Examination of the hand and wrist video
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It is most comfortable for the patient to have their hands positioned on a pillow. In this position look for obvious swellings, loss of alignment, muscle wasting and scars. Try to decide if changes are symmetrical or asymmetrical. Look at the nails for psoriatic changes of pitting and onycholysis, and also nailfold vasculitis.
Which joints are mainly affected? The distal interphalangeal joints, the proximal interphalangeal joints, the metacarpophalangeal joints or the wrists?
Look at the skin for rashes or signs of long-term steroid use such as thinning or bruising. Again, look at the palms of the hands:
- at the finger pulp
- signs of palmar erythema
- scars from carpal tunnel release.
Feel for peripheral pulses, muscle bulk and tendon thickening. Assess median and ulnar nerve sensation by touching gently either over the thenar and hyperthenar eminences or index and little fingers respectively. Radial nerve sensation is most reliably tested over the thumb and index finger web space.
Temperature can be assessed by comparing the forearm to the wrist and metacarpophalangeal joints. Gently squeeze across the metacarpophalangeal joints while watching the patient’s face.
Bimanually palpate any metacarpophalangeal joints which appear tender or swollen – this should be done by having your thumbs above and index fingers below the joint. The proximal and distal interphalangeal joints can be palpated again by using thumbs and index fingers to encircle the joint, squeezing each side gently in turn to detect fluctuance.
Both wrists should be bimanually palpated in a similar manner.
You should look at both elbows carefully for evidence of psoriasis and rheumatoid nodules, and feel along the ulnar border.
Wrist flexion and hyperextension should be assessed both actively and passively.
Ask the patient to extend their fingers fully against gravity – if they can’t, this may be due to joint disease, extensor tendon rupture or neurological damage – you may assess this by passive movement.
Extensor power and finger spread assesses radial and ulnar nerves. Abduction of the thumb assesses the median nerve.
The patient should be asked to make a full finger tuck – if they are unable to do this, again it may be due to nerve, joint or tendon damage – this again can be assessed passively.
Power grip is important functionally, as is pincer grip power. Other functional tests may be made such as picking up a small object, doing up a button or holding a pen or cup.
Phalen’s test for carpal tunnel syndrome: In patients whose history suggests a carpal tunnel syndrome Phalen’s test can be performed. This includes forced flexion of the wrist for 60 seconds reproducing the patient’s symptoms. This may be done in one of two ways [as demonstrated].