Introduce yourself, confirm the patient's name and date of birth. Obtain consent and a chaperone and then proceed to wash hands. Obtain a pillow or have a flat surface available to examine the patient's hands.
Ask whether the patient is in any pain, especially in the hands. Screen for pain or abnormal movements in the shoulder and elbow joints. Ensure that the patient is adequately exposed distally from the elbow joints, and ask them to sit on the end of the bed.
For all orthopaedic examinations remember: Look Feel Move Test.
Check if the patient is comfortable at rest. Patients with rheumatoid arthritis may show signs of fatigue or stiffness of the joints. Osteoarthritis can also present with stiffness, especially after continued use of the affected joint. Briefly observe the patient’s face for any psoriatic skin changes (dry, red, scaly skin). Psoriasis often presents behind the ears and around the hairline. Carefully observe the hands, as you may notice a wrist drop (sustained wrist flexion), caused by a lesion to the radial nerve.
Look for paraphernalia around the bed. It is important to look out for walking aids, which may be present if the patient has osteoarthritis affecting the hip or knees. This may give clues towards an overall diagnosis of osteoarthritis.
Ask the patient to place their hands on their shoulders to give you a better view of their arms. Inspect the elbows and surrounding area for any psoriatic plaques or rheumatoid nodules (firm lumps under the skin), the latter of which presents in rheumatoid arthritis.
Dorsal aspect of the hand
Ask the patient to place their hands on a flat surface, preferably a pillow for comfort. Inspect the dorsum of their hand from all angles, looking for any asymmetry or swellings. In rheumatoid arthritis, there may be swelling at the metacarpophalangeal (MCP) and proximal-interphalangeal (PIP) joints. Observe for any deformities such as:
Ulnar deviation of the fingers at the MCP joint: Symmetrical ulnar deviation is commonly present in late stage rheumatoid arthritis.
Claw hand (wrist flexion and fingers flexed at PIP and distal interphalangeal (DIP) joints): This is a presentation in Klumpke’s palsy.
Ulnar claw (flexion of the ring and little fingers only): This is a result of a lesion to the ulnar nerve.
Check for any muscle wasting, as this could suggest chronic pathology or a nerve lesion. Scars may indicate previous surgery. In this position, all visible muscles are supplied by the ulnar nerve.
A good acronym to remember what to look for is DAWSS. This stands for deformity, asymmetry, wasting, swelling or scars.
The entire function of the upper limb and shoulder girdle is to facilitate movement of the hand. There are three major muscle compartments involved in its movement.
Anterior forearm compartment
The muscles in this compartment are involved in pronation, wrist flexion, abduction and adduction and flexion of the fingers and thumb. Most of the compartment is innervated by the median nerve, except for the flexor carpi ulnaris and the lateral half of the flexor digitorum profundus, which are innervated by the ulnar nerve.
Posterior forearm compartment
The muscles in this compartment are involved in supination, wrist extension, finger extension, and both extension and abduction of the thumb. These are all innervated by the radial nerve.
Intrinsic muscles of the hand
The intrinsic muscles of the hand are involved in finer movements, such as the abduction, adduction and opposition of various digits. One group of muscles, the thenar group, has three muscles dedicated to movement of the thumb. These muscles, in addition to the lateral two lumbricals, are all innervated by the median nerve. All the other muscles in the hand are innervated by the ulnar nerve.
This is a partial palsy of the C8 and T1 nerve roots resulting from an injury to the brachial plexus, usually due to sudden abduction of the arm, which may occur during labour or “classically” due to catching a branch when falling from a tree. There is paralysis of the intrinsic muscles of the hand, resulting in a full claw. As the T1 root is also affected, the patient may also present with Horner's syndrome.
The ulnar nerve is most commonly damaged at the ulnar groove in the elbow, usually because of trauma. The nerve supplies the third and fourth lumbricals, which are involved in flexion at the MCP and extension at the PIP joints of the ring and little fingers. Damage to the nerve therefore leads to a deformity of these fingers, where there is hyperextension at the MCP joints and flexion at the PIP joints. There will also be weakness at the flexors of the anterior forearm compartment, the flexor carpi ulnaris (FCU) and (medial) flexor digitorum profundus (FDP).
Less commonly, the aponeurosis of the FCU can damage the nerve more distally at the cubital tunnel. Interestingly, this will result in a more pronounced ulnar claw, despite the lesion being more distal. This is because the FCU and (medial) FDP is still fully functioning, and their flexor activity exaggerates the clawing. This is known as the ulnar paradox.
Turn the patient's hands over and inspect their palmar aspects. Observe for any nodules. When present on the flexor tendons, this suggests trigger finger. Look for Dupuytren's contracture and palmar erythema, both of which indicate liver pathology. Observe for muscle wasting again, particularly at the thenar eminence, as these muscles are supplied by the median nerve. Thenar wasting is observed in carpal tunnel syndrome.
Inflammation of a flexor tendon can result in nodule formation which “catches” during finger flexion as the tendon moves through the pulleys. In early stages, with enough extension the nodule may suddenly “release,” resulting in a sensation that is similar to “triggering a gun.” The cause of trigger finger is usually unknown.
Observe for any protrusions caused by osteoarthritis present at the PIPs (Bouchard’s nodes) and DIP joints (Heberden’s nodes).
Observe for any deformities caused by rheumatoid arthritis, such as:
Boutonniere’s deformity: Flexion at the PIP joint with extension at the DIP joint.
Swan neck deformity: Hyperextension at the PIP joint with flexion at the DIP joint.
Finally, check the patient's nails for pitting or onycholysis (separation of the nail from the nailbed), both of which are present in psoriatic arthritis. Psoriatic arthritis may also present with swelling of an entire digit, also known as sausage finger.
Think of the “Outer Hebrides” when trying to remember that Heberden’s nodes are present distally to Bouchard’s.
Rheumatoid arthritis is a chronic autoimmune disorder that results in inflammation and swelling of the joints. In early disease, swelling occurs in a symmetrical pattern, predominantly at the PIPs of the hand. As the disease progresses, significant joint deformity occurs alongside wasting of the small muscles of the hand.
Psoritic arthritis is a seronegative spondyloarthropathy (i.e. is rheumatoid factor negative) which can occur in people suffering from the autoimmune skin disorder, psoriasis. If swelling predominates at the DIPs, this is more likely to indicate psoriatic arthritis.
Osteoarthritis is a progressive, degenerative disease which causes inflammation of the cartilage around the joints. In the hands, it can present with Heberden’s and Bouchard’s nodes, but also with damage at the carpometarcarpal joint of the thumb. These changes give the hands a square appearance.
Assess the temperature of the hands and joints using the dorsal aspects of your fingers. Temperature may be raised in inflammatory and septic arthritis.
Palpate the radial and ulnar pulses’ volume to assess flow to each hand.
Begin palpation of the carpal bones, metacarpals and phalanges in turn to assess for any fractures. If there is pain at the anatomical snuffbox, this is concerning, as it suggests a scaphoid fracture.
If a patient falls on an outstretched hand they can fracture their scaphoid bone. Blood supply to the scaphoid is from distal to proximal, and as a result, fractures to the proximal 1/3 of the scaphoid can lead to a complication called avascular necrosis, where the blood supply to local bone tissue is compromised.
Carefully palpate all joints for tenderness, swelling and warmth, starting proximally from the wrist, moving all the way to the DIP joints. Such signs suggest inflammation, and are typical of inflammatory arthritides. Squeezing across the metacarpal heads and the wrists will result in pain, particularly in rheumatoid arthritis.
Carefully palpate any nodules or swellings. Both Bouchard’s and Heberden’s nodes will feel bony and will protrude from the joints. Rheumatoid nodules will be firm, and will feel superficial, just under the skin. Spongy swellings suggest synovitis.
Palpate the muscle bulk in the thenar and hypothenar eminences. Reduced bulk indicates muscle wasting. The muscles in these areas are respectively supplied by the median and ulnar nerves. As such, reduced bulk can suggest a nerve lesion. For example, carpal tunnel syndrome can compress the median nerve, resulting in thenar muscle wasting.
You can also palpate the flexor tendons if you suspect trigger finger.
Crudely assess sensation of the hands by asking the patient if they can feel your fingers. A loss of sensation (paraesthesia) of the lateral three and a half digits on the palmar aspect suggests a diagnosis of carpal tunnel syndrome.
If there is any paraesthesia or tingling then you should perform a full upper limb neurological examination after this examination.
Compression of the recurrent branch of the median nerve as it passes through the flexor retinaculum at the wrist. Causes include obesity, repetitive strain, rheumatoid arthritis and pregnancy. The recurrent branch has both a motor and sensory component, both of which will be affected:
Motor: The nerve supplies the thenar muscles and the lateral two lumbricals. As a result, there may be weakness and wasting of the thenar eminence and hence also loss of thumb opposition and an inability to form a pincer grip.
Sensory: The nerve supplies sensation to the lateral palm and three-and-a-half digits on the palmar aspect. As a result, there can often be pain, numbness and paraesthesia in this area. The palmar aspect is spared medially as it is supplied by the ulnar nerve and the dorsum is (mostly) spared as it is supplied by the radial nerve.
Movement and power
Range of movement
Assess the range of movement at the wrists and MCP joints. There are several exercises you can ask the patient to perform to do this:
Wrist extension: Place palms together in a praying position and lower wrists to abdomen.
Digit flexion: Form a fist in each hand.
Digit abduction: With hands held out, separate fingers and thumb.
Thumb opposition: Touch thumb to little finger in each hand.
Range of movement may be reduced in many arthritic disorders and with previous fractures.
Test muscles supplied by the radial, ulnar and median nerves.
Wrist extension: Ask the patient to extend and pronate their elbows, keeping their fists clenched and their wrists at 180o ("please put your arms out like Superman"). Test the wrist extensors, innervated by the radial nerve, by asking the patient to resist an upward and downward movement. Patients with wrist drop would have little to no extension.
Finger abduction: Ask the patient to abduct their fingers against resistance. Be sure to use the same fingers as the patients to resist. This will test the first dorsal interosseous and abductor digiti minimi. The former abducts the index finger, whilst the latter abducts the little finger. These muscles are innervated by the ulnar nerve.
Thumb opposition: Ask the patient to position their palms face-up, and “oppose” their thumbs (i.e. move them medially) against resistance of your own. Alternatively, ask them to form a pincer grip with the little finger, and attempt to break it by pulling on the thumb only. These manoeuvres test the opponens pollicis of the thenar compartment, innervated by the median nerve.
Weakness in the intrinsic muscles of the hand often represents a proximal lesion at the spinal roots (for example Klumpke’s palsy) or brachial plexus (trauma or compression). Compression of the brachial plexus occurs in thoracic outlet syndrome and in Pancoast’s syndrome.
If bilateral hand weakness is present, then suspect a more diffuse process such as motor neurone disease or syringomyelia (a cyst or cavity in the spinal cord).
NOTE: You could assess median nerve function by testing thumb abduction against resistance, as the median nerve also innervated the abductor pollicis brevis (see complex box above). However, the abductor pollicis longus is also involved in thumb abduction and this is innervated by the radial nerve.
If you suspect a lesion to the T1 nerve root, you should closely inspect the face for Horner's syndrome as sympathetic fibres may be affected.
Thoracic outlet syndrome (TOS) is a group of disorders occurring due to compression of one or more of the neurovascular structures moving through the thoracic inlet. In neurogenic TOS, there is compression of the brachial plexus, particularly around roots C8 and T1. Therefore, patients may experience hand weakness most often in the muscles of the thenar eminence.
This is causes by a Pancoast tumour, that is, a tumour in the apex of the lung. Patients tend to experience a triad of symptoms:
Severe scapular, shoulder or upper extremity pain.
Hand weakness, which may lead to small muscle atrophy.
Horner's syndrome (ptosis, miosis and anhidrosis).
Pincer grip: Ask the patient to form a pincer grip by touching their thumb to their little finger. Attempt to break this with a pincer grip of your own and ask the patient to resist. This is an important functional grip involving both the thenar and hypothenar muscle compartments.
Power grip: Ask the patient to squeeze your finger. This is also an important functional grip involving the muscles of the anterior forearm compartment.
Next, ask the patient to pick up a 10p coin, hold a pencil and write or undo a button. These dextrous movements are important in day-to-day life.
If muscle weakness is present in the thenar eminence alongside palmar sensory loss in the lateral palm and three-and-a-half digits, Tinel’s test and Phalen’s manoeuvre can be helpful in confirming carpal tunnel syndrome. These tests will elicit paraesthesia in the territory of the median nerve by irritating the impinged nerve:
Percuss the median nerve at the wrist over the flexor retinaculum. If the patient experiences paraesthesia, then compression at this site is likely. Unfortunately, this test is not very sensitive.
This is also called the "reverse prayer sign". Ask the patient to flex their wrists such that the dorsal aspects of their hands are together with their wrists almost touching. The test is positive if the patient begins to experience paraesthesia.
Conclude your examination by thanking the patient for their time and washing hands once more. Offer to take a full history, examine the elbow, look at any old radiographs of the hand and assess the neurovascular status of the limb.
When assessing each other, click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end.
We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
Introduction: “Hello, I’m SimpleOSCE and I am a medical student. I've been asked to examine your hands today, would that be ok? Can I confirm your name and DOB? Thank you.”
Ask if the patient is in any pain.
Screen for pain or abnormal movement in shoulder and elbow.
Perform a brief general inspection (look behind the ears and hairline for psoriatic plaques).
Inspect the arms for psoriatic plaques and rheumatoid nodules.
Place the patient's hands on a pillow and carefully inspect the dorsal aspect (deformity, asymmetry, wasting, swelling or scars).
Inspect the palmar aspect of the hands for muscle wasting, Dupuytren's contractures and palmar erythema.
Inspect the fingers for Bouchard and Heberden’s nodes, and for rheumatoid deformities.
Inspect the nails for pitting or onycholysis.
Assess temperature using the dorsum of your hands.
Optional: Palpate the radial and ulnar pulses.
Palpate the carpal bones, particularly at the anatomical snuffbox.
Starting from the wrist, palpate each joint in turn assessing for pain or swelling.
Squeeze across metacarpal heads to assess for pain in rheumatoid arthritis.
Palpate the thenar and hypothenar eminences for wasting.
Optional: Palpate flexor tendon sheaths on the palmar aspect of the hand.
Crudely assess sensation or offer to accurately do so.
Movement and power (“move”)
Assess range of movement (wrist flexion and extension, digit flexion, extension and abduction, thumb opposition).
Test the motor function of the radial, median and ulnar nerves with wrist extension (radial nerve), digit abduction (ulnar nerve) and thumb opposition (median nerve) against resistance.
Test palmer and pincer grip strength.
Ask patient to demonstrate dexterity (e.g. pick up 10p piece, hold a pencil and write or undo a button).
Special tests (“test”)
If indicated, perform Tinel’s Test (tap the flexor retinaculum) and Phalen’s manoeuvre (reverse prayer sign).
Thank the patient and wash hands.
"To complete my assessment, I would like to take a full history, examine the elbow, look at any old radiographs of the hand and assess the neurovascular status of the limb."