Examination of the wrist

For the initial medical examination no specific equipment is required. The part of the body of the patient should be uncovered and all other parts of the body should be gowned prior to medical examination. Some critical elements of the examination such as limb movement may not be applicable if a fracture of a bone is suspected. For any musculoskeletal examination it is essential to have a thorough understanding of anatomy, as the examination will assess differences to normal anatomical structures and movements. It is necessary to acquire information on pre-existing pathologies or traumas, including the mechanisms of injury, changes in motility and function, swelling and received treatments. A clear description of current symptoms must be provided.

Inspection

The hallmarks of any musculoskeletal pathology are pain, redness (erythema), swelling, increased warmth, deformity, neurological symptoms and loss of function. The doctor will commence with a visual observation of the affected area, which will be compared to the contralateral, unaffected side. This will identify the presence of scars, rashes, lesions, asymmetry, deformity and atrophy. In the initial medical inspection the doctor will examine any morphological alterations in the anatomy the wrist and hand including:

Scars, rashes, or other lesions

Asymmetry

Deformity or atrophy

Anatomical differences compared with the healthy wrist

Dorsal (back of the hand) pain due to extensor tendonitis

Volar (palm of the hand) pain due to flexor tendonitis

Arthritis

Palpation

The palpation of the compromised region involves the examination of each joint and muscle groups and identification of areas of tenderness and deformity. Palpation is used to discriminate differences in tissue tension, texture and thickness, as well as identify shapes, structures and abnormalities. The examiner will also detect variations in temperature, tremors, pulses and note abnormal sensations: dysesthesia, diminished sensation and increased sensation. A gentle palpation of the wrist will focus on the identification of anatomical landmarks: radial/ulnar styloid, scaphoid, lunate, TFCC, triquetrum and other carpal bones up to the metacarpal bones of the hand. The examiner will:

Palpate each major joint and muscle group

Identify any areas of tenderness

Detect any deformities

Always compare with the other side

Range of motion

The patient is asked to actively move each joint to determine any changes in function, instability and level of pain. It is also critical to monitor the same movements of the non injured region of the body to obtain an overall functional status of the patient. If abnormalities are present, the patient is subjected to a range of passive tests to assess increased or impaired range of movement. Subsequently, specific instability tests may be performed. When examining the function of the wrist the doctor will use specific tests and measure any changes in the range of movement that may have been compromised by a pathology.

The main examination will include changes in: 

Flexion/Extension‍

The movements of the wrist are limited to a maximal flexion of 80º and an extension of 90º with a neutral position at 0º.

Radial/Ulnar abduction

‍Radial deviation or radial abduction is the movement of the wrist toward the thumb and radius bone of the forearm. Ulnar deviation or ulnar abduction is the movement of the wrist toward the little finger and ulna bone of the forearm.

Pronation / Supination

This is an actual forearm function, consisting in the rotation of the hand either palm up or down, respectively. The forearm bones, ulna and radius cross each other when performing supination.

Thumb Flexion/Extension

Metacarpo-phalangeal (MCP) joint of the thumb: Flexion/Extension 0º/60º. The thumb is moved towards the inner palm (flexion) or outwards (extension).

Thumb Abduction/Adduction

Thumb - inter-phalangeal joint: Extension/ Flexion -15º/80º

Abduction and adduction refer to the movement of the thumb forward and backward.

Thumb opposition is the movement used when the thumb touches the tip of the little finger.

Metacarpo-Phalangeal MCP joint

Fingers - Metacarpo-Phalangeal (MCP) joint Hyperxtension/Flexion, 20º / 90º. Shown here for the index finger.

Proximal-Inter-Phalangeal, PIP joint

Fingers - Proximal-Inter-Phalangeal (PIP) joint Extension / Flexion, 0º / 100º. When
the fingers are flexed all the nails should be parallel and point towards the centre of the thumb.

Distal Inter-Phalangeal, DIP joint

Fingers - Distal Inter-Phalangeal (DIP) joint Extension/Flexion, 0º / 70º. Shown here for the ring finger.

Neurological Examination

Specific tests will determine damage of the nerves and vessels of the wrist that could
arise from bone fractures or overuse of the wrist joint. These tests focus on
changes in sensation, compression of the median and radial nerves and altered
blood supply.

Nerve test: Sensation

The integrity of upper limb nerve function is tested by examining sensation on the
palmar and the dorsal aspects in relation to the areas innervated by the
median, ulnar and radial nerves. Numbness and tingling in specific skin areas
are indicative of neuropathy. The location of the specific area of the hand,
which is innervated by each nerve is tested to assess nerve function as
described below.

Median nerve

Palmar aspect of thumb, index, middle finger and lateral half of ring finger and distal half of the dorsal aspect of these fingers.

Radial nerve

Skin on most of the dorsum of the hand and fingers.

Ulnar nerve

Palmar aspect of little finger. Palmar aspect of the medial half of ring finger.  Distal half of the dorsal aspect of these fingers.

Phalen’s manoeuvre (carpal tunnel syndrome)

If holding the wrist flexed elicits symptoms (pain, tingling, burning, and numbness of the thumb, index and inner side of the ring finger) specific to median nerve it indicates a carpal tunnel syndrome.

Tinel’s Sign

It is used to establish nerve dysfunction of the median, ulnar and radial
nerves. The examiner taps or compresses the nerve at the wrist. A positive test
is indicated by a tingling sensation at the regions innervated by the specific nerve.
In case of the median nerve, the innervated areas are the thumb, index and
middle finger.

Compression test for median nerve

If compressing the median nerve at the distal palm of the onset of the carpal
tunnel causes pins and needles, the test confirms the diagnosis of carpal
tunnel syndrome.

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Compression test for ulnar nerve

Pain or discomfort when compressing at the wrist (ensheathing the ulnar nerve and artery) confirms ulnar nerve
damage.

Flick test for carpal tunnel syndrome

In this test the examiner shakes vigorously the hand of the patient. The test is
positive when flicking of the wrist will exacerbate the symptoms of carpal
tunnel syndrome.

Scaphoid fracture sign

The instability test assesses a number of clinical signs indicative of a scaphoid fracture: swelling and pain in the scaphoid region, tenderness in the “anatomical snuffbox”, pain on axial compression, pain while pronating the hand and with pinch grip.

Murphy’s Sign

The examiner inspects the dorsal aspect of the hand and if the knuckle of the third metacarpal bone (middle finger) is at the same level with the knuckles of the second and fourth metacarpals, it indicates the dislocation of the lunate.

Scaphoid shift test / Watson test for wrist injury scaphoid tubercle fracture

Watson test is used to detect scapho-lunate instability. The examiner places the thumb over the patient’s scaphoid tubercle while applying pressure. The wrist is then deviated from the ulnar to the radial position. The test is positive when the patient experiences pain or a clunk noise is heard.

Capillary refill

Capillary refill is a test performed to determine the rate at which blood refills empty capillaries. Normally it should be less than 3 seconds. The examiner applies pressure to the finger until it turns white, indicating that blood has been forced from the tip of the finger. Iftimerequired to return to colour following the pressure release exceeds 3 seconds it indicates poor peripheral perfusion and dehydration.

Oedema

Oedema is caused byaccumulationof fluid in the body’s peripheral tissues and usually occurs in the feet, ankles and legs.

Cyanosis arises when there is a low oxygen level in blood. It is a condition where the fingers, toes and lips appear blue.

Clubbing results from chronic low blood oxygen levels. The ends of the finger appear enlarged and the nails curved downwards.

Lymphatics

The lymphatic system is a network of tissues and organs, which play a very important role in the immune system by clearing away infections and keeping body fluids i

Special tests

Medical examination includes a range of special tests that have been developed to establish and quantify changes in the anatomy and function of limbs.

For the wrist and hand the examination includes the following tests:

1. Movement testing

2. Muscle strength test

3. Flexor tendon test

4. Finkelstein’s test

5. Instability tests: Shear test, Kirk Watson tests, Midcarpal instability, Distal Radio-Ulnar joint instability, Shuck tests, TFCC injuries, Scaphoid shift test, Scaphoid fracture sign, Murphy’s sign, Midcarpal instability, Trousseau’s sign

6. Vascular & Neurologic tests: nerve sensation of median, ulnar and radial nerves, Phalen’s maneuver, Tinel’s sign, compression test, Flick test, Allen’s test.

Movement Testing

The initial examination consists of evaluating abnormalities in the range of movement of the following functions. See Range of movement for specific images.

Wrist

Flexion/extension

Radial/ulnar deviation

1st Carpo-Metacarpal (CMC) Joint

Extension

Abduction

Opposition

Metacarpal-phalangeal (MCP) Joint

Flexion

Extension

Abduction/adduction

Inter-phalangeal (IP) / Distal IP / Proximal IP Joint

Flexion

Extension

Muscle strength test

Assessment of muscle strength of the wrist is achieved by testing the following movements and functions:

Wrist flexion/extension

Forearm pronation and supination

Grip strength

Key and pinch grip strength

Flexor tendon test

The flexor tendons originate from muscles at the elbow and form tendons at mid length of the forearm. They attach to the bones of the fingers allowing their flexion. Any damage to these tendons can impair the whole function of the hand. General examination will test the ability of the patient to bend and straighten the fingers. The strength of the hand is assessed by asking the patient to bend the injured finger, while the examiner holds the other fingers firmly.

Flexor digitorum profundus

To test the flexor digitorum profundus, the examiner holds down the finger while simultaneously allowing to flex the proximal inter-phalangeal joint. Failure to flex at the DIP joint indicates a lesion to the tendon of the flexor digitorum profundus.

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Flexor digitorum superficialis test

The examiner mobilises the distal inter-phalangeal joint (DIP) beside the finger to be tested and asks the patient to flex the finger with the exception of index finger, which is tested for pinch grip. Failure to flex the finger at the MCP joint indicates a lesion to the tendon of the flexor digitorum superficialis.

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Finkelstein's test for De Quervain’s tendinitis

With the patient keeping the hand closed in a fist the examiner deviates the wrist to the ulnar side. If the test is positive, pain is felt over the extensor pollicis brevis tendon.

Instability tests

Shear test for Lunate – Triquetrum ligament (LT)

The examiner holds the wrist firm with the thumb(s) on the palmar side and applies pressure on the pisiform bone and on the dorsal wrist on the triquetrum bone. The diagnosis of an injury to the Lunate - Triquetrum (LT) ligament is confirmed, if manipulation causes discomfort or excessive translation compared to the healthy side.

Kirk Watson test for Scapho-Lunate (S-L) instability

The scaphoid is stabilised with the examiner’s thumb to restrict palmar flexion, and the wrist is moved from ulnar deviation in extension to radial deviation in flexion.

With a scapho-lunate disruption, the scaphoid will sublux dorsally when the wrist is positioned in radial deviation and flexion, causing pain and popping sensation. The symptoms are alleviated when the thumb is released.

Midcarpal instability test 1

The examiner pulls axially the wrist while moving the wrist sideways, from radial to ulnar deviation. Jumping, catching or clunking is a positive result for midcarpal instability.

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Midcarpal instability test 2

Examiner loads axially the wrist with maximal ulnar deviation, then in neutral position, pronation and supination. Pain distal to the ulnar is indicative of a tear. Clicking and popping may be heard.

Shuck test for carpo-metacarpal joint (CMCJ) instability

The examiner holds the metacarpal between index and thumb, then pushing/pulling along the thumb axis. Noise of this joint causing pain is usually a sign of osteoarthritis, parascaphoid inflammation, radial carpal or mid carpal instability.

Triangular fibrocartilage complex (TFCC) injuries

The TFCC is an articular discus that lies on top of the distal ulna.

The press test is reliable for the detection of a TFCC tear. The examiner pushes the forearm upwards to the ulnar deviated wrist. Pain at the ulnar carpal joint is indicative of a tear.