Examination of the Hand and Wrist

by Stephen Holt, MD, MS

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    00:01 So next up, we're going to review the hand and wrist exam, which is a very common complaint in a primary care practice.

    00:07 Starting off, we'll do inspection, as we always do.

    00:10 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.

    00:17 So just by way of reminder, these are the metacarpophalangeal joints, the MCPS.

    00:22 These are the proximal interphalangeal joints or PIPs.

    00:27 These are your distal interphalangeal joints, the DIPs.

    00:31 Keep in mind that the thumb only has one interphalangeal joint, and then you have the MCP.

    00:37 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.

    00:50 Lastly, just in terms of range of motion, remember that 'serving soup' is supination.

    00:55 If you have your hand up, you're serving soup, so always remember that's supination.

    00:58 Whereas the opposite would be to pronate the hand and that's pronation.

    01:03 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.

    01:13 Now, looking on inspection for some specific findings that we may see with some conditions.

    01:17 So patients with osteoarthritis manifesting in the hand will oftentimes have inflammation of the PIPs and DIPs.

    01:25 And those are basically just osteophytic changes or potentially even angulations at those joints.

    01:31 When they're in the PIPs, we call them Bouchard's nodes.

    01:35 When they're in the DIPs, we call them Heberden's nodes.

    01:39 I always remember Bouchard's nodes start with a B and they're closer to the body.

    01:42 So it's one simple mnemonic to keep track of that.

    01:45 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.

    02:00 Psoriatic arthritis more often involves like osteoarthritis, the DIPs.

    02:04 And you can have pretty advanced destructive changes going on there.

    02:08 I'll just mention some of the other findings that you may see with rheumatoid arthritis.

    02:11 Ulnar deviation is a characteristic feature of advanced rheumatoid arthritis.

    02:15 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.

    02:25 With that we'll jump in and start looking at some specific conditions and how they may manifest in the hand.

    02:31 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.

    02:44 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.

    About the Lecture

    The lecture Examination of the Hand and Wrist by Stephen Holt, MD, MS is from the course Examination of the Upper Extremities.

    Included Quiz Questions

    1. Distal interphalangeal joints
    2. Proximal interphalangeal joints
    3. Metacarpophalangeal joints
    4. Carpometacarpal joints
    5. All distal and proximal interphalangeal joints can have Heberden's nodes
    1. Ganglion cyst
    2. Boutonniere deformity
    3. Swan neck deformity
    4. Heberden's node
    5. Bouchard's node

    Author of lecture Examination of the Hand and Wrist

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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