Rheumatological Examination of the Hands — Viva

Short Case Viva Defence

Candidate's opening statement (model answer)

"I examined this patient's hands using the systematic six-step routine — inspection, palpation, range of movement, function, additional sites, and neurovascular assessment. [1]

On inspection, there is symmetrical deformity of both hands with ulnar deviation and palmar subluxation at the metacarpophalangeal joints, swan-neck deformity of the 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 subcutaneous nodules on the extensor surface of the right forearm, consistent with rheumatoid nodules. [1]

Palpation confirms the synovitis — the joints are boggy, warm, and tender. The skin texture is normal, with no sclerodactyly. Crepitus is soft, not coarse and bony. [1]

Range of movement is reduced at the wrists and MCPs, with pain on flexion and extension. [1]

Function is impaired — the grip is weak bilaterally, the patient cannot make a full fist, and pinch grip is reduced. Writing is slow and deliberate. [1]

On additional examination, there are rheumatoid nodules at the right olecranon. There is no psoriasis on the elbows or the umbilicus. [1]

The pulses are present and the sensation is intact, with a negative Tinel and Phalen test. [1]

In summary, these findings are consistent with seropositive rheumatoid arthritis with active synovitis and extra-articular nodular disease, in high disease activity. I would confirm with serology for rheumatoid factor and anti-CCP, inflammatory markers, and hand X-rays for periarticular osteopenia and marginal erosions. I would calculate a DAS28 score to quantify disease activity. To complete my examination, I would examine the other joints, the skin, the chest, and the eyes." [1]

Examiner: "What is the single most discriminating observation in the first thirty seconds of the hand examination?"

"The type and distribution of the joint swelling. The distinction between soft, boggy, warm, tender, symmetrical swelling — synovitis, indicating an inflammatory arthritis such as rheumatoid arthritis — and hard, bony, irregular, non-tender, asymmetrical swelling — osteophytes, indicating osteoarthritis — is the first fork in the examination and it frames the entire differential before a single joint is palpated. The candidate who makes this distinction at inspection and confirms it at palpation has the core rheumatological competency. The candidate who calls all swelling 'arthritis' has lost the diagnosis." [1]

Examiner: "The DIP joint is spared in this patient. Why is that important, and what diseases involve the DIP?"

"The sparing of the DIP joints is a key discriminator for rheumatoid arthritis, because RA targets the MCP and PIP joints and the wrists and characteristically spares the DIP. The diseases that involve the DIP are osteoarthritis (Heberden nodes at the DIP, Bouchard nodes at the PIP), psoriatic arthritis (distal interphalangeal predominant pattern, often with adjacent nail involvement), and gout (any joint). So a patient with what looks like RA but who also has DIP involvement either has coexisting OA, or has PsA, or has gout — and the candidate must re-examine the nails, the skin, and the ears to look for the discriminating clues." [1]

Examiner: "How do you count the DAS28, and what does the score mean for this patient?"

"The DAS28 assesses 28 joints: the ten MCPs, the ten PIPs, both wrists, both elbows, both shoulders, and both knees. The DIPs, ankles, and MTPs are not counted. For each joint I record whether it is swollen and whether it is tender, giving a swollen joint count and a tender joint count out of 28 [2]. The DAS28 combines these counts with the ESR or CRP and the patient global assessment on a visual analogue scale. The thresholds are: over 5.1 is high disease activity, 3.2 to 5.1 is moderate, 2.6 to 3.2 is low, and under 2.6 is remission. This patient, with bilateral MCP and wrist synovitis, is in high disease activity and requires escalation of DMARD therapy under the treat-to-target strategy, aiming for remission or low disease activity."

Examiner: "What are the rheumatoid nodules, and what do they signify?"

"Rheumatoid nodules are firm, non-tender, mobile subcutaneous nodules found over pressure points — the olecranon, the extensor surface of the forearm, the MCP joints, and the Achilles tendon. They are found in approximately 20 to 30 per cent of patients with seropositive (RF-positive) rheumatoid arthritis, and their presence indicates more aggressive disease with a higher likelihood of extra-articular manifestations (vasculitis, pulmonary fibrosis, Felty syndrome) and more rapid radiographic progression. They are one of the features of the 1987 ACR criteria but are not part of the 2010 ACR/EULAR criteria, because the newer criteria focus on early disease and the nodules typically develop later." [1]

Examiner: "How would you distinguish this patient from one with Jaccoud arthropathy of SLE?"

"The key test is reducibility. In Jaccoud arthropathy of SLE, the ulnar deviation and MCP subluxation are caused by ligamentous laxity and tendon imbalance from recurrent inflammation, not by synovial erosion — so the deformities are correctable. I ask the patient to place their hands palms-down on the table, or I passively correct the deviation. In Jaccoud arthropathy the deformity corrects; in RA it does not because the joint is structurally destroyed. Other discriminators: Jaccoud arthropathy has minimal or no active synovitis on palpation, no rheumatoid nodules, no bony erosion on X-ray (the non-erosive arthropathy), and a positive ANA. The 2019 EULAR/ACR SLE criteria require a positive ANA as the mandatory entry criterion and the accumulation of at least 10 points, with musculoskeletal joint involvement scoring 6 [1]."

Examiner: "What nail and skin changes should you look for that would change the diagnosis?"

"I look for nail pitting and onycholysis, which would point to psoriatic arthritis; periungual telangiectasia and abnormal nailfold capillaries, which would point to a connective tissue disease (systemic sclerosis, dermatomyositis, SLE); Gottron papules (violaceous scaly papules over the MCP and PIP extensor surfaces), which are pathognomonic for dermatomyositis; sclerodactyly (tight, thickened, bound-down skin of the fingers), which is diagnostic of systemic sclerosis; digital pulp pitting scars and calcinosis, which are features of SSc; psoriatic plaques on the extensor surfaces of the elbows, the scalp, the umbilicus, and the natal cleft, which would confirm psoriatic arthritis; and palpable purpura, which would indicate small-vessel vasculitis. Each of these signs can change the diagnosis from RA to a different systemic disease, and the candidate who examines only the joints and not the skin and nails has missed the connective tissue diseases entirely." [1]

Examiner: "This patient has no carpal tunnel signs now. How would you test for it, and what is the mechanism in RA?"

"I test for carpal tunnel syndrome at the wrist with three bedside maneuvers: the Tinel sign (tapping over the flexor retinaculum reproduces median-nerve-distribution tingling), the Phalen test (holding both wrists in maximal palmar flexion for 60 seconds reproduces the symptoms), and the assessment of median nerve sensation and thenar muscle function (thumb opposition, abductor pollicis brevis). I also test for sparing of the palm — the palmar cutaneous branch of the median nerve passes superficial to the flexor retinaculum and is therefore spared, distinguishing carpal tunnel syndrome from a proximal median nerve lesion. In rheumatoid arthritis, the mechanism is tenosynovitis of the flexor tendons at the wrist, which narrows the carpal tunnel and compresses the median nerve. The Tinel sign and the Phalen test have only moderate sensitivity and specificity on meta-analysis and should be interpreted together with the clinical picture." [1]

Examiner: "What is the one lesson you would take from this case?"

"The single most important lesson is that the type of swelling and the distribution of the deformity generate the diagnosis in the first thirty seconds — but they must be confirmed by palpation (synovitis versus osteophyte) and integrated with the skin and nail examination and the functional assessment. The registrar who rushes to a diagnosis on inspection alone, without palpating for synovitis or counting the joints or testing the function, has done half the examination. The six-step routine — inspection, palpation, range of movement, function, additional sites, neurovascular — performed in the same order every time, is the sequence that collects the data the diagnosis requires and the sequence the examiner expects." [1]

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]