PCL 5 - Physical Examination of Hands & Wrists

History

1. Pain

   - vague/diffused → radiated from shoulder or neck / carpal tunnel syndrome

   - localised → arthritis

2. Stiffness

   - worse in mornings for rheumatoid arthritis

3. Swelling

   - wrist → arthritis / tendon sheath inflammation

   - individual joints → arthritis

4. Deformity

   - fingers & hand → rheumatoid arthritis

   - fingers → arthritis / gouty tophi (tohpi - nodular masses of uric acid crystals deposited in different soft tissue areas in body, most commonly fingers, elbow and big toe)

   - sudden onset of deformity → tendon rupture

5. Locking or snapping of finger (trigger finger)

   - inflammation of flexor tendon sheath (tenovaginitis)

6. Loss of function

   - history should include assessment of difficulties patient has in using hands and wrists

7. Neurological symptoms due to nerve compression

   - paraesthesiae (abnormal skin sensations (as tingling or tickling or itching or burning)
   usually associated with peripheral nerve damage)

   - limitation of complicated hand functions

Examination

- sit patient over side of bed and place hands of pillows with palms down

1. LOOK

   → wrists & forearms

   - erythema

   - atrophy

   - scars

   - rashes

   - swelling and its distribution

   - deformity

   - ulnar and hyloid prominence

   - muscle wasting of intrinsic muscles of hand (appearance of hollow ridges between metacarpal bones)

   
   

→ metacarpophalangeal joints

• skin abnormalities

• swelling

• deformity

• ulnar deviation & volar (palmar) subluxation of fingers (characteristic of rheumatoid arthritis (RA) but NOT pathognomonic)

→ proximal & distal interphalangeal joints (IPJ)

• skin changes & joint swelling

• characteristic deformities of RA

  - swan neck (hyperextension at proximal IPJ (subluxation) & fixed flexion deformity at distal IPJ (tendon shortening))

  - boutonniere deformity (fixed flexion of proximal IPJ & fixed extension of distal IPJ)

  - Z deformity of thumb (hyperextension of IPJ & fixed flexion and subluxation of metacarpophalangeal joint)

• characteristic changes of osteoarthritis (OA)

  - Heberden's nodes (osteophytes at distal IPJ)

  - Bouchard's nodes (osteophytes at proximal IPJ)

→ nails

• characteristic psoriatic nail changes (nail disease common in those suffering from psoriasis)

  - pitting (small depressions in nails)

  - onycholysis

  - hyperkeratosis (thickening of nail)

  - ridging & discolouration

→ palmar surface (hands turned over)

• scars (from tendon repairs or transfers)

• erythema

• muscle wasting of thenar (the fleshy area of the palm at the base of the thumb) / hypothenar (group of three muscles of the palm that control the motion of the little finger)eminences (due to disuse, vasculitis, peripheral nerve entrapment)

2. FEEL & MOVE

   (palm down position)

   → palpate wrists (both thumbs placed on dorsal surface by the wrists supported underneath by index fingers)

   - feel gently for synovitis (boggy swelling) & effusions

   - dorsiflex wrists gently (normal – possible to 75 degrees) & palmar flex (possible to 75
   degrees) with examiner's thumbs

   - test radial and ulnar deviation (20 degrees)

   - note tenderness / limitation of movement / joint crepitus

   - palpate ulnar styloid for tenderness (can occur in RA)

   - palpate tip of radial styloid for tenderness (de Quervain's tenosynovitis)

   - tenderness in anatomical snuff box (scaphoid injury)

   - tenderness distal to head of ulna for extensor carpi ulnaris tendonitis

→ metacarpophalangeal joints (MCPJ) (both thumbs)

• flex MCPJ with proximal phalanx held between thumb & forefinger → rock MCPJ backwards & forwards

• normal joint – very little movement

• ligamentous laxity / subluxation – considerable movement

→ interphalangeal joints (proximal & distal)

• palpate for tenderness , swelling, osteophytes

  
  

→ palmar tendon crepitus

• palmar aspects of examiner's fingers placed against palm of patient's hands while he / she flexes and extends the MCPJs

• tenosynovitis – inflamed palmar tendons can be felt creaking in their thickened sheaths and nodules can be palpated

  
  

→ trigger finger

• same manoeuvre as for palmar tendon crepitus

• RA → thickening of a section of digital flexor tendon is such that it tends to jam when passing through a narrowed part of its tendon sheath

• flexion of finger occurs freely up to a certain point where it sticks and cannot be extended (flexors are more powerful than extensors)

• application of greater force overcomes the resistance with a snap

→ carpal tunnel syndrome

• flex both wrists for 30 seconds (Phalen's wrist flexion test)

• if syndrome is present – paraesthesiae (pins & needles) precipitated in affected hand in distribution of median nerve

• more reliable than Tinel's sign (tapping over the flexor retinaculum which lies at the proximal part of the palm – produce similar paraesthesiae)

  
  

  → test active movements

  - wrist flexion and extension

  - compare both sides

  - test passive movements

  
  

  → thumb movements (hand flat, palm upwards & examiner's hand holds patient's fingers)

  - extension (stretch thumb outwards)

  - abduction (thumb pointed straight upwards)

  - adduction (asking patient to squeeze examiner's fingers)

  - opposition (get the patient to touch little finger with the thumb)

  *look for limitation of these movements and discomfort caused by them

  
  

  → metacarpophalangeal & interphalangeal movements

  - ask patient to make a fist then to straighten out the fingers

  - test fingers individually

  - if active flexion of one or more fingers is reduced → test superficialis and profundus flexor tendons

  - hold proximal finger joint extended and istruct patient to bend it

  - distal fingertip will flex if flexor profundus is intact

  - hold other fingers extended (to inactivate the profundus) and check finger flexion (inability – supercialis unable to work)

  
  

  3. FUNCTION

  - grip strength

  - getting patient to squeeze two of the examiner's fingers

  - key grip

  - hold key between the pulps of thumb and forefinger

  - ask patient to hold his grip tightly and try to open up his or her fingers

  - opposition strength

  - patient opposes thumb and individual fingers

  - difficulty by which these can be forced apart is assessed

  - practical test

  - ask patient to undo a button / write a pen

  - completed by formally assessing for neurological changes

  
  

  Videos

  http://www.youtube.com/watch?v=ysWOHe4dfpI

  OR

  http://www.youtube.com/watch?v=65mjCLGrGTE&p=53CC110348635B55&playnext=1&index=52