Examination: Hand and Wrist

There are 6 main concepts that need to be remembered for ALL of the regional examination of the musculoskeletal system:

  1. Position – always position your patient as you would like to examine them before you begin
  2. Look – inspect and observe the patient and around the patient's bedside
  3. Feel – for example, feeling a joint to see if it is hot or swollen
  4. Move – actively (the patient moves the joint) then passively (you do the movements for them)
  5. Function – can the patient move their joints in order to complete day to day tasks?
  6. Special tests – if applicable

  • Wash hands
  • Introduce yourself
  • Ask permission to examine the relevant part of the body
  • Expose the patient – ideally in underwear only, at least exposing the joint of interest and the joints above and below this
  • Reposition the patient – standing up at first

Position:
  • Position hands palm down on a pillow

Look:
  • At each joint including wrist
  • Ask patient to turn over hands and look at palmar aspect of hand
  • Look for signs such as;
    • Thenar/hypothenar muscle wasting
    • Trigger finger
    • Dupuytren’s contracture
    • Nail changes e.g.: pitting, onycholysis, nail fold vasculitis
    • Raynaud’s syndrome

Feel:
  • Before you feel, ask the patient if they are in any pain and if so, where.
  • Temperature
  • Radial pulse
  • Squeeze the metocarpal-phalangeal joints (MCPs) to assess for pain
  • Palpate each joint separately, including the wrist
  • Test sensation in ulnar, median and radial distribution
  • Feel for Dupuytren’s contracture
  • Feel for thenar or hypothenar muscle wasting

Move:
  • Actively:
    • Prayer sign: two palms pressed together towards the midline
    • Reverse prayer sign: two dorsal hands pressed together towards the midline
    • Make a fist, and now clench my index finger with your fist
    • Put each of your fingertips to your thumb in turn
    • Spread out your fingers – don't let me push them in
  • Passively:
    • Move the digits and wrists in turn

Function:
  • Do up button/pick up penny/use a pen

Special tests:
  • If carpal tunnel syndrome is suspected:
    • Phalen's test: hold hands for 60 sec in reverse prayer position, which will reproduce symptoms if median nerve is compressed (as in carpal tunnel syndrome)
      • Tinnel's test: tap repetitively and firmly over the palmar carpal retinaculum (just distal to the wrist) for 30 seconds - if there is median nerve compression then this should replicate their symptoms

To conclude the examination:
  • Thank the patient
  • Tell them they can get dressed now
  • Offer to examine the joint above and the joint below
  • Consider neurological examination of the limb examined


The complete examination of the musculoskeletal system includes:


written by: celine_lakra, first posted on: 08/01/12, 22:17

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