Rheumatoid Hand Examination
Rheumatoid hand examination requires systematic identification of classic deformities and functional assessment. Examiners expect you to recognize the pattern of joint involvement, identify tendon ruptures, and understand the pathophysiology behind each deformity. Always assess function, not just appearance.
Quick Reference One-Pager
Classic Deformities
- Ulnar drift at MCPs
- Swan neck: PIP hyperextension, DIP flexion
- Boutonnière: PIP flexion, DIP hyperextension
- Z-thumb deformity
- Caput ulnae (prominent ulnar head)
Tendon Ruptures
- EDC (little finger first - Vaughan-Jackson)
- EPL (at Lister's tubercle)
- FPL (Mannerfelt syndrome)
- Test each tendon individually
Functional Tests
- Grip and pinch strength
- Key grip (hold paper)
- Button/zip ability
- Write name
Key Points
- Synovitis causes tendon attrition
- Wrist affects hand function
- Always examine cervical spine (instability)
- Extra-articular features important
Pattern of Joint Involvement
RA Joint Distribution
Characteristic Pattern (Bilateral Symmetric):
- MCP joints (most common in hand)
- PIP joints
- Wrist (radiocarpal, midcarpal)
- MTP joints (feet)
Spared Joints in RA:
- DIP joints (usually osteoarthritis)
- CMC of thumb (may have secondary OA)
Key Differentiator:
- RA: MCP and PIP
- OA: DIP and CMC
Pathophysiology of RA Hand:
- Synovitis → Joint destruction → Deformity
- Synovitis → Tendon attrition → Rupture
- Ligament laxity → Subluxation/dislocation
- Muscle imbalance → Fixed deformities
Order of Tendon Ruptures (Vaughan-Jackson): Little → Ring → Middle → Index (EDC over ulnar head)
Observation
Initial Assessment
Look From Dorsal:
- Swelling (synovitis, effusion, nodules)
- Muscle wasting (interossei, thenar)
- Deformities (ulnar drift, subluxation)
- Scars (previous surgery)
- Skin (thin, fragile - steroids)
- Nodules (extensor surfaces)
Look From Lateral:
- Swan neck deformity
- Boutonnière deformity
- Z-thumb deformity
Look From Palmar:
- Thenar wasting
- Palmar nodules (flexor tenosynovitis)
- Carpal tunnel scars
Caput Ulnae:
- Prominent dorsal ulnar head
- Due to DRUJ destruction and supination of carpus
Classic Deformities
Swan Neck Deformity:
- PIP hyperextension
- DIP flexion
- Terminal tendon attenuates as lateral bands sublux dorsally
Causes in RA:
- MCP synovitis → intrinsic tightness
- PIP volar plate laxity
- FDS rupture or attenuation
Classification (Nalebuff):
- Description
- Full PIP flexion in all MCP positions
- Description
- PIP flexion limited by intrinsic tightness (MCP extension limits)
- Description
- Limited PIP flexion in all MCP positions
- Description
- Stiff, arthritic PIP (fixed)
Key Test: Intrinsic tightness test (Bunnell)
Tendon Examination
Extensor Tendon Ruptures
Vaughan-Jackson Syndrome:
- EDC ruptures over dorsally subluxed ulnar head
- Attritional rupture from caput ulnae
- Order: Little → Ring → Middle → Index
EPL Rupture:
- Usually at Lister's tubercle
- Cannot extend thumb IP (retropulsion)
- May occur with distal radius fracture or RA
Testing Each Extensor:
- EDC: Extend MCP against resistance for each finger
- EPL: Lift thumb off flat surface (retropulsion)
- EDM: May mask little finger EDC rupture
Special test
EDC Integrity Test
Individual extensor tendon assessment
Technique
- 1Hold MCP in flexion
- 2Ask patient to extend MCP against resistance
- 3Test each finger individually
Positive Sign
Inability to extend MCP against resistance
Indicates
EDC rupture for that digit (note: test early as EDM and interossei can compensate)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
EPL Integrity Test (Retropulsion)
EPL tendon assessment
Technique
- 1Place palm flat on table
- 2Ask patient to lift thumb straight up off surface
- 3Observe for tendon firing and thumb elevation
Positive Sign
Inability to lift thumb off table or extend IP joint
Indicates
EPL rupture - usually attritional at Lister's tubercle
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Flexor Tendon Ruptures
Mannerfelt Syndrome:
- FPL rupture over scaphoid osteophyte
- Cannot flex thumb IP
- Important functional loss
FDP Ruptures:
- Usually over carpal osteophytes
- Test each finger (DIP flexion with PIP extended)
FDS Function:
- Test by holding other fingers extended
- May compensate for FDP loss
Wrist Assessment
RA Wrist Changes
Observe:
- Caput ulnae (dorsal prominence of ulna)
- Radial deviation of wrist (compensates for ulnar drift)
- Extensor tenosynovitis (boggy swelling)
- Volar subluxation of carpus
Palpate:
- DRUJ stability (piano key test)
- Extensor tendon synovitis
- Carpal tenderness
Move:
- Range of motion (often limited)
- Crepitus
DRUJ Destruction:
- Caput ulnae = supinated carpus, prominent ulnar head
- Piano key sign positive
- Attritional tendon ruptures
Functional Assessment
Function Testing
Critical Functional Tests:
- Grip Strength: Dynamometer if available
- Pinch Strength: Key pinch, tip pinch
- Key Grip (Froment): Hold paper between thumb and index
- Opposition: Touch thumb to little finger
- Fine Motor:
- Pick up coins
- Button and unbutton
- Write name
- Turn key in lock
Document:
- Dominant hand
- Impact on daily activities
- Walking aid requirements (affects wrist loading)
Extra-Articular Features
Look for Extra-Articular RA
Skin:
- Rheumatoid nodules (extensor surfaces, olecranon)
- Thin, fragile skin (steroid use)
- Vasculitic lesions (nail fold infarcts)
Eyes:
- Dry eyes (secondary Sjögren's)
- Scleritis, episcleritis
Always Examine:
- Cervical spine (atlantoaxial instability)
- Elbows (nodules, flexion contracture)
- Feet (MTP involvement, similar deformities)
Ask About:
- Systemic symptoms (fatigue, weight loss)
- Pulmonary involvement
- Cardiovascular risk
Cervical Spine in RA: ALWAYS ask about and assess cervical spine:
- Atlantoaxial instability in 25-50% of RA patients
- Myelopathy symptoms: Hand clumsiness, gait disturbance
- Neck pain, occipital headache
- Important for surgical planning (anesthetic risk)
Pre-operative Cervical Spine X-rays: Essential before any surgery
Assessment Summary
- pip
- Hyperextension
- dip
- Flexion
- pathology
- Intrinsic tightness, VP laxity
- treatment
- FDS tenodesis, fusion
- pip
- Flexion
- dip
- Hyperextension
- pathology
- Central slip attenuation
- treatment
- Soft tissue if early, fusion if late
- pip
- Variable
- dip
- Variable
- pathology
- Radial sagittal band laxity
- treatment
- MCP arthroplasty
- pip
- N/A (MCP flexion)
- dip
- N/A (IP hyperextension)
- pathology
- EPB attenuation
- treatment
- Fusion or soft tissue rebalancing
- pip
- N/A
- dip
- N/A
- pathology
- DRUJ destruction
- treatment
- Darrach or Sauvé-Kapandji
Summary Presentation
“58-year-old woman with 15-year history of rheumatoid arthritis presents for hand assessment.”
Examination Sequence
Systematic Approach
- Observation: Swelling, deformities, muscle wasting, scars
- Extra-Articular: Nodules, nail fold infarcts, skin quality
- Specific Deformities: Name each deformity present
- Tendons - Extensors: EDC (each finger), EPL, EDM
- Tendons - Flexors: FDS, FDP, FPL
- Wrists: ROM, DRUJ (piano key), caput ulnae
- Intrinsic Testing: Bunnell test, interossei
- Function: Grip, pinch, fine motor, ADLs
- Cervical Spine: Range of motion, neurology
- Complete: Examine elbows, feet if time permits
Examiner Tips
Do
- Name each deformity specifically
- Test each extensor tendon individually
- Assess wrist (affects whole hand)
- Check function, not just appearance
- Mention cervical spine assessment
Don't
- Miss early tendon ruptures (test against resistance)
- Forget Vaughan-Jackson sequence
- Omit extra-articular features
- Neglect to mention surgical priorities
- Forget pre-op cervical spine X-rays