Hand and Wrist OSCE Examination

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

Wash your hands and put on personal protective equipment if appropriate.

Introduce yourself to the patient and make sure you mention your grade, for example 3rd year medical student/junior doctor/consultant.

Confirm the patient's details, usually using 3 points of identification: full name, date of birth and NHS or 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.

Begin with a general inspection of the patient and their surroundings, from the end of the bed or standing back from a seated patient. This often gives important clues before you touch the hands.

Look for signs of discomfort and check whether the patient is using mobility aids. Look for 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. One example is the psoriatic plaques (scaly patches of psoriasis, a skin condition) seen in psoriatic arthritis (joint inflammation linked to psoriasis). These are typically on the outer (extensor) surfaces such as the elbows. They would point towards an inflammatory cause of any hand changes you go on to find.

With the patient's palms resting facing down on the pillow, inspect the back (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 (the lining of the joint) becomes inflamed (synovitis). This causes a symmetrical swelling that characteristically affects the metacarpophalangeal (MCP) joints (the knuckles) and proximal interphalangeal (PIP) joints (the middle finger joints). It spares the distal interphalangeal joints (the joints nearest the fingertips). 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. It is caused by the central slip (the part of the extensor tendon that attaches to the middle finger bone) 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 (partial dislocation) 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 (a square-looking outline) at the base of the thumb is also common, reflecting osteoarthritis of the first carpometacarpal joint (where the thumb meets the wrist).

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 (thin red-brown lines under the nail) may indicate vasculitis (inflammation of blood vessel walls) or infective endocarditis (infection of the heart valves and lining). Nailfold infarcts (tiny dead patches of skin at the nail edge) can be a sign of the systemic vasculitis associated with rheumatoid arthritis. Koilonychia (spoon-shaped nails) points to iron deficiency, while leukonychia (white nails) is often due to minor injury but can also be a sign of systemic disease. For example, Terry's nails (most of the nail looks white, with a thin dark tip) and Muehrcke's lines (paired white bands across the nail) are linked to a low albumin, and Terry's nails are also linked to chronic liver disease. Also check for finger clubbing, the loss of the normal angle at the nail bed. It is not a joint sign, but it points to systemic disease that may accompany an arthropathy (joint disease). Examples are suppurative (pus-forming) lung conditions such as bronchiectasis, and inflammatory bowel disease (Crohn's disease and ulcerative colitis).

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 (an autoimmune disease that causes skin tightening; tight, shiny finger skin is called sclerodactyly), and any scars from previous surgery such as carpal tunnel release (surgery to relieve pressure on the median nerve). 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 (joint inflammation caused by urate crystals). They 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 damage to the T1 nerve root (the first thoracic nerve root, from the spine) or the ulnar nerve.

Look in the palm for Dupuytren's contracture, a thickening and fibrosis of the palmar fascia (the sheet of tissue under the skin of the palm) that produces a palpable cord. It usually draws 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. Look for psoriatic plaques on the extensor surface and rheumatoid nodules (firm subcutaneous lumps) over the olecranon (the bony point of the elbow). Also look for xanthomata (yellowish cholesterol deposits) that signal hyperlipidaemia (high blood fats).

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 palpate each MCP, PIP and DIP joint with both hands (bimanually), between your thumbs and index fingers. Feel for boggy soft-tissue swelling (soft and spongy, a sign of active synovitis) versus hard bony swelling (osteoarthritic nodes). Palpate the wrist joint line and the anatomical snuffbox (the hollow on the thumb side of the wrist). Tenderness in the snuffbox raises the possibility of a scaphoid fracture (a break in a small wrist bone). This is important because the scaphoid has a precarious blood supply and is at risk of avascular necrosis (bone death from loss of blood supply) if missed.

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

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 (bringing the thumb across to touch the other fingers). This 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. Radial nerve weakness causes a wrist drop (the wrist hangs flexed and cannot be lifted).
• Index finger abduction against resistance: tests the ulnar nerve (first dorsal interosseous, a muscle in the web between the thumb and index finger).
• Thumb abduction against resistance, with the thumb pointing up towards the ceiling away from the palm: tests the median nerve (abductor pollicis brevis, the short muscle that lifts the thumb away from the palm).

Preview the Hand and Wrist OSCE Examination quiz