Hand Examination OSCE: Rheumatoid Arthritis, OA and More

Why the Hand Examination Is One of the Richest OSCE Stations

The hands are a window into systemic disease. A 3-minute inspection of someone's hands can reveal rheumatoid arthritis, osteoarthritis, psoriatic arthropathy, gout, systemic sclerosis, infective endocarditis, anaemia, liver disease, and more. This is why the hand examination appears so frequently in OSCEs — it rewards systematic thinking and broad clinical knowledge.

The most common scenario is a patient with inflammatory or degenerative joint disease. Your job is to examine the hands thoroughly, identify the pattern of joint involvement, and reach a differential diagnosis.

The Hand Examination: Systematic Approach

1. Inspect from a Distance (Dorsal Surface)

Before touching, look at both hands together. Ask yourself:

Deformity — where are the joints affected?

Deformities specific to RA:

• Ulnar deviation at MCPJs — fingers deviate towards the little finger
• Swan neck deformity — PIP hyperextension + DIP flexion
• Boutonnière deformity — PIP flexion + DIP hyperextension
• Z-thumb (90/90 deformity) — MCP hyperextension + IP flexion of thumb
• Dorsal wrist swelling — synovitis of the wrist joint

Skin changes:

• Psoriatic plaques on the dorsum or nail pitting/onycholysis (psoriatic arthropathy)
• Tight, shiny skin — systemic sclerosis
• Subcutaneous nodules over the PIP/MCP joints — rheumatoid nodules (also check the olecranon)
• Gottron's papules (purple-red over the knuckles) — dermatomyositis
• Xanthomata over the tendons — hypercholesterolaemia

Nails:

• Pitting, onycholysis, subungual hyperkeratosis → psoriatic arthropathy
• Splinter haemorrhages → infective endocarditis, vasculitis
• Clubbing → lung cancer, bronchiectasis, cyanotic heart disease, liver cirrhosis
• Koilonychia (spoon-shaped nails) → iron deficiency anaemia
• Leukonychia (white nails) → hypoalbuminaemia (liver disease)

2. Inspect the Palmar Surface

Turn the hands over:

• Palmar erythema → liver disease, pregnancy, RA
• Dupuytren's contracture — thickening of the palmar fascia pulling the ring/little finger into flexion (associated with alcohol, liver disease, diabetes, epilepsy treatment)
• Thenar wasting → median nerve compression (carpal tunnel syndrome)
• Hypothenar wasting → ulnar nerve lesion
• Skin creases: pale creases indicate anaemia (haemoglobin <7–8 g/dL)

3. Feel the Temperature

Using the back of your hand, feel the dorsum of each hand. Warmth over specific joints indicates active synovitis (RA, gout, septic arthritis).

4. Palpate the Joints

Systematically squeeze each joint:

• MCP joints: Squeeze across the knuckles transversely — tenderness = synovitis (RA)
• PIP joints: Palpate individually for swelling (soft = synovitis; hard = osteophytes)
• DIP joints: Heberden's nodes (OA) are hard bony osteophytes; Bouchard's nodes at PIP
• Wrist: Palpate the joint line on the dorsum; check for effusion

5. Assess Function

Three key functional tests:

1. 1Power grip: "Squeeze my fingers as hard as you can" — tests intrinsic and extrinsic muscle power
2. 2Pinch grip: "Pick up this coin" — tests precision grip (median nerve, thenar muscles)
3. 3Extension: "Open your hands out flat" — inability to fully extend = flexor tendon tethering or PIP/DIP disease

Also test:

• Prayer sign (dorsiflexion of wrists): inability to fully dorsiflex suggests wrist involvement
• Reverse prayer sign (palmarflexion): tests palmar wrist extension

6. Assess Sensation and Neurovascular Status

In any hand examination, briefly assess:

• Light touch in median nerve distribution (thumb, index, middle finger, lateral half of ring)
• Radial pulse at the wrist
• Capillary refill of the fingertips

RA vs OA: The Essential Comparison Table

The GALS Screen

In OSCEs you may be asked to perform a GALS (Gait, Arms, Legs, Spine) screen — a 2-minute locomotor screening examination used to identify any musculoskeletal abnormality.

Three screening questions to ask first: "Do you have any pain or stiffness in your muscles, joints, or back? Can you dress yourself completely without difficulty? Can you walk up and down stairs?"

How to Present Your Findings

"On examination of the hands, there was bilateral symmetrical swelling of the MCP and PIP joints, with soft boggy consistency consistent with active synovitis. There was ulnar deviation at the MCPJs bilaterally. The DIP joints were spared. There were no rheumatoid nodules palpable over the elbows. The hands were warm over the involved joints. Functional assessment showed reduced power grip bilaterally and difficulty with fine pinch. The palmar skin was normal and there was no thenar wasting. These findings are consistent with active rheumatoid arthritis with bilateral symmetrical MCP/PIP involvement. I would complete my assessment by examining the elbows for nodules, assessing the feet, reviewing the eyes for episcleritis, and requesting RF, anti-CCP, CRP, ESR, and X-rays of the hands and feet."

Common Examiner Follow-Up Questions

"What are the extra-articular manifestations of rheumatoid arthritis?"

"Rheumatoid arthritis can affect almost any organ system. In the eyes: episcleritis, scleritis, keratoconjunctivitis sicca (secondary Sjögren's). In the lungs: pleural effusion, pulmonary nodules, fibrosing alveolitis, obliterative bronchiolitis. Cardiovascular: pericarditis, accelerated atherosclerosis, vasculitis. Neurological: peripheral neuropathy, mononeuritis multiplex, carpal tunnel syndrome, cervical myelopathy from atlantoaxial subluxation. Haematological: anaemia of chronic disease, Felty's syndrome (RA + splenomegaly + neutropenia). Systemic: rheumatoid nodules (over pressure areas — olecranon, sacrum, occiput), amyloidosis (late complication)."

"A patient has DIP joint involvement with nail pitting. What is the most likely diagnosis and how would you investigate?"

"DIP joint involvement with nail changes strongly suggests psoriatic arthropathy — a seronegative spondyloarthropathy. I would look for psoriatic plaques (classically on the extensor surfaces of the elbows and knees, the scalp, and behind the ears), onycholysis, and subungual hyperkeratosis. Investigation: inflammatory markers (CRP, ESR), RF (negative — seronegative), X-rays of hands showing 'pencil-in-cup' deformity in advanced disease, and HLA-B27 if axial involvement is suspected. I would refer to rheumatology and dermatology jointly. Treatment includes NSAIDs, DMARDs (methotrexate), and biologics (TNF inhibitors, IL-17 inhibitors) for refractory disease."

"What is Dupuytren's contracture and what are the associated conditions?"

"Dupuytren's contracture is a progressive fibrosis of the palmar fascia causing contracture of the ring and little fingers into flexion — the fingers cannot be straightened. It is caused by fibroblast proliferation and collagen deposition. Associated conditions include: alcoholic liver disease (the most commonly tested association), diabetes mellitus, phenytoin use, manual labour/vibration exposure, Peyronie's disease (penile fibrosis), and plantar fibromatosis (Ledderhose disease). It is more common in men of Northern European descent. Treatment is surgical fasciectomy or collagenase injection (Xiapex) for those with significant functional impairment."

Related guides: [Musculoskeletal History OSCE](/blog/musculoskeletal-history-osce) · [Peripheral Vascular Examination OSCE](/blog/peripheral-vascular-examination-osce)