Hand

• Assess whether there is joint swelling, and in which joints. Common causes of swelling in the wrist → arthritis or sprain, MCP → synovitis and in PIP/DIP → osteoarthritis (Bouchard's and Heberden's nodes). Assess whether there are contractures (Dupuytren), atrophy (thenar muscles → median nerve compression), ganglion, or deformities due to previous or current fracture.
• Consider about whether there are pathological changes in the hand by performing a systematic inspection of the four sides of the hand. The hand is inspected dorsally, volarly, ulnarly, and radially. Look for joint swelling, contracture, muscle atrophy, ganglion, and deformity.

• Assess the patient's ability and willingness to move fingers and hand and whether the range of motion is normal, reduced, or asymmetrical. Note whether pain occurs at the start, middle, or end of movement – important to distinguish between tendon, joint, and capsule pathology.
• Consider whether the movement pattern points to flexor tendon injury → lack of active flexion in the PIP/DIP or thumb's IP, extensor tendon injury → lack of active extension in the DIP/MCP, trigger finger → locking during extension from a flexed position, mallet finger → missing active extension in DIP. Also assess whether thumb function (opposition, pinch grip) is weakened (median nerve involvement), and whether pain during active movement corresponds with findings from inspection and palpation.

• MCP joint: Articulatio metacarpophalangea
• PIP joint: Articulatio interphalangea proximalis
  DIP joint: Articulatio interphalangea distalis
• IP joint general: Articulatio interphalangea

• Assess about passive movement is painful, reduced, or has abnormal end-feel. Consider whether the findings point to arthritis → swelling, reduced range, painful end-feel, ligament injury → increased side instability, lack of endpoint in the range of motion, CMC‑1 osteoarthritis → pain with passive extension + adduction of the thumb, crepitation, Skier’s thumb → instability in the ulnar collateral ligament (UCL) of the thumb's MCP, or whether there is de Quervain's tenosynovitis → pain over the radial styloid process with passive ulnar deviation of the wrist.
• Consider About pain during passive movement corresponds with inspection findings (swelling, ganglion, contracture) and findings during active movement. Assess whether the thumb's movements (abduction/adduction) are painful or unstable, which may indicate CMC‑1 osteoarthritis or UCL rupture.

• Extension thumb 65°
• Carpometacarpal, 15°
• Metacarpophalangeal, 50°
• Interphalangial, 90°

Flexion MCP thumb. Keep your wrist in a neutral position, and unevenly stabilize your wrist. Bring the MCP joint of the thumb into full flexion.

Abduction thumb 60°

Palmar abduction (perpendicular to the palm). Normal range of motion 0–60°

Thumb abduction. Keep the wrist in a neutral position, and stabilize the wrist ulnarly. Abduct the thumb at the MCP joint.

Thumb adduction to 0°

Return of the thumb toward the palm/index finger plane. Normal range of motion is back to 0°

Thumb adduction. Keep the wrist in a neutral position, and stabilize the wrist ulnarly. Adduct the thumb at the MCP joint.

• Assess Strength in the wrist (extension, flexion), hand grip, pincer grip, opposition grip, finger abduction, finger adduction, thumb (extension, flexion, abduction), little finger (extension, flexion, abduction), and finger (extension, flexion) in MCP, PIP, and DIP.
• Consider Muscle function and differentiate between the different muscle groups.

• Assess whether there is joint swelling and pain in the wrist, MCP-, PIP- and DIP-joints → possible diagnoses are arthritis, synovitis, osteoarthritis.
• Consider whether palpation for pain and swelling in joints and bone structures reinforces or weakens findings from inspection, active, passive, and isometric movement.

You must first form an impression of whether the range of motion in the wrist is reduced or normal. If the range of motion is reduced, you must determine whether there is a capsular pattern (flexion and extension equally reduced); this could indicate traumatic arthritis in the wrist, early osteoarthritis, or rheumatoid arthritis based on the information you obtain from the medical history. If there is a history of wrist trauma without a previously diagnosed condition, you should consider a missed scaphoid fracture. If, during the examination, you find reduced extension but normal flexion (non-capsular pattern) in a patient with a history of trauma, you should consider whether Subluxation of carpal bones; if there is information about a previous fracture injury, you must consider the development of pseudoarthrosis.

If during the wrist examination you find full mobility and negative isometric tests, you must consider a ganglion in the wrist if the pain occurs when pinching, and an injury to the ulnar or radial collateral ligament if the pain appears during extension.

If, during the wrist examination, you find normal range of motion but pain with extension of the wrist, you must consider that the cause of the patient's complaints may be involvement of one of the extensor tendons (remember the 6 extensor compartments). The most common in general practice is inflammation of the tendon sheath of m. abductor pollicis longus and m. extensor pollicis brevis in compartment 1, so-called de Quervain's tenosynovitis, which you test with the Finkelstein test. Another condition that we can see in general practice is rupture of m. extensor pollicis longus in compartment 3 in connection with undisplaced radius fractures in elderly people. In the other compartments, it is usually tendinopathies or tenosynovitis in patients with acute or chronic overload or in rheumatics.

If during the wrist examination you find normal range of motion, but a positive test with isometric flexion in the wrist, it may be a tendinopathy in m. flexor carpi ulnaris after an acute overload, or a tenosynovitis in mm. flexor digitorum profundus due to overload or as a finding in rheumatics. Be aware that there may simultaneously be clinical findings similar to carpal tunnel syndrome.

Carpal tunnel syndrome causes pain and paresthesia in the median-innervated area of the hand, often in combination with thenar atrophy, tested by Phalen's test and Tinel's sign.