Summary of Common Conditions Seen in OSCEs

Hints and Tips for the Exams

Doing the Examination

• Careful observation is very important because most hand diagnoses such as scleroderma, rheumatoid arthritis (RA) and common nerve palsies can often be picked up on observation alone. State what you see but do not list all the negatives.
  
• Feel the temperature using the back of your hand over the wrist and metacarpophalangeal (MCP) joints to check for joint inflammation.
  
• Bimanual palpation of joints: Squeeze gently with the index finger and thumb in an anteroposterior direction with one hand and in a mediolateral direction with the other hand.
  
• Get the patient to shut their eyes and familiarise them with the test for sensation by touching the chest.
  
  
  
  • Radial nerve: Touch over the web space between the thumb and index finger on the posterior surface of the hand.
    
  • Median nerve: Touch over the thenar eminence.
    
  • Ulnar nerve: Touch over the hypothenar eminence.
  
  
• Fix the elbow by pinning it to the patient’s side before testing supination and pronation. Test wrist abduction and adduction with the elbow in the same position. Test flexion and extension at the wrist by asking the patient to perform the prayer and inverse prayer positions.
  
• When testing movement at a particular joint, use your other hand to fix the joint above that being tested.

Figure 18.1 Severe clubbing

Figure 18.2 Bouchard’s nodes

Figure 18.3 Heberden’s and Bouchard’s nodes in osteoarthritis

Figure 18.4 (a, b) Ulnar deviation in rheumatoid arthritis

Performing the Special Tests

• Tinel’s test: Extend the wrist and tap over the carpal tunnel to see whether symptoms of carpal tunnel syndrome can be reproduced.
  
• Phalen’s test: Forced flexion of the wrists for 60 seconds can reproduce the symptoms of carpal tunnel syndrome.
  
• Froment’s sign: This is a test for ulnar nerve palsy. If the thumb adductor is weak, the interphalangeal joint of the thumb flexes when an attempt is made to pull out a piece of paper held between the thumb and index finger.
  
• Finkelstein’s test: This is performed if De Quervain’s tenosynovitis is suspected. The thumb is flexed, and the fingers are then flexed over it to form a fist (with the thumb under the fingers). The wrist is then adducted – if this causes pain, the test is positive and confirms De Quervain’s tenosynovitis.

Presenting the Findings

This is where most candidates slip up, especially if several hand joints are involved. As usual, it is wise to start by stating any obvious abnormalities that strongly point to a diagnosis. If several joints are involved, do not individually state each joint that is involved. This is very time-consuming, is boring for the examiner and adds little information to your presentation. A better approach is to state the groups of joints involved and the disease this pattern is consistent with, for examples ‘The wrists, PIP and MCP joints are red, hot and swollen in a symmetrical distribution; this is consistent with a diagnosis of RA.’

Common Variations at This Station

• Task (7–10 minutes): ‘This is a 29-year-old who complains of painful hands. Take a brief focused history and examine the patient’s hands.’
  There are some key questions to ask in the focused history (see also Chapter 40 on history of joint pain for more detail):
  
  
  
  • Are your joints stiff in the morning?
    
  • Which joints are involved?
    
  • Are there any extra-articular features?
    
  • Is there any functional impairment?
  
  
• Task (7–10 minutes): ‘Perform a GALS screen of this patient’s musculoskeletal system and then examine the hands’. You should aim to spend no more than 2–3 minutes performing the GALS screen at this station. Look particularly for large-joint pathology, axial involvement and psoriatic plaques.
  
• Task (5–10 minutes): ‘This patient complains of pins and needles in her hand at night. Examine her hands and then give her some brief advice on management.’
  
• This is probably the most difficult variation at this station. This type of scenario is frequently tested in finals OSCEs, and it is important to follow the generic structure:
  
  
  
  • Confirmation of diagnosis (e.g. nerve conduction studies)
    
  • Conservative measures: splinting, weight loss
    
  • Medical measures: analgesia, treatment of underlying disorders
    
  • Steroid injections
    
  • Surgery: surgical decompression of the carpal tunnel
    
  • Safety netting: for example, carpal tunnel syndrome can be a first presentation of RA so you must tell your patient to report development of any joint pain or extra-articular features

Stay updated, free articles. Join our Telegram channel

Join