Hand and Wrist examination

Hand & Wrist Examination – OSCE Guide

Dr Lewis Potter

Hand and wrist examination frequently appear in OSCEs and you’ll be expected to identify the relevant clinical signs using your examination skills. This hand and wrist examination OSCE guide provides a clear step-by-step approach to examining the hand and wrist, with an included video demonstration. The hand and wrist examination can be broken down into five key components: look, feel, move, function and special tests. This can be helpful as an aide-memoire if you begin to feel like you’ve lost your way during an OSCE.

Download the hand and wrist examination PDF OSCE checklist, or use our interactive OSCE checklist. To learn more about the anatomy of the hand, check out our bones of the hand guide.

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Briefly explain what the examination will involve using patient-friendly language: “Today I’m going to examine the bones of your hands and wrists. The examination will involve me first looking at the hands, then feeling the joints and finally asking you to do some movements.”

Gain consent to proceed with the examination.

Adequately expose the patient’s hands, wrist and elbows.

Position the patient seated with their hands on a pillow.

Ask the patient if they have any pain before proceeding with the clinical examination.

Look

General inspection

Clinical signs

Perform a brief general inspection of the patient, looking for signs suggestive of underlying pathology:

Scars: may provide clues regarding previous upper limb surgery.

Wasting of muscles: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron lesion.

Objects or equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current clinical status:

Aids and adaptations: splints are often used to manage hand and wrist pathology.

Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications (e.g. analgesia).

Close inspection of the hand

Dorsal aspect of the hand

With the patient’s palms facing down, inspect the dorsum of each hand for signs suggestive of underlying pathology:

Hand posture: note any abnormalities of hand posture which may indicate underlying pathology (e.g. Dupuytren’s contracture, ulnar deviation secondary to rheumatoid arthritis).

Scars: inspect for evidence of scars which may indicate previous surgery or trauma.

Swelling: note any areas of swelling, by comparing the hands and the wrists.

Skin colour: erythema of the soft tissue may indicate cellulitis or joint sepsis

Bouchard’s nodes: occur at the proximal interphalangeal joints (PIPJ) and are associated with osteoarthritis.

Heberden’s nodes: occur at the distal interphalangeal joints (DIPJ) and are associated with osteoarthritis.

Swan neck deformity: occurs at the distal interphalangeal joint (DIPJ) with clinical features including DIPJ flexion with PIPJ hyperextension. Swan neck deformity is typically associated with rheumatoid arthritis.

Z-thumb: hyperextension of the interphalangeal joint, in addition to fixed flexion and subluxation of the metacarpophalangeal joint (MCPJ). Z-thumb is associated with rheumatoid arthritis.

Boutonnières deformity: PIPJ flexion with DIPJ hyperextension associated with rheumatoid arthritis.

Skin thinning or bruising: can be associated with long-term steroid use (e.g. common in patients with active inflammatory arthritis).

Psoriatic plaques: salmon coloured plaques with a silvery scale. Patients who have psoriasis are at significantly increased risk of developing psoriatic arthritis.

Muscle wasting: can occur secondary to chronic joint pathology or lower motor neuron lesions (e.g. median nerve damage secondary to carpal tunnel syndrome).

Splinter haemorrhages: a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.

Nail pitting and onycholysis: associated with psoriasis and psoriatic arthritis.

Janeway lesions: non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and soles). Janeway lesions are typically associated with infective endocarditis.

Osler’s nodes: red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. They are typically associated with infective endocarditis.

Palmar aspect of the hand

With the patient’s palms facing up, inspect each hand for signs suggestive of underlying pathology:

Hand posture: note any evidence of abnormal hand posture (e.g. clawed hand secondary to Dupuytren’s contracture).

Scars: inspect for evidence of scars which may indicate previous surgery or trauma (e.g. carpal tunnel surgery).

Swelling: note any areas of swelling, by comparing the hands and the wrists.

Dupuytren’s contracture involves thickening of the palmar fascia, resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb.

Thenar/hypothenar wasting: isolated wasting of the thenar eminence is suggestive of median nerve damage (e.g. carpal tunnel syndrome).

Elbows: inspect for evidence of psoriatic plaques or rheumatoid nodules.

Inspect the dorsum of the hand

Inspect the palms

Inspect the elbows

Abnormal hand posture secondary to chronic rheumatoid arthritis 1

Inflammation of the proximal interphalangeal joints 2

Bouchard's nodes 3

Heberden's nodes 4

Swan neck deformity 5

Boutonnière deformity 6

Plaque of psoriasis 7

Dorsal hand muscle wasting 8

Splinter haemorrhages 9

Onycholysis 10

Dupuytren's contracture 11

Carpal tunnel scars 12

Hypothenar wasting 13

Ganglion cyst 14

Types of arthritis

Osteoarthritis (OA) is the most common form of arthritis and is characterised by joint pain worsened with activity, localised loss of cartilage, remodelling of adjacent bone and associated inflammation. Typical findings in the hands include swellings at the distal interphalangeal joints (Heberden’s nodes) and proximal interphalangeal joints (Bouchard’s nodes) which represent osteophyte formation. There is often associated crepitus and reduced range of joint movement.

Rheumatoid arthritis (RA) is an autoimmune disease characterised by inflammation of the synovial joints, periarticular tissue destruction and a variety of extra-articular features (e.g. rheumatoid nodules, scleritis, nail fold infarcts and peripheral nerve entrapment). Patients typically experience joint pain (present even at rest), joint swelling and morning joint stiffness. Typical findings in the hands include symmetrical joint inflammation typically affecting the proximal interphalangeal joints, metacarpophalangeal joints and wrist joints. Other features of RA in the hands include muscle wasting, ulnar deviation, swan neck deformity, Boutonnière’s deformity and Z-thumb deformity.

Psoriatic arthritis is an autoimmune disease associated with psoriasis that is characterised by inflammation of the joints and the surrounding tendons. Typical clinical features in the hands include joint swelling, joint pain and dactylitis (swelling of whole digits).

Feel

Temperature

Palms up

Assess and compare the temperature of the joints of the hand and elbow using the back of your hands.

Increased temperature of a joint, particularly if also associated with swelling and tenderness may indicate septic arthritis or inflammatory arthritis.

Radial and ulnar pulse

Palpate the radial and ulnar pulse to confirm adequate blood supply to the hand.

Thenar and hypothenar eminence bulk

Palpate the muscle bulk of the thenar and hypothenar eminences: wasting can be caused by disuse atrophy as well as lower motor neuron lesions (e.g. ulnar and median nerve).

Palmar thickening

Support the patient’s hand and palpate the palm to detect the typical bands of thickened palmar fascia associated with Dupuytren’s contracture.

Median and ulnar nerve sensation

1. Assess median nerve sensation over the thenar eminence and index finger.

2. Assess ulnar nerve sensation over the hypothenar eminence and little finger.

Assess and compare joint temperature

Assess the radial pulse

Assess the ulnar pulse

Palpate the thenar and hypothenar eminences

Assess palmar thickening

Assess median nerve sensation

Assess ulnar nerve sensation

Palms down (dorsum)

Radial nerve sensation

Assess radial nerve sensation over the first dorsal webspace.

Temperature

Assess and compare the temperature of the joints on the dorsal aspect of the hand (e.g. metacarpophalangeal joints) and elbow using the back of your hands.

Metacarpophalangeal joint squeeze

Gently squeeze across the metacarpophalangeal (MCP) joints and observe for verbal and non-verbal signs of discomfort. Tenderness is suggestive of active inflammatory arthropathy.

Bimanual joint palpation

Bimanually palpate the joints of the hand, assessing and comparing for tenderness, irregularities and warmth:

Metacarpophalangeal joint (MCPJ)

Proximal interphalangeal joint (PIPJ)

Distal interphalangeal joint (DIPJ)

Carpometacarpal joint (CMCJ) of the thumb (squaring of the joint is associated with OA)

Anatomical snuffbox

Palpate the anatomical snuffbox for tenderness which is suggestive of a scaphoid fracture.

Bimanual wrist palpation

Palpate the wrists for evidence of joint line irregularities or tenderness.

Elbows

Elbow palpation

Palpate the patient’s arm along the ulnar border to the elbow and note any tenderness, rheumatoid nodules or psoriatic plaques.

Assess radial nerve sensation

Assess temperature over the MCP joints

Perform MCP joint squeeze

Palpate the MCP joints

Palpate the PIP joints

Palpate the DIP joints

Palpate the CMC joints

Palpate the wrist

Palpate anatomical snuffbox

Palpate the elbows

Scaphoid fracture

The scaphoid is the largest bone in the proximal row of carpal bones and is also the most commonly fractured. It often occurs due to a fall on an outstretched hand. As a result of the poor blood supply to the scaphoid, fractures can be slow to heal and avascular necrosis of the proximal fragment of the scaphoid can occur. Tenderness in the anatomical snuffbox is highly suggestive of a scaphoid fracture.

Move

The joints of the hand and wrist should be assessed and compared.

If the patient is known to have an issue with a particular hand, you should assess the ‘normal’ hand first for comparison.

Active movement

Active movement refers to a movement performed independently by the patient. Ask the patient to carry out a sequence of active movements to assess the function of various joints. As the patient performs each movement, note any restrictions in the range of the joint’s movement and also look for signs of discomfort.

It’s important to clearly explain and demonstrate each movement you expect the patient to perform to aid understanding.

Finger extension

Instructions: “Open your fist and splay your fingers.”

Finger flexion

Instructions: “Make a fist.”

Wrist extension

Normal range of movement: 90º

Instructions: “Put the palms of your hands together and extend your wrists fully.”

Wrist flexion

Normal range of movement: 90º

Instructions: “Put the backs of your hands together and flex your wrists fully.”

Passive movement

Passive movement refers to a movement of the patient, controlled by the examiner. This involves the patient relaxing and allowing you to move the joint freely to assess the full range of joint movement. It’s important to feel for crepitus as you move the joint (which can be associated with osteoarthritis) and observe any discomfort or restriction in the joint’s range of movement.

If abnormalities are noted on active movements (e.g. restricted range of movement), assess joint movements passively.

Ask the patient to fully relax and allow you to move their hand and wrist for them.

Warn them that should they experience any pain they should let you know immediately.

Repeat the above movements passively, feeling for any crepitus during the movement of the joint.

Active finger flexion

Active wrist extension

Active wrist flexion

Passive wrist flexion and extension

Motor assessment

The following screening test will allow you to quickly assess the motor function of the radial, ulnar and median nerve.

Wrist and finger extension against resistance

Nerve assessed: radial nerve

Muscles assessed: extensors of the wrist and fingers

Instructions:

1. Ask the patient to hold their arms out in front of them with their palms facing downwards –“Hold your arms out in front of you, with your palms facing the ground.”

2. Ask the patient to extend their fingers and wrist joints, keeping their hands in this position whilst you apply resistance – “Extend your fingers out in front of you, cock your wrists back and don’t let me pull them downwards.”

Index finger ABduction against resistance

Nerve assessed: ulnar nerve

Muscles assessed: first dorsal interosseous (FDI)

Instructions:

1. Ask the patient to splay their fingers and stop you from pushing their fingers together – “Splay your fingers outwards and don’t let me push them together.”

2. Apply resistance to the patient’s index finger using your own index finger to assess abduction.

Thumb ABduction against resistance

Nerve assessed: median nerve

Muscle assessed: abductor pollicis brevis

Instructions: Ask the patient to turn their hand over so their palm is facing upwards and to position their thumb over the midline of the palm. Advise them to keep it in this position whilst you apply downward resistance with your own thumb – “Point your thumbs to the ceiling and don’t let me push them down.”

Finger extension against resistance (radial nerve)

Finger ABduction against resistance (ulnar nerve)

Thumb ABduction against resistance (median nerve)

Function

Assess the patient’s hand function using the fine motor screening tests below.

Power grip

Instructions: “Squeeze my fingers with your hands.”

Pincer grip

Instructions: “Squeeze my finger between your thumb and index finger.”

Pick up a small object

Instructions: “Could you please pick up the coin off the table.”

Power grip

Pincer grip

Assessment of hand dexterity

Special tests

Tinel’s test

Tinel’s test is used to identify median nerve compression and can be useful in the diagnosis of carpal tunnel syndrome.

To perform the test, simply tap over the carpal tunnel with your finger.

Interpretation

If the patient develops tingling in the thumb and radial two and a half fingers this is suggestive of median nerve compression.

Tinel's test

Phalen’s test

If the history or examination findings are suggestive of carpal tunnel syndrome, Phalen’s test may be used to further support the diagnosis.

Ask the patient to hold their wrist in maximum forced flexion (pushing the dorsal surfaces of both hands together) for 60 seconds.

Interpretation

If the patient’s symptoms of carpal tunnel syndrome are reproduced then the test is positive (e.g burning, tingling or numb sensation in the thumb, index, middle and ring fingers).

Phalen's test

Carpal tunnel syndrome

Carpal tunnel syndrome occurs as a result of compression of the median nerve as it traverses through the wrist via the carpal tunnel. Typical clinical features include pain and paraesthesia in the distribution of the median nerve (index finger, thumb and lateral half of the ring finger). Grip weakness can also develop secondary to wasting of the thenar muscles which receive motor innervation from the median nerve.

To complete the examination…

Explain to the patient that the examination is now finished.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

Summarise your findings.

Example summary

“Today I examined Mrs Smith, a 32-year-old female. On general inspection, the patient appeared comfortable at rest, with no stigmata of musculoskeletal disease. There were no objects or medical equipment around the bed of relevance.

“Assessment of the hands and wrists revealed a normal appearance with no tenderness on palpation. The range of movement of the joints in both hands was normal. There was no evidence of weakness or sensory disturbance in the hands. “

“In summary, these findings are consistent with a normal hand and wrist examination.”

“For completeness, I would like to perform the following further assessments and investigations.”

Further assessments and investigations

Neurovascular examination of the upper limbs.

Examination of the elbow joint and shoulder joint.

Further imaging if indicated (e.g. X-ray and MRI).

Summary