General history is taken including pathology that can affect treatment results, e.g. diabetes and tobacco.

Any ipsilateral upper limb pathology must be noted and considered; this can modify therapeutic indications.

It is important to identify the circumstances of the trauma (fall from height while walking, skiing, car accident…) and specify if it is a low- or high-energy injury and if it is a domestic, sports or work accident and try to describe the mechanism of trauma as precisely as possible: direct or indirect, in forced extension or flexion, with impact on radial, ulnar or median nerves.

Hyperextension injuries, for example, orient towards a diagnosis of scapholunate lesion if the impact is to the thenar eminence and towards a TFCC lesion if it is directed to the hypothenar side, as do injuries in forced rotation ‘reverse drill’.

The date of the accident sometimes becomes difficult to determine when it goes back weeks, months or even years before presentation but is directly relevant to the choice of treatment.

It is crucial to get the patient to pinpoint the pain even if it is rarely excruciating in wrist ligament injuries.

The patient often just points to the whole wrist declaring ‘my wrist is painful’.

The examiner should get the patient to specify whether pain is palmar or dorsal or in the inside of the wrist and then further localize it to the radial, ulnar or middle of the wrist.

It is useful to get the patient to use a finger to actually point out the point of maximal pain intensity. This simple gesture is very useful to guide the rest of the clinical examination.

Is the pain permanent, upon intense effort or on certain movements? It may be triggered by simple flexion/extension or by more complex movements such as extension with ulnar inclination or with certain actions such as pressure on the hand to lift oneself out of a chair, open a jar or hold a cooking pan. All these elements specified during the examination will help localize the site of pain and its repercussions on the use of the wrist.

This may be evaluated by the visual analogue scale that gives a numerical measurement reproducible for a series of examinations.

It is important that the patient himself specifies the disabling effect of pain on the wrist, both on daily activities – such as opening a door, a jam jar or carrying a bottle of water – as well as professional ones. Validated and accepted questionnaires may be used. A comprehensive list of all the questionnaires is beyond the scope of this book, but the two most used globally are the DASH (disability of the arm, shoulder and hand) (Fig. 2) developed in 1994 by representatives of the Institute for Work and Health (IWH) and the American Academy of Orthopaedic Surgeons (AAOS) and translated from American to French by Dubert et al. [2] and the PRWE (patient-rated wrist evaluation) score developed by MacDermid in 1998 (Fig. 3) [3]. Besides being filled out by the patient far from surgeon’ s influence, these are reproducible from one patient to another as well as for the same patient from one consultation to the next.

These are totally painless and fully reproducible at will without apprehension or discomfort. They are pneumatic such as generated upon forced flexion ‘cracking’ the metacarpophalangeal or proximal phalangeal joints.

This is palpable, audible and sometimes visible. It can be benign in hyperlax wrists, but is most frequently pathological, with pain and sometimes apprehension. In this case it indicates scapholunate, lunotriquetral or midcarpal instability. The examination will attempt to then trace its origin.

These are painful without obvious triggering and are provoked by specific movements. Ulnar clicking may denote underlying TFCC rupture.

These are usually associated with primary complaints discussed previously, and the examiner needs to help the patient accurately describe them. A frequent ­presentation is stiffness usually in flexion-extension or pronosupination and rarely in radial or ulnar inclination. Another is decreased force – usually secondary to pain.

This is usually normal in chronic or subacute (more than 6 weeks) ligament injuries. A dorsal subluxation of the ulnar head may sometimes indicate distal radioulnar dislocation. In recent injuries, diffuse oedema is usual and adds little to the examination.

Active and passive mobility is compared to the contralateral side.

Flexion-extension:

The patient sits facing the examiner with the elbow on the table, the forearm vertical. The goniometer is placed on the dorsal aspect of the hand, wrist and forearm in flexion and palmarly in extension (Fig. 4). Normal values are approximately 80° and 70°, respectively [1].

It is measured with elbow to trunk, flexed at 90°, and forearm horizontal. It is more difficult than flexion-extension and approximate measures should be avoided. A limb of the goniometer placed vertically in the axis of the arm and the other in the plane of the hand with the eye of the examiner at patient’s hand level gives more precise readings (Fig. 5). Normal values of pronation and supination are 70–85° and 90°, respectively [1].

The hand is in supination with the goniometer placed on the dorsum of the forearm, wrist and hand, one limb along the third finger and the other in the axis of the mid-forearm (Fig. 6). Ulnar inclination is usually up to 40°, while radially it rarely exceeds 20°.

Strength is measured using a dynamometer ‘grip strength’ (Fig. 7).

When a mechanical Jamar dynamometer is used, it should neither be too large nor too narrow and should be adjusted to the second spacing as shown by a study on 288 patients – 89 % of whom attained maximum force in this position [4]. The elbow is placed on the table, without resting the forearm, wrist or hand (Fig. 8).

Three measurements are taken for each side alternating rapidly between pathological and contralateral sides to detect potential malingerers. The patient is asked to grip strongly, maximally and briefly. This attitude seems the most logical and widely accepted; however, Haider et al. – in a study on 100 healthy volunteers – showed that the maximum values noted in a single measurement and the average of three measurements showed the same variation (about ±8 kg) and showed no ­statistically significant difference [5]. In 2008, Gunther et al. studied 769 adult Caucasians (403 men and 366 women) aged 20–95 [6].

The normal values obtained are shown in Table 1. The authors noted a ratio of 95 % between right and left sides and that grip strength increases till the age of 35 when it slowly starts decreasing.