1. Environmentgeneral appearance
2. Nails
3. Fingers
4. Dorsumwrist
5. Palmforearm
6. Wrist dorsum: palpatemove
7. Fingers: palpatemove 
8. Palmar side: palpatemove 
9. Function tests

Environmentgeneral appearance

• See Rheumatoid Examination.
• For hand examinationplace sitting pt's hands on pillowpalms down.

Nails

• Vasculitic changes [2cm black lesionsdue to local infarction] (RA).
• Splinter hemorrhages (SLERA).
• Periungual telangiectases (SLEscleroderma).
• 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 MCPas examine.
• Redness (inflammation).
• Sausage shaped digits (psoriatic arthritissometimes 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 [DIP1MCP] (OA).
• Finger ulnar deviation [MCP] (RA).
• Ulnar nerve deformity (nerve entrapment).
• Contraction deformity of fingers (scleroderma).
• Calcinosis [palpable calcium nodes] (scleroderma).
• Telangiectasia (scleroderma).

Dorsumwrist

• Scars.
• Rasheserythema.
• 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: palpatemove

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

Fingers: palpatemove

• 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: palpatemove 

• 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 tendonsnodules.
• Trigger finger (RA):
  • Similar to above but flexion is prevented at a point.
  • Pt. increases force until it snapsand 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 holdingcan 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.

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