1. Environment, general appearance
2. Nails
3. Fingers
4. Dorsum, wrist
5. Palm, forearm
6. Wrist dorsum: palpate, move
7. Fingers: palpate, move 
8. Palmar side: palpate, move 
9. Function tests

Environment, general appearance

• See Rheumatoid Examination.
• For hand examination, place sitting pt's hands on pillow, palms down.

Nails

• Vasculitic changes [2cm black lesions, due to local infarction] (RA).
• Splinter hemorrhages (SLE, RA).
• Periungual telangiectases (SLE, scleroderma).
• Pin-sized pitting (psoriatic arthritis).
• Hyperkeratosis [thickening] (psoriatic arthritis).
• Onycholysis [nail separates from distal nail bed] (psoriatic arthritis).
• Discolouration (psoriatic arthritis).
• Ridges (psoriatic arthritis).
• Anemia.
• Nailfolds with magnifying glass: dilated capillary loops (scleroderma).

Fingers

• Move from DIP to MCP, as examine.
• Redness (inflammation).
• Sausage shaped digits (psoriatic arthritis, sometimes AnS or Reiter's).
• Nicotine stains (NSAID s/e increased risks).
• Arthitis mutilans [fingers shortened] (advanced destruction).
• Tophi (gout).
• Swan neck deformity (RA).
• Boutonniere's deformity (RA).
• Z deformity of thumb (RA).
• Bouchard's nodes [PIP] (OA)
• Heberden's nodes [DIP, 1st MCP] (OA).
• Finger ulnar deviation [MCP] (RA).
• Ulnar nerve deformity (nerve entrapment).
• Contraction deformity of fingers (scleroderma).
• Calcinosis [palpable calcium nodes] (scleroderma).
• Telangiectasia (scleroderma).

Dorsum, wrist

• Scars.
• Rashes, erythema.
• Skin tightening (scleroderma).
• Muscle wasting on dorsum of hand.
• Ulnar deviation.

Palm

• Scars from operations.
• Erythema.
• Wasting.
• Anemia.

Forearm

• Subcutaneous nodules at elbow (RA).

Wrist dorsum: palpate, move

• Ask pt. if Dr can move joints, about tender areas.
• Pt's hand is palm down.
• Both Dr's thumbs on wrist dorsum midline, fingers under wrists.
• Palpate for synovitis, effusions.
• Palpate ulnar styloid tenderness (RA).
• Dorsiflexion [normal: 75°].
• Palmarflexion [normal: 75°].
• Abduction [normal: 75°].
• Adduction [normal: 75°].

Fingers: palpate, move

• Palpate with 2 thumbs as with Wrist.
• Nodules (RA).
• Tenderness.
• Warmth.
• Swelling.
• Volar subluxation test:
  • Pt. holds hand like showing off an engagement ring.
  • Dr grips a proximal phalynx between Dr's thumb and forefinger.
  • Dr moves MCP joint to and fro.
  • Normal joints will have little movement.

Palmar side: palpate, move 

• Tinel's sign (carpal tunnel):
  • Dr. taps on pt's flexor retinaculum.
  • Positive test: paresthesia over median nerve distribution.
• Palmar tendon crepitus (tenosynovitis):
  • Dr's fingertip pads on pt's palm.
  • Pt. flexes and extends MCPs.
  • Listen for crepitus during motion.
  • Palpate for thickened tendons, nodules.
• Trigger finger (RA):
  • Similar to above but flexion is prevented at a point.
  • Pt. increases force until it snaps, and continues flexing inward.

Function tests

• Grip strength:
  • Pt's squeezes examiner's fingers. 
• Opposition test:
  • Pt. holds thumb to baby finger.
  • Does pt. have difficulty then in moving them apart. 
• Paper grip:
  • Pt. holds piece of paper between thumb and index fingertip pads
  • While holding, can pt. then open other fingers.
• Daily activity test:
  • Writing name with a pen.
  • Grasping a utensil.
• Wrist flexion test (carpal tunnel):
  • Pt. flexes both wrists for 30 sec.
  • Parasthesia arises in affected hand.
• See Power Scale Reference.