Igo Goldberg M'D, Hand Surgeon

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Clinical Examination of the Wrist
Igo Goldberg M.D, Hand Surgeon Tel-Aviv, Israel
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MOST COMMON CAUSES OF WRIST PAIN - 1
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MOST COMMON CAUSES OF WRIST PAIN - 2
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What constitutes the first part of every thorough
physical examination?
A thorough history
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STEPS IN TAKING A PATIENT HISTORY
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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

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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?

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WRIST MOTION IMPAIRMENT - 1

• The wrist functional unit represents 60 of the
  upper extremity (UE) function.
• Flexion-Extension unit 70 of wrist
  function70x6042 of UE function.
• Radial-Ulnar deviation unit 30 of wrist
  function 30x6018 of UE function
• ?????? ?? ???? ?????-???? ?????? ????? ???? ????
  ?????? ?? ???? ?????? ??????

Normal ROM 60-60 F-E
Normal ROM 20-30 R-U
Wrist fusion 10 extension 10 ulnar deviation
Functional ROM 10-10 F-E
Functional ROM 0-10 R-U
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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
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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

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How much wrist motion is required for most
activities of daily living (ADL) ?
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  20 ???? ???? 41(10)(?')
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  ???? ???? 41(10)(?')
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  ???? ???? 44(234)

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TOPOGRAPHIC ANATOMY OF THE WRIST
middle axis 4th finger
VOLAR
radial
central
ulnar
Radial border 1st comp
Ulnar border FCR
Ulnar border FCU
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TOPOGRAPHIC ANATOMY OF THE WRIST
Dorsal
Radial border 1st comp
Radial border 2nd comp
Ulnar border 4th comp
Ulnar border FCU
ulnar
central
radial
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COMMON CAUSES OF WRIST PAIN ACCORDING TO
TOPOGRAPHIC AREAS - 1
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COMMON CAUSES OF WRIST PAIN ACCORDING TO
TOPOGRAPHIC AREAS - 2
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COMMON DIAGNOSTIC TESTS AND PROVOCATIVE MANEUVERS
ACCORDING TO TOPOGRAPHIC AREAS - 1
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COMMON DIAGNOSTIC TESTS AND PROVOCATIVE MANEUVERS
ACCORDING TO TOPOGRAPHIC AREAS - 2
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PROVOCATIVE TESTS

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?.????? ??? ??????? ?? ???? ???

• 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

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1.Dorsal wrist (DWS) test

• ?????? ??? S-L
• This joint is not painful to palpation.
• If painful, suspect
• S-L dissociation
• Kienbocks 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)

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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
• Kienbocks disease

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3.Articular/nonarticular (ANA) test.

• Always compare to the other side
• If severe pain
• Periscaphoid synovitis
• Scaphoid instability
• SLAC changes

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4.Scaphotrapeziotrapezoid (STT) test

• Palpation of this joint is not painful
• If painful, suspect
• Triscaphe synovitis
• Triscaphe OA

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5.Scaphoid shift maneuver (SSM)(Watson test,
scaphoid shear test)

• If painful rotary subluxation, periscaphoid
  arthritis

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6. S- L shear test
Pressure on the scaphoid tubercle
Pressure on dorsal aspect of the lunate
Simultaneous pressure in opposite directions
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7.Scapholunate ballottement test
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?.????? ??? ??????? ?? ???? ???

• Areas involved
• DRUJ
• TFCC
• Ulnar carpus

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1.DRUJ

• Decreased and/or painful pronosupination
• Degenerative disease
• Subluxation
• Piano key sign exaggeration of normal ulna
  head prominance.
• Dorsal subluxation
• Articular effusion

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Ulnar impingement or impaction syndrome

• Decreased and/or painful pronosupination while
  ulnar head is pressed volarward and the
  pisiformis pressed dorsally

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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

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3.ULNAR CARPUS

• LT compression test direct pressure along
  ulnoradial axis by palpating within the ulnar
  snuffbox. (Linscheids test)
• If painful
• LT instability
• Synovitis
• Degenerative disease
• Partial synchondrosis

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LT instability Reagans test(L-T ballottement,
shuck, shear)
Pressure on the lunate
Pressure on the triquetrum
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LT instability Masquelets test
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LT instability Masquelets test
Pressure on pisiformis
Pressure on dorsal aspect of the lunate
Simultaneous pressure in opposite directions
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TH instability test

• Grasping of the triquetrum
• Stabilization of capitate and carpus with other
  hand
• Volar and dorsal stressing of the triquetrum

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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.

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?.????? ??????? ??????????? ??????????

• Radiocarpal anteroposterior drawer test

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The pivot shift of the mid-carpal joint

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• ????? ????? ?? ????
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• ???????? ????? ??? ??? ??? ????? ????? ???
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The pivot shift of the mid-carpal joint

• ????
• ???? ????? ???? ??? ???????? "????" ???????
  ?????? "????" ???????????.
• ?????? ??"? ???? ?????? ???? ???? ?????? ???? ???
  ?????? ?"? ??????
• ?????? ?????? LT .
• ????? ????? ??? ??????? ??"? (?? ????? ????)
  ???????? "????" ????
• ??????? ????? ????? ??? ????? ??????? ?????
  ???????, ????? ????????
• "?????" ????? ?????? ????? ?????? ??????.

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?.????? ??????? ??????????? ??????????

• Midcarpal anteroposterior drawer test

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?.????? ??????? ?????????????

• CMC1 tests
• Grind test
• Stress test
• Adduction test

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Carpal boss
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?.????? ??? ?????? ?????? ????? ???

• Finkelsteins test
• Wet leather sign
• ECU problems synovitis, subluxation, stenosis,
  partial rupture
• Pisiformis problems fractures, OA
• Hook of hamate
• FCR tendinitis
• intersection syndrome
• Substitution maneuvers

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COMMON DIAGNOSTIC TESTS AND PROVOCATIVE
MANEUVERS
List of publications and suggested readings
for download in
www.goldberg-hand.co.il
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Thank you !