Examinations
CPSA · Clinical examination · Musculoskeletal
Hand & wrist (rheumatological) examination
Look → feel → move → function → special tests. The pattern of joint involvement separates rheumatoid arthritis, osteoarthritis and psoriatic/gout.
Practise it out loudPosition: Hands on a pillow, palms down then up.
The routine
Look
- 1Dorsum: swelling, deformity (ulnar deviation, swan-neck, boutonnière, Z-thumb), muscle wasting, skin/nails (psoriasis, nail pitting)
- 2Palms: wasting of thenar/hypothenar eminence, palmar erythema
- 3Elbows: rheumatoid nodules, psoriatic plaques
Feel
- 1Temperature; palpate each joint (MCP, PIP, DIP, wrist) for synovitis/tenderness
- 2Squeeze across the MCPs (tender in active RA); check the anatomical snuffbox; median/ulnar sensation
Move & function
- 1Active then passive: wrist flex/extend, finger flex/extend, thumb opposition
- 2Function: grip, pincer, pick up a small object, undo a button
Special tests
- 1Tinel’s / Phalen’s for carpal tunnel; test median (thumb abduction) and ulnar (finger abduction) motor function
Signs & what they mean
Symmetrical MCP/PIP swelling, ulnar deviation, sparing DIPsRheumatoid arthritis
Bouchard’s (PIP) and Heberden’s (DIP) nodes, squaring of the thumbOsteoarthritis
Nail pitting, dactylitis, DIP involvementPsoriatic arthritis
Thenar wasting + reduced thumb abduction + positive Tinel/PhalenCarpal tunnel syndrome (median nerve)
To complete, I would…
- Examine other joints (a screening GALS)
- Assess function and ask about impact on daily life
- Request hand X-rays and relevant bloods (RF, anti-CCP, urate)
OSCE tips
- DIP involvement points away from RA (towards OA/psoriatic).
- Always assess function, not just the joints — it drives management.
- Squeeze the MCPs — tenderness suggests active synovitis.