Inspection Palpation Movements Special Tests Neurological Examination Joints above and below
Inspection • The wrist / hand should be positioned on a table or pillow – Palmar aspect • • • •
Radial deviation (secondary to Colles’ fracture) Ulnar deviation (rheumatoid arthritis) Scars Muscle wasting – thenar and hypothenar eminences / forearm muscles (the latter is associated with rheumatoid arthritis and muscular dystrophy) • Swelling of the wrist / hand – localised (ganglion, rheumatoid nodule) or generalised (rheumatoid arthritis) • Any colour changes – erythema
• Medial aspect – Prominence of the ulna (after Colles’ fracture)
• Laterally aspect – – – –
Distal radial swelling (de Quervain’s disease) Anterior tilting of the plane of the wrist (Smith’s fracture) Posterior tilting of the plane of the wrist (Colles’ fracture) Anterior subluxation (rheumatoid arthritis, old carpal injuries and infective arthritis)
• Dorsal aspect – Ganglion – exaggerated by palmar flexion of the wrist – Diffuse swelling of the wrist (rheumatoid arthritis, infections and Sudeck’s atrophy)
Palpation • Does it hurt? ALWAYS ask the patient before touching them! – Assess skin temperature (use dorsal surface of your hand to compare temperatures) – Start from the radial side and move in a circle around the wrist – Diffuse tenderness around wrist (common in inflammatory lesions / Sudeck’s atrophy) – Thickening and tenderness over the sheaths of abductor pollicis longus (APL) and extensor pollicis brevis (EPL) (de Quervain’s’ Tenosynovitis) – Anatomical snuffbox (scaphoid fractures and wrist sprains) – Distal radioulnar joint (following disruption e.g. after Colles’ fracture) – Lunate – locate by dorsiflexing the wrist – Proximal pole of scaphoid – Ulnar styloid – Hook of hamate – Pisiform (pisiform triquestral degenerative changes) – Distal pole of scaphoid
Special Tests • Scapholunate instability – Scapholunate ballotment • Stabilise the patient’s lunate between your thumb and index finger of one hand and the scaphoid between the thumb and index finger of the other • The scaphoid is then pushed in volar and dorsal directions • Discomfort in this area suggests the possibility of injury to the scapholunate ligament (SLL)
Special Tests • De Quervain’s Tenosynovitis – Finklestein’s Test • With the thumb adducted, the wrist is passively ulnar deviated while the patient is trying to resist it • Pain on the radial aspect of the wrist and hand indicates DeQuervain’s tenosynovitis of the wrist
Special Tests • Carpal tunnel Syndrome – Compression of median nerve within the carpal tunnel – Tinel’s test • Paraesthesia provoked by tapping over the nerve at the wrist • 74% sensitivity, 91% specificity
– Phalen’s test • Passively flex both the wrists for 1-2 minutes • A positive test is indicated if symptoms are provoked or worsen within 60 seconds • 61% sensitivity, 83% specificity
– Carpal tunnel compression test • Similar to Phalen’s test, but with direct pressure from the examiner’s fingers over the carpal tunnel
Special Tests • Pseudostability test – Hold patients hand in your right hand and forearm with your left; the normal wrist clunks on palmar displacement of hand on forearm. Non-specific test – Resistance to movement - pseudostability and may be due to wrist pathology
• Distal radio ulnar joint (DRUJ) – Piano key sign - for instability - ballottement of ulnar head, (prominence of ulna)
Special Tests • Squeeze and turn test – The examiner stabilises the patient's forearm with one hand while with the other hand, he grasps the patient's hand as if for a vigorous handshake – When the patient resists forced passive rotation, or when there is active rotation against resistance, pain usually is elicited – If the pain is caused by compressing the ulna against the radius, it is mostly suggestive of chondromalacia
• Ulnar impingement test – For Triangular Fibrocartilage Complex (TFCC) – Shake hands with patient; ulnar deviate wrist whilst rotating the forearm – A positive test is indicated by pain
Special Tests • Kirk Watson’s Scaphoid shift test – Examiner sits opposite patient and grasps the opposite forearm and wrist on its radial side (left for left side and vice versa) – Examiner’s thumb is placed on scaphoid tubercle on the radio-volar aspect of the wrist (applying pressure) and the examiner’s index finger on scapholunate ligament on the dorsal aspect of the wrist – Hold the patient’s hand at the metacarpals in fully adducted and slightly extended position – Keeping this pressure on the scaphoid, gradually ABDUCT and flex the wrist – This movement produces rotation of the scaphoid in a volar direction – This is resisted by the examiner’s thumb (see above) – Normal - can feel scaphoid flexing in radial deviation, thumb pushed away – SLL injury- pressure of examiner's thumb prevents initiation of flexion of scaphoid, and then Clunk occurs on sudden pressure from bones. Patient may withdraw hand with pain 'apprehension test' – Must compare to opposite wrist – N.B. 20 % of normal people have positive
Special Tests • Lunotriquetral instability – Lunotriquetral ballotment test (Reagan test) • Stabilise the lunate between thumb and index finger of one hand and the triquetrum between the thumb and index finger of the other • The pisiform and triquetrum are pushed in a volar to dorsal direction • Discomfort in this area suggests the possibility of injury to lunotriquetral interosseous ligament
Special Tests • Kleinman Shear Test (shuck test) – Examiner sits opposite patient and places contralateral thumb over dorsum of lunate and index finger over pisiform – Attempt to squeeze your own (examiner’s) thumb and index finger together – Pushing the pisiform dorsal causes pain in the lunotriquetral joint
