Setting up and getting started

  • Look for any walking aids
  • Look around the bed for medications (e.g. artificial tears)
  • Look for any physical aids, e.g. hand grabbers
  • Look for any O2 – sign of lung fibrosis
  • Look at the face for signs of scleroderma facies
    • ‘Beak nose’
    • Telangactasia –
    • Puckering of the lips
    • Small mouth
  • Expose the forearms and elbows. You can ask the patient to do this themselves, and this can give you a quick assessment of how able they are to move their hands.
  • Ask the patient to rest their hands somewhere comfortable. if they are sat at a table, this could be on the table, or if you are on the ward, rest them on a cushion on the patient’s knee.

Examining the hands

Again, remember the overall pattern – LOOK FEEL MOVE

Ask if the patient has any pain in the hands. If yes, ask SOCRATES questions for pain.
Crouch down so the hands are at eye level.
Observe

  • Nodules
  • Deformity
  • Hand position at rest
  • Ask about range of movement
  • Scars
  • Gently feel the temperature of the hands with the back of your hand

Nails

There are loads of signs in the nails! Below is a table of various nail and finger abnormalities:
Sign
Description
Related disease
Pitting and splitting
Multiple tiny nail depressions
Psoriatic arthropathy
Onycholysis
Painless separation of the nail from the nail bed
Psoriatic arthropathy, autoimmune thyroid disease
Hyperkeratosis
Excessive nail growth
Psoriatic arthropathy
Longitudinal ridging
Longitudinal ridging
RA
Nail fold artefacts
Small black streaks
Vasculitis
Nail fold capillaries
Small blood vessels in the nail
Scleroderma/SLE
Periungal erythema
Redness of the nails
Connective tissue disorders
Gottran’s papules
Scaling pink/purple papules over the knuckles
Dermatomyositis
Sclerodactyly
Tightening of the skin
Scleroderma
Raynaud’s phenomenon
White fingers when cold, become blue as they warm
Systemic scelrosis, scleroderma/SLE, primary Reynaud’s
 

Skin

Look at the skin of the hands, arms and face. Skin changes you might see are shown below:
Sign
Related disease
Purpura, buffalo hump, moon face, papery thin skin
Caused by steroid treatment (usually of RA)
Psoriatic plaques on extensor surfaces
Psoriatic arthropathy
Telangactasia
Tophi
Chronic tophaceous Gout
Rhematoid nodules (elbows)
RA
Palmar erythema
RA
Tight, thick, shiny skin
Atrophy of finger pulp
Calcinosis (calcium deposits)

Feel

Tell the patient you are going to feel the joints and bones in the hand. Tell them to tell you if they have any pain

Make sure you look at the patient’s face as you feel the joints!
Start at the DIP’s:
Feel the joints and bones, and try to move the joint
Look and feel for any deformities
Feel for bony swellings
Feel for boggyness – synovitis

  • To elicit synovitis you can ask the patient to make a fist. In normal individuals, the knuckles will be well defined, in synovitis, they will be swollen and ill-defined

Look for dislocations and subluxations – particularly common in RA.
Look and feel for muscle wasting:

  • Diffuse atrophy – general wasting of the muscles of the hand. Probably as a result of disuse of the hand due to joint stiffness and pain
  • Ulnar nerve lesion pattern – wasting of the hypothenar eminence (muscles on the palm of the hand that control the little finger) and interosseous muscles. Thenar eminence (muscles on the palm of the hand under the thumb) is usually spared
  • Median nerve lesion – wasting of the thenar eminence. May be a complication of carpal tunnel syndrome, which is secondary to RA. In which case there will also be sensory loss in the distribution of this nerve (thumb, first two fingers, inner aspect of third finger.

Do the same at the other joints

  • Remember the joint line for the MCP join is distal to the knuckle (not on the knuckle)

Move

There are seven movements to test. Note that the patient might not be able to perform the movements for several different reasons (pain, inflammation, advanced disease).
  • Prayer sign – Normal individual should be able to get the forarms horizontal, with 90’ of extension at the wrist
  • Reverse Prayer – Same as above, but with backs of hands touching, not palms. Again should be able to get roughly 90’ of flexion
  • Grip – Ask the patient to grip you’re first two fingers. Check flexion ability of the fingers.
  • Make a fist – Checks flexion
  • Pincer – Ask the patient to touch their thumb with their first finger. Repeat with all four fingers, and both hands
  • Pincer strength – Ask the patient to pince with force their thumb and first finger. Do it with both hands at the same time, and interlock the two pince’s. Try to pull the patient’s hands apart.

Show the elbows

Ask the patient to touch their left shoulder with their left hand, and right shoulder with their right hand. Check the elbows for rheumatid nodules, gouty tophi and signs of psoriasis. Feel along the ulnar boarder, and right into the joint line.

  • The presence of rheumatoid nodules in a patient with RA means they are have about an 80% chance of having seropositive disease
  • Ask the patient to place their hands back on the pillow with hands pointing upwards – quickly examine the hands from this angle:
    • check the patient can actually supinate their hands to this position
    • look for dupuytren’s
    • look for scars
    • look for wasting

Special tests

  • Tinels Test – carpal tunnel syndrome tap over the palmar aspect of the wrist on the radial side (over the median nerve area). In the presence of CTS, there may be a sensation of parasthesia ± pain in the hand.
  • Falens Test–reverse prayer sign – parasthesia / pain in the median nerve distribution in the presence of carpal tunnel syndrome if the hands are held in the revere prayer position for 1 minute.
  • Finkelstien’s test – ask the patient tohold their thumb inside a clenched fist, and then you press over the MCP of the thumb. Tests for tendonitis of adductor policis longus, and extensor policis brevis, which may occur after repeated movements involving adduction of the thumb (e.g. lifting up a child under the armpits
  • Scaphoid Fractureask the patient to put their hand palm down on a surface, then stretch out the fingers. Press over the anatomical snuff box (just lateral to the tendo to the thumb). Pain in this region indicates scaphoid fracture.
Volkmanns ischaemic contracture of the hand – after ischaemia of the hand (e.g. due to suprecondylar fracture), there is flexion of the digits, into a ‘claw-like’ or ‘digging’ posture.

Function

In a full examination of the hands you would also want to assess function, although in the OSCE, you might not be expected to. This would basically involve asking the patient to carry out some simple tasks, for example:
  • Do up a shirt button
  • Take the top off a medicine bottle
  • Ask to mime combing the back of the hair – testing external rotation of the shoulder
  • Pick up various sized coins off a table
  • Ask the patient if it is pain or stiffness (lack of range of movement) that is preventing them for performing these tasks

Finishing off

In the OSCE, say you would like to do:
  • Full upper limb neuro exam
  • Full exam of the joints above (elbow and shoulder)
  • Examine radial and brachial pulses
 

Hand signs by disease

Osteoarthritis

  • Heberden’s nodes – Don’t let these confuse you in cases of RA – up to 60% of women over 70 have Heberden’s nodes, so their presence does not mean RA isn’t present!
  • Bouchard’s nodes
  • Square hand

Rheumatoid arthritis

  • Dislocation and subluxation
  • Rheumatoid nodules – fibrous material surrounded by inflammatory cells. Found at the elbows, over extensor tendons, and along the ulnar border of the forearm
  • Palmar erythema
  • Swan necking
  • Hyperextension of PIP, with fixed flexion of DIP and MCP
  • Ulnar deviation
  • Synovitis
  • Thinning and waxing of the skin – due to steroid treatment
  • Z thumb
  • Butonniere’s deformity – looks like pressing a button
  • Triggering of the finger – a nodule on the flexor tendon can affect the smooth contraction and extension of the finger, as the nodule passes through tendon loops.

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