Step-by-Step OSCE Guide

GETTING STARTED

1. Perform hand hygiene and don appropriate PPE.
2. Introduce yourself: “Hi, I’m Jamie, one of the advanced clinical practitioners.”
3. Confirm the patient’s full name and date of birth.
4. Explain the exam: “I’d like to examine your hands and wrists today. I’ll be looking at movement, sensation and strength.”
5. Gain verbal consent and offer a chaperone.
6. Ask about any current pain, stiffness, numbness or weakness.
7. Expose the patient’s hands, wrists and elbows.
8. Position the patient seated with both hands resting on a pillow in front of them.

GENERAL INSPECTION

9. Look at the hands, wrists and forearms for signs of:
   – Swelling, erythema or deformity
   – Muscle wasting (thenar/hypothenar eminences)
   – Scars, rashes, skin/nail changes (e.g. psoriatic)
   – Joint deviation or nodules (RA or OA)
   – Involuntary movements or tremor

PALPATION

10. Assess temperature across both wrists and MCP joints using the back of your hands.
11. Palpate:
   – Radial and ulnar pulses
   – Thenar and hypothenar muscle bulk
   – Palmar thickening (Dupuytren’s)
12. Sensory assessment:
   – Median nerve – index fingertip
   – Ulnar nerve – little fingertip
   – Radial nerve – first dorsal web space
13. MCP squeeze test – gently compress MCP joints across both hands.
14. Bimanually palpate joints of the hand (MCP, PIP, DIP, CMC) for tenderness/swelling.
15. Palpate the anatomical snuffbox (scaphoid tenderness).
16. Bimanually palpate the wrist joints.
17. Palpate along the ulnar border of the forearm to the elbow.

MOVEMENT

18. Ask the patient to perform:
   – Finger extension and flexion
   – Wrist extension and flexion
19. Then assess against resistance:
   – Wrist/finger extension (radial nerve)
   – Index finger abduction (ulnar nerve)
   – Thumb abduction (median nerve)

FUNCTION

20. Assess power grip – ask patient to squeeze your fingers.
21. Assess pincer grip – pick up a small object (e.g. coin or pen lid).
22. Assess fine motor function – ask the patient to do up a shirt button or write a word.

SPECIAL TESTS

23. Tinel’s test – tap over carpal tunnel to provoke tingling in median nerve distribution.
24. Phalen’s test – hold wrists in forced flexion for 30–60 seconds to reproduce symptoms.

CLOSING THE EXAM

25. Let the patient know the exam is finished and thank them.
26. Offer assistance to redress.
27. Perform hand hygiene.
28. Summarise your findings concisely.
29. Suggest further assessments as needed – e.g. full upper limb neurovascular exam, elbow joint assessment, or imaging (X-ray, USS, nerve conduction studies).

Hand and wrist complaints are common – especially in RA, OA and carpal tunnel syndrome. A focused, structured approach helps differentiate the underlying cause efficiently.