So next up, we're going to
review the hand and wrist exam,
which is a very common
complaint in a primary care practice.
Starting off, we'll do
inspection, as we always do.
And I want to first highlight the
anatomy just to make sure we're clear
on the naming of some joints since
I'll be going through them as we walk
through the different diagnoses.
So just by way of reminder, these are
the metacarpophalangeal joints, the MCPS.
These are the proximal
interphalangeal joints or PIPs.
These are your distal
interphalangeal joints, the DIPs.
Keep in mind that the thumb only has one
interphalangeal joint, and then you have the MCP.
And then back here, the only really
genuinely mobile metacarpal bone in the hand
is the thumb metacarpal bone and it articulates with
the CMC, the carpometacarpal joint of the hand.
Lastly, just in terms of range of motion,
remember that 'serving soup' is supination.
If you have your hand up, you're serving
soup, so always remember that's supination.
Whereas the opposite would be to
pronate the hand and that's pronation.
Otherwise, wrist extension, wrist
flexion, finger flexion, extension,
we've talked about some of those
things during the strength exam,
which we don't need to review again here.
Now, looking on inspection for some specific
findings that we may see with some conditions.
So patients with osteoarthritis
manifesting in the hand
will oftentimes have
inflammation of the PIPs and DIPs.
And those are basically just osteophytic changes
or potentially even angulations at those joints.
When they're in the PIPs, we
call them Bouchard's nodes.
When they're in the DIPs, we
call them Heberden's nodes.
I always remember Bouchard's nodes start
with a B and they're closer to the body.
So it's one simple mnemonic
to keep track of that.
In contrast, patients with rheumatoid arthritis
more often have a problem with the MCP joints,
and there may either be
inflammation in those areas:
warmth, boggy edema can occur there as well
as, of course, progressive destructive changes.
Psoriatic arthritis more often
involves like osteoarthritis, the DIPs.
And you can have pretty advanced
destructive changes going on there.
I'll just mention some of the other findings
that you may see with rheumatoid arthritis.
Ulnar deviation is a characteristic
feature of advanced rheumatoid arthritis.
And then while we're not going to see it here, you
can see evidence of Boutonniere's deformities
and occasionally the
swan neck deformity as well.
With that we'll jump in and start
looking at some specific conditions
and how they may manifest in the hand.
Patients who report enlarged
bumps on the back of the hand that can rarely
be tender, but more often are just uncomfortable,
those are ganglion cysts.
They're essentially an extension of the
synovial fluid that's in the carpal bones
and those, you can push on them,
they'll have some "bowiness" to them
though they are otherwise relatively
firm and they're completely benign
and oftentimes resolve spontaneously,
though it may take a year or two.