Rheumatoid: Hand Exam
  1. Environment, general appearance
  2. Nails
  3. Fingers
  4. Dorsum, wrist
  5. Palm, forearm
  6. Wrist dorsum: palpate, move
  7. Fingers: palpate, move 
  8. Palmar side: palpate, move 
  9. Function tests
Environment, general appearance
Nails
  • Vasculitic changes [2cm black lesions, due to local infarction] (RA).
  • Splinter hemorrhages (SLE, RA).
  • Periungual telangiectases (SLE, scleroderma).
  • Pin-sized pitting (psoriatic arthritis).
  • Hyperkeratosis [thickening] (psoriatic arthritis).
  • Onycholysis [nail separates from distal nail bed] (psoriatic arthritis).
  • Discolouration (psoriatic arthritis).
  • Ridges (psoriatic arthritis).
  • Anemia.
  • Nailfolds with magnifying glass: dilated capillary loops (scleroderma).
Fingers
  • Move from DIP to MCP, as examine.
  • Redness (inflammation).
  • Sausage shaped digits (psoriatic arthritis, sometimes AnS or Reiter's).
  • Nicotine stains (NSAID s/e increased risks).
  • Arthitis mutilans [fingers shortened] (advanced destruction).
  • Tophi (gout).
  • Swan neck deformity (RA).
  • Boutonniere's deformity (RA).
  • Z deformity of thumb (RA).
  • Bouchard's nodes [PIP] (OA)
  • Heberden's nodes [DIP, 1st MCP] (OA).
  • Finger ulnar deviation [MCP] (RA).
  • Ulnar nerve deformity (nerve entrapment).
  • Contraction deformity of fingers (scleroderma).
  • Calcinosis [palpable calcium nodes] (scleroderma).
  • Telangiectasia (scleroderma).
Dorsum, wrist
  • Scars.
  • Rashes, erythema.
  • Skin tightening (scleroderma).
  • Muscle wasting on dorsum of hand.
  • Ulnar deviation.
Palm
  • Scars from operations.
  • Erythema.
  • Wasting.
  • Anemia.
Forearm
  • Subcutaneous nodules at elbow (RA).
Wrist dorsum: palpate, move
  • Ask pt. if Dr can move joints, about tender areas.
  • Pt's hand is palm down.
  • Both Dr's thumbs on wrist dorsum midline, fingers under wrists.
  • Palpate for synovitis, effusions.
  • Palpate ulnar styloid tenderness (RA).
  • Dorsiflexion [normal: 75].
  • Palmarflexion [normal: 75].
  • Abduction [normal: 75].
  • Adduction [normal: 75].
Fingers: palpate, move
  • Palpate with 2 thumbs as with Wrist.
  • Nodules (RA).
  • Tenderness.
  • Warmth.
  • Swelling.
  • Volar subluxation test:
     Pt. holds hand like showing off an engagement ring.
     Dr grips a proximal phalynx between Dr's thumb and forefinger.
     Dr moves MCP joint to and fro.
     Normal joints will have little movement.
Palmar side: palpate, move 
  • Tinel's sign (carpal tunnel):
     Dr. taps on pt's flexor retinaculum.
     Positive test: paresthesia over median nerve distribution.
  • Palmar tendon crepitus (tenosynovitis):
     Dr's fingertip pads on pt's palm.
     Pt. flexes and extends MCPs.
     Listen for crepitus during motion.
     Palpate for thickened tendons, nodules.
  • Trigger finger (RA):
     Similar to above but flexion is prevented at a point.
     Pt. increases force until it snaps, and continues flexing inward.
Function tests
  • Grip strength:
     Pt's squeezes examiner's fingers. 
  • Opposition test:
     Pt. holds thumb to baby finger.
     Does pt. have difficulty then in moving them apart. 
  • Paper grip:
     Pt. holds piece of paper between thumb and index fingertip pads
     While holding, can pt. then open other fingers.
  • Daily activity test:
     Writing name with a pen.
     Grasping a utensil.
  • Wrist flexion test (carpal tunnel):
     Pt. flexes both wrists for 30 sec.
     Parasthesia arises in affected hand.
  • See Power Scale Reference.