Musculoskeletal investigations - Examining the elbow, wrist and hand

The anatomy of the hand and wrist is complex, write Mr Steve Lipscombe and Dr Dan Bunstone.

Deformity due to rheumatoid arthritis. Heberden's nodes visible (Photograph: SPL)

Upper limb examinations can be complex. The aim of this article is to provide a logical thought process to aid reaching a diagnosis. It is not designed to cover all possibilities. We will consider each area in turn.

Osteoarthritis can affect any upper limb joints but most commonly affects the base of the thumb and hand. Rheumatoid arthritis should always be considered, affecting the smaller joints symmetrically and commonly the elbow.

Consider the position and shape of the fingers. The presence of nodules around the elbow is an important sign.

The elbow
Ask the patient to fully flex and extend the elbow. Flexion and extension will be excessive in hyperlaxity disorder or may be lost following injury or immobilisation. Full flexion allows inspection of the bursal area of the elbow (bursitis is a common complaint) and the recognition of any rheumatoid nodules.

Crepitus and pain during movement suggests osteoarthritis. The radiocapitellar joint at the elbow can be stressed by asking the patient to clench the fist whilst supinating and pronating the forearm.

This movement should always be performed with the elbows at the side to prevent shoulder movements compensating for any restriction.

Palpate the mobile wad of muscle around the lateral border of the elbow. Tenderness here, exacerbated by resisted wrist extension, suggests lateral epicondylitis (tennis elbow).

Less commonly, pain on the medial border of the elbow exacerbated by resisted wrist flexion can occur (golfer's elbow) but careful assessment of the ulnar nerve should be performed. Nerve entrapment in the cubital tunnel (paraesthesia in the ulnar border of the hand with weakness) may be the cause.

The wrist
The wrist is perhaps the trickiest of the three areas because the anatomy is close together and landmarks can be difficult to find. Determine where the problem is and attempt to localise it to the radial, central or ulnar border.

Radial-sided problems can involve the thumb joints (commonly osteoarthritis of the base of the thumb in middle-aged women) with pain made worse by grinding the thumb against the trapezium.

De Quervain's tenosynovitis affects the tendons at the base of the thumb. It can be determined by tucking the thumb into the palm with the fingers and moving the wrist into ulnar deviation. This will exacerbate the pain if De Quervain's tenosynovitis is present (Finkelstein's test).

Palpation of the area of the anatomical snuffbox while completing this movement can identify scaphoid problems such as avascular necrosis (think steroids, alcoholism, and trauma). The radial styloid can be felt here during this movement, along with the scaphoid at the base of the thumb.

Carpal instability is also tricky to elicit (such as scapholunate dissociation detected by the Kirk-Watson test) but the history of trauma and subsequent pain and clicking is most helpful.

Kirk-Watson test (Photograph: authors' image)

Central wrist pain is found with lunate pathology such as Kienbock's disease (typically middle-aged males without clear history of trauma), carpal instability, and ganglions, which are typically dorsal from the scapholunate ligament.

Aside from the palpable swelling of a ganglion, examination may be limited to the location of pain and tenderness.

Ulnar-sided wrist pain may be related to carpal instability and osteoarthritis of the joints. Specific instability and degeneration of the distal radioulnar joint can be demonstrated by gripping the ulnar head while the elbow is flexed and attempting to deviate it in a dorsal and palmar directions.

The hand
Inspection of the hand and digit position at rest is vital. Attempt to determine whether any abnormality is related to nerve dysfunction (associated parasthesia and pain), tendon problems (rupture secondary to rheumatoid arthritis) or Dupuytren's disease.

Dupuytren's disease typically affects the ring and little finger (Photograph: SPL)

Muscle wasting of the hypothenar eminence and small muscles of the hand suggest ulnar nerve dysfunction. Clawing of the digits, more pronounced when asked to make a slow grip, is also suggestive of ulnar nerve dysfunction. This can be subtle with more proximal lesions (the ulnar paradox).

Thenar eminence muscle wasting corresponds to the median nerve. Paraesthesia in the two digits innervated by the ulnar nerve supports ulnar nerve pathology. Paraesthesia in the radial digits indicates median nerve pathology.

Deformity of the digits (typically ring and little finger) is associated with thickening and nodularity of the palmar skin identified with Dupuytren's disease. Assess such nodules carefully as swelling associated with the tendon sheath may represent a trigger finger.

Ulnar drift (asymmetrical power of the small muscles of the hand) and associated finger deformity (Swan neck) are the hallmarks of rheumatoid arthritis. Functional assessment using keys and everyday objects rather than assessing individual joint movement is far more useful in such circumstances.

Osteoarthritis in the digits is one of the most common sites of occurrence. It tends to involve the distal joints with swellings (mucoid cysts and Heberden's nodules), pain and stiffness.

Upper limb examinations can be difficult, but with a logical approach to history and examination, a diagnosis can often be easily reached.

  • Mr Lipscombe is an orthopaedic registrar in Aintree, and Dr Bunstone is a GP principal in Cheshire

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