Rheumatological Examination of the Hands — Clinical Case

DCE Short Case 1 — The Symmetrical Inflammatory Hands (Rheumatoid Arthritis)

Patient brief (provided to trainee)

Patient: Mrs Margaret Chen, 52 years old, bookkeeper. ^[1]

Presenting complaint: Progressive pain, stiffness, and swelling of both hands over 18 months, worst in the mornings. Morning stiffness lasts approximately two hours. She has increasing difficulty with her work (typing, writing), turning taps, and opening jars. She has noticed small lumps on her right forearm. ^[1]

Instruction: "Please examine this patient's hands. Present your findings and offer a differential diagnosis." ^[1]

Examination findings (trainee elicits):

• Inspection: Symmetrical deformity of both hands with ulnar deviation and palmar subluxation at the MCP joints, swan-neck deformity of the right index and middle fingers, and a Z-deformity of the right thumb. The DIP joints are spared. Soft, boggy swelling at the second and third MCP joints bilaterally and at the wrists. Firm, non-tender subcutaneous nodules (1 cm) on the extensor surface of the right forearm and at the right olecranon. No sclerodactyly, no Gottron papules, no nail pitting, no psoriatic plaques.
• Palpation: The swollen joints are warm and tender on pressure and on movement. The skin texture is normal. Crepitus is soft at the MCPs and wrists. No coarse bony crepitus.
• Range of motion: Reduced at the wrists (flexion 40 degrees, extension 30 degrees) and the MCPs, with pain. The DIPs have a full range.
• Function: Grip strength reduced bilaterally. Pinch grip preserved but weaker on the right. Writing is slow and deliberate. Difficulty picking up a coin and turning a key. Cannot make a full fist (fingertips do not reach the palm).
• Additional: Rheumatoid nodules at the right olecranon and extensor forearm. No psoriatic plaques on the elbows. Shoulder movement full and painless.
• Neurovascular: Radial pulses present, capillary refill under 2 seconds. Sensation intact in median and ulnar nerve territories. Tinel sign negative, Phalen test negative. ^[1]

Presentation template (model answer)

"I have examined this patient's hands. On inspection, there is symmetrical deformity of both hands with ulnar deviation and palmar subluxation at the MCP joints, swan-neck deformity of the right index and middle fingers, and a Z-deformity of the right thumb. The DIP joints are spared. There is soft, boggy, warm, tender swelling consistent with active synovitis at the second and third MCP joints bilaterally and at the wrists. There are firm, non-tender rheumatoid nodules on the extensor surface of the right forearm and at the right olecranon. Range of movement is reduced at the wrists and MCPs. Function is impaired — the grip is weak, the patient cannot make a full fist, and she has difficulty with fine tasks and turning a key. The pulses are present, the sensation is intact, and the Tinel and Phalen tests are negative. ^[1]

In summary, these findings are consistent with seropositive rheumatoid arthritis with active synovitis, extra-articular nodular disease, and functional impairment. I would confirm with a history of morning stiffness, serology for rheumatoid factor and anti-CCP, inflammatory markers, and hand X-rays. I would calculate a DAS28 score to quantify disease activity. ^[1]

To complete my examination, I would examine the other joints, the skin, the chest, and the eyes." ^[1]

Discussion

Examiner: "What is your diagnosis and what are the classification criteria?" ^[1]

"The most likely diagnosis is seropositive rheumatoid arthritis. The 2010 ACR/EULAR classification criteria require synovitis in at least one joint, no better alternative diagnosis, and a score of six or more from joint involvement, serology, acute phase reactants, and symptom duration ^[1]. This patient, with bilateral small-joint involvement, symptoms over six weeks, and high inflammatory markers, clearly meets the criteria. The rheumatoid nodules indicate seropositive, more aggressive disease."

Examiner: "How would you quantify her disease activity?" ^[1]

"I would calculate the DAS28 ^[2]. The 28 joints are the ten MCPs, ten PIPs, both wrists, both elbows, both shoulders, and both knees. I count the swollen and the tender joints, combine with the ESR and the patient global assessment, and produce a single score. Over 5.1 is high disease activity, 3.2 to 5.1 is moderate, 2.6 to 3.2 is low, under 2.6 is remission. Given the bilateral MCP and wrist synovitis and the prolonged morning stiffness, she is in at least moderate-to-high disease activity and requires DMARD escalation."

Examiner: "What is your management plan?" ^[1]

"An integrated, multidisciplinary approach. Pharmacologically, I would initiate or escalate DMARD therapy under the treat-to-target strategy aiming for remission or low disease activity. Methotrexate is the anchor drug (10 to 25 mg weekly with folic acid), with sulfasalazine and hydroxychloroquine if triple therapy is indicated. If the target is not met, I would escalate to a biologic (TNF inhibitor, rituximab, tocilizumab, abatacept) or a JAK inhibitor. Short-term corticosteroids for bridging during flares. NSAIDs for symptomatic relief. I would refer to a hand therapist for joint protection, splinting, and exercises, to an occupational therapist for aids and adaptations, and to a rheumatologist for ongoing disease management. I would also assess her cardiovascular risk (RA carries a risk equivalent to diabetes), her bone density (osteoporosis risk), and her vaccination status. If medical therapy fails to control pain or function, I would consider surgical referral for synovectomy, arthroplasty, or tendon repair." ^[1]