1. The hands are quite difficult to examine as there are a number of signs which can be detected from them. Try and remember each of these and also some of the causes behind the signs.

2. As always, wash your hands, explain the procedure to the patient and gain informed consent.

3. Firstly place the patient's hands on a pillow in between you and them, ensuring the patient is comfortable.

4. Next have a look at the hands. In particular look for swellings, deformities, muscle wasting, scars - particularly carpal tunnel release scars, skin changes, rashes, nail pitting or onycholysis, nailfold vasculitis, palmar erythema. If there are joint swellings note which joints are involved and whether the changes are symmetrical or not.

5. Next you need to feel the hands. This should look as smooth as possible so try and develop your own technique. A good one is to start proximally and work towards the fingers. So, start by feeling the radial pulses and the wrist joints with the two thumbs on the extensor surface and the index fingers on the flexor surface. Then feel the muscle bulk in the thenar and hypothenar eminences. In the palms, feel for any tendon thickening and assess the sensation over the relevant areas supplied by the radial, ulnar and median nerves. As with all other joints, you should assess the temperature over the joint areas and compare these with the temperature of the forearm. Next you should squeeze over the row of metacarpophalangeal joints whilst watching the patient's face for any discomfort. You should then move onto any MCP joints which are noticeably swollen. Palpate these bimanually with your two thumbs on the dorsum and two index fingers on the palm. Move onto the interphalangeal joints and again palpate any which are swollen. This palpation is done with one of the thumbs on the top and the other on one of the sides. The index fingers go on the vacant sides of the joint.

6. At this point you should also look at the underside of the elbows to check for any psoriatic plaques as these could suggect the presence of psoriatic arthritis and for any rheumatoid nodules.

7. The movements which should be assessed are wrist flexion and extension, finger extension and flexion as well as abduction. You should also test thumb abduction and opposition.

8. One special test which you may like to employ is Phalen's test. Forced flexion of the wrist, either against the other hand or by the examiner for 60 seconds will recreate the symptoms of carpal tunnel syndrome. Froment's test may also be performed to check Ulnar nerve function by asking the patient to hold a piece of paper between their thumb and index finger (hence checking adductor pollicis). In a patient with Ulnar nerve palsy the interphalangeal joint of the thumb will flex to compensate.

9. Finally you should perform a functional assessment of the patient. This involves forming a power grip around your middle and index fingers, a pincer grip against your index finger and asking your patient to pick up a small object such as a coin.

10. Thank the patient and wash your hands again.

© Matthew Green and Laura Henderson 2006.