Hand and Wrist OSCE Examination

Contents

1. Introduction
2. General Inspection
3. Inspection of the Hands (Look)
4. Palpation (Feel)
5. Movement (Move)
6. Assessment of Function
7. Neurovascular Assessment
8. Special Tests
9. Completing the Examination
10. Quiz

Introduction

Wash your hands and don personal protective equipment if appropriate.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient's details, taking 3 points of identification usually; full name, date of birth and NHS/hospital number.

Obtain consent for the examination, ensuring to explain what the examination will entail.

Ask the patient if they have any pain anywhere in their hands or wrists before you begin, so that you can be gentle around any tender areas and avoid causing distress.

Expose the patient's arms to above the elbow and position them sitting comfortably with their hands resting on a pillow or examination cushion placed on a table. This supports the joints, relaxes the muscles and allows you to compare both hands side by side.

General Inspection

Begin at the end of the bed with a general inspection of the patient and their surroundings, as this often gives important clues before you touch the hands.

Look at the patient for signs of discomfort, whether they are using mobility aids, and whether there are any splints, wrist supports or walking sticks nearby that hint at chronic joint disease. The presence of aids and adaptations such as adapted cutlery or jar openers suggests a long-standing loss of hand function.

Scan for clues to the underlying diagnosis elsewhere on the body, such as the psoriatic plaques of psoriatic arthritis (typically on the extensor surfaces such as the elbows), which would point towards an inflammatory cause of any hand changes you go on to find.

Inspection of the Hands (Look)

With the patient's palms resting facing down on the pillow, inspect the dorsum of each hand carefully, comparing left with right. Look at the skin, nails, joints and overall posture of the hand.

Look for joint swelling and deformity. In rheumatoid arthritis, the synovium becomes inflamed (synovitis), causing a symmetrical swelling that characteristically affects the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints while sparing the distal interphalangeal joints. Over time, the inflammation damages the joint capsule and tendons, producing the classic deformities:

• Swan-neck deformity – hyperextension at the PIP joint with flexion at the distal interphalangeal (DIP) joint.
• Boutonnière deformity – flexion at the PIP joint with hyperextension at the DIP joint, caused by the central slip of the extensor tendon rupturing so the joint "buttonholes" through.
• Z-thumb – fixed flexion of the MCP joint with hyperextension of the interphalangeal joint.
• Ulnar deviation at the MCP joints (the fingers drift towards the little-finger side), and subluxation of the MCP joints.

In contrast, osteoarthritis tends to produce bony rather than soft swellings, and characteristically affects the distal joints. Heberden's nodes are bony swellings at the DIP joints, whilst Bouchard's nodes are bony swellings at the PIP joints. These represent osteophytes (new bone formation) at the joint margins, a response to the loss of articular cartilage. Squaring at the base of the thumb is also common, reflecting osteoarthritis of the first carpometacarpal joint.

Image - Heberden's nodes, the bony swellings at the distal interphalangeal joints seen in osteoarthritis of the hand

Creative commons source by Drahreg01 [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]

Inspect the nails for signs of underlying disease. Nail pitting (small depressions in the nail plate) and onycholysis (separation of the nail from the nail bed) are features of psoriasis and psoriatic arthritis. Splinter haemorrhages may indicate vasculitis or infective endocarditis, and nailfold infarcts can be a sign of the systemic vasculitis associated with rheumatoid arthritis. Koilonychia (spoon-shaped nails) points to iron deficiency, while leukonychia (whitening of the nail bed) reflects a low albumin, as seen in chronic liver disease. Also check for finger clubbing, the loss of the normal angle at the nail bed; although not a joint sign, it points to systemic disease (such as suppurative lung conditions or inflammatory bowel disease) that may accompany an arthropathy.

Image - finger clubbing, with loss of the normal nail-bed angle, a marker of underlying systemic disease

SimpleMed original image, credit 'SimpleMed original'

Image - splinter haemorrhages, fine longitudinal red-brown streaks under the nail that may point to vasculitis or infective endocarditis

SimpleMed original image, credit 'SimpleMed original'

Examine the skin over the dorsum. Look for the scaly, salmon-pink plaques of psoriasis, the tight, shiny, thickened skin of systemic sclerosis (sclerodactyly), and any scars from previous surgery such as carpal tunnel release. Thin, fragile skin with bruising may suggest long-term corticosteroid use.

Image - well-demarcated scaly plaques of psoriasis; finding these on the skin or nails points to psoriatic arthritis as the cause of any hand joint changes

SimpleMed original image, credit 'SimpleMed original'

Note any localised swellings. A ganglion is a smooth, fluid-filled cyst that arises from a joint capsule or tendon sheath, most often on the dorsum of the wrist. Gouty tophi are firm, chalky-white deposits of urate crystals seen around the small joints in chronic gout, which can ulcerate and discharge. Both are useful pointers to the underlying diagnosis.

Now ask the patient to turn their hands over so the palms face upwards, and inspect the palmar surface. Look for thenar (base of the thumb) and hypothenar (base of the little finger) muscle wasting. Thenar wasting is an important sign of median nerve compression in carpal tunnel syndrome, because the median nerve supplies most of these muscles. Generalised wasting of the small muscles of the hand suggests a T1 nerve root or ulnar nerve lesion.

Look in the palm for Dupuytren's contracture, a thickening and fibrosis of the palmar fascia that produces a palpable cord, usually drawing the ring and little fingers into a fixed flexed position. It is associated with diabetes, alcohol excess, smoking and a family history. Also note any palmar erythema (reddening of the palms), which can be seen in rheumatoid arthritis, pregnancy and chronic liver disease.

Finally, ask the patient to point their fingers towards you so you can inspect the elbows, looking for psoriatic plaques on the extensor surface, rheumatoid nodules (firm subcutaneous lumps) over the olecranon, and xanthomata (yellowish cholesterol deposits) that signal hyperlipidaemia.

Palpation (Feel)

Before palpating, remind the patient to tell you if anything is tender and watch their face for signs of discomfort throughout.

Assess the temperature of the hands and wrists using the back of your hand, comparing both sides and comparing the hands with the forearms. Warmth over a joint suggests active inflammation (synovitis), as occurs in a rheumatoid flare or septic arthritis, whilst cool, dusky hands may indicate poor peripheral perfusion.

Palpate the radial pulse at the wrist and, if indicated, the ulnar pulse, to confirm an adequate arterial supply to the hand.

Palpate the thenar and hypothenar muscle bulk to confirm any wasting noted on inspection, and palpate the palm for the firm cord of a Dupuytren's contracture.

Feel along the flexor tendons in the palm as the patient flexes and extends the fingers. A palpable nodule that catches and then releases with a snap, sometimes locking the finger in flexion, indicates trigger finger (stenosing tenosynovitis), where a thickened tendon struggles to glide through its pulley.

Systematically palpate the small joints of the hand. Gently squeeze across the MCP joints in one movement and watch the patient's face; tenderness on the MCP squeeze test is a useful early sign of inflammatory arthritis. Then bimanually palpate each MCP, PIP and DIP joint between your thumbs and index fingers, feeling for boggy soft-tissue swelling (active synovitis) versus hard bony swelling (osteoarthritic nodes). Palpate the wrist joint line and the anatomical snuffbox; tenderness in the snuffbox raises the possibility of a scaphoid fracture, which is important because the scaphoid has a precarious blood supply and is at risk of avascular necrosis if missed.

Movement (Move)

Assess movement actively first (the patient moves themselves), then passively (you move the joint) if active movement is limited or painful. Comparing the two helps distinguish a problem with the muscles, tendons or nerves (active movement reduced but passive movement preserved) from a problem within the joint itself (both active and passive movement reduced).

Assess active movements by asking the patient to:

• Make a fist and then fully straighten the fingers – this screens finger flexion and extension and is a quick test of overall hand function.
• Extend the wrists by putting the palms together in a "prayer" position, then flex the wrists in a reverse-prayer position to assess wrist flexion and extension.
• Move the wrists from side to side to assess radial and ulnar deviation, the side-to-side movement at the wrist joint.
• Touch the tip of the thumb to the tip of the little finger to test thumb opposition, which depends on the median-nerve-supplied thenar muscles and is often impaired in carpal tunnel syndrome.

If active movement is reduced, repeat the movements passively, feeling for any crepitus (a grating sensation that suggests joint surface roughening in osteoarthritis) and noting the range of movement.

Next assess movements against resistance, which doubles as a quick screen of the three main nerves supplying the hand:

• Wrist and finger extension against resistance – tests the radial nerve. Weakness produces a wrist drop.
• Index finger abduction against resistance – tests the ulnar nerve (first dorsal interosseous muscle).
• Thumb abduction against resistance, with the thumb pointing up towards the ceiling away from the palm – tests the median nerve (abductor pollicis brevis).

Assessment of Function

Hand function is what matters most to patients, so it is always assessed. Ask the patient to:

• Demonstrate a power grip by gripping two of your fingers tightly – this tests overall gross hand strength.
• Demonstrate a pincer (precision) grip by pinching your finger between their thumb and index finger – this requires intact median nerve function and fine motor control.
• Perform a practical functional task, such as picking up a small object (e.g. a coin), undoing a button or holding a pen as if to write.

Difficulty with these tasks demonstrates the real-world impact of any deformity, weakness or sensory loss found earlier in the examination, and helps guide the need for occupational therapy and adaptations.

Neurovascular Assessment

A focused neurovascular assessment confirms which nerve, if any, is involved. The three nerves and their sensory territories are:

• Median nerve – the palmar aspect of the thumb, index, middle and radial half of the ring finger. Test sensation over the index finger pulp (note that the skin over the thenar eminence is supplied by the palmar cutaneous branch, which arises before the carpal tunnel and so is typically spared in carpal tunnel syndrome).
• Ulnar nerve – the little finger and ulnar half of the ring finger. Test sensation over the pulp of the little finger.
• Radial nerve – the dorsum of the hand over the first web space (the skin between the thumb and index finger). Test sensation over the dorsal first web space.

Assess light touch sensation in each territory, comparing both hands and asking the patient to confirm it feels the same on each side. Reduced or altered sensation localises the lesion to a specific nerve, while a "glove" distribution of sensory loss suggests a peripheral neuropathy such as that seen in diabetes.

For the motor assessment, the movements against resistance described above already screen each nerve: thumb abduction (median), finger abduction (ulnar) and wrist/finger extension (radial).

Finally, confirm the vascular supply with the capillary refill time: press on a fingertip for five seconds and release; colour should return in less than two seconds. A prolonged refill time suggests impaired peripheral perfusion.

Special Tests

Special tests are performed if the history or examination suggests a specific diagnosis, most commonly carpal tunnel syndrome (median nerve compression at the wrist) or an ulnar nerve lesion.

Tinel's test assesses for median nerve compression. Tap (lightly percuss) over the carpal tunnel on the palmar aspect of the wrist. The test is positive if this reproduces tingling or paraesthesia in the median nerve distribution (thumb, index, middle and radial half of the ring finger). The mechanism is that mechanical irritation of an already-compressed and sensitised nerve triggers abnormal nerve impulses felt as tingling.

Phalen's test also supports a diagnosis of carpal tunnel syndrome. Ask the patient to hold both wrists in full flexion by pressing the backs of their hands together for up to 60 seconds. The test is positive if the patient's symptoms (tingling, burning or numbness in the median nerve distribution) are reproduced. Sustained wrist flexion further reduces the space within the carpal tunnel, increasing pressure on the median nerve.

Froment's test assesses ulnar nerve function, specifically the adductor pollicis muscle. Ask the patient to grip a sheet of paper between the thumb and the side of the index finger while you try to pull it away. If the ulnar nerve is impaired, the weak adductor pollicis cannot hold the paper, so the patient compensates by flexing the thumb at the interphalangeal joint using flexor pollicis longus (a median nerve muscle). This visible thumb flexion is a positive Froment's sign.

Bear in mind that Tinel's and Phalen's tests are useful supporting clues rather than definitive: both have only moderate sensitivity, so a negative result does not exclude carpal tunnel syndrome. Where the diagnosis is in doubt, it is confirmed with nerve conduction studies.

Completing the Examination

Thank the patient and help them re-dress if needed, then wash your hands.

Summarise your findings to the examiner.

To complete the examination, state that you would perform a full upper limb neurological examination and examine the joint above and below (the elbow and shoulder), as well as a GALS screen if a more widespread arthropathy is suspected. You would also assess function further with a formal occupational therapy review, and request relevant investigations such as X-rays of the hands and wrists, blood tests (inflammatory markers, rheumatoid factor and anti-CCP antibodies), and nerve conduction studies if carpal tunnel syndrome or another nerve lesion is suspected.

Quiz

Preview the Hand and Wrist OSCE Examination quiz