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PreMedEaz PreClinEazy y SurgEazy FinalsEazyOSCEazy NISH DALAVAYE THE MUSCULOSKELETAL STATION SESSION TIME: 2 HOURS Role Medical student Setting A&E Patient Mr Thalapathy, a 48 y/o male presents with acute joint pain and swelling Student taskTake a concise history from the patient regarding his presenting symptoms. STUDENT At 7 minutes, the examiner will stop you, ask you to summarise your findings and present a differential diagnosis. INSTRUCTIONS SPOT DIAGNOSIS A 77-year-old female presents with a hot, swollen knee. She has a fever and restricted range of motion. She has a past medical history of diabSEPTIC ARTHRITIS and rheumatoid arthritis. A 54 year old man presents with a 2-day history of severe pain and swelling of his left toe. He drinks 6 beers daily. He recently was also GOUT diagnosed with heart failure. A 25-year old man with frequent and painful urination. He has had REACTIVE progressive right knee swelling. He is sexually active with two female partners. He has bilateral conjunctivitis. ARTHRITIS A 70-year old woman presents with a swollen, painful right knee. She has a past medical history of haemochromatosis. An x-ray is performed and PSEUDOGOUT showed chondrocalcinosis. JOINT P AIN HISTOR Y – FOCUSED QUESTIONS FULL NAME, DATE OF BIRTH, AGE, OCCUPATION, SYMPTOM SCREENING HISTORY OF PRESENTING COMPLAINT SYSTEMS REVIEW • Fever • Site: “Where do you feel the pain?” • Fatigue • Character: “Can you describe the pain to me?”gger the pain” • Trauma • Association: “Did you notice anything else?”?” • Obesity • Stiffness • Unexplained weight loss • Swelling • Recent travel • Redness • Recent unprotected sex • Extra-articular features • Skin rash • Fever • Weight loss • Low back pain • Timing: “When does it occur?”, “How long does it last?”, “How has it • Uveitis changed?” • Exacerbating / relieving factors: “Is there anything that makes it worse / better?” • Better/ worse with exercise SOCIAL/ FAMILY/ DRUG HISTORY • Severity: “From 1 to 10, 10 being the worst pain you’ve ever felt, how severe is it?”, “How is it affecting your life?”, “Does it wake you up at night?” • Functional questions: • “During your normal day, what are you able to do for yourself?” • “Does your condition interrupt your ability to do your normal activities?” PAST MEDICAL/ SURGICAL HISTORY • “Can you walk up and down the stairs without any difficulty?” • “Does anyone from your family need to help with cooking, shopping or dressing?” • History of MSK disease? • “Do you have any carers coming into your home?” • History of previous fractures? • “Could you describe what the carers do for you when they come? • History of psoriasis? History of diabetes? • Family history of rheumatological disease • Smoking , Alcohol, IVDU, Medications (e.g. NSAIDs, Steroids, Minocycline, Isoniazid etc), Allergies • History of peptic ulcer disease? • Housing status, Number of stairs • History of infections? • Psychological impact • History of joint surgery/ any planned operations? • ICE GOUT PSEUDOGOUT PSORIATIC ARTHRITIS REACTIVE ARTHRITIS OSTEOARTHRITIS RHEUMATOID ARTHRITIS TRAUMA NON-INFLAMMATORY INFLAMMATORY JOINT EFFUSION SEPTIC BLEEDING S.AUREUS IATROGENIC N. GONORRHOEAE TRAUMA BLEEDING DISORDER “HORRIFIC”icaemia, Hereditary D Diuretics What are the causes E Ethanol of gout? L Leukaemia A RenAl Impairment Y Lesch–nYhan syndrome What are the GOUT PSEUDOGOUT SEPTIC ARTHRITIS distinguishing features • Man • Haemochromatosis • Very acute • Acute • Hyperparathyroidis• High fever HISTORY • Binge drinking • Pre-existing joint between acutely hot, • Renal stones damage/prosthesis • Tsthi • Reduced ROM tender joint JOINTS TARGETED • 1 MTP classically • Knees & wrists • Single hot joint e.g. knee differentials ?PRESENTING THE HISTOR Y PATIENT DETAILS & KEY PRESENTING COMPLAINT HISTORY OF PRESENTING COMPLAINT RELEVANT NEGATIVES RELEVANT PMH/PSH/SH/DH ICE TOP DIFFERENTIAL & WHY OTHER DIFFERENTIALSHOT , SWOLLEN JOINT INVESTIGATIONS SPECIFIC EXTRA STEPS ANY SEPTIC GOUT PSEUDOGOUT HOT, TENDER JOINT ARTHRITIS Seek urgent ABCDE ASSESSMENT orthopaedic review BEDSIDE SEPSIS 6 Consider STI screen Consider stool MC&S Fasting glucose ECG Focused MSK examination Consider urinalysis & urine MC&S FBC CRP/ESR LFTs Clotting Screen Serum uric acid Bone profile & PTH BLOODS (after 4-6 weeks) U&Es VBG Lipid Profile Iron Studies Blood cultures IMAGING Joint Aspiration (Send for gram stain, WCC, culture, & polarised light microscopy for crystals) Consider dual-energy SPECIAL Consider MRI scan CT scan Plain X-rays TESTS (AP & Lateral views) JOINT ASPIRATE INTERPRETATION WBC CAUSES CLARITY COLOUR COUNT NEUTROPHIL CULTURE CRYSTALS 3 COUNT (/MM ) TRANSLUCENT COLOURLESS < 200 CELLS < 25 % NEGATIVE ABSENT NORMAL RHEUMATOID ARTHRITIS GOUT INFLAMMATORY JOINT PSEUDOGOUT TRANSLUCENT - OPAQUYELLOW 2000 – 75000 NEGATIVE PRESENT / ABSENT EFFUSION CELLS ≥ 50 % PSORIATIC ARTHRITIS PRESENT IN REACTIVE ARTHRITIS GOUT/ PSEUDOGOUT OSTEOARTHRITIS NON-INFLAMMATORY TRANSLUCENT < 2000 CELLS < 25 % NEGATIVE ABSENT JOINT EFFUSION TRAUMA STRAW-LIKE SEPTIC JOINT S.AUREUS EFFUSION OPAQUE YELLOW-GREEN >50000 CELLS ≥ 75 % POSITIVE ABSENT N. GONORRHOEAE BLEEDING DISORDER BLEEDING JOINT BLOODY RED < 2000 CELLS EFFUSION TRAUMA 50 - 75 % NEGATIVE ABSENT IATROGENIC PSEUDOGOUT GOUT RHOMBOID-SHAPED, POSITIVELY-BIREFRINGENT CNEEDLE-SHAPED, NEGATIVELY-BIREFRINGENT CRYSTALS Joint fluid is analysed under plane-polarised light RADIOLOGICAL FEATURES OF GOUT PUNCHED-OUT EROSIONS (‘’RAT-BITE) SCLEROTIC OVERHANING LESIONS SOFT TISSUE SWELLING INTRA-OSSEOUS LESIONS PRESERVED JOINT SPACE PRESERVED BONE DENSITY Credit: Radiology for Medical Finals: A case-based guide S Stones (history of renal stones) What are the T Tophi or erosions indications for urate- O Over two gout attacks per year lowering therapy in gout? R Renal failure E Elderly GOUT MANAGEMENT MEDICAL MONITORING CONSERVATIVE MDT APPROACH NSAIDs (GP, PHYSIOTHERAPIST, OCCUPATIONAL THERAPY) ACUTE MANAGEMENT) MONITOR URIC ACID LEVELS FULL FUNCTIONAL ASSESSMENT (FOR ACUTE MANAGEMENT) (ASSESS FOR & MANAGE CARDIOVASCULAR RISK) MONITOR U&Es CHARITIES/ SOCIETIES INTRA-ARTICULAR STEROIDS e.g. UK Gout Society (FOR ACUTE MANAGEMENT IF NSAIDs/AIM TO BRING URIC ACID LEVELS ARE INEFFECTIVE/ CONTRA -INDICATUNDER 300 MICROMOL/L WEIGHT LOSS & AVOID ALCOHOL (WHEN ON URATE-LOWERING THERAPY) ALLOPURINOL LOW PURINE DIET (FOR LONG-TERM PREVENTION IF MEETS INDICATIONS) AVOID RED MEAT, SEAFOOD, OILY FISH REVIEW MEDICATIONS (IF ALLOPURINOL NOT TOLERATED/ INEFFECTIVE / RENAL FAILURE) Joint fluid is analysed with a Gram Stain & microscopy STAPHYLOCOCCUS AUREUS Joint fluid is analysed with a Gram Stain & microscopy NEISSERIA GONORRHOEAE SEPTIC ARTHRITIS MANAGEMENT ABCDE ASSESSMENT & SEPSIS 6 GIVE ANALGESICS & ANTIPYRETICS & ORGANISE START EMPIRICAL ANTIBIOTIC THERAPY BASED ON CONSIDER LIASION WITH SURGEONS & URGENT ORTHOPAEDIC REVIEW LOCAL HOSPITAL GUIDLINES ORTHOPAEDIC TEAM FOR SURGICAL INTERVENTION IF NOT RESPONDING ARRANGE BLOOD TESTS, INCLUDING START DIRECTED ANTIBIOTICS ONCE CAUSATIVE FBC, U&Es, ESR & CRP ORGANISMS CONFIRMED IV ANTIBIOTICS FOR 2–4 WEEKS THEN SWITCHED TO TAKE BLOOD CULTURES BEFORE ORAL PREPARATIONS IN SUBSEQUENT MONTH ANTIBIOTIC THERAPY ARRANGE JOINT ASPIRATION OF SYNOVIAL FLUID & SEND FOR GRAM STAIN, PERFORM REGULAR JOINT ASSESSMENTS WCC, MICROSCOPY AND CULTURE. MDT APPROACH WITH PHYSIOTHERAPY & SOURCE CONTROL WITH DRAINAGE OF OCCUPATIONAL THERAPY PURULENT FLUID CONSIDER VTE PROPHYLAXIS & AIM FOR EARLY MOBILISATION Role Medical student Setting GP Patient Miss Lara Croft, a 44 y/o woman presents with pain in multiple joints Student taskTake a concise history from the patient regarding his presenting symptoms. STUDENT At 7 minutes, the examiner will stop you, ask you to summarise your findings and present a differential diagnosis. INSTRUCTIONS SPOT DIAGNOSIS A 60-year-old woman presents because of pain in her fingers and knees. The stiffness lasts for about 10 minutes in the morning. The pain is worseHRITIS in the evening. The DIP and PIP joints are affected. A 54 year old woman presents with worsening joint pain in her hands and wrists. The pain is in both hands and is worse predominantly in theMATOID morning, when she also has significant stiffness for an hour. The MCP &THRITIS PIP joints are affected. JOINT PAIN NON - INFLAMMATORY INFLAMMATORY WORSENS WITH IMMOBILITY WORSENS WITH MOVEMENT IMPROVES WITH MOVEMENT IMPROVES WITH IMMOBILITY PAIN WORST IN MORNING PAIN WORST IN EVENING MORNING STIFFNESS > 30 MINS MORNING STIFFNESS < 30 MINS SWELLING & LOSS OF FUNCTION SWELLING & LOSS OF FUNCTION REDNESS & WARM NO REDNESS OR WARMTH EXTRA-ARTICULAR SYMPTOMS NO EXTRA-ARTICULAR SYMPTOMS SYMMETRIC ASYMMETRIC What are the extra-articular manifestations of RA? HAEMATOLOGICAL LUNGS EYES Anaemia of chronic disease Pleurisy Keratoconjunctivitis sicca (normocytic) Pleural effusion Scleritis Anaemia GI bleeding from NSAIDS/ Steroids (microcytic) Interstitial lung disease Episcleritis Reduced folate due to methotrexate (macrocytic) Nodules in lung parenchyma HEART Splenomegaly NEUROVASCULAR Pericarditis Felty Syndrome Neutropenia Myocarditis Raynaud phenomenon ↑ risk of lymphoma ↑ risk of myocardial infarction , Baker cyst rupture stroke , CHF , and atrial fibrillation MUSCULOSKELETAL Vasculitis SKIN Carpal tunnel syndrome Peripheral neuropathy C1 & C2 cervical involvement Mononeuritis multiplex Rheumatoid nodules OSTEOARTHRITIS RHEUMATOID ARTHTITIS Mechanical – wear & tear Autoimmune Similar incidence in men and women More common in woman Monoarthritis Symmetric polyarthritis No synovitis – only bony enlargement Synovitis present No significant inflammatory response Significant inflammatory response Target joints- Hips, Knees, D, CMC, PIP, Spine Target joints- PI, MCP, Wrists, Elbows, C-spine, Knees Joints spared- MCP , Wrist, Ankles Joints spared- DI, CMC, T/L/S spine Morning stiffness < 30 minutes Morning stiffness > 30 minutes Improves with rest Improves with use Unilateral symptoms Bilateral symptoms No systemic/ extra-articular features Systemic & extra-articular features present Investigations show no inflammation Investigations show evidence of inflammation Joint aspiration < 2000 WBC/mm 3 Joint aspiration > 2000 WBC/mm 3 Evidence of bone formation (osteophytes) Evidence of bone loss (marginal erosions, periarticular osteopenia) OSTEOARTHRITIS RHEUMATOID ARTHTITIS Focused Focused BEDSIDE MSK MSK BEDSIDE examination examination FBC FBC U&Es U&Es LFTs BLOODS INVESTIGATIONS CRP/ ESR BLOODS LFTs Rheumatoid factor CRP/ ESR Anti-CCP IMAGING IMAGING Plain X-rays Plain X-rays & (AP & Lateral views) (AP & Lateral views) & SPECIAL SPECIAL Consider MRI Consider MRI TESTS TESTS RADIOLOGICAL FEATURES OF OA L OSS OF JOINT SPACE O STEOPHYTE FORMATIONS S UBCHONDRAL CYSTS S UBCHONDRAL SCLEROSIS Credit: Radiology for Medical Finals: A case-based guide RADIOLOGICAL FEATURES OF RA L OSS OF JOINT SPACE E ROSIONS S OFT TISSUE SWELLING S OFT BONES (OSTEOPENIA) Credit: Radiology for Medical Finals: A case-based guide OSTEOARTHRITIS MANAGEMENT CONSERVATIVE MEDICAL SURGICAL MDT APPROACH (GP, PHYSIOTHERAPIST, OCCUPATIONAL THERAPY) (WITH PPI COVER FOR NSAIDs) JOINT REPLACEMENT FULL FUNCTIONAL ASSESSMENT (IF CONSERVATIVE OR MEDICAL MANAGEMENT FAILS) (ASSESS FOR & MANAGE CO -MOINTRA-ARTICULAR STEROIDS (IN SELECT CASES) WEIGHT LOSS & EXERCISE CHARITIES/ SOCIETIES RHEUMATOID ARTHRITIS MANAGEMENT CONSERVATIVE MEDICAL MONITORING MDT APPROACH NSAIDs/ (GP, PHYSIOTHERAPIST, OCCUPATIONAL THERAPY)ULAR STEROIDS MONITOR DISEASE ACTIVITY (FOR SYMPTOM -CONTROL) USING THE DAS28 SCORE FULL FUNCTIONAL ASSESSMENT (ASSESS FOR & MANAGE CO -MORBIDITIES) DMARDs MONITOR IMPACT ON LIFE (SHOULD BE COMMENCED EARLYUSING THE HEALTH ASSESSMENT QUESTIONNAIRE (HAQ) CHARITIES/ SOCIETIES e.g. National Rheumatoid Arthritis SocieBIOLOGICs PERFORM DEXA SCANS STOP SMOKING AT INTERVALS ENSURE UP-TO DATE INTRA-ARTI(FOR FLARE-UPs) REGULAR FBC,U&E & LFT VACCINATION STATUS MONITORING FOR METHOTREXATE THERAPY DRUG MECHANISM OF ADVERSE NOTES ACTION EFFECTS Inhibits • Liver toxicity • Prescribed with dihydrofolate • Bone marrow folic acid METHOTREXATE reductase preventing suppression • Must avoid DNA synthesis • Lung toxicity taking • Teratogenic trimethoprim & co-trimoxazole • Bone marrow Anti-inflammatory & toxicity What are the adverse DMARDs SULFASALAZINE immunosuppressive (leukopenia) effects • Haemolysis Can be combined (G6PD deficiency) in pregnancy with • Rash folate effects of DMARDs • Oligospermia supplementation used in RA? HYDROXY- Affects intracellul• Retinal toxicity CHLOROQUINE signalling pathways • Corneal deposits Inhibition of • Hepatotoxicity LEFLUNOMIDE pyrimidine synthesis • Hypertension • Teratogenic • Causes TB INFLIXIMAB TNF-α inhibitor reactivation Check TB status ADALIMUMAB • Demyelination BIOLOGICS Decreased RITUXIMAB Anti-CD 20 Infusion reaction response to vaccines LET’S HA VE A BREA THER! HOPE YOU ARE ALL ENJOYING THE SESSION! TRICKY HAND EXAMINATION COMING UP NEXT! @OSCEazyOfficial @osceazyofficial OSCEazy Osceazy@outlook.com Role Medical student Setting GP Patient Mr Stephen Strange, a 43 y/o male has a history of joint pain Student tasPerform a focused examination of his hand and wrists STUDENT At 7 minutes, the examiner will stop you and ask you to summarise your findings INSTRUCTIONSSPOT DIAGNOSIS – HAND EXAMINA TION A 48-year-old woman with hypothyroidism develops numbness and tingling in the right thumb, index, and middle fingers. She iCARPAL TUNNEL and is right-handed. On exam, there is wasting of her thenar musSYNDROME but no sensory loss in that area. A 78 year old man presents with pain in his left hand. On examination, he has swollen distal interphalangeal joints. ThOSTEOARTHRITIS crepitus during finger extension. A 25 year old woman fell off her horse and landed with her hands. On examination, there is severe tenderness in the anatomical snuffboxOID FRACTURE A 19 year old man has recently struggled to write. On examination, there is poor grip strength and sensory deficit in the medial aspect ofVE the palmar surface of his hand. He has elbow pain. PALSY A drunk student fell asleep on his chair overnight after a heavy night out. When he woke up, he was unable to bend his right wrist RADIAL NERVE backwards. There is decreased sensation in his posterior forearm. PALSY On examination, a patient’s finger is fixed in a flexed position TRIGGER pain. A ‘pop’ sound is heard on extension FINGER A 34 year old professional gamer develops pain in the radial sDE QUERVAIN She has been caring for her newborn baby. TENOSYNOVITIS Credit: Radiology for Medical Finals: A case-based guide SCAPHOID FRACTURE MALLET FINGER BOXER’S FRACTURE Credit: AMBOSS COLLES FRACTURE GAMEKEEPER’S THUMB The hand & wrist examination WIPE ’’Hello, my name is …. and I am a medical student. Can I confirm your name and age please. Today, I’ve been asked to perform an examination of your hand and wrist. What that will involve is me taking a general look of your hand, having a feel of your joints and asking you to perform different movements. Does that sound okay? Do I have your consent? Just to let you know, I will also be talking out loud to the examiner while I perform the examination to let him/her know what I am looking for. Are you in any pain at the moment? Where is the pain? Which joint? The examination should not be painful but if you feel any discomfort, please let me know. Can I ask which is your dominant hand? I will give you a pillow and you can rest you hands on top of this’’. LOOK FEEL MOVE SPECIAL TESTS NEUROLOGICAL FUNCTION Look for signs of rheumatoid arthritis MCP SWELLING WITH RHEUMATOID NODULES PIP SWELLING ULNAR DEVIATION BOUTONNIERE DEFORMITY SWAN-NECK DEFORMITY Z-THUMB & MULTIPLE DEFORMITIES MCP JOINT REPLACEMENT SCARSLook for signs of osteoarthritis B HEBERDEN’S NODES H BOUCHARD’S NODES HEBERDEN’S NODES WITH BOUCHARD’S NODES MUCOID CYST SQUARING OF THE WRIST TOPICAL NSAIDs Look for signs of psoriatic arthritis PSORIATIC PLAQUE NAIL PITTING ONYCHOLYSIS DACTYLITIS PENCIL-IN-CUP DEFORMITYLook for signs of systemic sclerosis RAYNAUD PHENOMENON SCLERODACTYLY CALCINOSIS TELANGIECTASIAS Look for signs of gout GOUTY TOPHI SYNOVITISLook for signs of dermatomyositis GOTTRON’S PAPULES MECHANIC’S HANDS STEROID ID BRACELET TAR STAINING Look for signs of carpal tunnel syndrome CARPAL TUNNEL RELEASE SCAR THENAR WASTING WRIST SPLINT MOBILITY AIDSLook for signs of endocrinopathies SPADE-LIKE HANDS THIN SKIN THYROID ACROPACHY FINGERPRICK GLUCOSE MARKS Look for signs of chronic liver disease PALMAR ERYTHEMA DUPUYTREN’S CONTRACTURE LEUCONYCHIA CLUBBING BRUISING What are the different causes of clubbing? ATRIAL MYXOMA e.g. COELIAC DISEASE CANCER INFECTIVE CYANOTIC MALABSORPTION CIRRHOSIS ENDOCARDITIS HEART DISEASE INFLAMMATORY BOWEL DISEASE LYMPHOMA ‘CCC’ CARDIOVASCULAR CAUSES CLUBBING GASTROINTESTINAL CAUSES ‘MILC’ RESPIRATORY CAUSES ‘ABCDE’ ABSCESS BRONCHIECTASIS LUNG CANCER RHEUMATOID EMPYEMA PULMONARY DISEASE FIBROSIS CYSTIC FIBROSIS DON’T SAY COPD OSCE TIP S Swellings Tell examiner you are E Erythema inspecting for… A Atrophy D Deformities S Scars LOOK FEEL MOVE BEDSIDEMobility aids, splint, medications SKIN:Colour, scars, rheumatoid nodules, swellings, Palmar erythema, sclerodactyly, sp-li e hands, arachnodactyly, telangiectasias, thinning, bruises, rashes JOINTS:eberden’s nodes, bouchard’s nodes, z-deformity, swan neck deformity, boutonniere deformity, ulnar deviation, mallet finger, dislocations NAILS:Clubbing, nail pitting, onycholysis, subungual hyperkeratosis, nailfold vasculitis, splinter haemorrhages MUSCLES:Wasting of intrinsic muscles ARMS: Psoriatic plaques, gouty tophi, rheumatoid nodules FACE:Psoriatic plaques, skin tightening, acromegaly, lupus rash SPECIAL TESTS NEUROLOGICAL FUNCTIONCHECK TEMPERATURE BOTH PALMAR & DORSALPALPATE RADIAL PULSES TOGETHERPALPATE MUSCLE BULK & PALMAR THICKENING THENAR EMINENCE WASTING DUPUYTREN’S CONTRACTUREWhat are the different carpal bones? PROXIMAL ROW SCAPHOID, LUNATE, TRIQUETRUM, PISIFORM “Some LoversTry Positions… DISTAL ROW TRAPEZIUM, TRAPEZOID, CAPITATE, HAMATE …That They Can’t, Handle” CREDIT: THE SKELETAL SYSTEM.NET Palpate anatomical snuffbox & carpal bonesWhat are the borders & contents of the anatomical snuffbox?Squeeze across MCP joints BIMANUALLY PALPATE MCP,PIP, DIP & IP JOINT USE 4-FINGER TECHNIQUE & LOOK AT PATIENT’S FACE CREDIT: www.medistudents.com OSCE TIP Passively move fingers at MCP , PIP, DIP & IP during joint palpation LOOK FEEL MOVE BEDSIDEMobility aids, splint, medications PALMAR ASPECT SKINColour, scars, rheumatoid nodules, swellings,eck temperature Palmar erythema, sclerodactyly, sp-li e hanPalpate both radial pulses together arachnodactyly, telangiectasias, thinning, Palpate thenar and hypothenar eminence JOINTS:Heberden’s nodes, bouchard’s nodes, z-deformity, swan palmar thickening neck deformity, boutonniere deformity, ulnar deviation, mallet finger, dislocations DORSAL ASPECT NAILS: Check temperature hyperkeratosis, nailfold vasculitis, splinter haemorrhagesal snuffbox & carpal bones Squeeze across MCP joints MUSCLES: Wasting of intrinsic muscles Bimanually each individual jointCHECFOR PAINT’S FACE Passively move each individual joint ARMS: Psoriatic plaques, gouty tophi, rheumatoidPalpate arms & elbows FACE: Psoriatic plaques, skin tightening, acromegaly, lupus rash SPECIAL TESTS NEUROLOGICAL FUNCTION TEST ACTIVE & PASSIVE MOVEMENTS WRIST FLEXION (80°) & RADIAL (20°) & ULNAR SUPINATION (80°) & EXTENSION (70°) DEVIATION (40°) PRONATION (70°) CIRCUMDUCTION FINGERS FLEXION (90°) & ABDUCTION & EXTENSION (30°) ADDUCTION THUMB ABDUCTION & FLEXION & EXTENSION ADDUCTION OPPOSITION OFFER TO TEST EXTRINSIC TENDON FUNCTIONS FLEXOR DIGITORUM FLEXOR DIGITORUM FLEXOR & EXTENSOR PROFUNDUS SUPERFICIALIS POLLICIS LONGUS LOOK FEEL MOVE BEDSIDE:Mobility aids, splint, medications TEST RANGE OF MOTION ACTIVELY & PASSIVELY PALMAR ASPECT SKIN:Colour, scars, rheumatoid nodules, swellings,heck temperature WRIST FINGERS THUMB Palmar erythema, sclerodactyly, sp-li e handPalpate both radial pulses together arachnodactyly, telangiectasias, thinning, bPalpate thenar and hypothenar eminence WRIST FLEXION FINGER FLEXION THUMB FLEXION Palpate for palmar thickening FINGER EXTENSION THUMB EXTENSION JOINTS:Heberden’s nodes, bouchard’s nodes, z-deformity, swan WRIST EXTENSION neck deformity, boutonniere deformity, ulnar deviation, RADIAL DEVIATION FINGER ABDUCTION THUMB ABDUCTION mallet finger, dislocations DORSAL ASPECT Check temperature ULNAR DEVIATION FINGER ADDUCTION THUMB ADDUCTION NAILS:Clubbing, nail pitting, onycholysis, subunguPalpate anatomical snuffbox & carpal bones PRONATION THUMB OPPOSITION hyperkeratosis, nailfold vasculitis, splinteSqueeze across MCP joints MUSCLES: Wasting of intrinsic muscles Bimanually each individual joint CHECK PATIENT’S FACESUPINATION FOR PAIN CIRCUMDUCTION ARMS: Psoriatic plaques, gouty tophi, rheumatoid nodulesely move each individual joint Palpate arms & elbows OFFER TO TEST INDIVIDUAL JOINT FUNCTION FACE:Psoriatic plaques, skin tightening, acromegaly, lupus rash SPECIAL TESTS NEUROLOGICAL FUNCTION TEST PINCER GRIP FUNCTION WHICH NERVE MOTOR FUNCTION IS ALSO BEING TESTED? ANTERIOR INTORROSEOUS NERVE ANTERIOR INTORROSEOUS SYNDROME TEST POWER GRIP FUNCTION TEST FINE MOTOR FUNCTION ASK WHICH IS THEIR DOMINANT HAND PICK UP A PEN & WRITE PICK UP A COIN TURN A KEY UNDO SHIRT BUTTON LOOK FEEL MOVE BEDSIDE:Mobility aids, splint, medications PALMAR ASPECT TEST RANGE OF MOTION ACTIVELY & PASSIVELY SKIN:Colour, scars, rheumatoid nodules, swellings, Check temperature Palmar erythema, sclerodactyly, sp-li e hands,Palpate both radial pulses together WRIST FINGERS THUMB arachnodactyly, telangiectasias, thinning, bruPalpate thenar and hypothenar eminence WRIST FLEXION FINGER FLEXION THUMB FLEXION JOINTS:Heberden’s nodes, bouchard’s nodes, z-deformity, swan for palmar thickening WRIST EXTENSION FINGER EXTENSION THUMB EXTENSION neck deformity, boutonniere deformity, ulnar deviation, RADIAL DEVIATION FINGER ABDUCTION THUMB ABDUCTION mallet finger, dislocations DORSAL ASPECT Check temperature ULNAR DEVIATION FINGER ADDUCTION THUMB ADDUCTION NAILS:Clubbing, nail pitting, onycholysis, subungualPalpate anatomical snuffbox & carpal bones hyperkeratosis, nailfold vasculitis, splinter haemorrhages PRONATION THUMB OPPOSITION Squeeze across MCP joints CHECK PATIENT’S FACE SUPINATION MUSCLES: Wasting of intrinsic muscles Bimanually each individual joint FOR PAIN ARMS: Psoriatic plaques, gouty tophi, rheumatoid nodulesively move each individual joint CIRCUMDUCTION Palpate arms & elbows FACE:Psoriatic plaques, skin tightening, acromegaly, lupus rash OFFER TO TEST INDIVIDUAL JOINT FUNCTION SPECIAL TESTS NEUROLOGICAL FUNCTION ASK WHICH HAND IS THEIR DOMINANT HAND TEST PINCER GRIP FUNCTION “Make an OK sign. Don’t let me break the grip” TEST POWER GRIP FUNCTION “Squeeze my fingers in you hands” TEST FINE MOTOR FUNCTION “Pick up a 10p coin”/ “Pick up pen”/ ‘’Do up a shirt button”/ ‘Write a line” ASK IF IT IS PAIN OR STIFFNESS THAT IS PREVENTING THEM FROM PERFORMING TASKS TEST THE SENSORY FUNCTIONS OF THE MEDIAN NERVE, ULNAR NERVE & RADIAL NERVE COMMON NERVE PALSIES AT RESTDR CUMA WRIST DROP CLAW HAND APE HAND RADIAL NERVE PALSY ULNAR NERVE PALSY MEDIAN NERVE PALSY D R C U M A TEST RADIAL NERVE MOTOR FUNCTION TEST WRIST EXTENSION AGAINST RESISTANCE RADIAL NERVE PALSY CAUSES • Compression of axilla e.g. Saturday night palsy • Humerus fracture (midshaft/ supracondylar). • Repetitive pronation/supination of forearm e.g. screwdriver use MOTOR DEFICITS Wrist drop: loss of elbow, wrist, and finger extension WRIST DROP TEST MEDIAN NERVE MOTOR FUNCTION TEST THUMB ABDUCTION AGAINST RESISTANCEDuring flexion MEDIAN NERVE PALSY CAUSES • Supracondylar fracture of humerus (proximal lesion) • Carpal tunnel syndrome and wrist laceration (distal lesion) MOTOR DEFICITS HAND OF BENEDICTION • Atrophy of thenar muscles • Impaired flexion of wrist, thumb, index, and middle finger • Proximal injury à Hand of benediction (active sign) • Ask the patient to make a fist • Loss of thumb opposition and abduction (due to weakness of FPL, FPB) • Loss of index & middle finger flexion (due to weakness of FDS, radial half of FDP) • MCP extended th • Only partial flexion digit (due to ulnar half of FDP) • Distal injury à median claw when extending fingers • Due to weakness of lumbricals I and II • Recurrent branch of median nerve injury à Ape hand • Due to unopposed adductor pollicis action • Anterior interosseous nerve injury à inability to make ‘OK’ sign • Due to loss of flexion in distal joints of thumb and index finger APE HAND TEST ULNAR NERVE MOTOR FUNCTION TEST FINGER ABDUCTION AGAINST RESISTANCE TEST ULNAR NERVE NORMAL MOTOR Credit: AMBOSSS FUNCTION TEST FROMENT’S SIGN (IF PAPER AVAILABLE) ULNAR NERVE LESION Credit: AMBOSSSAt rest ULNAR NERVE PALSY CAUSES • Proximal injury • Fracture of medial epicondyle of the humerus • Cubital tunnel syndrome • Distal injury • Ulnar tunnel syndrome • Hook of hamate fracture MOTOR DEFICITS • Loss of wrist flexion & medial fingers. • Loss of fingers abduction/ adduction • Ulnar claw on digit extension at rest • Hyperextension at MCP joints • Hyperflexion at PIP & DIP joints • Due to paralysis of medial lumbricals • Ulnar paradoxà more proximal lesions = less severe ULNAR CLAW LOOK FEEL MOVE BEDSIDE:Mobility aids, splint, medications PALMAR ASPECT TEST RANGE OF MOTION ACTIVELY & PASSIVELY SKIN:Colour, scars, rheumatoid nodules, swellings, Check temperature Palmar erythema, sclerodactyly, sp-li e hands, WRIST FINGERS THUMB Palpate both radial pulses together arachnodactyly, telangiectasias, thinning, bruiPalpate thenar and hypothenar eminence WRIST FLEXION FINGER FLEXION THUMB FLEXION Heberden’s nodes, bouchard’s nodes, z-deformity, swan for palmar thickening WRIST EXTENSION FINGER EXTENSION THUMB EXTENSION JOINTS: neck deformity, boutonniere deformity, ulnar deviation, RADIAL DEVIATION FINGER ABDUCTION THUMB ABDUCTION mallet finger, dislocations DORSAL ASPECT Check temperature ULNAR DEVIATION FINGER ADDUCTION THUMB ADDUCTION NAILS: Clubbing, nail pitting, onycholysis, subungualPalpate anatomical snuffbox & carpal bones PRONATION THUMB OPPOSITION hyperkeratosis, nailfold vasculitis, splinter Squeeze across MCP joints MUSCLES: CHECK PATIENT’S FACE SUPINATION Wasting of intrinsic muscles Bimanually each individual joint FOR PAIN ARMS: Psoriatic plaques, gouty tophi, rheumatoid nodulesively move each individual joint CIRCUMDUCTION Palpate arms & elbows FACE: Psoriatic plaques, skin tightening, acromegaly, lupus rash OFFER TO TEST INDIVIDUAL JOINT FUNCTION SPECIAL TESTS NEUROLOGICAL FUNCTION TEST SENSATION OF ASK WHICH HAND IS THEIR DOMINANT HAND RADIAL, ULNAR AND MEDIAN NERVE TEST PINCER GRIP FUNCTION TEST SENSATION OVER 1 DORSAL WEBSPACE (RADIAL NERVE)“Make an OK sign. Don’t let me break the grip” TEST SENSATION OVER INDEX FINGER (MEDIAN NERVE) TEST SENSATION OVER LITTLE FINGER (ULNAR NERVE) TEST POWER GRIP FUNCTION “Squeeze my fingers in you hands” TEST MOTOR FUNCTION AGAINST RESISTANCE TEST FINE MOTOR FUNCTION WRIST EXTENSION AGAINST RESISTANCE (RADIAL NERVE) “Pick up a 10p coin”/ “Pick up pen”/ ‘’Do up a shirt button”/ ‘Write a line” THUMB ABDUCTION AGAINST RESISTANCE (MEDIAN NERVE) FINGER ABDUCTION AGAINST RESISTANCE (ULNAR NERVE) ASK IF IT IS PAIN OR STIFFNESS THAT IS OFFER TO CHECK FROMENT’S SIGN (ULNAR NERVE) PREVENTING THEM FROM PERFORMING TASKS Credit: RADIOPAEDIA What are the boundaries & structures that pass through the carpal tunnel? 9 TENDONS & 1 NERVE 2 Which hand muscles L Lumbricals (Lateral) which are innervated O Opponens pollicis Credit: AMBOSSS by themedian nerve? A Abductor pollicis brevis F Flexor pollicis brevis L Local extrinsic pressure (e.g. ganglions) O Obesity P Pregnancy What are the causes E Endocrine (hypothyroidism, acromegaly) of carpal tunnel RA syndrome? Rheumatoid Arthritis M Mechanical (fracture) I Idiopathic DE DiabEtes CREDIT: Dr Wijaya, 2018 Why is there no loss of sensation over the thenar eminence in carpal tunnel syndrome? nerv e M e dian Palmar cutaneous l branch of anee median nerve https://musculoskeletalkey.com/open-techniques-for-carpal-tunnel-release/ SPECIAL TESTS CARPAL TUNNEL SYNDROME PROVOCATIVE MANOEUVRES PHALEN’S TEST TINEL’S TEST Credit: AMBOSSS • ASK THE PATIENT TO HYPERFLEX BOTH HANDS & HOLD DORSAL S• PERCUSS OVER THE FLEXOR ASPECT OF THE WRIST • OFFER TO WAIT FOR 1 MINUTE • POSITIVE TEST = PAIN +/- PARAESTHESIA IN MEDIAN NERVE DISTRIBUTION • POSITIVE TEST = PAIN +/- PARAESTHESIA IN MEDIAN NERVE DISTRIBUTION W Wear splints often worn at night What are the key R Rest management steps I Inject steroid for carpal tunnel syndrome? S Surgical decompression T Take diuretics LOOK FEEL MOVE BEDSIDE:Mobility aids, splint, medications PALMAR ASPECT TEST RANGE OF MOTION ACTIVELY & PASSIVELY SKIN:Colour, scars, rheumatoid nodules, swellings, Check temperature Palmar erythema, sclerodactyly, sp-li e hands, Palpate both radial pulses together WRIST FINGERS THUMB arachnodactyly, telangiectasias, thinning, bruises, rashes WRIST FLEXION FINGER FLEXION THUMB FLEXION Palpate thenar and hypothenar eminence JOINTS: Heberden’s nodes, bouchard’s nodes, z-deformity, swane for palmar thickening WRIST EXTENSION FINGER EXTENSION THUMB EXTENSION neck deformity, boutonniere deformity, ulnar deviation, mallet finger, dislocations DORSAL ASPECT RADIAL DEVIATION FINGER ABDUCTION THUMB ABDUCTION ULNAR DEVIATION FINGER ADDUCTION THUMB ADDUCTION NAILS: Clubbing, nail pitting, onycholysis, subungual Check temperature hyperkeratosis, nailfold vasculitis, splinter haemorrhagestomical snuffbox & carpal bones PRONATION THUMB OPPOSITION Squeeze across MCP joints MUSCLES: Wasting of intrinsic muscles Bimanually each individual joint CHECK PATIENT’S FACE SUPINATION Passively move each individual joint FOR PAIN CIRCUMDUCTION ARMS: Psoriatic plaques, gouty tophi, rheumatoid nodules Palpate arms & elbows OFFER TO TEST INDIVIDUAL JOINT FUNCTION FACE: Psoriatic plaques, skin tightening, acromegaly, lupus rash SPECIAL TESTS NEUROLOGICAL FUNCTION TINEL’S TEST TEST SENSATION OF ASK WHICH HAND IS THEIR DOMINANT HAND Percuss over the flexor aspect of the wristb&erve for RADIAL, ULNAR AND MEDIAN NERVE parasthesias st TEST PINCER GRIP FUNCTION TEST SENSATION OVER 1 DORSAL WEBSPACE (RADIAL NERVE) “Make an OK sign. Don’t let me break the grip” PHALEN’S TEST TEST SENSATION OVER INDEX FINGER (MEDIAN NERVE) Make a reverse prayer. TEST SENSATION OVER LITTLE FINGER (ULNAR NERVE) TEST POWER GRIP FUNCTION “Squeeze my fingers in you hands” Offer to wait for 60 seconds and observe for parasthesias. TEST MOTOR FUNCTION AGAINST RESISTANCE TEST FINE MOTOR FUNCTION WRIST EXTENSION AGAINST RESISTANCE (RADIAL NERVE) “Pick up a 10p coin”/ “Pick up pen”/ ‘’Do up a shirt button”/ ‘Write a line” THUMB ABDUCTION AGAINST RESISTANCE (MEDIAN NERVE) FINGER ABDUCTION AGAINST RESISTANCE (ULNAR NERVE) ASK IF IT IS PAIN OR STIFFNESS THAT IS OFFER TO CHECK FROMENT’S SIGN (ULNAR NERVE) PREVENTING THEM FROM PERFORMING TASKS THANK PATIENT PRESENTING THE HAND & WRIST EXAMINATION • I performed a hand and wrist examination on Mrs Ramsey, a 60 year old woman who presented with pain in her hands • On general inspection of the hands, there was no evidence of deformity, asymmetry, wasting, swelling or scars • On palpation, the temperature was normal and there was no tenderness on bimanual palpation of all joints • There was a normal range of movement in the hand and no obvious functional impairment • The sensory and motor modalities were both intact • In summary, this was a normal hand and wrist examination • To complete my examination, I would take a focused history from the patient and examine the joint above. I would also like to perform a full neurovascular assessment of the upper limbs and look at any available imaging. THANK YOU FOR AN AMAZING YEAR! IT’S BEEN A PRIVILEDGE AND I’M GRATEFUL YOUR SUPPORT Image credits – Wikimedia Commons, AMBOSS, Radiopaedia, DermNet NZ, Life in the Fast Lane, Physical Diagnosis PDX Video credits– https://www.youtube.com/watch?v=iWPKLhttps://www.youtube.com/watch?v=HhnjWoJG5vM https://www.youtube.com/watch?v=km0Ah34v6b4tps://www.youtube.com/watch?v=a9ndY7f772o @OSCEazyOfficial @osceazyofficial OSCEazy Osceazy@outlook.com