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.
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
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
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 is a 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.
According to AMA guidelines for impairment assessment these are the recommended range of movements below.
Metacarpo-phalangeal (MCP) joint of the thumb: Flexion/Extension 0º/60º. The thumb is moved towards the inner palm (flexion) or outwards (extension).
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.
Special tests are carried out to confirm nerve irritation of the spine.
Passive neck flexion
With the patient supine, the examiner places the hands on the posterior side of the head over the occiput. Next, the head is passively flexed anteriorly with the chin reaching the chest. A positive result is reproduction of neurological symptoms to the lower extremities.
Vertebral artery test
The patient is in a supine position and the head gently pulled and twisted to each side. If blurred vision, dizziness, slurred speech, level of consciousness (LOC) appear it may indicate a partial or complete obstruction of the vertebral artery.
Spurling test - Foraminal compression
With the patient in a sitting position, the examiner exercises pressure with both hands on the patient’s head pushing downwards and flexing and the head laterally.
If pain arises on the flexed side it may indicate pressure on cervical nerve roots caused by osteoarthritis, osteoporosis, spinal stenosis or instability of the cervical spine. If the vertebral artery test is also positive it suggests damage to the vessel.
Neck distraction test - Manual traction test
With the patient lying on a supine position, the examiner places one hand under the patient’s chin and the other on the occiput. The head is gently lifted and an axial traction force is gradually applied up to 30 pounds. The test is positive if the pain is relieved or decreased when the head is lifted or distracted, indicating pressure on nerve roots.
Shoulder abduction test
The patient places the hand of the affected extremity on the head to support the arm in the scapular plane. A positive response is alleviation of patient symptoms that are associated with the relief of a sensory sign (also named Bakody’s sign) possibly due to a disc protrusion, impinging on the nerve or the nerve root. When positive, this test is also combined with motor weakness, radicular paraesthesia, lateral extradural lesions and a good response to surgical treatment.
When the patient has difficulties in swallowing (dysphagia), this could be due to the obstruction of the cervical spine caused by subluxation, osteophyte protrusion, soft tissue swelling, tumors of the anterior spine or a pathology of the esophagus (i.e. herniation of the mucous membrane). Lateral views of the cervical spine demonstrated approximately 25% anterolisthesis in a bilateral facet subluxation. There is a narrowing of the central canal secondary to the anterolisthesis.
Tinel’s sign - Brachial plexus test
This test determines the status of the brachial plexus, which is a group of nerves exiting the vertebrae from C4 to T1 innervating the shoulder and the arm. The patient is sitting with the head slightly bent to the side. The examiner taps the brachial plexus of the same side along the nerves from the neck to the shoulder. A positive sign shows a tingling sensation on the nerve fibres, indicating a pathology of the brachial plexus.
Mechanisms of “burners.”
(A) Traction to the brachial plexus from ipsilateral shoulder depression and contralateral lateral neck flexion.
(B) Direct blow to the supraclavicular fossa at Erb's point
(C) Compression of the cervical roots or brachial plexus from ipsilateral lateral flexion and hyperextension.
Brachial plexus stretch test
Pathologies of the brachial plexus produce a feeling of electric shock, numbness or burning sensation at the neck radiating to the arm. (In most severe cases when the nerves are severed the movement of the shoulder, arm and fingers may be impaired). For the stretch test, the patient is seated and the examiner places one hand on the shoulder and the other onto the head and stretches the brachial plexus by flexing the patient’s head. By stretching the neck to the right the pain radiating to the left shoulder indicates a pathology of the plexus. Conversely, a pain sensation radiating on the opposite right shoulder, is indicative of possible impingement of the nerve roots.
The patient holds both arms at shoulder level and bent at the elbows. The hands are opened and closed to a fist. The test is positive if the patient is unable to maintain the position, shows reduced hand function, or loss of sensation in the upper extremities? This may indicate a thoracic outlet syndrome (disorders caused by compression to vessels or nerves between collarbone and first rib (thoracic outlet). This causes pain in shoulders and neck and finger numbness.
Straight leg raise
Straight leg raise (SLR) is used to determine the irritation of the lumbosacral nerve. While lying on the back, passively flex the straight leg from the hip up to 90 degrees. Pain should be felt at an angle between 30º and 70º and disappear when lowering the leg at 10º. If positive, this test demonstrates a possible herniated disk and irritation of the sciatic nerve.
Test for lumbosacral nerve root irritation. Patient is supine, and the physician passively elevates each of the patient's legs in turn, keeping the knee extended, and flexing at the hip to an angle of 90º.
This test is used for lumbosacral nerve root irritation and to discriminate between a nerve or muscle origin of lower back pain. The patient is supine, and the examiner lowers the patient's leg about an inch from the position in which pain was elicited. While holding the leg elevated, the patient's foot is passively dorsiflexed. If pain is increased, a nerve aetiology is likely at L4, L5, or S1 levels; conversely a muscle aetiology is likely if no pain arises.
Variations of straight leg raise test:
Once reached the leg elevation causing the pain, flex the knee. If no pain is felt with straight leg raise, flex the cervical spine to the chest and repeat the test. Pain should be relieved by flexing the knee (Kerning) or aggravated by flexing the neck (Brudinski). Used for herniated disk and dural sheath irritation.
Well straight leg raising test
The patient straightens and raises the opposite leg to the one causing pain. If pain is felt on the leg lying low, it may indicate a herniated disk.
Seated at table edge, bend forward, flex the neck, extend one knee and dorsiflex the foot. If sciatic pain occurs it indicates a problem to the sciatic nerve.
Tension sign/Bowstring test
Passive straight leg rise until pain is felt, flex the knee to release symptoms, apply pressure to the popliteal fossa (depression behind the knee joint). If pain returns it means sciatic nerve issues.
This test is used to determine if patient is malingering. The examiner cups the calcaneus of each leg with his/her hands. When the patient raises the leg straight, the examiner should feel pressure on calcaneus remaining onto the bed, which is used as leverage for the opposite, elevating leg. If no pressure is felt, the patient is simulating the spine problem.
Femoral nerve stretch test
Lying on the side, passively extend the leg at the hip with the knee bent at 90º. If pain, numbness or tingling is felt at the anterior/lateral thigh, it shows femoral nerve root impingement.
Stork/Single stance test
While balancing on leg, arch the spine backwards. If pain occurs, it indicates spondylolysis or spondylolisthesis.
A blunt object is run along the lateral side of the inner foot from the heel to the big toe (fanning of toes). The test is positive if the big toe extends and the other toes abduct. This is a plantar reflex and may indicate brain or spinal cord trau
The examiner runs fingernails gently along the crest of the patient’s calf bone (tibia). If the big toe extends and the other toes abduct, and plantar reflex it can indicate brain or spinal cord trauma.
The patient holds a deep breath and blows into the closed fist by strongly contracting the abdominal muscles. If spinal pain increases it may indicate a herniated disk.
The patient is asked to lift the feet of 2-6 inches off the bed for 30 seconds. If the patient is unable to lift, hold the legs or feels spinal pain, it may indicate herniated disk and impinged lumbar nerve.
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.
Palmar aspect of thumb, index, middle finger and lateral half of ring finger and distal half of the dorsal aspect of these fingers.
Skin on most of the dorsum of the hand and fingers.
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 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.
Compression test for ulnar nerve
Pain or discomfort when compressing the sulcus ulnaris at the elbow or Guyon’s canal 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.
An absent or weak pulse may affect blood perfusion to the entire or one part of the body. The pulse is measured in areas were an artery passes close to the skin such as at the wrist. The index and middle fingers are placed over the underside of the wrist below the base of the thumb. The fingers are pressed firmly until the examiner feels the pulse and counts the beats for one full minute.
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 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.
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
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.
The initial examination consists of evaluating abnormalities in the range of movement of the following functions. See Range of movement for specific images.
1st Carpo-Metacarpal (CMC) Joint
Metacarpal-phalangeal (MCP) Joint
Inter-phalangeal (IP) / Distal IP / Proximal IP Joint
Muscle strength test
Assessment of muscle strength of the wrist is achieved by testing the following movements and functions:
Forearm pronation and supination
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.
Test of finger tendons: Flexor digitorum superficialis and flexor digitorum profundus
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 of the tendon of the flexor digitorum superficialis.
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.
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.
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.
Distal Radio-Ulnar joint (DRUJ) instability
The examiner holds the wrist on the radial side and moves the ulna in a lateral plane. Clicking, popping or pain confirm diagnosis of DRUJ instability.
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.
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.
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.
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.