Chapter 6 The wrist/carpal joints

ANATOMY 149

Bony landmarks to be palpated 150

The wrist (radiocarpal) joint 149

Ligaments 150

Muscles 151

Flexors 151

Extensors 152

Abductors/radial deviators 153

Adductors/ulnar deviators 154

MEASUREMENT 155

Range of movement 155

Flexion 155

Extension 156

Adduction/ulnar deviation 157

Abduction/radial deviation 158

Observational/reflective checklist 160

Muscle strength: Oxford muscle grading 161

Extensors 161

Flexors 163

Adductors/ulnar deviators 165

Abductors/radial deviators 167

Joint girth 169

Wrist 169

Grip strength 170

The hand-held dynamometer 170

Anatomy

The wrist (radiocarpal) joint

1. It is a synovial ellipsoid joint.

2. It is formed between the distal surfaces of the radius and articular disc, and the scaphoid, lunate and triquetral of the proximal row of the carpal bones.

3. The capsular ligaments are the dorsal radiocarpal, palmar radiocarpal and palmar ulnocarpal ligaments.

4. The wrist joint has collateral ligaments – the radial and ulnar collateral carpal ligaments.

5. The movements that take place are flexion, extension, abduction (radial deviation) and adduction (ulnar deviation).

Bony Landmarks to be Palpated

The radius – styloid process and dorsal tubercle.

The ulna – head of ulna and ulnar styloid process.

The carpus – pisiform, hook of hamate, tubercle of scaphoid and tubercle of trapezium.

Ligaments

Table 6.1The ligaments of the radiocarpal joint

Muscles

Flexors

Table 6.2The flexors of the wrist

Extensors

Table 6.3The extensors of the wrist

Abductors/radial deviators

Table 6.4The abductors/radial deviators of the wrist

Adductors/ulnar deviators

Table 6.5The adductors/ulnar deviators of the wrist

Measurement

Range of Movement

Flexion

Fig 6.1 Goniometric measurement of wrist flexion.

Starting position:

The patient is positioned in sitting, their forearm resting on a table in pronation and their wrist in a neutral position. The hand is over the end of the table.

Stabilization:

The clinician stabilizes the forearm if necessary.

Goniometer axis:

The axis of the goniometer is placed at the level of the ulnar styloid process.

Stationary arm:

This is parallel to the long axis of the ulna.

Moveable arm:

This is parallel to the long axis of the 5th metacarpal.

Command to patient:

‘Move your hand downwards as far as you can.’

End position:

The wrist is flexed to the limit of motion.

Trick movements:

Ensure that no wrist deviation occurs as the hand is flexed.

NB: It may be necessary to reposition the stationary and moveable arms of the goniometer prior to taking the reading, as they may have moved when the patient flexed their wrist.

Extension

Fig 6.2 Goniometric measurement of wrist extension.

Starting position:

The patient is positioned in sitting, their forearm resting on a table in pronation and their wrist in a neutral position. The hand is over the end of the table.

Stabilization:

The clinician stabilizes the forearm if necessary.

Goniometer axis:

The axis of the goniometer is placed at the level of the ulnar styloid process.

Stationary arm:

This is parallel to the long axis of the ulna.

Moveable arm:

This is parallel to the long axis of the 5th metacarpal.

Command to patient:

‘Move your hand upwards as far as you can.’

End position:

The wrist is extended to the limit of motion.

Clinical tip

Ensure that no wrist deviation occurs as the hand is extended.

NB: It may be necessary to reposition the stationary and moveable arms of the goniometer prior to taking the reading, as they may have moved when the patient extended their wrist.

Adduction/ulnar deviation

Fig 6.3 Goniometric measurement of wrist adduction/ulnar deviation.

Starting position:

The patient is positioned in sitting, forearm pronated, their hand resting on a table.

Stabilization:

The clinician stabilizes the forearm.

Goniometer axis:

The axis of the goniometer is placed on the dorsal aspect of the wrist over the capitate bone.

Stationary arm:

This is along the mid-line of the forearm.

Moveable arm:

This is parallel to the long axis of the shaft of the 3rd metacarpal.

Command to patient:

‘Move your hand outwards as far as you can.’

End position:

The wrist is adducted/ulnar deviated to the limit of motion.

Ensure that the wrist is not moved into flexion or extension as the patient adducts/abducts to each side.

Clinical tip

To find the capitate bone, follow the shaft of the 3rd metacarpal proximally on the dorsal surface of the hand. At the end of the metacarpal you will feel the proximal head. After that your finger will slide onto a square(ish) flat structure, which is the capitate bone.

Abduction/radial deviation

Fig 6.4 Goniometric measurement of wrist abduction/radial deviation.

Starting position:

The patient is positioned in sitting, forearm pronated, their hand resting on a table.

Stabilization:

The clinician stabilizes the forearm.

Goniometer axis:

The axis of the goniometer is placed on the dorsal aspect of the wrist over the capitate bone.

Stationary arm:

This is along the mid-line of the forearm.

Moveable arm:

This is parallel to the long axis of the shaft of the 3rd metacarpal.

Command to patient:

‘Move your hand in towards you as far as you can.’

End position:

The wrist is abducted to the limit of motion.

Ensure that the wrist is not moved into flexion or extension as the patient abducts/radial deviates.

Notes

Treatment record

Observational/reflective checklist

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