Phys · general-medicine
Rheumatological Examination of the Hands — The DCE Short-Case Routine
Also known as hand examination · rheumatological examination of the hands · examine this patient hands · examination of the hands · hand examination rheumatology · DCE short case hands · PACES hand examination · Heberden nodes · Bouchard nodes · swan-neck deformity · boutonniere deformity · ulnar deviation · Z-deformity thumb · dactylitis · sausage digit · Jaccoud arthropathy · sclerodactyly · Gottron papules · rheumatoid nodules · gouty tophi · DAS28 joint count · carpal tunnel syndrome examination · Phalen test · Tinel sign · Dupuytren contracture
Consultant-physician-depth guide to the systematic rheumatological examination of the hands for the FRACP DCE short case and the MRCP PACES Station 3 — the single most frequently set short case in the examination. Covers the six-step routine (inspection, palpation, range of motion, function, additional sites, neurovascular), the discriminating deformities of RA (ulnar deviation, swan-neck, boutonniere, Z-deformity thumb), OA (Heberden and Bouchard nodes, first CMC squaring), PsA (dactylitis, nail pitting, onycholysis), gout (tophi), SLE (Jaccoud arthropathy), SSc (sclerodactyly) and dermatomyositis (Gottron papules), the synovitis versus bony swelling distinction, the DAS28 joint count, the carpal tunnel bedside tests, the say-aloud presentation templates, and the examiner discussion questions by finding.
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- Acute monoarthritis of a hand joint with overlying erythema, intense tenderness and systemic upset is septic arthritis until proven otherwise — aspirate before concluding it is a flare of inflammatory arthritis
- New bilateral inflammatory hand arthritis (symmetrical MCP and PIP swelling with prolonged morning stiffness over six weeks) is rheumatoid arthritis until excluded — early DMARD initiation within the window of opportunity prevents erosive damage, so refer urgently to rheumatology
- Sclerodactyly with digital pulp pitting scars or active digital ulcers is systemic sclerosis with a high risk of digital infarction and critical digital ischaemia — this is a rheumatological emergency in the acute phase
- Rapidly progressive skin thickening proximal to the MCP joints with tendon friction rubs is diffuse cutaneous systemic sclerosis with a high risk of scleroderma renal crisis within the first few years — screen blood pressure twice weekly and have ACE inhibitor ready
- Acute bilateral hand swelling with nail dystrophy and dactylitis in an asymmetric distribution is psoriatic arthritis — examine the nails, scalp, umbilicus and natal cleft for hidden psoriasis before attributing it to RA
Rheumatological Examination of the Hands — The DCE Short-Case Routine
Meet the patient
A 54-year-old woman is your DCE short case. From the foot of the bed, you see symmetrical deformity of both hands with ulnar deviation at the MCP joints, spindling of the fingers, and subcutaneous nodules on the extensor surfaces. The DIP joints are spared. The instruction is examine this patient's hands.[1]
The thirty-second inspection generates the differential before you touch the patient: the type of swelling (soft and boggy means synovitis), the distribution (symmetrical MCP and PIP with sparing of the DIP points to rheumatoid arthritis), the deformities (ulnar deviation, possible swan-neck), and the extra-articular features (nodules mean seropositive disease). The six steps that follow confirm, quantify, and complete the assessment.[1]
References7ShowHide
- [1]Neogi T, Aletaha D, Silman AJ, et al. The 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for rheumatoid arthritis: Phase 2 methodological report Arthritis Rheum, 2010.PMID 20872596
- [2]Prevoo ML, van 't Hof MA, Kuper HH, van Leeuwen MA, van de Putte LB, van Riel PL Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis Arthritis Rheum, 1995.PMID 7818570
- [3]Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P, Mielants H; CASPAR Study Group Classification criteria for psoriatic arthritis: development of new criteria from a large international study Arthritis Rheum, 2006.PMID 16871531
- [4]Neogi T, Jansen TL, Dalbeth N, et al. 2015 Gout classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative Ann Rheum Dis, 2015.PMID 26359487
- [5]Aringer M, Costenbader K, Daikh D, et al. 2019 European League Against Rheumatism/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus Arthritis Rheumatol, 2019.PMID 31385462
- [6]van den Hoogen F, Khanna D, Fransen J, et al. 2013 classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative Ann Rheum Dis, 2013.PMID 24092682
- [7]D'Arcy CA, McGee S The rational clinical examination. Does this patient have carpal tunnel syndrome? JAMA, 2000.PMID 10865306