How to do a hand exam for an OSCE

The routine - neurological exam is brief and only if indicated.

  1. Wash hands introduce and gain consent
  1. Ask for pain
  2. Expose arms to above elbows.
  1. Examine extensor surfaces
    1. Looking for nodules, psoriatic plaques, scars, tophi.
  1. Inspection of Dorsum of hand (proximal to distal)
    1. Skin
      1. Rash
      1. Atrophy
      2. Nodules
      3. Tophi
      4. White fingers
      5. Sclerodactyly
      1. Purpura (use of steroids)
    1. Nails
      1. Pitting
      2. Onycholysis - nail coming off (may suggest psoriatic)
      3. Splinter haemorrhages or clubbing.
        1. Suggestive of vascular.
    1. Soft tissue
      1. Wasting in dorsal interossei or diffuse atrophy
      1. Swelling in gutters of MCP
    1. Bones
      1. Wrist - sublaxation of carpus/distal radioulnar joint
      1. MCP - swelling and/or sublaxation/ulnar deviation
      2. IPJ - swelling, Swan neck, Boutoniere or Z deformity in thumb. Heberden's nodes and/or Bouchard's nodes.
        Dactylitis and PIPJ and/or DIPJ swelling in psoriatic arthritis.
  1. Inspect Palmar surface of hand.
    1. Skin - palmar erythema, pallor, calcinosis or vasculitis
    1. Muscles - wasting of intrinsics, thenar eminence or hypothenar?
  1. Palpation
    1. Feel temperature - above and below and then on joint
    1. Feel for swelling on the joint
      1. Boggy synovial swelling
      1. Effusion (fluctuant)
      1. Bony swelling (hard) (e.g heberden's node)
    1. Feel for tenderness
    1. Special tests
      1. Depress distal ulna
      1. MCP squeeze
      2. Bimanual palpation of IPJ
  1. MOVE
    1. With forearms supinated make a fist
      1. Flexion of MCP and IP.
    1. Pronate forearms
    1. Extend little finger alone
      1. To check extensor tendon - little finger is EWS.
    1. Extend all fingers
    2. Place palms together
      1. Tells you for flexion deformities in IP joints
      2. Then bend wrists (so shows wrist extension)
    1. Place dorsums together and bend hands
      1. Shows wrist flexion.
  1. Special tests
    1. Squeeze 2 fingers (power grip)
    1. Pincer grip - test strength
    2. Hold paper between fingers
    3. Hook grip - test strength
    1. You could ask doing some buttons or writing.

Neurology
  1. Sensory exam
    1. Outside of index finger
    1. Outside of little finger
    2. 1st web space on dorsum
    1. Distal middle finger
    1. Glove distribution test
  1. Motor
    1. Abduction or adduction
    2. Abduction of thumb
    3. Extension of wrist
    4. Hook grip (c8 already tested)

Consider Tinel's and Phalen's test/

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