motor: place a piece of paper between patient's fingers and ask them to adduct the fingers ? if weak, then 'Froment?s sign' is positive
- Remember ?PAD-DAB? ? Palmar Interosseus Adducts and the Dorsal Interosseus Abducts
- Ulnar nerve sensory: medial side of the volar (palmar) aspect of the pulp of the little finger- Median nerve motor: thumb and
- Median nerve sensory: lateral side of the volar (palmar) aspect of the pulp of the 1st or index finger
- Radial nerve motor: wrist extension
- Radial nerve sensory: 1st dorsal webspace (between thumb and 1st finger, on dorsum of hand)
