Hand Examination

1. Wash hands
2. Introduce yourself and thank patient
3. Make sure patient is sitting on bed, position height adequately and expose patient at least to elbow
4. Place a pillow on the patient's lap
5. Make a show of standing back and inspecting the room
   1. Note cushingoid appearance - if present remember to screen for upper limb proximal myopathy
   2. Make a point of inspecting patients shoe
   3. Acknowledge presence of mobility aides
6. Perform the hand functionality exam
   1. Hands out front with palms facing floor (starting position, can see rupture of extensor tendons with extensor tendon deficit - sign of rheumatoid arthritis)
   2. Make a fist (can see integrity of MCP, iron salute sign of haemochromatosis - Aust Fam Physician. 2009 Mar;38(3):113-4.)
   3. supinate (assesses strength and function at wrist and elbow)
   4. Let go of fist - hands should be with palms facing towards the sky (assess signs in palm, can see trigger finger, thickening of fascia, thickening of flexor tendons, integrity of thenar eminence and hypothenar emincence for median nn and ulnar nn wasting respectively)
   5. Make a fist - look at the integrity of PIPJs and DIPJs
   6. Expose elbows - look for psoriasis, feel for rheumatoid nodules (can be subcutaneous), release flexion and feel for bursitis in gouty arthritis
   7. Prayer sign (tests wrist flexion, make sure this is done properly, may need to help patient, can screen for wrist pathology)
   8. Inverse prayer sign (again tests passive ROM wrist)
   9. Arms outstretched (tests elbow carrying angle - wide carrying angle could indicate hypermobility syndromes such as Ehlers-danlos syndrome)
   10. Hands behind head (tests shoulder ROM)
   11. Hands behind back (tests shoulder ROM)
7. Inspect the nails
   1. onycholysis
   2. nail bed pitting (> 4 pits associated with psoriatic arthropathy)
   3. Ridging (vertical ridges are normal, horizontal ridges signal pathology) 
   4. Hyperkeratosis
   5. Splinter haemorrhages (rheumatic fever + IE cases, SLE - due to vasculitis secondary to immune complex deposition)
   6. Periungual telangiectasias of SLE, scleroderma, dermatomyositis
8. Inspect hand
   1. general deformities to be appreciated
   2. OA - distal heberden's nodes, proximal bouchard's nodes
   3. RA - symmetrical small joint synovitis (DIPJs spared), volar (palmar) subluxation of the MCPJs, Z deformity, boutonnaires deformity, swan neck deformity, ulnar deviation of the MCPs, subluxation of joints, nodules, palmar erythema, entrapment neuropathy causing wasting of the muscles of the hand
   4. Gout - gouty tophi
   5. Sero-negative arthritis- esp psoriatic arthritis: eg the deformities of arthritis mutilans, scars of psoriatic arthropathy, dactylitis, involvement of the DIPJs
   6. Grottons papules (dermatomyositis), mechanics hand (anti-synthetase syndrome)
9. Ask patient about the presence of any pain or tenderness
10. Palpate the ulnar styloid
    1. If there was deficiency in wrist flexion/ extension passively assess ROM
    2. Palpate around the styloid and locate the extensor carpi ulnaris and palpate it specifically
11. Palpate the CMC joints of both hands using the four finger approach. Make a point at observing the patient carefully
12. At this point test for tinnel's sign noting the anatomy of the flexor retinaculum which starts at the distal palmar crease and extends for 1cm distally
13. Palpate the MCPJs of both hands (best practice is 4 finger technique - two supporting in horizontal plane and two palpating in vertical plane) - note that the MCPJs are actually inferior to the bony prominence
14. Palpate the PIPJs of both hands
15. Palpate the DIPJs of both hands
16. Palpate the flexor tendons for thickening
17. Test for flexor joint crepitus bilaterally at the A1 pully - test each hand 
18. Test nerve function
    1. Radial nerve with wrist extension
    2. Ulnar nerve with finger abduction
    3. Median nerve with thumb abduction (move the thumb to the proper place for this)
19. Test functionality
    1. Opposition strength
    2. Grip strength 
    3. Pincer strength
    4. Multi-step command testing real life functionality
       1. What is your dominant hand (right)
       2. Please take this jar in your left hand
       3. Open the lid of the jar with your right hand
       4. Take the key out
       5. Pretent my hand is a lock and unlock it
       6. Please place the key back into the jar
       7. Close the lid with your left hand
20. Check behind the scalp and ears for tophi and psoriasis (can sometimes be tricky to find)
    1. Look in the helix
    2. Carefully check the scalp line for psoriasis
21. Inspect cervical spine for scars
22. Look in eyes
    1. scleritis, episcleritis, conjunctivitis, scleromalacia perforans, cataracts (steroid effect)
23. Look in mouth
    1. ulcers (if associated with MTx use), telangiectasia, dental caries - as risk for endocarditis
    2. Xerostomia of sjogrens disease
24. Palpate for parotid swelling
    1. sarcoidosis
    2. mumps
    3. IgG4 disease
    4. Sjogren's syndrome
25. Uncover the legs
26. Perform screening test of lower limbs
    1. general shake of legs
    2. Hip flexion, abduction, external, internal rotation
27. Look at toenails
28. Look at sole of feet - keratoderma blennorrhagica
29. Palpate Achilles tendon for nodules and insertion site for enthesitis
30. Palpate plantar fascia at insertion site for tenderness 
31. Auscultate lungs for interstitial lung disease (start from back and go upwards)
    1. Only ankylosing spondylitis has apical predominant fibrosis
32. Percuss for pleural effusions
    1. Rheumatoid arthritis/ SLE
33. Lie patient at 45 degrees
34. Inspect for signs of pulmonary hypertension
    1. systolic v waves
    2. RV heave
    3. Thrill of TR
    4. palpable P2
    5. PSM at tricupsid region with inspiratory accentuation for functional TR
    6. Short diastolic murmur in pulmonary region, worse on inspiration --> graham-steel murmur of PR
    7. MR and AR --> RA, SLE, Ank spond
35. Inspect abdomen for signs of Felty's syndrome
36. Turn to examiner and request to examine all the joints, look at a urinalysis and perform fundoscopy