How to examine the hands

OSCEs are interesting beasts. They’re designed to measure one’s clinical prowess, although end up being a very artificial process that requires specific attention to learn, rather than just clinical experience. As a result, examinations in particular end up becoming a rehearsed routine that can be rattled off under intense pressure, without much actual thought as to what one is looking for in the first place. What I’ve tried to do here is write the ‘script’ but also give an idea of what to be thinking along the way, to help answer examiner questions and also to help be an actual doctor (which I’m hoping is the ultimate goal). Of course everyone will have their own style, and this is simply my own, but hopefully it might provide a useful framework. In particular I find it much easier to demonstrate movements rather than trying to describe them, and it helps build rapport between you and the patient if they’re playing a game of copying you #psychologywin.

The Dance

Introduction

*Student enters cubicle, washes hands and smiles*

“Good morning, my name is Will Sloper, I’m one of the fourth year medical students, I’ve been asked to do a quick examination of your hands, would that be alright?”

*Patient says yes*

“Thank you, may I ask your name? And how old are you if you don’t mind me asking”

(please could I ask you to roll up your sleeves?/remove your jumper?/put the cat down?)

“Before I begin, are you in any pain at the moment?”

*Patient says no/a little/yes my hand hurts*

“Great/Okay well I’ll be quick and do my best not to cause you any (more) pain. Is there anywhere that’s really sore to touch?”

*patient points at specific point*

“Alright, I’ll avoid that finger/bruise/bleeding open fracture as much as I can”

*Student offers cushion to patient. Patient places hands palms down on cushion on lap or table*

LOOK

“Firstly I’ll have a look at your wrists…”

*Student looks intently at wrists*

“…your hands…”

*ditto*

“…your fingers, and nails.”

*Student dwells on nails slightly to ensure examiner knows they have been thoroughly inspected*

“Lovely, please could you turn your hands over?”

*smiles*

*Patient turns hands over, while student watches patient’s face*

“Was there any pain while turning your hands over?”

*no*

“I’ll have a quick look at your palms…”

*Student looks intently at palms*

“…and wrists…”

*again*



FEEL

Now if it’s alright I’ll feel your wrists and palms”

*Student feels pulses, then the thenar and hypothenar eminences and then the palm*

“Lovely, thank you, can you please close your eyes for a moment and say ‘yes’ if you can feel me touch your hand?”

*Student lightly touches both eminences and index and little finger tips*

*yes, yes, yes, yes…*


“Does this make your fingers tingle?”

*Student lightly taps skin over carpal tunnel*

*no*

“Great, put your palms down again please and I’ll do the same on the back”

*Patient turns hands over, student watches face again*

“Close your eyes again and say yes if you can feel this”

*Student lightly touches first dorsal interosseous*

*yes*

“Thank you”

*Student places backs of hands on forearm for 2 seconds, wrist, then over the mcp joints*

“Let me know if this is at all tender” (if patient has identified tender area, address the fact that you do have to touch it, but will be as careful as possible)

*Student lightly squeezes the mcp joints while watching the patient’s face*


“I’ll now have a quick feel of each joint in turn”

*Student bimanually palpates each joint in turn, comparing each group with the other hand, and watching the patient’s face the whole time*

“Thank you, I’ll just do the same on your wrists”

*Student bimanually palpates wrists, guess what, while watching the patient’s face*

“Lovely, now I will just feel your forearms”

*Student runs hand up ulnar aspect of forearm while holding wrist with other hand*

MOVE

“Right, we’re almost there!” *smiles*

“Lastly I need you to do some movements for me if that’s alright, could I ask you to straighten your fingers as much as you can”

*Student then passively extends patient’s fingers gently, while watching the patient’s face*

“Thank you, next can you make a fist for me?”

*Student passively flexes patient’s fingers gently, again… FACE*

“Now could you do this?” *Student extends own wrists and places them together in prayer position in friendly and personable style*

*Patient copies student, #facialsurveillance*

“And now this?” *Student flexes own wrists and places together in equally nonthreatening manner*

*Patient copies student, #facialsurveillance*

Squeeze my fingers as hard as you can?”

“Finally could you spread your fingers as far as you can, and then do this?…”

*Student opposes thumb to each finger in turn, and patient does the same*

“…and could you pick this up for me with your index finger and thumb?”

*Student produces coin/magic bean/small rodent*


Conclusion


“Well thank you very much, I’ve finished my examination, do you have any questions for me?”

*Patient says no*


“Thanks again”

*Student smiles, washes hands and turns to examiner*



Presentation

“I performed an examination of the hands and wrists on Mrs Phalange who reported tenderness in her left wrist and upon inspection, noted the presence of a longitudinal scar/slight bruise on the dorsum of the right hand. The rest of the examination was normal, with sensation of the median, ulnar and radial nerves intact and good movement and function of all joints”

(Obviously this bit is going to vary hugely – practice making up a bunch of different presentations and you might find that in the exam, you can adapt one you’ve already made to fit your current patient)

“To complete my examination, I would like to:

  • take a full history
  • do a regional musculoskeletal exam of the elbow
  • do a neurological and peripheral vascular exam of the upper limbs

Why do the exam?

The main purpose of the hand exam is to elicit whether the patient has any:

  • pain
  • stiffness
  • reduction of function
  • evidence of previous disease/surgery

And as with all musculoskeletal examinations, it’s a good idea to follow a structure of:

  • look
  • listen
  • feel
  • move

And always, always, always…

  • ask about pain
  • compare the two sides

The things to look out for in the hand exam are as follows:

  • Looking
    • swelling
    • muscle wasting
    • deformity
    • skin changes
      • bruising
      • thinning
      • rashes
    • scars
    • nail changes
      • onycholysis
      • pitting
      • vasculitis of nail folds
  • Feeling
    • pulses
      • vascular impairment?
    • muscle wasting
      • may suggest nervous injury or carpal tunnel syndrome
    • tendon thickening
    • sensation
      • carpal tunnel, peripheral neuropathy
    • temperature
      • inflammation is hot
      • Raynaud’s is cold
    • nodules
      • Heberden’s nodes in osteoarthritis
      • gouty tophi
      • rheumatoid nodules
    • squeezing
      • tenderness is early sign of inflammation
    • joint palpation
      • warm, rubbery swollen joints are suggestive of active synovitis
    • Tinel’s test
      • special test for carpal tunnel syndrome
    • Phalen’s test
      • same idea
  • Moving
    • failure of movement could be:
      • muscular
      • neurological
      • tendinous
      • articular
    • Passive extension may help determine which
    • Picking up a coin/small rodent gives an idea of function

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