Diagnosing synovitis of the hand and wrist

Summary: This article provides excellent pictures and descriptions for the physical examination of synovitis of the hands. The descriptions are detailed as well as possible to facilitate reproducibility. The study found that the examination of the wrist joint line at the capitate yielded the best combination of sensitivity and specificity. Resulting positive predictive values never exceeded 80%. Negative predictive values were stronger. Note that this study yielded higher sensitivity than a prior study reviewed here that did not use a structured examination.

Patients: Adults with “history of morning stiffness in the small joints of their hands and/or pain in the small joints of the hands and wrist, with or without swellings. Onset of symptoms was not less than 3 months.”

Examiners: Experienced rheumatologists who were blinded to the reference standard. Unclear is the examiners were blinded to the patients’ histories.

Examination method:

A Delphi method with 21 rheumatologists identified 4 examination methods thought to be the most important. Below are brief descriptions for some of the maneuvers, but the article provides much more detail with figures.

  1. MCP scissor – examine MCP joint lines for swelling or tenderness while MCPs flex 90 degrees
  2. MCP squeeze – to assess tenderness on sides of MCPs
  3. PIP 4-finger – examine for swelling or tenderness while squeezing joint from sides
  4. Wrist 2-thumb – follow third meta-carpal proximally till encountering capitate. Follow capitate proximally until dimple at the wrist joint line.

Reference standard: Ultrasonographer who was blinded to the study who assessed :components of synovitis (i.e. effusion, proliferation and hyperaemia)”

Results:

Finding Sensitivity Specificity
 Wrist 2-thumb  80% 54%
MCP scissor
(swelling at second MCPjoint)
74% 50%
MCP squeeze
PIP 4-finger

Reference:

Almoallim H, Attar S, Jannoudi N, Al-Nakshabandi N, Eldeek B, Fathaddien O, & Halabi H (2012). Sensitivity of standardised musculoskeletal examination of the hand and wrist joints in detecting arthritis in comparison to ultrasound findings in patients attending rheumatology clinics. Clinical rheumatology, 31 (9), 1309-17 PMID: 22673791

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