The Examination of the Wrist

by Mark Ernst, MD, FRCSC, DipSportMed

The wrist is essentially a double row of small bones intertwined to form a malleable hinge between the hand and the forearm. Due to its complexity, wrist injuries and dysfunctions are difficult to treat, so that accurate diagnosis is crucial. A consistent pattern of examination is essential to obtain optimal results.

HISTORY

As always the history is a critical prelude to any assessment, the first essential being to establish the mechanism of injury:

• Onset: Acute or chronic (repetitive strain injury)
• Location of symptoms
• Associated symptoms e.g. numbness due to ulnar or radial nerve entrapment in a displaced fracture
• Treatments already provided (physiotherapy, bracing, medications)

If Traumatic

Consider:

• Involvement of the distal radius. This is a common feature of wrist injuries seen in ambulatory care.
• Fractures of the carpal bones. These are not uncommon, with scaphoid fractures representing about seventy percent of these. If left untreated these fractures can produce significant disability.
• Ligamentous disruption/joint dislocations, in which early recognition is vital, since management of a chronic injury is much more difficult and the risk of development of arthritis is high.

If Atraumatic

Consider:

• Arthritis, an important contributor to chronic wrist pain, which can be the result of a distant acute episode.
• Tendinopathy and Neuropathy as in De Quervainís tenosynovitis or ulnar and median nerve entrapments.
• Avascular Necrosi, can be associated with sickle cell anaemia, diabetes and Type II or IV hyperlipidaemia. Known as Kienboch's AVN when affecting the lunate, and Preiser's AVN when affecting the scaphoid. AVN appears as complete opacification of the bone on x-ray.

EXAMINATION

• Assess ventral and dorsal surfaces.
• View wrists in radial and ulnar deviation.
• Assess dorsal and palmar flexion, passive and active.
• Alignment: Compare side to side, use goniometer if in doubt.
• Color and sweat pattern: In reflex sympathetic dystrophy skin may be dry.

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• Neurovascular exam: Look for areas of mottling and color change, areas of wasting as in the thenar or hypothenar eminences. Two-point discrimination should be able to distinguish two points at 10mm or less separation. (Test index and fifth fingers)

• PALPATION most important: Specific areas of pain correlate closely with x-ray finding. (see below)
• Stability testing for ligament laxness and possible disruption.
• Exclude concomitant elbow injury.
• Range of Movement must be assessed on both sides.

PALPATION

1. Dorsal

• Scaphoid tubercle: Tenderness here indicates pain at distal pole of scaphoid.
• Sulcus dorsal to tubercle: Tenderness here indicates pain at the proximal pole of the scaphoid.
• In line with the sulcus between the 2nd and 3rd knuckles: Tenderness here indicates ligament tenderness in the scapho-lunate interval.
• Immediately ulnar to this: The lunate bone
• Small depression further to the ulnar side: The lunotriquetral interval.
• On the ulnar edge of the wrist: The Triangular fibro-cartilage complex area and ulnar styloid.

2. Palmar

• At ulnar edge of palmar aspect of wrist. Pisiform bone.
• Distal to this the hook of the hamate (very difficult to find)

SPECIFIC TESTS

• Phalen's test: In carpal tunnel syndrome palmar flexion of the wrist to 90 degrees for one minute exacerbates or reproduces the symptoms.
• Watson's test: For scapho-lunate instability. The wrist is grasped with the examiner's thumb over the scaphoid tuberosity. The wrist is then moved from ulnar to radial deviation. The examiner will feel a significant 'clunk' and the patient will experience pain (even on the normal side). Side to side comparison is necessary. The mechanism is that if the scapho-lunate ligament is disrupted the scaphoid will tend to turn down and the lunate to turn up. This manoeuvre reproduces the subluxation.
• Finkelstein's test: For De Quervainís tenosynovitis. Dorsal thumb pain is experienced when the wrist is deviated in an ulnar fashion and the thumb is flexed across the palm.
• Tinel's sign: Tapping over the dorsum of the wrist precipitates pain in the median nerve distribution.
• Allen's test: For vascular supply. The patient clenches the fists to pump blood away from the hands. The examiner applies pressure over the ulnar and radial arteries. The patient opens his hands and the examiner releases pressure over one of the arteries to assess arterial filling.
• Froment's sign: Assessing ulnar nerve damage. The patient is asked to hold a sheet of paper firmly between the 3rd and 4th fingers. If the examiner can pull the paper from between the fingers the test is positive. Rationale; the ADductors have purely Ulnar nerve supply, the ABductors have shared innervation.
• Stability of the distal radio-ulnar joint: Assess in pronation, supination and neutral position. It will always seem tighter in supination.
• Midcarpal instability: If unstable may require splinting for activity and physiotherapy strengthening program.