Rheumatoid Hands Examination
The rheumatoid hand examination tests your ability to recognize classic deformities, assess tendon integrity, and understand the pathomechanics. Examiners expect you to describe findings systematically, understand the functional implications, and know the surgical options for each deformity pattern.
Quick Reference One-Pager
Classic Deformities
- Swan neck: PIP hyperextension, DIP flexion
- Boutonniere: PIP flexion, DIP hyperextension
- Z-thumb: MCP flexion, IPJ hyperextension
- Ulnar drift at MCPJs
- Caput ulnae (dorsal prominence)
Tendon Ruptures
- EDC: Vaughan-Jackson (little finger first)
- EPL: Mannerfelt (thumb extension)
- FPL: Mannerfelt syndrome
- Test each tendon individually
Extra-Articular Signs
- Rheumatoid nodules (elbow, fingers)
- Nail fold vasculitis
- Skin thinning
- Muscle wasting
Functional Assessment
- Key pinch
- Grip strength
- Fine motor (buttons)
- ADLs (feeding, dressing)
Introduction and Approach
Setting the Scene
Patient Positioning: Seated facing you, hands resting on pillow
Exposure: Both hands and forearms to elbows, remove rings and watch
Consent Script: "I'd like to examine your hands. Please tell me if anything is painful."
Key Principle: The rheumatoid hand examination is a classic orthopaedic examination that demonstrates your understanding of pathomechanics and surgical indications.
Look (Inspection)
Skin:
- Thinning (steroid effect)
- Rheumatoid nodules
- Scars from previous surgery
- Nail fold vasculitis (infarcts)
Joints:
- MCPJ synovitis (soft swelling)
- Ulnar drift at MCPJs
- PIPJ deformity (swan neck vs boutonniere)
- DIPJ sparing (usually)
Tendons:
- Extensor tenosynovitis (swelling over dorsum)
- Tendon ruptures (dropped fingers)
- Caput ulnae (dorsal prominence of ulnar head)
Classic Deformities
Understanding the Patterns
Swan Neck Deformity:
- PIPJ hyperextension, DIPJ flexion
- Mechanism: FDS rupture or volar plate laxity
- Lateral bands slip dorsal to axis
- Test: Can PIPJ flex when MCP held extended?
Boutonniere Deformity:
- PIPJ flexion, DIPJ hyperextension
- Mechanism: Central slip rupture
- Lateral bands slip volar to axis
- Elson test to assess central slip
Z-Thumb (Thumb Boutonniere):
- MCPJ flexion, IPJ hyperextension
- Mechanism: EPB/EPL imbalance, MCP volar plate laxity
- Severely impairs pinch
Ulnar Drift:
- MCPJ ulnar deviation
- Mechanism: Radial sagittal band attenuation
- Extensor tendons slip ulnar
- Intrinsic tightness develops
- pipj
- Hyperextension
- dipj
- Flexion
- mechanism
- FDS rupture, volar plate laxity
- test
- Flexibility with MCP extended
- pipj
- Flexion
- dipj
- Hyperextension
- mechanism
- Central slip rupture
- test
- Elson test
- pipj
- dipj
- mechanism
- EPB/volar plate laxity
- test
- Pinch strength
- pipj
- dipj
- mechanism
- Radial sagittal band rupture
- test
- Passive correction
Tendon Assessment
Vaughan-Jackson Lesion: Sequential EDC rupture starting at ulnar side (little finger first, then ring, middle). Caused by attritional rupture over rough caput ulnae.
Mannerfelt Lesion: FPL rupture from attrition over scaphoid osteophyte (volar carpal boss).
Key Principle: Test each tendon individually - don't rely on juncturae!
Special test
Individual Extensor Testing
Identify tendon ruptures masked by juncturae
Technique
- 1Hold adjacent fingers in flexion to eliminate juncturae
- 2Ask patient to extend tested finger at MCP
- 3Test each finger individually (index, middle, ring, little)
- 4Compare with other hand
Positive Sign
Cannot extend finger at MCP with adjacent fingers held flexed
Indicates
EDC tendon rupture (Vaughan-Jackson if ulnar-sided)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
EPL Testing
Assess extensor pollicis longus integrity
Technique
- 1Place palm flat on table
- 2Ask patient to lift thumb straight up off table (retropulsion)
Positive Sign
Cannot lift thumb off table
Indicates
EPL rupture - common in RA (Lister's tubercle attrition)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
FPL Testing
Assess flexor pollicis longus (Mannerfelt lesion)
Technique
- 1Stabilize thumb MCP joint in extension
- 2Ask patient to flex IPJ of thumb
Positive Sign
Cannot flex thumb IPJ
Indicates
FPL rupture - Mannerfelt syndrome (attrition over scaphoid)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Elson Test
Assess central slip integrity (boutonniere)
Technique
- 1Flex PIPJ 90 degrees over edge of table
- 2Ask patient to extend PIPJ against resistance
- 3Observe DIPJ
Positive Sign
DIPJ extends (goes rigid) while PIPJ remains weak
Indicates
Central slip rupture - lateral bands subluxed volar, extending DIP
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Nalebuff Classification
Type I: Flexible in all positions
- Treatment: Flexor tenodesis, DIP fusion
Type II: Limited PIPJ flexion with MCP extension
- Intrinsic tightness
- Treatment: Intrinsic release
Type III: Limited PIPJ flexion in all MCP positions
- Joint involvement
- Treatment: Manipulation, soft tissue release
Type IV: Fixed, stiff PIPJ with joint destruction
- Treatment: Arthroplasty or fusion
Extra-Articular Manifestations
Systemic Signs to Look For
Rheumatoid Nodules:
- Location: Olecranon, finger extensor surfaces, flexor sheaths
- Significance: Seropositive disease, methotrexate can increase
Vasculitis:
- Nail fold infarcts (splinter hemorrhages)
- Digital gangrene (severe disease)
- Skin ulceration
Nerve Compression:
- Carpal tunnel syndrome (flexor tenosynovitis)
- Ulnar nerve at elbow
- Posterior interosseous nerve (elbow synovitis)
Muscle Wasting:
- Thenar (median), hypothenar (ulnar)
- Intrinsic wasting (T1/ulnar)
- Forearm wasting (disuse, myopathy)
Complete the Systemic Screen:
- Elbows: Nodules, ulnar nerve
- Eyes: Episcleritis, scleritis, dry eyes (Sjogren's)
- Cervical spine: Atlantoaxial instability (before intubation!)
- Chest: Interstitial lung disease
- Skin: Vasculitic rash, leg ulcers
Functional Assessment
Hand Function
Pinch Types:
- Key (lateral) pinch: Thumb to side of index
- Tip pinch: Thumb to index fingertip
- Tripod pinch: Thumb, index, middle
Grip:
- Power grip: Grasp cylinder
- Hook grip: Carry bag
Fine Motor:
- Button/unbutton
- Pick up coin
- Write name
- Turn key
ADLs:
- Feeding: Fork, knife, cup
- Dressing: Buttons, zips
- Hygiene: Toileting, washing
Surgical Priority Assessment
Priority Order for Reconstruction:
- Wrist stabilization first (provides stable platform)
- MCPJ arthroplasty
- Tendon reconstruction
- PIPJ procedures last
Timing Considerations:
- Disease activity (wait for remission if possible)
- Medication optimization
- Cervical spine clearance
- Cardiovascular assessment
Wrist Examination
Wrist-Specific Findings
Caput Ulnae Syndrome:
- Prominent dorsal ulnar head
- DRUJ instability (piano key sign)
- Risk of EDC rupture
- Treatment: Darrach, Sauve-Kapandji, or ulnar head replacement
Carpal Collapse:
- Radial deviation of carpus
- Ulnar translocation
- Supination deformity
- Radiographs: Scalloped carpal bones
Flexor Tenosynovitis:
- Volar wrist swelling
- Carpal tunnel symptoms
- Trigger fingers
- Treatment: Synovectomy, CTR
Special test
Piano Key Sign
Assess DRUJ stability (caput ulnae)
Technique
- 1Stabilize radius with one hand
- 2Push ulnar head dorsally and volarly with other hand
- 3Compare with contralateral side
Positive Sign
Excessive dorsal-volar translation of ulnar head
Indicates
DRUJ instability - caput ulnae syndrome
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Summary Presentation
“56-year-old woman with long-standing seropositive rheumatoid arthritis presents with progressive hand dysfunction.”
Examination Sequence
Systematic Approach
- Introduction: Consent, positioning, exposure
- Look dorsal: Skin, joints, tendons, wrist
- Look palmar: Thenar/hypothenar, skin, tendons
- Specific deformities: Name and classify each
- Tendon testing: Each extensor individually, EPL, FPL
- Special tests: Elson, piano key, Phalen's
- Sensory: Median, ulnar nerve territories
- Functional: Pinch, grip, fine motor
- Extra-articular: Elbows, nodules, vasculitis
- Complete: "I would examine cervical spine and take radiographs"
Examiner Tips
Do
- Name each deformity precisely (swan neck, boutonniere, Z-thumb)
- Test each tendon individually
- Demonstrate Elson test correctly
- Mention cervical spine clearance for surgery
- State surgical priority order (wrist → MCP → digits)
Don't
- Miss tendon ruptures by relying on juncturae
- Forget extra-articular manifestations
- Skip functional assessment
- Miss carpal tunnel symptoms
- Forget to compare sides