Clinical Examination of the Wrist
Igo Goldberg M.D, Hand Surgeon
Tel-Aviv, Israel
MOST COMMON CAUSES OF WRIST PAIN - 1
Fracture and
Malunion
Radius-ulna
Scaphoid
Other carpal bones
Traumatic
Disorders
Degenerative
Inflammatory
Disease
Nonunion
Scaphoid
Capitate
Hamate
Chondritis/Osteochondritis/
Posttraumatic arthritis
SNAC
SLAC
Piso-triquetral arthrosis
Hamate-triquetral arthrosis
Hyperextension radioscaphoid impingement
(Gymnast’s wrist)
Ulno-carpal impingement
Ligamentous Injuries and Instability
Perilunate (scapholunate,lunotriquetral)
Midcarpal (intrinsic,extrinsic)
Radiocarpal (ventral or dorsal subluxation,ulnar translocation)
Dorsal wrist syndrome
Distal radioulnar joint (luxation,subluxation,TFCC injury)
Carpo-metacarpal j (1st CMC;2nd-3rd CMC;carpal boss;4th-5th CMC)
Extensor Carpi Ulnaris
Tendon Subluxation
Connective Tissue
Diseases
Rheumatoid arthritis
Systematic lupus
erythematosus
Chondritis/
Primary Arthrosis
Metabolic diseases
Gout /pseudogout
Hyperparathyroidism
Chondrocalcinosis
Tendonitis
Tenosynovitis
Repetitive Strain
Injury
MOST COMMON CAUSES OF WRIST PAIN - 2
Infective
Disorders
Common Bacterial/Atypical Agent
Specific Granulomatous Disease
Neoplastic
Disorders
Ganglia
(extraosseous/
Intraosseous/occult)
Tendon Cysts
Bone Tumors
Enchondroma,
Osteoid osteoma,
Chondromatosis,etc.
Soft Tissue Tumors
Pigmented villonodular
synovitis,
Giant cell tumor,etc
Malignant
Tumors
Congenital and
Developmental
Disorders
Simple Osseous Cyst
Madelung’s deformity
Muscular Anomalies
Extensor brevis manus
Carpal Coalition
Scapholunate
Scaphotrapezial
Lunotriquetral
Neurological
Disorders
Traumatic
Palmar branch median n. (from section)
Sens.branch radial n. (from injection)
Dorsal sens.branch ulnar n. (direct contusion)
Distal post.interosseous n. (recurrent ganglion)
Vascular
Disorders
Aneurysm/thrombosis of the ulnar artery
Avascular necrosis of the lunate (Kienbock’s disease) ; of the scaphoid (Preiser’s disease) ;
Of the capitate; of the triquetrum
Compressive
Carpal tunnel syndrome (CTS)
Wartenberg’s syndrome
Guyon’s syndrome
T.O.S
Radicular compression
What constitutes the first part of every
thorough physical examination?
A thorough history
STEPS IN TAKING A PATIENT HISTORY
CLINICAL EXAMINATION
• ROM active, passive
• Grip - Jamar dynamometer (flat curve, rapid exchange grip strength,
coefficient of variation)
• Pinch - Pinchmeter
• Circumference measurements
• (Volumetric measurements)
• Palpation
• Provocative tests
• Anaesthetic examination
• DASH Questionnaire
• Mayo evaluation score
RANGE OF MOTION (ROM)
“The wrist is a key joint of the hand” – Starling Bunnel
Wrist movement occurs around three principal functional axes: yet all of them are complex
and are not restricted to a fixed geometric axis.
•
Flexion-Extension :
transverse axis, sagital plane
•
Radial-Ulnar deviation:
sagital axis, coronal (frontal) plane
•
Pronation-Supination :
longitudinal axis, horizontal plane
What is their relative contribution to the upper extremity (UE) function?
WRIST MOTION IMPAIRMENT - 1
The wrist functional unit represents 60% of the upper extremity (UE) function.
Flexion-Extension unit: 70% of wrist function:70%x60%=42% of UE function.
Radial-Ulnar deviation unit: 30% of wrist function: 30%x60%=18% of UE function
‫ישור חשיבות גדולה יותר מאשר לשמירה על טווח ההטיות לצדדים‬-‫לשמירה על טווח כיפוף‬
Normal ROM 20-30 R-U
Normal ROM 60-60 F-E
Wrist fusion:
10 extension
10 ulnar deviation
Functional ROM: 0-10 R-U
Functional ROM: 10-10 F-E
WRIST MOTION IMPAIRMENT - 2
Pronation-Supination
Impairments of pronation-supination are ascribed to the elbow because the major
muscles for this function are inserted about the elbow. This applies even if the
loss of rotation results primarily from the wrist involvement in the presence of an
intact elbow
The relative value of this motion unit
is 28% of the UE function
Normal ROM : 80-80 P-S
Functional position: 20 P
WRIST MOTION IMPAIRMENT - 3
The relative contribution of various motion units to the upper extremity (UE)
function:
• F-E 42%
• P-S 28%
• R-U 18%
How much wrist motion is required for most activities of daily
living (ADL) ?
PALMER (1985)
Ruy (1991)
Flexion
50
400
Extension
300
400
Radial deviation
100
100
Ulnar deviation
150
300
‫האם טווח התנועה בשורש היד חשוב בכל מחיר ?‬
‫מה הם שני התפקידים העיקריים של היד ?‬
‫‪ .1‬אחיזה (על כל צורותיה)‬
‫‪ .2‬מגע‬
‫תקנות המל"ל‬
‫ ‪ 20%‬נכות‬‫"קשיון נוח" שורש יד‬
‫ ‪ 10%‬נכות‬‫קשיון ברוטציה של האמה במנח נוח‬
‫"קשיון נוח" של כל האצבעות (במצטבר)‪ 31% -‬נכות‬
‫[תקנה ‪()10(41‬ב')]‬
‫[תקנה ‪()10(41‬ז')]‬
‫[תקנה ‪])2+3+4(44‬‬
‫מסקנה‪:‬‬
‫תפקודן התקין של האצבעות חשוב יותר מתפקודו של שורש היד !!!!!!!‬
‫גבר בשנות ה‪ 40-‬טופל עקב שבר ברדיוס רחיקני ע"י קיבוע חיצוני וגבס‪.‬‬
‫תמונות רנטגן וטווחי תנועה בשורש יד "יפים‪"....‬‬
‫יישור‬
‫כיפוף‬
‫סופינציה‬
‫פרונציה‬
‫‪...............‬ויד פגועה קשה‬
‫‪?.................................‬‬
TOPOGRAPHIC ANATOMY OF THE WRIST
middle
axis 4th
finger
VOLAR
ulnar
Ulnar
border
FCU
Ulnar
border
FCR
Radial
border
1st
comp
central
radial
TOPOGRAPHIC ANATOMY OF THE WRIST
Dorsal
Radial
border
1st
comp
Radial Ulnar
border border
4th
2nd
comp
comp
Ulnar
border
FCU
radial
central
ulnar
COMMON CAUSES OF WRIST PAIN ACCORDING TO TOPOGRAPHIC
AREAS - 1
COMMON CAUSES OF WRIST PAIN ACCORDING TO TOPOGRAPHIC
AREAS - 2
Volar areas
Radial
Central
Dorsal areas
Ulnar
Radial
Central
Ulnar
COMMON DIAGNOSTIC TESTS AND PROVOCATIVE MANEUVERS
ACCORDING TO TOPOGRAPHIC AREAS - 1
Area
Volar
Radial
• 1CMC Grind Test
• Palpation of STT joint
• Finkelstein’s Test
• FRC Palpation Test
• Tinel’s sign over the
• Palmar Cutaneous Branch of
Median Nerve
Central
• FDC Palpation Test
• Phalen’s Test
• Tinel’s sign over the Median
Nerve
Ulnar
• Palpation of the Hook
of the Hamate
• Piso -Triquetral Grind
Test
• FCU Palpation Test
• Tinel’s sign over the
Ulnar Nerve
COMMON DIAGNOSTIC TESTS AND PROVOCATIVE MANEUVERS
ACCORDING TO TOPOGRAPHIC AREAS - 2
Area
Dorsal
Radial
Central
Ulnar
• 1 CMC Grind Test
• Finger Extension Test (FET)
• LT Shear Test
• 2-3 CMC Shear test
• Palpation of Anatomic
snuffbox/
Articular-Nonarticular test
• Intersection Syndrome
•Tinel’s sign over the sensory
branch of Radial Nerve
)Wartenberg’s Neuralgia)
• Scaphoid shift )Watson’s( test
• SL Shear Test
• “Catch-up clunk” )Lichtman’s
Test)
• EPL Test
• EIP Test
• Radio-Carpal Subluxation Test
• Palpation of Extensor
Digitorum Brevis Manus
• Derby’s Method for LT
dissociation
• Ballottement Test
• Triquetral Impingement
Ligament Tear (TILT) test
• Ulnar Snuff Box Compression
test
• Piano Key Test
• Press Test
• Ulno-Carpal impaction test
• Ulnar styloid impaction test
• EDM test
• ECU Palpation Test
• ECU Subluxation Provoc Test
• Tinel’s sign over the Dorsal
Branch of Ulnar Nerve
‫‪PROVOCATIVE TESTS‬‬
‫א‪-‬‬
‫ב‪-‬‬
‫ג‪-‬‬
‫ד‪-‬‬
‫ה‪-‬‬
‫בדיקת הצד הרדיאלי של שורש היד‬
‫בדיקת הצד האולנרי של שורש היד‬
‫בדיקת המפרקים הרדיוקרפלים ומידקרפלים‬
‫בדיקת המפרקים הקרפומטקרפלים‬
‫סיבות חוץ פרקיות לכאבים בשורש היד‬
‫בדיקת הצד הרדיאלי של שורש היד‬.‫א‬
1.
2.
3.
4.
5.
6.
Dorsal wrist (DWS) test
Finger extension (FET) test
Articular/nonarticular (ANA) test
Scaphotrapeziotrapezoid (STT) test
Scaphoid shift maneuver (SSM)
Ballotment test (shear) test for SL
1.Dorsal wrist (DWS) test
•



: S-L ‫לבדיקת פרק‬
This joint is not painful
to palpation.
If painful, suspect:
S-L dissociation
Kienbock’s disease
Dorsal wrist syndrome
(S-L joint overloading with
wrist pain secondary to S-L
ligament synovitis and/or tear
preceding evidence of rotary
subluxation of the scaphoid)
2.Finger extension (FET) test
(wrist-flexion finger-extension maneuver)
• Usually not painful
• If painful:
 Periscaphoid
inflammation
 Radiocarpal or midcarpal
instability
 Symptomatic rotary
subluxation of scaphoid
 Kienbock’s disease
3.Articular/nonarticular (ANA) test.
• Always compare to the
other side
• If severe pain:
 Periscaphoid
synovitis
 Scaphoid instability
 SLAC changes
4.Scaphotrapeziotrapezoid (STT)
test
• Palpation of this joint
is not painful
• If painful, suspect:
 Triscaphe synovitis
 Triscaphe OA
5.Scaphoid shift maneuver (SSM)
(Watson test, scaphoid shear test)
• If painful: rotary subluxation, periscaphoid arthritis
6. S- L shear test
Pressure on the scaphoid tubercle Pressure on dorsal aspect of the lunate
Simultaneous pressure in opposite directions
7.Scapholunate ballottement test
‫בדיקת הצד האולנרי של שורש היד‬.‫ב‬
Areas involved:
1. DRUJ
2. TFCC
3. Ulnar carpus
1.DRUJ
Decreased and/or painful pronosupination:
 Degenerative disease
 Subluxation
“Piano key” sign: exaggeration of normal ulna head
prominance.
 Dorsal subluxation
 Articular effusion
Ulnar impingement or impaction
syndrome
Decreased and/or
painful pronosupination
while ulnar head is
pressed volarward and
the pisiformis pressed
dorsally
2.TFCC
Suspected when:
 Loss of forearm prosupination and wrist motion
 Tenderness over TFCC dorsally
 Palpable and/or audible click with forearm rotation or
radioulnar deviation (Ulnar carpal abutment test)
Necessitates: Three compartment arthrography
3.ULNAR CARPUS
LT compression
test: direct pressure
along ulnoradial axis by
palpating within the ulnar
snuffbox. (Linscheid’s test)
If painful:
 LT instability
 Synovitis
 Degenerative disease
 Partial synchondrosis
LT instability: Reagan’s test
(L-T ballottement, shuck, shear)
Pressure on the lunate
Pressure on the triquetrum
LT instability: Masquelet’s test
LT instability: Masquelet’s test
Pressure on pisiformis
Pressure on dorsal aspect of the lunate
Simultaneous pressure in opposite directions
TH instability test
1. Grasping of the triquetrum
2. Stabilization of capitate and carpus with other
hand
3. Volar and dorsal stressing of the triquetrum
TILT: Triquetral Impingement
Ligament Tear syndrome
Triad of:
Localized triquetral pain
History of hyperflexion injury
Normal radiographs
Mechanism: cuff of fibrous tissue that has
become detached from the ulnar sling
mechanism and chronically impinges on the
triquetrum, resulting in synovitis, bony
eburnation and pain.
‫בדיקת המפרקים הרדיוקרפלים‬.‫ג‬
‫ומידקרפלים‬
Radiocarpal anteroposterior drawer test
‫‪The “pivot shift” of the mid-carpal joint‬‬
‫‪.1‬‬
‫‪.2‬‬
‫‪.3‬‬
‫‪.4‬‬
‫‪.5‬‬
‫מרפק מכופף ל‪ 90 -‬עם אמה בסופינציה מלאה‬
‫אחיזה יציבה של האמה‬
‫הטיה רדיאלית מקסימלית של שורש היד‬
‫סופינציה נוספת לכף היד ללא תנועה בשורש היד‬
‫העברת היד מהטיה רדיאלית לאולנרית‬
‫‪The “pivot shift” of the mid-carpal joint‬‬
‫הסבר‬
‫במנח שתואר לעיל ראש הקפיטטום "ננעל" בלונטום והמטום "ננעל" בטריקווטרום‪.‬‬
‫העצמות הנ"ל אינן יכולות לנוע יותר וולרית משום שהן נעצרות ע"י קפסולה‬
‫קידמית ורצועה ‪. LT‬‬
‫במידה וקיים קרע ברצועות הנ"ל )או רפיון מולד( הקפיטטום "יוצא" מתוך‬
‫הלונטום ובזמן העברת היד מהטיה רדיאלית להטיה אולנרית‪ ,‬השורה הרחיקנית‬
‫"קופצת" בחזרה למקומה מלווה בנקישה מכאיבה‪.‬‬
‫בדיקת המפרקים הרדיוקרפלים‬.‫ג‬
‫ומידקרפלים‬
Midcarpal anteroposterior drawer test
‫בדיקת המפרקים הקרפומטקרפלים‬.‫ד‬
CMC1 tests:
Grind test
Stress test
Adduction test
Carpal boss
‫סיבות חוץ פרקיות לכאבים בשורש היד‬.‫ה‬
• Finkelstein’s test
• “Wet leather” sign
• ECU problems: synovitis, subluxation,
stenosis, partial rupture
• Pisiformis problems: fractures, OA
• Hook of hamate
• FCR tendinitis
• intersection syndrome
• Substitution maneuvers
COMMON DIAGNOSTIC TESTS AND PROVOCATIVE MANEUVERS
List of publications and suggested readings
for download in:
www.goldberg-hand.co.il
Thank you !