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Hand examination

You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here
Please examine this lady's hands

The most common hand conditions that you will be asked to examine
are rheumatoid arthritis or osteoarthritis

Introduce yourself
Confirm patient details
Wash you hands
Ask permission to examine the patients hands

Next question <+

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You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part 8 soon.

Click here
Exposure:

Full exposure of patients hands, forearms and above the elbows is

essential for this examination

If the patient has a watch or any wrist jewellery you should politely ask if
they can remove this for the examination

The patient should place their hands palms facing upwards on their lap
or on a table if present

Next question <+

v
Pass the MRCS Home e>

Hand examination

You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here

Inspection:

This is the most important part of the examination and will give you the
most information

It is important to be systematic and compare left and right

Any examination of hands should be logical and follow a sequence, no

matter what the pathology

We recommend the following sequence:

Wrists:

Radial deviation of the wrists bilaterally

Thumbs:

Z deformity

Fingers:

Ulnar deviation

Boutonniere's and Swan neck deformities

Palm:
Palmar erythema

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Hand examination

You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here

Palpation:

No tenderness of joints

Rheumatoid nodules at elbows

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Hand examination

You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here

Peripheral neurovascular exam of hands:

Peripheral nerve exam:

Radial
Motor - Ask patient to cock wrists and resist you pushing them down
Sensation over base of thumb

Ulnar
Motor - Abducts fingers and resists you pushing them together
Sensation over medial border of hand

Median
Motor -Abduct thumb and resist you pushing against it
Sensation over lateral border of index finger

If appropriate (in the case of suspicion of carpal tunnel syndrome) carry

out:

Tinel's test: Tapping over the median nerve at the wrist reproduces
tingling sensation in the distribution of the median nerve.

Phalen's test: Maximal flexion of the wrist for 60 seconds reproduces

symptoms.

Allens' test: this will assess ulnar arterial supply (usually dominant
supply) to hand whilst radial artery is occluded.

To perform an Allen's test:

1. Hold the patient's hand above his or her heart
2. Ask the patient to make a fist
3. Apply pressure to both the radial and the ulnar arteries
4. With the hand elevated the patient should then open the hand. The
hand should appear pale and have limited capillary refill
5. The ulnar arterial pressure should be released whilst still occluding
the radial artery
6. The hand should return to normal colour within 5 seconds

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Hand examination

You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here

Functional assessment:

Assess power grip grip your fingers

Assess precision grip: hold a pen or fasten a button on shirt

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Hand examination

You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here

Conclusion:

Thank the patient

Wash your hands
Turn to the examiner and say you are ready to present your findings

, Next question -. ]
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- .
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You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here
Summary

This is Mrs Jean Smith, a 54-year-old lady who has presented to clinic
today with regards to her hands. Examination shows generalised
swelling of the hands with bilateral radial deviation of the wrists, Z
deformity of the thumbs, ulnar deviation of the fingers with
Boutonniere's and Swan neck deformities. The joints are not tender or
warm, however, there is palmar erythema and she has rheumatoid
nodules at the elbow. Mrs Smith's general function is good but today
she has poor precision function (cannot button up shirt). Finally,
neurological examination of the hands is normal

Next question <+

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Hand examination

You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here

What is your diagnosis?

Rheumatoid arthritis (RA)

It is highly unlikely that this is anything else as the patient has all the
classical features

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Hand examination

You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here

What wou ld you do to complete your examination?

Examine any other affected joints

Look for extra-articular signs of rheumatoid arthritis

Radiographs of affected joints

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You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here
If this was the first presentation then blood tests would be requ ired. What
would you request and why?

Full blood count: looking for anaemia of chronic disease

Erythrocyte sedimentation rate (ESR): typically raised in

rheumatolog ical disease

Rheumatoid factor: positive in approximately 70% of cases

Antinuclear antibody: positive in approximately 30% of cases

Next question <+

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You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here
What is rheumatoid arthritis?

Symmetrical, inflammatory poly-arthropathy with systemic

manifestations

More common in females

Most common decade of presentation is 5th - 6th

70% of patients are rheumatoid factor positive

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Click here

What is the pathology of rheumatoid arthritis?

Rheumatoid synovitis

Increase in inflammatory cells predominantly macrophages and T

lymphocytes

Joint effusion

Soft tissue swelling around the joint

Granulation tissue known as pannus forms over the inflamed synovium

and articular cartilage. Pannus releases enzymes and cytokines that
destroy the underlying cartilage This reaction is most marked at the
joint periphery

Erosion can progress to bone and combined with soft tissue swelling
affect joint tendons leading to joint instability and deformity

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- .
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You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here
Can you name some extra-articular features of rheumatoid arthritis?

Rheumatoid nodules
Lymphadenopathy
Vascu litis
Atherosclerosis
Pleural and pericardia! effusions
Fibrosing alveo litis
Splenomegaly
Felty's: splenomegaly, RA and neutropaenia
Scleritis and episcleritis

Next question <+

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Hand examination

You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here

What are rheumatoid nodules?

Accumulation of collagen with a central area of necrosis and

surrounding cells; fibroblasts and macrophages
Most commonly seen on extensor surfaces
Affect approximately 20% of patients with RA.

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Hand examination

You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here

What are the radiological changes seen in a joint affected by rheumatoid

arthritis?

Loss of joint space

Juxta-articular osteopaenia
Bone erosions
There are no osteophytes
Soft tissue swelling

Next question •
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Hand examination

You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here

How is rheumatoid arthritis managed?

Early referral to a rheumatologist is now recommended by NICE

Management can be divided into general, medical or surgical:
General advice:
Stop smoking as this increases symptoms
Exercise and physiotherapy
Medical:
Analgesia
Steroids: orally or intra-articular
Disease modifying anti-rheumatic drugs (DMARDs): Act by decreasing
or modulating inflammation and hence disease progression
Early use is associated with better long term prognosis
Methotrexate and sulfasalazine are 1st line
Methotrexate: Taken weekly and needs folic acid. Do not use if
pregnant, pre-existing lung disease. Side effects: pneumonitis,
hepatotoxicity, oral ulcers, lethargy, myelosuppression
Sulfasalazine: side effects include: myelosuppression, oral ulcers,
nausea, lethargy and decreased sperm count
Regular FBC, U+Es and LFTs are essential if on DMARDs
Surgical:
NICE recommends that anyone with RA should have an early surgical
opinion if conservative I medical management has failed to control
symptoms.

This includes:

Persistent pain
Decreasing joint function
Progressive joint deformity
Imminent tendon rupture
Nerve entrapment

Source: Rheumatoid arthritis, NICE Clinical Guideline (February 2009)

Next question ..
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Hand examination

You are the CT1 in the Orthopaedic clinic. The next patient has already been seen by your consultant but he has asked you to
examine the patient's hands as he knows you are sitting MRCS part B soon.

Click here

Key Information

The most common hand conditions that you will be asked to examine
are those with rheumatoid arthritis or osteoarthritis

Any examination of hands should be logical and follow a sequence, no

matter what the pathology

We recommend the following sequence:

Inspection: wrists, palms, thumbs, fingers including nails and finally the
dorsum

Palpation: palpate each joint individually, feeling for tenderness, warmth

and nodules.

Perform active and passive movements of each joint

Peripheral nervous examination: both sensory and motor function

should be thoroughly examined

Functional assessment: assessment of general and precise function .

This can be tested by asking the patient to hold a large object such as a
golf ball for general function.

Precision function can be tested by asking them to hold a pen or button

their shirt

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