Background Musculoskeletal (MSK) examination lacks standardization and appropriate validation^1,2. Ultrasound (US) has the potential to facilitate early diagnosis of arthritis ^3,4. There is a current trend incorporating the use of US in daily rheumatological practice. This approach should be evaluated carefully particularly in developing countries as it will add burden on routine care for patients with arthritis. MSK examination is a simple, cost free and easily available tool to diagnose arthritis.

Objectives to standardize the MSK examination of the hand and wrist joints and to evaluate the accuracy of this standard technique to diagnose arthritis in comparison to US findings.

Methods A standardized approach to MSK examination of the hand and wrist joints was formulated by the authors. The objective of this approach is to diagnose arthritis; joint line tenderness and/or swelling. The Delphi technique was used to establish a consensus among 24 rheumatologists on the most important methods to be followed. Agreement level among two rheumatologists performing the MSK exam was calculated. Patients aged 18-75 years with symptoms suggestive of inflammatory arthritis more than 3 months were included in the study from two centers in Jeddah, Saudi Arabia. Ultrasound (US) was performed in the same day of visit where MSK exam of hand and wrist joints were performed based on the standard approach.

Results A total of 2,112 joints in 98 patients were assessed both clinically and with US. On MSK examination based on the standard approach, 746 joints were swollen (35.3%), 515 joints were tender (24.5%). On US examination, 711joints had joint effusion (33.6%), 102 joints had proliferation (4.8%) and 19 joints had synovial hyperemia (0.08%).The sensitivity of standard MSK examination were high in the wrist joint using the two thumbs technique (80%), in 2nd and 3rd metacarpophalangeal (MCP) joints using the scissor and squeeze techniques (74%) and (70%) respectively and in the 3^ed proximal interphalangeal joint (PIP) using the four fingers technique (68.6%). Inter-observer reproducibility assessment had as agreement of 81.5% (78%>98%) for joint effusion.

Conclusions The two thumbs technique for the wrist joints, the scissor and squeeze techniques for MCP joints and the four fingers technique for PIP joints are useful tools if used appropriately to diagnose arthritis clinically.

1. Coady, D.A., D.J. Walker, and L.J. Kay, Teaching medical students musculoskeletal examination skills: identifying barriers to learning and ways of overcoming them. Scand J Rheumatol, 2004; 33(1): p. 47-51.

2. Dacre, J. and I. Haq, Assessing competencies in rheumatology. Ann Rheum Dis, 2005; 64(1): p. 3-6.

3. Filer, A, et al., Utility of ultrasound joint counts in the prediction of rheumatoid arthritis in patients with very early synovitis. Ann Rheum Dis, 70(3): p. 500-7.

4. Wakefield, R.J., et al., The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: a comparison with conventional radiography. Arthritis Rheum, 2000; 43(12): p. 2762-70.

Disclosure of Interest H. Almoallim Grant/Research support from: This research was supported by Alzaidi chair of research in rheumatic diseases, Umm Alqura University. US machines and ultrasonographers were provided by Abbott pharmacuticals, S. Attar: None Declared, N. Janoudi: None Declared, B. Eldek: None Declared, N. Alnagshabandi: None Declared, H. Halabi: None Declared, O. Fathaldin: None Declared