Examination of the hand

Inspection

Nails
o Signs of psoriasis (nail pitting , ridging , onycholysis, hyperkeratosis)
o Signs of vasculitis(nail-fold infarctions , splinter hemorrhages)
o Clubbing

Skin

Color
o Redness acute arthritis as septic arthritis & gouty arthritis)
o Purpura & ecchymosis Steroid therapy
o Abnormal pigmentations Psoriasis

Consistency
o Thin skin steroid use
o Thick & greasy skin acromegally
o Tight , adherent & shiny systemic sclerosis
 Lesions & Scars
o Lesions psoriasis , vasculitis , gouty tophi & telangectasia
o Scars surgical (synvectomy, joint replacement)-endoscopic(arthroscopy)-traumatic

Muscles

o Isolated wasting of thenar eminence median nerve lesion

o Wasting of hypothenar eminence + 1st dorsal interosseus muscle with sparing of thenar
eminence ulnar nerve lesion
o Generalized wasting of thenar , hypothenar eminences + other small muscles of the hand
with dorsal guttering
1) Rheumatoid arthritis
2) Combined median & ulnar nerve lesions
3) Brachial plexus lesion or T1 lesion
4) Cachexia

Joints

Distribution
o Symmetrical RA or asymmetrical Seronegative arthropathies
o Proximal or distal
 Deformities

o Deformities of RA
a) Z-shaped deformity of hand ulnar deviation of MCP joints + radial deviation of wrist joint
b) Z-shaped deformity of thumb flexion of MCP + hyper-extension of IP
c) Fusiform finger due to swelling of proximal IP
d) Mallet finger due to flexion deformity of distal IP
e) Swan-neck deformity due to flexion of distal IP+ hyper-extension of proximal IP
f) Boutonniere deformity due to hyper-extension of distal IP + flexion of proximal IP

o Other deformities

a) Kyphosis ankylosing spondylitis

b) Sclerodactyly scleroderma (thickening and tightness of the skin of fingers &toes
c) Claw hand ulnar nerve lesion (hyperextension of MCP + flexion of IP of 4th & 5th fingers)
d) Dupuytren contracture flexion deformity of hand especially little & ring finger due to
thickening & shortening of the palmar fascia

Swelling

Classified into extra-articular and articular

Extra-articular SC nodules
Articular bone swelling , soft tissue swelling and effusive swelling
 SC nodules (in RA)
1) Pathology formed of fibrinoid degeneration with inflammatory cells covered with fibrous
capsule
2) Site extensor surface of limbs (esp.forearm) , pressure points (elbow,knee) and in relation to
tendons (small as extensor tendons of hand or big as tendon achiles)
3) Character variable in size , oval , firm , painless , non-tender and mobile
4) DD SC nodules of rheumatic fever , Bouchard & Heberden nodules of OA , Tophi of gouty
arthritis
5) Complications Ulceration and infection , rupture tendon (drop finger&foot) , trigger finger
6) Significance
o Diagnostic it is strongly associated with +ve RF
o Prognostic it is associated with poor prognosis