HAND AND WRIST EXAM

Inspection

S = swelling
E = erythema	Palmar Erythema (associated with various conditions such as portal hypertension, RA, liver disease, etc.)
A = atrophy	Thenar and hypothenar eminence Interossei muscles Dupuytren’s contracture
D = deformity	OA – Squaring of the wrist – Bouchard’s nodes (PIP) – Heberden’s nodes (DIP) RA – Joint swelling (not DIP) – Prominent ulnar head – Radial wrist deviation – Ulnar deviation and subluxation of the MCPs – Swan neck deformity (PIP hyperextension with DIP flexion) – Boutonniere’s deformity (PIP flexion with DIP extension) Psoriatic arthritis – Any joint involved including DIPs – Dactylitis
Skin changes	Note any psoriasis, psoriatic nail changes, gouty tophi, vasculitis (splinter hemorrhages), scars

Say: I will be palpating different regions for pain or tenderness
Ask for patient permission prior to start
Palpate systematically in the following manner:
- Ulnar head and styloid
- Triangular fibrocartilaginous complex (TFCC) – between ulnar head and carpal bone
- Abductor pollicis longus and extensor pollicis brevis (for DeQuervain’s tenosynovitis)
- Anatomical snuffbox
- Pisiform, hook of the hamate
- Metacarpals
Palpate for wrist effusion
- Use thumbs to palpate radiocarpal joint space and slide thumb over the joint line
- Fluid ballottement between the thumbs
Palpate for MCP effusion
- Joint line is 1cm distal to tip of the knuckle when MCP is flexed
- Use 4 finger technique to check for tenderness, fullness, and fluid ballottement
  - Thumb and index on dorsal/volar aspects, using two fingers on other hand to feel sides of joints
Palpate for PIP/DIP effusion
- 4 finger technique, check for tenderness, fullness, and fluid
Flexor tendonitis
- Palpate flexor tendons for tenderness
- Check for nodules or crepitus while extending/flexing each finger

Ask patient to make a fist with their thumb out, then extend all their fingers
PIP/DIP
- Ask patient to tuck in all their fingers
- 0-80 degrees in the DIP, 100-120 degrees PIP (flexion)
MCP
- Extension should be 10-20 degrees
- Flexion should be 90-100 degrees
- Adduction and abduction
Thumb
- Flexion, extension, adduction, abduction, circumduction, opposition
Wrist
- Flexion (70-90 degrees)
- Extension (70-90 degrees)
- Radial and ulnar deviation
- Supination, pronation, circumduction
- Tuck Sign
  - During wrist/finger extension, look for a bulge forming on dorsal wrist

Nerve	Motor	Sensory
Median Nerve	“Okay” sign	Palmar aspect of index finger
Radial Nerve	“Thumbs up”	Dorsal side of radial half of hand and 1st web space
Ulnar Nerve	Finger abduction	Fifth finger

Stability testing
- Wrist
  - Stabilize forearm, grasp hand, sublux wrist up and down
- Piano Key Sign
  - Hold patient’s hand and depress the ulnar head
  - If it depresses and comes up again like a piano key, this is a positive test for radioulnar ligament disruption, seen in RA
- MCPs
  - With MCPs flexed, try and sublux proximal phalanx anteriorly and posteriorly
  - With MCPs flexed, provide valgus and varus stress on fingers, should be little movement
- IPs
  - Apply valgus and varus stress to assess collaterals
Carpal Tunnel Syndrome
- Phalen’s sign
  - Patient holds wrist in complete flexion for a minute
  - Burning/paresthesia over the first, second, third fingers indicates CPS
- Tinel’s sign
  - Tap on median nerve, and if burning/paresthesia over first three fingers occurs, this indicates CPS
DeQuervain’s tenosynovitis
- Finkelstein’s test
  - Patient makes a fist with thumb in, examiner moves wrist into ulnar deviation
  - Pain along radial wrist is a positive sign