Hand and Wrist Examination

Hand and wrist complaints are common presentations especially if you are working in General Practice, A&E or orthopaedics/rheumatology. Therefore it is important to be able to do a thorough assessment for your OSCE clinical examinations. As you are likely to get patients with chronic conditions in OSCEs, it is important to be familiar with the following conditions and their signs; Rheumatoid arthritis, Osteoarthritis and psoriatic arthritis. As usual for MSK examinations we will follow a “look, feel, move”, special tests and functional checks.

Wash hands

  • Wash your hands using the Ayliffe technique

Introduce yourself

  • Introduce yourself and give your name and grade

“Hi, my name is Dave Bassett and I am a 4th year medical student”

Check patient details

  • Clarify patient's identity by confirming their name and asking for their DOB

Describe examination

  • Explain what examination you are performing and what this involves

“I have been asked to examine your hands and wrist. This involves having a look, a feel and asking you to do a few exercises.”

Gain verbal consent

“Would this be ok with you?”

Expose appropriately

  • Ideally, the patient should be examined wearing a t-shirt. 

Reposition

  • Ensure the patient is standing for the purposes of this examination

"Can I check if you are in any discomfort at the moment?"

NB: Most clinicians will start with the good hand/wrist first to build trust with the patient 

“I'm just going to start off with having a look at your hands and then we'll move on to a few exercises”

Dorsum (back of hand)

  • Inspect for the symmetry of the hand posture at rest
  • Look for skin changes: swelling, thinning, bruising, rashes, or palmar erythema. If you find joint swelling, check whether the changes are symmetrical or not. 
  • Look for scars: the scars could indicate an injury or a past surgery.
  • Pallor: Anaemia or peripheral vascular disease
  • Check for muscle wasting: could indicate a neurological problem
  • Check the nails for pitting, nailfold vasculitis, onycholysis or clubbing
  • Bones deformities:
  • Z-shaped thumb: hyperextension of the IP joints with a subluxation and fixed flexion of the MCP joint indicate rheumatoid arthritis.
  • Knuckle guttering and Boutonnières deformity (DIP hyperextension with PIP flexion) could indicate rheumatoid arthritis

Palms

  • Look for palmar erythema, and symmetry of the hand posture
  • Check for abnormalities like clawed hand
  • Swelling: Ganglion
  • Muscle wasting: muscle wasting at the thenar/hypothenar eminence could be suggestive of carpal tunnel syndrome
  • Deformity: Dupuytren’s contracture (flexion deformity)

NB: Ask the patient before starting if they have any pain in their wrist and hands. When feeling the wrist, ask them to let you know if there is any pain when you palpate. Observe the face of the patients for the signs of pain and tenderness while you move the wrist and IP joints.

" If I can just start off with checking the back of your hands, please rest your hands on this pillow"

Dorsal assessment (back of hand)

  • Assess the temperature at the wrist and MCP joints and compare with the temperature at the forearms by using the back of your hand. 
  • Gently squeeze the metacarpophalangeal (MCP) joints and feel for any bony swellings, effusions or inflammation
  • Palpate the anatomical snuffbox for tenderness: Often tender in scaphoid fractures
  • Assess the radial nerve sensation by touching the first dorsal webspace
  • Squeeze the joints and palpate the MCP, PIP and DIP joints 
  • Check for tendon tenderness around ulnar styloid: A positive test indicates extensor carpi ulnaris tendinitis
  • Check for tendon tenderness around radial styloid: A positive test indicates De Quervain's tenosynovitis

 

Palmar assessment

  • Temperature: feel the temperature of the skin at the wrist and MCP joint lines with the back of your hands. Compare with the temperature at the forearms. Warm joints could indicate septic arthritis, cellulitis or an inflammatory condition.
  • Check the bulk of the thenar and hypothenar eminences: A wasting could indicate an ulnar or median nerve problem
  • Palpate the flexor tendon sheath (palm of hand) for thickening, which could be indicative of Dupuytren’s contracture
  • Trigger digit: fully flex each digit individually. Release it back and feel the tendon base.
  • Assess the sensations of the median nerve by touching the thenar eminence or index finger
  • Assess the sensations of the ulnar nerve by touching the hypothenar eminence or little finger
  • Check both radial and ulnar pulses 

 

NB: Assess the movements initially active (patient does it) then passive (you do the movements)

  • Feel for crepitus during passive movements
  • Finger flexion: Ask the patients to make a fist. Inability to do so may indicate joint or tendon deformity.
  • Finger extension: Ask the patient to open their fist and spread their fingers apart
  • Wrist flexion: Reverse prayer position - back of the hands together and flex the wrists fully (Normal ROM: 70º)
  • Wrist extension: Prayer position: palms of hands together and extend the wrists fully (Normal ROM: 80º)
  • Thumb movement: ask the patients to stretch the thumb to the opposite side to check for extension, point the thumb in the air for restricted abduction, and touch the thumb to the palms to check adduction. Inability to perform these functions could indicate an abnormality in the thumb joints or median nerve.

Phalen’s test

“I am going to perform a test on your wrist joint. Let me know if you feel any pain or abnormal sensations in your fingers”

  • Ask the patients to hold the wrist in forced flexion position by placing the back of their hands into a reverse prayer sign position
  • Hold position for 60 seconds 

A positive test could indicate carpal tunnel syndrome if they get pain or paraesthesia

Tinel’s test

  • Hold wrist in neutral position and tap over the carpal tunnel
  • Continue to do this for 30 seconds to 60 seconds

A positive test could indicate carpal tunnel syndrome if they get pain or paraesthesia

"I'm just going to ask you to do a few everyday things to check how you can manage to do them."

  • Ask the patients to squeeze your fingers with their hands
  • Ask the patient to carry out a few everyday tasks to assess fully; undoing a button, holding a cup or writing with a pen

Thank patient

  • Let the patient know you have finished examining them and thank them for their time. 

“That’s the end of the exam. Thank you for your time.”

Summarise your findings and state other exams for completion

“Today I have seen Mrs Anderson...To complete the examination I would examine the elbow joints as well as conducting a full upper limb neurological assessment.”

State what investigations you would perform

  • Explain to the examiner what tests and investigations you would perform based on your findings and the patient’s history;
  • Xray

  • MRI/ US scan