Rheumatological Examination of the Hands — Clinical Case

DCE Short Case 1 — The Symmetrical Inflammatory Hands (Rheumatoid Arthritis)

Patient brief (provided to trainee)

Patient: Mrs Margaret Chen, 52 years old, bookkeeper. [1]

Presenting complaint: Progressive pain, stiffness, and swelling of both hands over 18 months, worst in the mornings. Morning stiffness lasts approximately two hours. She has increasing difficulty with her work (typing, writing), turning taps, and opening jars. She has noticed small lumps on her right forearm. [1]

Instruction: "Please examine this patient's hands. Present your findings and offer a differential diagnosis." [1]

Examination findings (trainee elicits):

• Inspection: Symmetrical deformity of both hands with ulnar deviation and palmar subluxation at the MCP joints, swan-neck deformity of the right index and middle fingers, and a Z-deformity of the right thumb. The DIP joints are spared. Soft, boggy swelling at the second and third MCP joints bilaterally and at the wrists. Firm, non-tender subcutaneous nodules (1 cm) on the extensor surface of the right forearm and at the right olecranon. No sclerodactyly, no Gottron papules, no nail pitting, no psoriatic plaques.
• Palpation: The swollen joints are warm and tender on pressure and on movement. The skin texture is normal. Crepitus is soft at the MCPs and wrists. No coarse bony crepitus.
• Range of motion: Reduced at the wrists (flexion 40 degrees, extension 30 degrees) and the MCPs, with pain. The DIPs have a full range.
• Function: Grip strength reduced bilaterally. Pinch grip preserved but weaker on the right. Writing is slow and deliberate. Difficulty picking up a coin and turning a key. Cannot make a full fist (fingertips do not reach the palm).
• Additional: Rheumatoid nodules at the right olecranon and extensor forearm. No psoriatic plaques on the elbows. Shoulder movement full and painless.
• Neurovascular: Radial pulses present, capillary refill under 2 seconds. Sensation intact in median and ulnar nerve territories. Tinel sign negative, Phalen test negative. [1]

Presentation template (model answer)

"I have examined this patient's hands. On inspection, there is symmetrical deformity of both hands with ulnar deviation and palmar subluxation at the MCP joints, swan-neck deformity of the right index and middle fingers, and a Z-deformity of the right thumb. The DIP joints are spared. There is soft, boggy, warm, tender swelling consistent with active synovitis at the second and third MCP joints bilaterally and at the wrists. There are firm, non-tender rheumatoid nodules on the extensor surface of the right forearm and at the right olecranon. Range of movement is reduced at the wrists and MCPs. Function is impaired — the grip is weak, the patient cannot make a full fist, and she has difficulty with fine tasks and turning a key. The pulses are present, the sensation is intact, and the Tinel and Phalen tests are negative. [1]

In summary, these findings are consistent with seropositive rheumatoid arthritis with active synovitis, extra-articular nodular disease, and functional impairment. I would confirm with a history of morning stiffness, serology for rheumatoid factor and anti-CCP, inflammatory markers, and hand X-rays. I would calculate a DAS28 score to quantify disease activity. [1]

To complete my examination, I would examine the other joints, the skin, the chest, and the eyes." [1]

Discussion

Examiner: "What is your diagnosis and what are the classification criteria?" [1]

"The most likely diagnosis is seropositive rheumatoid arthritis. The 2010 ACR/EULAR classification criteria require synovitis in at least one joint, no better alternative diagnosis, and a score of six or more from joint involvement, serology, acute phase reactants, and symptom duration [1]. This patient, with bilateral small-joint involvement, symptoms over six weeks, and high inflammatory markers, clearly meets the criteria. The rheumatoid nodules indicate seropositive, more aggressive disease."

Examiner: "How would you quantify her disease activity?" [1]

"I would calculate the DAS28 [2]. The 28 joints are the ten MCPs, ten PIPs, both wrists, both elbows, both shoulders, and both knees. I count the swollen and the tender joints, combine with the ESR and the patient global assessment, and produce a single score. Over 5.1 is high disease activity, 3.2 to 5.1 is moderate, 2.6 to 3.2 is low, under 2.6 is remission. Given the bilateral MCP and wrist synovitis and the prolonged morning stiffness, she is in at least moderate-to-high disease activity and requires DMARD escalation."

Examiner: "What is your management plan?" [1]

"An integrated, multidisciplinary approach. Pharmacologically, I would initiate or escalate DMARD therapy under the treat-to-target strategy aiming for remission or low disease activity. Methotrexate is the anchor drug (10 to 25 mg weekly with folic acid), with sulfasalazine and hydroxychloroquine if triple therapy is indicated. If the target is not met, I would escalate to a biologic (TNF inhibitor, rituximab, tocilizumab, abatacept) or a JAK inhibitor. Short-term corticosteroids for bridging during flares. NSAIDs for symptomatic relief. I would refer to a hand therapist for joint protection, splinting, and exercises, to an occupational therapist for aids and adaptations, and to a rheumatologist for ongoing disease management. I would also assess her cardiovascular risk (RA carries a risk equivalent to diabetes), her bone density (osteoporosis risk), and her vaccination status. If medical therapy fails to control pain or function, I would consider surgical referral for synovectomy, arthroplasty, or tendon repair." [1]

DCE Short Case 2 — The Bony Nodular Hands (Osteoarthritis)

Patient brief

Patient: Mr Robert Jones, 68 years old, retired builder. [1]

Presenting complaint: Gradually progressive stiffness and knobbly deformity of the finger joints over many years, with pain at the base of the thumbs on gripping and pinching. Morning stiffness is brief (10 to 15 minutes). Worse after heavy use. [1]

Instruction: "Please examine this patient's hands." [1]

Examination findings:

• Inspection: Hard, bony, irregular nodules at the DIP joints bilaterally (Heberden nodes) and at the PIP joints (Bouchard nodes), with squaring of the first carpometacarpal joints bilaterally. The MCP joints are normal. No soft swelling, no warmth, no synovitis.
• Palpation: The nodules are hard, bony, and non-tender. The first CMC joints are tender on the grind test. Crepitus is coarse and bony at the DIP, PIP, and first CMC joints. The skin is cool.
• Range of motion: Mildly reduced at the affected DIP and PIP joints and the first CMC joints.
• Function: Grip strength preserved. Pinch grip impaired from first CMC pain. Difficulty turning a key (the grind test reproduces the pain).
• Additional and neurovascular: Normal. [1]

Presentation

"I have examined this patient's hands. On inspection, there are hard, bony, irregular nodules at the DIP joints (Heberden nodes) and at the PIP joints (Bouchard nodes), with squaring of the first carpometacarpal joints bilaterally. The MCP joints are normal. There is no soft swelling, no warmth, and no synovitis. Crepitus is coarse and bony. The first CMC joints are tender on the grind test. Function is impaired for pinch grip and key turning from the first CMC OA, but grip strength is preserved. In summary, these findings are consistent with primary nodal osteoarthritis with first CMC involvement. To complete my examination, I would examine the knees, hips, and spine for the generalised OA pattern." [1]

Discussion

Examiner: "How do you distinguish this from rheumatoid arthritis?" [1]

"Five points. First, the swelling is hard and bony, not soft and boggy. Second, the joints are cool and non-tender, not warm and tender. Third, the morning stiffness is brief (under 30 minutes), not prolonged. Fourth, the distribution involves the DIP and the first CMC (which RA spares) and spares the MCP (which RA targets). Fifth, the inflammatory markers and the rheumatoid factor are typically normal. The radiographic features are osteophytes, subchondral sclerosis, asymmetrical joint space narrowing, and subchondral cysts — not the periarticular osteopenia and symmetric marginal erosions of RA." [1]

DCE Short Case 3 — The Sausage Digit (Psoriatic Arthritis)

Patient brief

Patient: Mr Daniel Smith, 38 years old, graphic designer. [1]

Presenting complaint: Swelling of the entire left fourth finger for three months, with nail changes. He has a history of psoriasis affecting the elbows and the scalp. [1]

Instruction: "Please examine this patient's hands." [1]

Examination findings:

• Inspection: Uniform swelling of the entire left fourth finger (dactylitis or sausage digit). Isolated swelling of the right index DIP joint. Multiple nail pits and onycholysis of several fingernails. The MCP joints are spared. Well-demarcated, scaly, erythematous plaques on the extensor surface of both elbows and at the umbilicus.
• Palpation: The dactylitic finger is diffusely swollen, warm, and tender. The right index DIP is boggy and tender. No rheumatoid nodules.
• Range of motion: Reduced at the left fourth finger (all joints) and the right index DIP.
• Function: Impaired for the dactylitic finger, especially for typing.
• Additional and neurovascular: Normal. Psoriatic plaques on elbows and umbilicus. [1]

Presentation

"I have examined this patient's hands. On inspection, there is uniform swelling of the entire left fourth finger — a classic dactylitis or sausage digit — with isolated swelling of the right index DIP joint. Multiple nails show pitting and onycholysis. The MCP joints are spared. There are scaly, erythematous, well-demarcated plaques on the extensor surface of the elbows and at the umbilicus, consistent with psoriasis. In summary, these findings are consistent with psoriatic arthritis, distal interphalangeal predominant pattern, with dactylitis, nail involvement, and cutaneous psoriasis. I would apply the CASPAR criteria and arrange HLA-B27 and hand X-rays. To complete my examination, I would examine the scalp and the natal cleft for further psoriasis, and the spine for spondyloarthropathy features." [1]

Discussion

Examiner: "What are the CASPAR criteria, and how does this patient meet them?" [1]

"The CASPAR criteria require inflammatory articular disease plus at least three points from: current psoriasis (2 points), a personal history of psoriasis (1), a family history of psoriasis (1), current dactylitis or a history recorded by a rheumatologist (1), radiographic juxta-articular new bone formation (1), rheumatoid factor negativity (1), and nail dystrophy including onycholysis, pitting, and hyperkeratosis (1) [3]. This patient scores current psoriasis (2) plus dactylitis (1) plus nail dystrophy (1) plus RF negativity (assumed, 1), a total of 5, well above the threshold of 3. The asymmetry, the DIP involvement, the nail changes, and the dactylitis are the discriminating features that separate PsA from RA."

Aletaha et al. (2010 ACR/EULAR RA criteria), Arthritis Rheum 2010; Prevoo et al. (DAS28), Arthritis Rheum 1995; Taylor et al. (CASPAR criteria), Arthritis Rheum 2006; Neogi et al. (2015 gout criteria), Arthritis Rheumatol 2015; Aringer et al. (2019 SLE criteria), Arthritis Rheumatol 2019; van den Hoogen et al. (2013 SSc criteria), Arthritis Rheum 2013; RACP DCE Examination Handbook; MRCP PACES; Hutchinson's Clinical Methods; Talley and O'Connor Clinical Examination. [1]