Peter Vince Balint - Ultrasonography of the Hand in Rheumatology

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Springer International Publishing AG, part of Springer Nature 2018

Peter Vince Balint and Peter Mandl (eds.) Ultrasonography of the Hand in Rheumatology

1. Clinical Examination of the Hand and Wrist in Rheumatology

Eszter Kovari 1, Reka Kurucz 2, Peter Mandl 3, Geza P. Balint 4 and Peter Vince Balint 2

(1)

Semmelweis University, Doctoral School of Clinical Medicine, Budapest, Hungary

(2)

3rd Rheumatology Department, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary

(3)

Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria

(4)

Ambulatory Care Clinic, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary

Keywords

Hand Wrist Physical examination Clinical examination

Inspection

Visual inspection is the first step of any physical examination (Fig. lists the most common findings, which may occur in a rheumatological setting. Involved joints may be counted and mapped. This may provide important information for classifying arthritis, i.e. as mono-/oligo- and polyarthritis, ray pattern typical in psoriatic arthritis, etc.

Fig. 1.1

Inspection of the dorsal aspect of the hands and wrists

Fig. 1. 2

Testing skin temperature

Table 1.1

Common signs on visual inspection in rheumatic and musculoskeletal diseases

Sign	Localization
Erythema	Single/multiple joint (e.g. septic arthritis)
Region (e.g. palmar erythema in SLE: systemic lupus erythematosus with hepatic involvement)
Diffuse (e.g. cellulitis, erysipelas)
Pallor	Single or multiple digits (e.g. Raynauds phenomenon)
Cyanosis	Fingertip, nail bed (e.g. acrocyanosis)
Diffuse (e.g. Raynauds phenomenon)
Cutis reticularis/marmorata	Diffuse (e.g. antiphospholipid syndrome)
Mottled skin	Varied (e.g. vitiligo)
Stained skin	Fingertips (nicotine)
Diffuse (e.g. diffuse yellow in carotenemia)
Suffusion	Dorsal surface of the hand (e.g. glucocorticoid use)
Scars, wounds and keloids	Palmar (e.g. median nerve release scars)
Dorsal (e.g. common injuries, scars, ulcerated gouty tophi, Gottrons sign)
Subcutaneous calcinosis	Diffuse (e.g. CREST syndrome)
Cracks and fissures	Diffuse (e.g. mechanics hand, dermatomyositis)
Atrophy	Diffuse (e.g. systemic sclerosis, glucocorticoid use)
Slacking skin	Dorsal (e.g. anetoderma in systemic lupus erythematosus)
Diffuse (e.g. cutis laxaEhlers-Danlos syndrome)
Nail bed lesions	Localized (e.g. nailfold vasculitis, splinter haemorrhage)
Swelling	Diffuse (e.g. puffy hands in remitting seronegative symmetrical synovitis with pitting edema, algodystrophy, palindromic rheumatism, paraneoplastic syndrome)
Single/multiple finger (e.g. dactylitis, spina ventosa)
Single/multiple joint/tendon (e.g. rheumatoid arthritis)
Deformity	Diffuse nail (e.g. hourglass deformity)
Single nail (e.g. pitting subungual hyperkeratosis, Beaus lines, oil drop patches, onycholysis in psoriatic arthritis, mycosis)
Diffuse finger (e.g. clubbing)
DIP: distal interphalangeal joint (e.g. Heberdens node)
PIP: proximal interphalangeal joint (e.g. Bouchards node)
CMC joint (e.g. squaring in rhizarthrosis)
Ulnar head (e.g. piano key sign in rheumatoid arthritis, Bayonet deformity or Madelungs deformity)
Palmar aponeurosis (e.g. Dupuytrens syndrome, cheiroarthropathy)
Diffuse (e.g. Volkmanns contracture)
Gangrene, ulcer	Fingertip (e.g. systemic sclerosis)
Malalignment	Swan-neck deformity (proximal interphalangeal joint hyperextension and distal interphalangeal joint flexion)
Boutonniere (or buttonhole) deformity (proximal interphalangeal joint flexion and distal interphalangeal joint extension)
Radial deviation of the wrist (e.g. juvenile idiopathic arthritis)
Ulnar deviation and subluxation of the metacarpophalangeal joints (e.g. rheumatoid arthritis)
Z or zigzag deformity of the thumb (e.g. rheumatoid arthritis)
Muscle atrophy	Thenar (e.g. carpal tunnel syndrome)
Hypothenar (e.g. Guyons tunnel syndrome)
Interossei (e.g. rheumatoid arthritis)
Claw hand (e.g. syringomyelia)
Non-voluntary movement	Single muscle/diffuse (e.g. fasciculation, tremor)

Palpation

Temperature of the skin may be decreased in diffuse fashion seen in Raynauds phenomenon; however, localized hyperthermia over a joint or area is more common and may be commonly found in septic arthritis and cellulitis/panniculitis, respectively (Fig. ). Crepitation may be detected over the tendon sheath of finger flexor tendons in chronic flexor tenosynovitis and de Quervains tenosynovitis.

Fig. 1. 3

Placing palms together to test for diabetic cheiroarthropathy

Fig. 1.4

Palpation of joint swelling

Fig. 1.5

Use of the Leeds dactylometer

Fig. 1.6

Radial pulse palpation

Fig. 1.7

Capillary refill test

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