At the wrist, palpate the distal radius and ulna on the lateral and medial surfaces. Palpate the groove of each wrist joint with your thumbs on the dorsum of the wrist, your fingers beneath it. Note any swelling, boggi-ness, or tenderness.
Guarded movement suggests injury. Poor finger alignment is seen in flexor tendon damage.
Diffuse swelling in arthritis or infection; localized swelling or ganglia from cystic enlargement. See Table 15-6, Swellings and Deformities of the Hands (pp. 529-531).
Flexion contractures in the ring, 5th and 3rd fingers, or Dupuytren's contractures, arise from thickening of the palmar fascia (see p. 531).
Tenderness over the distal radius in Colles' fracture. Any tenderness or bony step-offs are suspicious for fracture.
Swelling and/or tenderness suggests rheumatoid arthritis if bilateral and of several weeks' duration.
Palpate the anatomic snuffbox, a hollowed depression just distal to the radial styloid process formed by the abductor and extensor muscles of the thumb. The "snuffbox" becomes more visible with lateral extension of the thumb away from the hand.
Tenderness over the "snuffbox" suggests a scaphoid fracture.
Palpate the eight carpal bones lying distal to the wrist joint, and then each of the five metacarpals and the proximal, middle, and distal phalanges.
Palpate any other area where you suspect an abnormality.
Compress the MCP joints by squeezing the hand from each side between the thumb and fingers. Alternatively, use your thumb to palpate each MCP joint just distal to and on each side of the knuckle as your index finger feels the head of the metacarpal in the palm. Note any swelling, bogginess, or tenderness.
Synovitis in the MCPs is painful with this pressure—a point to remember when shaking hands.
The MCPs are often boggy or tender in rheumatoid arthritis (but rarely involved in osteoarthritis).
Now examine the fingers. Palpate the medial and lateral aspects of each PIP joint between your thumb and index finger, again checking for swelling, bogginess, bony enlargement, or tenderness.
Using the same techniques, examine the DIP joints.
PIP changes seen in rheumatoid arthritis; Bouchard's nodes in osteoarthritis
Hard dorsolateral nodules on the DIP joints, or Heberden's nodes, common in osteoarthritis
In any area of swelling or inflammation, palpate along the tendons inserting Tenderness and swelling in on the thumb and fingers. tenosynovitis, or inflammation of the tendon sheaths. De Quervain's tenosynovitis over the extensor and abductor tendons of the thumb as they cross the radial styloid
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