You should approach the examination of the hands in the following order: - Inspection
- Palpation
- Active / Passive Movement
- Functional (Special) tests
- Follow an organized approach every time so that you do not forget any steps.
- Compare left and right hands to identify any abnormalities.
- Active movement; the patient does it. Passive movement; the examiner moves the joint.
- Make note of how many joints are affected, which joints are involved, and whether the changes are symmetrical between both hands.
- Some rheumatic diseases are classically symmetrical (eg. rheumatoid arthritis), while others are not (eg.gout)
- Always start from the wrist and move down to the digits for consistency.
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Pattern Recognition- In rheumatic diseases, the distribution of involved joints is a clue to the underlying diagnosis. Being common diseases, you should memorize the joint distributions of OA and RA (see figure below). Keep in mind that presentations are variable within each disease, and you will rarely see all of the joints involved early.
- RA; early = PIPs, MCPs, MTPs. late = knees, wrists, elbows, ankles, hips, jaw. Inflammation (swelling, warmth, morning stiffness >60min) on examination / history. Spares DIPs and small joints of toes.
- OA; MTP of the big toes, PIPs, DIPs, CMC joint of thumbs, hips, knees, shoulders, lumbar and cervical spine.
| | The affected joints in Osteoarthritis and Rheumatoid Arthritis. The blacked out joints are frequently affected, while the greyed out joints are less frequently affected. | |
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