Clinical Examination of the Wrist






CRITICAL POINTS





  • Successful clinical examination of the wrist requires a thorough knowledge of wrist anatomy, biomechanics, and pathology.



  • The wrist examination includes a complete history, visual inspection, objective assessments, and a systematic physical examination, including palpation and provocative testing.



  • The keys to a successful examination are to link the symptoms with the underlying palpable structures and to correlate the mechanism of the injury with the physical findings.



  • Before the wrist is examined, a careful inspection of the entire upper extremity should be performed to rule out other extrinsic and more proximal causes for the wrist symptoms.



  • The bony and soft tissue anatomy is systematically palpated to define areas of tenderness and to determine the area of maximum tenderness.



  • The symptomatic wrist should always be compared with the uninvolved side.



  • Starting the examination in an asymptomatic area helps the patient develop trust in the examiner and may reduce wrist guarding.



  • By methodically examining each structure in each zone, the examiner can most effectively localize the patient’s symptoms and develop a differential diagnosis.



The diagnosis of “wrist sprain” was at one time a common and acceptable diagnosis for the patient with wrist pain. More recently, however, as the understanding of wrist anatomy, mechanics, and pathology has evolved, more sophisticated clinical examination procedures have been developed, allowing more specific diagnosis of wrist problems.


The wrist is a highly complex joint in a very compact space. Successful clinical evaluation of the wrist requires a thorough knowledge of wrist anatomy, biomechanics, and pathology. Also required is knowledge of surface anatomy and the corresponding underlying structures. The keys to a successful examination are to link the symptoms with the underlying palpable structures and to correlate the mechanism of the injury with the physical findings. Some common conditions may be easily identified on the basis of the clinical examination, whereas others may require additional diagnostic studies, imaging, and repeat evaluations.


The components of the wrist examination include a thorough history, visual inspection, objective assessments, and a systematic physical examination, including palpation and provocative testing to identify tenderness and abnormal motion between bones. Before the wrist is examined, the entire upper extremity should be inspected to rule out other extrinsic and more proximal causes for the wrist symptoms.




History of the Injury or Onset


A detailed history can provide insight into the nature of the wrist problem and can help focus the subsequent physical examination. The patient’s age, dominance, occupation, and avocations should be noted. The date of onset of the problem and the circumstances related to the onset need to be explored. If the wrist problem resulted from a single incident or injury, the mechanism of the injury should be reviewed thoroughly, including the position of the wrist at the time of injury and the subsequent degree and direction of stress. For example, an acute rotational injury to the forearm or a fall on the pronated outstretched upper extremity can result in a triangular fibrocartilage complex (TFCC) injury. Mayfield describes a progression of perilunar instability initiated radially or ulnarly, depending on the position of the wrist during loading. For example, dorsiflexion and supination usually produce radially initiated perilunate injuries, whereas palmar-flexion and pronation forces may result in ulnarly initiated perilunar injuries. Weber and Chao found that load applied to the radial side of the palm with the wrist in extreme dorsiflexion produces scaphoid fracture.


If the wrist condition developed over time, and not as a result of a single injury, it is important to explore potential causes. Some patients have definite ideas about what caused their wrist to hurt, but others require careful questioning. New responsibilities at work or home that increase physical demands on the wrist, increased productivity requirements, an awkwardly configured workstation, and participation in a new hobby or sport are examples of factors that may precipitate symptoms.


The presence of symptoms such as pain; swelling; numbness and tingling; temperature and color changes; and abnormal sounds, such as clicks, grating, or clunks, should be noted. Their location, frequency, intensity, and duration should also be discussed. Some patients may present with very localized symptoms, whereas others report more diffuse discomfort. In the latter case, it is sometimes helpful to instruct the patient to point to the most painful spot or spots to attempt to localize the problem. Some patients may say they have pain all the time and have difficulty qualifying their symptoms. It is sometimes helpful to start by asking patients if they have pain at the present moment or “right now” as a way to help them begin to focus more specifically on when and how often their symptoms occur. The activities, positions, or conditions that aggravate the symptoms and the measures taken to obtain relief are discussed. It is important to review previous treatment interventions such as orthoses, anti-inflammatory medications, injections, and therapy, and to gauge the efficacy of the treatments. The effect the wrist condition has had on the patient’s ability to work and perform his or her usual life tasks needs to be discussed to determine the degree of disability caused by the wrist problem.




Inspection of the Wrist


Visual inspection of the wrist and comparison to the uninvolved side can provide clues about the nature of the problem. As the patient enters the clinical setting, the examiner can observe the posture of the involved side and wrist. The posture of the neck, shoulder, and elbow should be noted because wrist symptoms may sometimes be referred from an extrinsic and more proximal site. Spontaneous use can be noted to give an indication of the extent of disability and to later correlate observations with the patient’s report of disability. If the patient enters holding a heavy briefcase or bag with the involved side and then later reports inability to lift any weight at all, the reliability of their symptom report would be in question.


The wrist should be visually inspected and compared with the uninvolved side. On the dorsal side, the skin, nails, color, and muscle bulk should be observed. Any masses, such as a dorsal ganglion ( Fig. 7-1 ) or traumatic or surgical scars are noted. The six extensor compartments can be inspected for any focal tubular swelling, as seen with tenosynovitis, or for any evidence of ruptures or extensor lags. Some predictable conditions involve the extensor tendons, and these should be kept in mind when examining the extensor compartments ( Table 7-1 , online). The contour, alignment, and profile of the wrist are observed in comparison with the contralateral side. Characteristic examples of abnormalities include the post-traumatic deformity that occurs with radius shortening following a malunited distal radius fracture. Another example is the prominent distal ulnar head indicative of distal radioulnar joint (DRUJ) disruption ( Fig. 7-2 ). The profile of the wrist is observed to detect any malalignment such as a volar sag, or carpal supination ( Fig. 7-3 , online), compared with the other side. On the palmar side, the fingertips can be observed for callusing or atrophy to determine extent of use. The thenar and hypothenar eminences are inspected for muscle bulk.




Figure 7-1


Dorsal wrist ganglion, the most common mass on the dorsum of the wrist.



Figure 7-2


Prominence of the distal ulna, indicating distal radioulnar joint disruption.





Figure 7-3


Volar sag of the wrist indicating ulnocarpal instability.


Table 7-1

Extensor Tendon Conditions
































Compartment Structure Clinical Problem
First


  • Abductor pollicis longus



  • Extensor pollicis brevis

de Quervain’s tenosynovitis
Second


  • Extensor carpi radialis longus



  • Extensor carpi radialis brevis

Intersection syndrome
Third Extensor pollicis longus Rupture at Lister’s tubercle following distal radius fracture, wrist injury, or with rheumatoid arthritis
Fourth


  • Extensor digitorum communis



  • Extensor indicis proprius

Tendinitis; rupture with rheumatoid arthritis
Fifth Extensor digiti minimi Rupture with rheumatoid arthritis
Sixth Extensor carpi ulnaris Tendinitis; subluxation




Objective Assessments


The active and passive range of motion (ROM) of all planes of wrist motion, as well as of supination and pronation, should be assessed. Compensatory maneuvers used by the patient when motion is limited need to be identified and eliminated. For example, the patient may elevate the elbow when attempting wrist flexion. When forearm rotation is limited, the patient may substitute with shoulder motions. Measurement with a goniometer helps ensure an accurate assessment. The most reliable method for measuring wrist flexion and extension is the volar/dorsal technique ( Fig. 7-4 ). The examiner needs to determine whether any restrictions are the result of pain or a mechanical cause, such as capsular contracture or a malunited fracture. Normal ROM of the wrist and functional ROM should be considered when evaluating wrist motion. Normal maximum ROM of the wrist has been documented with the use of wrist goniometry. However, there is some variation in normal values. Therefore the uninvolved side should be measured for comparison. Functional ROM (i.e., the motion of the wrist required to perform most activities of daily living [ADLs]) has also been documented. Palmer and colleagues found that functional wrist motion is between 5 degrees of flexion and 30 degrees of extension, 10 degrees of radial deviation, and 15 degrees of ulnar deviation. Ryu and coworkers found that 40 degrees of wrist extension, 40 degrees of wrist flexion, and a total of 40 degrees of radial and ulnar deviation are needed to perform most ADLs.




Figure 7-4


Range of motion measurement of wrist extension (A) and flexion (B) .


Swelling of the wrist and hand can be measured with a volumeter. Both involved and uninvolved sides are measured for comparison. The volumeter has been found by Waylett-Rendall and Seibly to be reliable to within 1% of the total volume when one examiner performs the measurements. van Velze and associates found that the left nondominant side was 3.3% smaller than the dominant right side with volume measurement in a study of 263 male laborers. She concluded that the volume of one hand could be used as a reliable predictor of the volume of the other. The measurement of bilateral wrist circumference may also be used as an indicator of swelling.


Grip strength testing is advocated by some as a reliable indicator of true impairment that deserves further investigation in cases of obscure wrist pain. Czitrom and Lister found a significant correlation between decreased grip strength and positive bone scans and confirmed pathology with chronic wrist complaints. Submaximal effort was ruled out with the use of rapid-exchange grip testing and a bell curve with five-position grip testing using the Jamar dynamometer.


LaStayo and Weiss describe the GRIT (i.e., the gripping rotatory impaction test), which is used to identify ulnar impaction using a standard dynamometer to test grip with the forearm in three positions: neutral, supination, and pronation. The rationale for the test relates to the fact that ulnar impaction correlates with positive ulnar variance and gripping with pronation maximizes potential impaction and gripping with supination reduces it. The supination and pronation readings are calculated as a ratio, that is, supination/pronation, and the potential for impaction is considered high if the GRIT ratio is more than 1 on the involved and no different from 1 on the uninvolved side.


Sensibility examination is done to screen for possible nerve compressions. Semmes-Weinstein light-touch threshold testing has been found to be the most sensitive clinical test for detecting nerve compression. The median, ulnar, and dorsal radial sensory nerve (DRSN) can become compressed or irritated at the level of the wrist and can be a source of wrist symptoms. Particular attention is paid to the cutaneous distribution of these nerves with sensibility testing.




Diagnostic Injection


Injections are utilized to assist diagnosis and predict surgical success. Shin and coworkers recommend that injections should be performed in joints or along tendons that may be injured and that they can help to distinguish between intra-articular and extra-articular pathology. Bell and colleagues suggest that midcarpal injection with lidocaine is a useful diagnostic test to determine the presence or absence of intracarpal pathology in patients with chronic wrist pain and normal routine radiographs by evaluating grip strength and pain relief after injection. They found that midcarpal injection of lidocaine that resulted in a 28% improvement of grip strength had a statistically significant association with intracarpal pathology later diagnosed by wrist arthroscopy. These authors conclude that diagnostic injection can be an effective tool in the evaluation of the patient with chronic wrist pain. The authors point out limitations of their study, including the small sample size of normal subjects and uncertainty regarding penetration of the lidocaine into the radiocarpal joint, which would affect results if the TFCC or radiocarpal joint was the source of pathology. Freeland cautions that more study is needed to establish a reliable diagnostic test and threshold values.


Green reported the results of a retrospective study that supports the value of carpal tunnel steroid injections as a reasonably accurate diagnostic test for carpal tunnel syndrome (CTS). Ninety-nine wrists in 89 patients receiving carpal tunnel injection were subsequently treated surgically. Correlations between results of injections and subsequent operations indicate that a good response to injection is an excellent diagnostic and prognostic sign. On the other hand, poor relief from injection does not mean that the patient is a poor candidate for surgery. In a more recent review of published studies, Boyer reports that the predictive value of corticosteroid injection should be considered unproved at this time.




Physical Examination


Palpation and provocative testing are the core of the examination. The goal is to define areas of tenderness by systematically palpating the bony and soft tissue anatomy and to determine the area of maximum tenderness. These tender areas are then related to a specific underlying structure, such as the bone, tendon, or joint. The provocative tests are performed to identify carpal instabilities. Patients with carpal instabilities often complain of pain, decreased motion, and “clicks or clunks” with motion of the wrist. The provocative tests may reproduce these sounds, which are the result of abnormal carpal movements. A painless click or clunk may be obtained in the asymptomatic wrist with lax ligaments and is not considered a sign of disease. The symptomatic wrist should always be compared with the uninvolved side. The sequence of the evaluation can be tailored to the patient’s area of maximum tenderness. Starting the examination in an asymptomatic area will help the patient to trust the examiner and may reduce the tendency toward wrist guarding.


Torosian et al describe a systematic approach to wrist examination. They divide the wrist into five zones: three dorsal and two volar. By methodically examining each structure in each zone, the examiner can most effectively localize the patient’s symptoms and develop a differential diagnosis. Table 7-2 (online) lists common wrist conditions for each zone and the corresponding clinical signs and tests.




Table 7-2

Wrist Conditions and Clinical Signs and Tests
































Radial Dorsal Zone Clinical Signs and Tests
First CMC joint arthritis


  • Positive grind test



  • Tender with palpation of the first CMC joint



  • Shoulder sign

de Quervain’s tenosynovitis


  • Positive Finkelstein’s test



  • Tender with resisted thumb abduction



  • Tender with palpation of first extensor compartment

EPL tendinitis (drummer’s palsy) Tenderness with palpation of and resistance to the EPL
Scaphoid fracture, nonunion


  • Tender with palpation of the scaphoid in the snuffbox



  • Tender with palpation over the volar prominence and dorsal aspect of the scaphoid

Scaphoid AVN (Preiser’s disease) Clamp sign
DRSN neuritis (Wartenberg’s neuralgia)


  • Tingling and pain with percussion along the course of the DRSN



  • Diminished light touch threshold over the dorsal thumb and web with Semmes-Weinstein testing

Intersection syndrome (squeaker wrist) Tenderness, friction and crepitus during wrist motion with radial deviation at the distal dorsal forearm 4–5 cm proximal to the radial styloid
Radioscaphoid arthritis, ST arthritis Tenderness with palpation of radial styloid and ST joint



































Central Dorsal Zone
Gymnast’s wrist


  • Tender with palpation over the distal radioscaphoid interval



  • Pain with wrist hyperextension and radial deviation

Keinböck’s disease Tender with palpation of the lunate
Scapholunate Positive radial stress test (Watson’s test)
Dissociation/instability


  • Clamp sign



  • Positive scaphoid thrust test



  • Tender with palpation of the scaphoid in the snuffbox

Dorsal wrist ganglion Observable swelling over the dorsum of the wrist
Dorsal wrist syndrome


  • Positive resisted finger extension test



  • Tender with palpation of the SL interval

CMC joint ligament injury


  • Tender with palpation of the CMC joints



  • Positive Linscheid’s test



  • Positive metacarpal stress test

Wrist extensor tendinitis


  • Tenderness with palpation of wrist extensor tendons



  • Pain or discomfort with resisted wrist extension

PIN neuritis Pain with palpation of the dorsum of the wrist proximal to Lister’s tubercle






































Ulnar Dorsal Zone
Ulnar styloid fracture/nonunion Tender with palpation
DRUJ instability, incongruity, arthrosis


  • Piano key test/sign



  • Ulnar compression test



  • Tender with palpation

TFCC injury


  • Ulnar fovea sign



  • Positive findings with ligamentum subcruentum testing



  • Positive press test



  • Positive relocation test



  • Positive pisiform boost test

Ulnocarpal abutment


  • Positive TFCC load test



  • Positive ulnocarpal stress test

Hamate fracture Tender with palpation
Triquetral fracture Tender with palpation
Midcarpal instability


  • Positive midcarpal shift test



  • Tender in the triquetral-hamate area

Lunotriquetral instability


  • Positive shear, ballottement, ulnar snuffbox tests



  • Tender with palpation of the lunotriquetral interval

ECU tendinitis


  • Tender with palpation and resistance to the ECU



  • Positive ECU synergy test

ECU subluxation Subluxation, pain and snapping with forearm supination and wrist ulnar deviation
































Radial/Ulnar Volar Zone
Volar wrist ganglion Observable swelling usually at the volar radial wrist at the base of the thumb
FCR tendinitis Tender with palpation and resisted wrist flexion
Carpal tunnel syndrome


  • Positive Phalen’s test



  • Positive Tinel’s test



  • Positive Durkan’s carpal compression test



  • Nocturnal numbness in the median nerve distribution



  • Diminished light touch threshold

Radial artery occlusion or insufficiency Positive Allen’s test (timed Allen’s test)
Pisotriquetral arthritis Positive pisotriquetral shear test
Hamate hook fracture


  • Tender with palpation of the hamate hook



  • Increased pain with resisted flexion of the small and ring fingers

Ulnar nerve compression (cyclist’s palsy)


  • Numbness and paresthesias of small and half of the ring fingers



  • Diminished light touch threshold of the small and ulnar half of the ring fingers with Semmes-Weinstein test



  • Positive Tinel’s sign over the Guyon’s canal

Hypothenar hammer syndrome Positive Allen’s test

AVN, avascular necrosis: CMC, carpometacarpal; DRSN, dorsal radial sensory nerve; DRUJ, distal radioulnar joint; ECU, extensor carpi ulnaris; EPL, extensor pollicis longus; FCR, flexor carpi radialis; PIN, posterior interosseous nerve; ST, scaphotrapezial; TFCC, triangular fibrocartilage complex.


Radial Dorsal Zone


The structures to examine in the radial dorsal zone include the radial styloid, the scaphoid, the scaphotrapezial (ST) joint and trapezium, the base of the first metacarpal and the first carpometacarpal (CMC) joint, the tendons of the first and third extensor compartments, and the DRSN.


The radial styloid is palpated on the radial aspect of the wrist proximal to the anatomic snuffbox with the wrist in ulnar deviation ( Fig. 7-5 ). Tenderness of the styloid may indicate contusion, fracture, or radioscaphoid arthritis. The last is common with longstanding scapholunate dissociation and scaphoid instability. Tenderness may be aggravated by radial deviation.




Figure 7-5


Palpation of the radial styloid.


The scaphoid is palpated just distal to the radial styloid in the snuffbox, which is formed by the tendons of the extensor pollicis longus (EPL) on the ulnar border and the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) on the radial border. The scaphoid is most easily palpated when the wrist is in ulnar deviation because the proximal carpal row slides radially and the scaphoid assumes an extended or vertical position when the wrist is in ulnar deviation. Tenderness of the scaphoid in the snuffbox may indicate scaphoid fracture, nonunion, avascular necrosis (Preiser’s disease), or scaphoid instability. The clamp sign refers to the patients grasp of the volar and dorsal aspects of the scaphoid when asked to indicate where the wrist hurts ( Fig. 7-6 ).




Figure 7-6


Clamp sign indicative of scaphoid fracture.


The ST joint and trapezium are palpated just distal to the scaphoid. Opposition of the thumb to the small finger and ulnar deviation of the wrist makes the trapezium more prominent and easier to palpate. Circumduction of the thumb while palpating facilitates differentiation between the base of the thumb metacarpal and the adjacent trapezium. Tenderness in this region may indicate ST arthritis, which may result from scaphoid instability.


The base of the first metacarpal and the first CMC joint are localized by palpating in a proximal direction along the dorsal aspect of the flexed first metacarpal until a small depression can be felt. This depression represents the first CMC joint. Tenderness here is often caused by degenerative arthritis. The grind test has been described for CMC arthritis and involves axial compression of the first metacarpal with rotation ( Fig. 7-7 ). This clinical maneuver grinds the articular surfaces of the base of the first metacarpal and the trapezium. A positive test elicits pain, and crepitus may be felt. First CMC joint arthritis may be accompanied with radial subluxation of the base of the first metacarpal. If the subluxation is more than 2 to 3 mm, the outline of the thumb will form a step called the “shoulder sign” ( Fig. 7-8 ). Occasionally, CMC joint pain may be caused by laxity or instability. To test for CMC joint instability or laxity, the metacarpal is distracted and moved in a side-to-side or radioulnar direction while the trapezium is stabilized. Comparison with the opposite side allows determination of whether joint laxity or instability is present.




Figure 7-7


Grind test for arthritis of the carpometacarpal joint of the thumb is performed by applying axial pressure with rotation.

Apr 21, 2019 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Clinical Examination of the Wrist
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