Introduce yourself.
Ask "do you have any pain or stiffness in your hands"
Position the patient with their hands palms down, resting on a pillow.
Expose the patient's arms up to their sleeves.

Look
Begin with the back of the hands.

• Skin: Erythema, nail pitting or other changes, rheumatoid nodules, ganglia, Dupuytren's contracture on palms
• Muscle: Wasting of muscles (guttering in hand)
• Bone & Joint: Swelling of the joints, ulnar deviation, z-thumb , boutonniere deformity, swan-neck deformity, fixed flexion, Heberdens nodes (DIP), Bouchards nodes (PIP).

Check behind the elbows for rheumatoid nodules and psoriatic plaques.


Feel

• Temperature: warm, swollen joints are indicative of active disease.
• Wrist Joint Margins: palpate the ulna head, radial styloid and carpal bones. Pain over the anatomical snuff box may indicate a scaphoid fracture. Tenderness over the ulna head is found in extensor carpi ulnaris tendinitis and pain over the radial styloid may indicate de Quervain’s tenosynovitis.
• Carpal Joint Margins: look at the patient's face to see if this is tender. Feel whether the joint is soft (rheumatoid) or hard (osteoarthritis or gouty tophi). Squeeze the MCP joints noting whether this is painful (active disease). Palpate the individual joints. 

Move
Active then passive movement of the wrist then carpal joints.

• Wrist Flexion (0-80°): put your hands together in a prayer sign
• Wrist Extension (0-70°): put the back your hands together in a reverse prayer sign
• Ulna (0-40°): bend the wrist so that the little finger nears the ulnar
• Radial Deviation (0-20°): bend the wrist so the thumb nears the radius
• Finger Flexion/Extension (0-90°): make a fist and straighten the fingers out
• Finger abduction: spread your fingers out, testing the dorsal interossei supplied by the ulnar nerve

Special Tests:

Carpal tunnel syndrome

• Tinnel’s Sign: Tap on their wrist repeatedly to reveal tingling in the median nerve distribution
• Phalen’s Sign: Hold hands in forced flexion (reverse prayer sign), this maneuver causes median nerve compression eliciting carpal tunnel symptoms.

Ulnar Nerve Function

• Froment's Sign: Ask patient to hold a piece of paper between thumb and finger, tests adductor pollicis. Those with ulnar nerve palsy find it difficult to effectively grip the paper.

De Quervain's Tenosynovitis

• Finkelstein's Test: Ask the patient to flex the thumb then deviate the wrist to the ulnar side. Pain on this movement indicates De Quervain's Tenosynovitis.

Functional assessment
Apart from inspection this is the second most important component of the exam.

Pincer grip: the patient makes a ring with their first finger and thumb and you try and break it with your own.
Power grip: the patient squeezes your finger
Undo button
Writing/holding a pen

Neurological Assessment
Tone: patient flexes/extends fingers in a wave. Ask them to open and close their hands very quickly (is slow in myotonica dystrophica)
Power:
Median: patient sticks thumb in the air, you try and press it down in to teir hand towards their little finger
Ulnar: patient abducts all fingers, you abduct yours and try and adduct their little finger with yours, and their thumb with yours (testing "like-with-like"
Radial: patient extends wrist and you try to flex it
Sensation: check pinprick and light touch just in one area for each nerve
Median: lateral thumb
Ulnar: medial little finger
Radial: anatomical snuffbox