Checklist

WIPER

• Hands on a pillow on the patient's lap

Physiological parameters

• Ask if there is any pain

Systemic observations

• Aids/splints

• Ears: gouty tophi

• Face: scleroderma, acromegaly, hypothyroidism

• Elbow extensor surfaces: rheumatoid nodules, psoriasis plaques

Look

• Skin: scars, palmar erythema, finger pulp infarcts, cyanosis, nail changes

• Soft tissues: muscle wasting, swelling around tendons

• Bone: Heberden's and Bouchard's nodes (OA), square wrists and finger deformities in RA (z-thumb, swan neck and ulnar drift deformities), joint subluxations

Feel

• Skin: temperature, tenderness

• Soft tissues:

• nodules, cords and fascial contractures (Dupuytren's)

• joints: tenderness, swelling, mucous cysts, ganglions

• tendons: boggy swelling (tenosynovitis), ruptures

• Bone: bone tenderness, crepitus, instability

Vascular

• Radial and ulnar pulses

• Capillary refill time

• Allen's test (see Chapter 26, Arterial examination of the upper limbs)

Sensory nerves

• Median: palmar thenar eminence and radial 3.5 fingers

• Ulnar: palmar hypothenar eminence and ulnar 1.5 digits

• Radial: dorsum of hand first web space

Motor nerves

• Median:

• thumb abduction (‘palm up, thumb vertical’)

• thumb and index finger: ‘OK sign’

• Ulnar:

• interossei PAD/DAB: cross fingers test

• adductor pollicis: Froment's (thumb-paper test)

• abductor digiti minimi: little fingers pressed against each other

• Radial:

• extensor pollicis longus: ‘flat palm down on table, lift thumb’

• extensor digitorum communis: extension of four digits

Move

• Test active then passive ROM with a view to identifying neurological, tendon or joint stiffness, crepitus, triggering, instability.

• Assess MRC power grading for each muscle or composite movement as required (see Chapter 38, Focal neurological examination).

Ask patient to make a fist, then to extend all the fingers.