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Clinical examination of the wrist
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Clinical examination of the wrist
General history A focused history will guide clinical examination. Ask about hand dominance, occupation, sporting level and previous injuries. There are four main symptoms that should be explored in some detail: 1. pain; 2. stiffness; 3. weakness; 4. clicking. Pain is important and enquiry should be made about its site (radial, central or ulnar; dorsal or volar), onset (insidious, following trauma), character (dull ache, sharp on movement), radiation (forearm, hand), exacerbating factors (particular movements), relieving factors (rest, analgesia), and severity (preventing work or self-care). The location of the pain is a strong guide towards the diagnosis, and this helps focus the clinical examination. The most common site of pain for a variety of pathologies is detailed in Figure 1.
Ashley W Newton David H Hawkes Vijay Bhalaik
Abstract Accurate clinical assessment of the wrist can be difficult, due to the large number of structures that are found in a confined space, which give rise to a range of pathologies. It is therefore essential that clinicians develop a thorough and systematic technique of examination to elucidate the cause of the patient’s wrist symptoms. This paper outlines key points for the clinical assessment of the symptomatic wrist. This is followed by an overview of the potential pathologies in each anatomical wrist zone, their typical symptoms and the pertinent examination findings the surgeon should seek to elicit. Thinking of the wrist as a series of five zones facilitates identification of the pathology. The described zones are radialedorsal, radialevolar, ulnar edorsal, ulnarevolar and central. Tips for the interpretation of each test are also included, along with an assessment of the sensitivity and specificity of relevant tests and its implications. Often, the better the clinical examination, the more productive the radiological examination.
General examination Positioning The examination should be conducted with the examiner sitting directly opposite the patient (so the patient can be observed for signs of discomfort) with a table between upon which the patient can rest their elbow. This position facilitates comfort and allows forearm rotation to be controlled (Figure 2). Both hands, wrists and forearms need to be exposed to allow comparison with the contralateral side. The examination should then follow the standard orthopaedic format of ‘look, feel, move’ followed by special/provocative tests.
Keywords carpus; clinical assessment; examination; wrist
Inspection (look) Look at the hand and wrist, paying particular attention to skin condition, swellings, muscle atrophy and deformity. Specific signs to seek on inspection are listed in Box 1. Diagnoses such as rheumatoid arthritis should be obvious at this stage of the examination.
Introduction The wrist is a complex anatomical arrangement, with multiple interconnected structures in a relatively confined space. This can make identification of the pathology responsible for particular symptoms potentially difficult. It is necessary to adopt a systematic approach to examination in order to narrow the wide differential diagnosis. This requires a sound knowledge of not only wrist anatomy, but the potential pathologies and the provocative tests which help delineate them from each other. This article will deal with general considerations concerning systematic examination of the wrist, then explore common causes of wrist symptoms and how to examine for them. The focus is on sub-acute and elective conditions in the adult.
Palpation (feel) Elicit tenderness, instability, crepitus, and clicking by palpation. Determine if masses are superficial or deep, fixed or mobile, hard or fluctuant. The different zones for palpation are considered later in this article in reference to each pathology and are summarised in Box 2. It is important to consider the dorsal and volar surface anatomy during palpation (Figure 3). Pulses of the radial and ulnar artery are palpated and sensation in the distribution of the median, ulnar, and superficial radial nerves is checked. Range of motion (move) The wrist has multiple points of articulation, which produce a variety of movements including flexion, extension, radial and ulnar deviation, pronation and supination which should be compared with the contralateral side (Figure 4). Flexion and extension originate from the radiocarpal and midcarpal joints and loss of this motion suggests pathology in these joints. Supination and pronation occur at the distal radioulnar joint (DRUJ) and disease of this joint leads to decreased rotation. In addition to assessing movements in isolation, a useful measure of combined functional motion is the ‘dart throwing motion’ (Figure 5).
Ashley W Newton MBChB MRes MRCS PGCTLCP FHEA Specialty Registrar, Trauma and Orthopaedic Surgery, North West (Mersey) Deanery, Health Education England, Liverpool, UK. Conflict of interest: none declared. David H Hawkes MBChB MPhil MRCS Specialty Registrar, Trauma and Orthopaedic Surgery, North West (Mersey) Deanery, Health Education England, Liverpool, UK. Conflict of interest: none declared. Vijay Bhalaik MBBS MRCS FRCS Consultant Hand and Upper Limb Surgeon, Wirral University Teaching Hospital, Arrowe Park Hospital, Wirral, UK. Conflict of interest: none declared.
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DORSAL st 1 CMC joint arthritis STT joint arthritis Radial styloid arthritis De Quervain’s Tenosynovitis Intersection syndrome Wartenberg syndrome ECRL/ECRB tendonitis
Lunotriquetral instability DRUJ osteoarthritis DRUJ instability ECU tendonitis ECU instability
CENTRAL Midcarpal instability Scapholunate dysfunction RADIAL ULNAR Keinbock’s disease SLAC wrist Carpal tunnel syndrome st 1 CMC joint arthritis FCU tendonitis FCR tendonitis Ulna nerve compression Scaphoid non-union Pisotriquetral arthritis Carpal tunnel syndrome TFCC tear Ulnocarpal abutment VOLAR Figure 1 Wrist pathology listed by site of pain. CMC, carpometacarpal; DRUJ, distal radioulnar joint; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; SLAC, scapholunate advanced collapse; STT, scaphotrapezial trapezoid; TFCC, triangular fibrocartilage complex.
refers to the ability of a test to correctly identify those without the condition. A reminder about interpreting sensitivity and specificity is found in Box 3. A number of the tests relating to wrist pathology have either a limited sensitivity or specificity and it is clearly essential that we understand these limitations if the correct diagnosis is to be established.
Special tests The numerous special tests for wrist pathology vary in their reported sensitivity and specificity. No single test is completely pathognomonic, hence several features must be interpreted in the clinical context of each individual patient to arrive at a diagnosis; a process of pattern recognition. Whilst it is clearly evident clinicians should understand how to correctly perform these special tests is it equally important to have an understanding of the psychometric properties of each test. Sensitivity describes the ability of a test to correctly identify those patients with a particular condition. Conversely, specificity
Radialedorsal symptoms Thumb carpometacarpal joint osteoarthritis Osteoarthritis of the first carpometacarpal (CMC) joint e often referred to as base of thumb arthritis e is a very common
Figure 2 Positioning for clinical examination of the wrist. The examiner sits opposite the patient with a small arm table between them.
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other hand is used to stabilize the wrist. A positive result is pain, with or without crepitus. The traction shift (subluxation-relocation) test is an alternative, which is performed by applying longitudinal traction to the thumb, followed by alternating volar and dorsal pressure to the base of the first metacarpal. This provokes subluxation and relocation of the joint and is positive if there is pain. Both of these tests are easy to perform and have high quoted specificity. Higher sensitivity has been reported for the adduction test. In the adduction test the patient places the affected hand on the examination table with the elbow flexed 90 and the forearm in neutral rotation. The examiner places his or her ipsilateral hand such that the examiner’s thumb rests over the head of the thumb metacarpal dorsally. The examiner’s contralateral hand supports the ulnar side of the patient’s hand to maintain the patient’s wrist in a neutral position in order to prevent ulnar deviation of the patient’s wrist. The examiner firmly directs an adduction force downward onto the patient’s metacarpal head until the patient’s thumb metacarpal lies parallel to the mid axis of the index metacarpal or until a firm end point is reached (Figure 6). Pain at the first CMC joint represents a positive test. Sensitivity and specificity estimates are detailed in Table 1.2,3 It is worth noting that point tenderness over the joint has both good sensitivity and specificity. Pitfalls in the examination of base of thumb arthritis include inconsistent correlation between clinical findings and radiological features, which may account for some of the low reported sensitivity rates. A patient with severe degenerative changes on radiographs may have little or no pain.
Signs to look for on inspection C
C C C C
Swelling, e.g. over extensor carpi ulnaris tendon, first extensor compartment Masses, e.g. ganglia, rheumatoid nodules Deformity, e.g. radial deviation, Z thumb Scars, e.g. previous distal radius fixation, carpal tunnel release Muscle wasting, e.g. thenar eminence, first dorsal interosseous
Box 1
Suggested order for palpation of the whole wrist
Radial side: C C C C C C C
First carpometacarpal joint Scaphotrapezial trapezoid joint Radial styloid First extensor compartment Second extensor compartment Scaphoid Flexor carpi radialis tendon
Central C C C
Lunate Scapholunate joint Carpal tunnel
STT joint arthritis Patient’s with scaphotrapezial trapezoid (STT) joint arthritis usually report a history of deep thenar eminence pain and base of thumb pain. Test the patient’s dart throwing motion (see Figure 5), which will often be painful and have reduced range. On examination, there is tenderness over the surface landmark of the joint, which is just distal and ulnar to the anatomical snuff box (Figure 3). The final stage of base of thumb arthritis is pantrapezial arthritis (Eaton-Littler stage IV) in which the STT joint is involved. As such the two conditions described above commonly co-exist.
Ulnar side C C C C C C C
Hook of hamate Pisotriquetral joint Lunotriquetral joint Distal radioulnar joint Ulnar soft spot Extensor carpi ulnaris tendon Flexor carpi ulnaris tendon
Palpation of these structures can be supplemented by special tests as described in the text
De Quervain’s tenosynovitis This is a stenosing tenosynovial inflammation of the first extensor compartment, which contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. Women are affected more commonly than men and patients typically present between the ages of 30 and 50, with the gradual onset of pain over the first extensor compartment at the level of the radial styloid process. Firstly, look for swelling over the first dorsal compartment and palpate for point tenderness. Caution must be taken with the nomenclature of the provocative tests for de Quervain’s e errors in how the tests are performed have propagated through the literature and into text books. The Finkelstein manoeuvre4 is performed by the examiner grasping the patient’s thumb and quickly deviating the hand in an ulnar direction, which provokes pain over the radial styloid (Figure 7a) when positive. The Eichhoff manoeuvre5 (which is often erroneously called Finkelstein’s) is performed by asking the
Box 2
condition with a prevalence of 8% in the general population.1 Patients typically present with pain on the radial side of the dorsum of the wrist, centred over the thumb CMC joint. Pain is worst on activity. Weakness or difficulty with pinch may be marked and activities, such as opening bottles, cause difficulty. Inspection may show swelling over the joint. ‘Squaring’ of the base of the thumb may be seen in later disease, followed by adduction of the thumb metacarpal and compensatory hyperextension of the metacarpophalangeal joint. With advanced disease this gives the characteristic ‘Z’ thumb appearance. Palpation is likely to elicit joint tenderness and crepitus. The range of motion at the CMC joint is restricted. The grind test is performed by rotating the patient’s first metacarpal whilst applying axial compression. The examiners
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Figure 3 Dorsal (left) and volar (right) wrist surface anatomy. CMC, carpometacarpal; DRUJ, distal radioulnar joint; SL, scapholunate.
The WHAT test6 (wrist hyperflexion and abduction of the thumb) is an active test, which stresses the APL and EPB tendons. The patient is examined with the wrist flexed, thumb abducted and metacarpophalangeal and interphalangeal joints of the thumb in extension. Resisted thumb abduction/extension is then tested and a positive result is reported pain over the first extensor compartment (Figure 7c). This isolates the tendons of the first extensor compartment. Contrary to tests for base of
patient to clench their own thumb into a fist and then deviate in an ulnar direction (Figure 7b). When positive this leads to pain, which is relieved once the thumb is extended, even when the wrist remains ulnarly deviated. Due to the passive nature of both of these tests (i.e. the tendons of the first extensor compartment are not active during the tests) other pathology of the radial border of the wrist can also cause pain and give a false-positive result.
Figure 4 Normal range of motion of the wrist. Pronation 75 (a) and supination 80 (b) flexion 75 (c) and extension 75 (d) radial deviation 20 (e) and ulnar deviation 35 (f).
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Figure 5 The dart throwing movement. A composite movement of the wrist from supination-radial deviation-extension (left), to pronation-ulnar deviation-flexion (right). This assesses functional wrist movement.
thumb arthritis, tests for de Quervain’s have high sensitivity but low specificity. In other words, patients with de Quervain’s are very likely to have a positive test, but patients with a positive test do not necessarily have de Quervain’s tenosynovitis (Table 1).6
Sensitivity and specificity e definition and worked example Sensitivity e probability of a positive result in patients with the disease (true positive rate) i.e. the probability of detecting the disease if the patient truly has it. Specificity e probability of a negative test in patients without the disease i.e. correctly determining that they don’t have the disease. Example interpretation: A patient has radial sided wrist pain and you suspect they have first carpometacarpal (CMC) joint arthritis. You examine them with the grind test, which has 30% sensitivity and 92% specificity. C
If the patient has first CMC joint arthritis, there is a 30% chance the test will be positive i.e. 30% chance of testing positive if they do have first CMC joint arthritis This means that even if the test is negative, the patient may well still have first CMC joint arthritis (this test isn’t very sensitive at detecting cases of first CMC joint arthritis)
C
If the patient does not have first CMC joint arthritis, there is a 92% chance the test will be negative i.e. 92% chance of test being normal if they don’t have first CMC joint arthritis This means if the test is positive, there is a good chance the patient has first CMC joint arthritis (the test is specific, i.e. it is not usually positive in other wrist pathology)
Radial styloid arthritis Radial styloid arthritis is the first stage of scapholunate advanced collapse (SLAC) wrist. Care must be taken to differentiate base of thumb arthritis and de Quervain’s from this condition, as all have point tenderness in a similar region. This should be done using knowledge of surface anatomy in conjunction with the appropriate provocative tests. Intersection syndrome Intersection syndrome is a less common phenomenon caused by inflammation at the point of crossover of the first (abductor pollicis longus and extensor pollicis brevis) and second (extensor carpi radialis longus (ECRL) and brevis (ECRB)) extensor compartments.7 It is associated with repetitive wrist extension and is relatively more common in rowers and weight lifters. Patients have point tenderness and swelling over the intersection, which can be palpated on the dorsal forearm 4 cm proximal to Lister’s tubercle (refer to Figure 3). Some patients will have crepitus on flexion and extension at the same point. Wartenberg syndrome Wartenberg syndrome is a rare compression neuropathy of the superficial sensory branch of the radial nerve. The nerve is compressed by a scissoring action of the brachioradialis and ECRL tendons during forearm pronation. Patients present with ill-defined dorsoradial wrist pain, paraesthesia or numbness. These symptoms can be exacerbated by movements, which increase traction on the nerve, including repetitive wrist flexion and ulnar deviation. Tinel’s sign is commonly positive, either over the radial styloid (type 1) or just distal to the brachioradialis muscle belly, which is 9 cm proximal to the radial styloid (type 2) or a combination of the two (type 3). Pronation of the forearm with ulnar deviation exacerbates symptoms. There is an association with de Quervain’s tenosynovitis. This is problematic because provocative tests for de Quervain’s
Important note: Sensitivity and specificity alone cannot be used to calculate the percentage chance of a patient who tests positive actually having first CMC joint arthritis (positive predictive value). This varies depending on how common first CMC joint arthritis is in the patients being tested (i.e. the prevalence)
Box 3
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Figure 6 Thumb adduction test. The examiner stabilizes the ulnar side of the patient’s wrist with one hand (a) and adducts the thumb by pressing over the first metacarpal head (b).
tenosynovitis can also exacerbate the symptoms of Wartenberg syndrome e and this needs to be considered during assessment.
(radial side of scaphoid affected early). Grip strength and pinch strength are both reduced. On examination a scaphoid non-union may be tender to axial compression. The examiner palpates the scaphoid between their thumb (on the scaphoid tubercle volarly) and index finger (in the anatomical snuffbox dorsally). If the patient is developing SNAC, inspection may reveal swelling of the dorsoradial aspect of the wrist related to a combination of osteophytes and focal synovitis. There will be tenderness to palpation of the radioscaphoid articulation. Extension and radial deviation will be decreased and/or painful.
Radialevolar symptoms FCR tendonitis Flexor carpi radialis (FCR) tendonitis is a relatively uncommon condition linked to repetitive wrist flexion. Pathologically it is characterized by inflammation within the tendon’s synovial sheath, which causes pain on the volar and radial aspect of the wrist. Look for swelling over the tendon (Figure 8). There is tenderness to palpation over the volar and radial forearm along the course of the FCR tendon at the level of the distal wrist flexion crease. The provocation manoeuvre is resisted wrist flexion and radial deviation with palpation of the FCR tendon.
Carpal tunnel syndrome Carpal tunnel syndrome is a constellation of symptoms and signs that result from median nerve compression within the carpal tunnel, beneath the transverse carpal ligament. It is the most common compressive neuropathy. It is associated with diabetes, hypothyroidism, rheumatoid arthritis, pregnancy and amyloidosis. The assessment of patients with suspected carpal tunnel syndrome centres around the history, followed by an assessment of median nerve sensory and motor function. Patients classically present with radial-sided hand pain and paraesthesia that wakes them from sleep. The numbness is in the distribution of the median nerve e the radial three and a half digits. Clumsiness is a feature if the recurrent motor branch to the thenar eminence is involved. Inspection may reveal thenar atrophy; test for weakness of resisted abduction. Altered sensation should be examined for in the median nerve distribution using graduated monofilaments. Tinel’s, Phalen’s and Durkan’s tests are often used in the diagnosis of carpal tunnel syndrome. Tinel’s test is performed by tapping over the patient’s median nerve at the distal wrist crease and is positive if it provokes paraesthesia in the median nerve distribution. Phalen’s test requires the patient to flex both wrists to 90 for 60 seconds and is positive if this produces paraesthesia in the median nerve distribution. Durkan’s pressure provocation test requires the examiner to press over the patient’s carpal tunnel with their thumb for 60 seconds and is positive if this produces paraesthesia in the median nerve distribution. A combination of wrist flexion (Phalen’s) with pressure applied (Durkan’s) for 60 seconds (Figure 9) gives good sensitivity (96%) and specificity (80%). Sensitivity and specificity values for a range of tests are shown in Table 2.8e10 There are many clinical tests for carpal tunnel syndrome, but there are no gold standard diagnostic criteria e
Scaphoid non-union In the early stages of this condition patients may present with few or no symptoms. Over time, chronic non-union leads to scaphoid collapse and progressive arthritis (scaphoid non-union advanced collapse (SNAC) wrist). This occurs in a characteristic pattern; firstly radial side of scaphoid and radial styloid, then scaphocapitate arthrosis, and finally periscaphoid arthrosis. However, the lunocapitate joint may remain relatively unaffected. Patients present with a history of progressive pain, stiffness and weakness. They may or may not recall previous wrist trauma. There is a reduced range of wrist flexion and extension. The stiffness is most marked in extension and radial deviation
Comparison of tests for first carpometacarpal joint arthritis and de Quervain’s disease Test
Sensitivity
Specificity
Grind Traction shift Thumb adduction Point tenderness Eichhoff test WHAT test
30e44% 66.7% 95% 94% 89% 99%
92e97% 100% 93% 81% 14% 29%
Table 1
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Figure 8 Flexor carpi radialis (bottom of image) and flexor carpi ulnaris (top of image) S indicates the scaphoid tubercle position, and P indicates the position of the pisiform.
Figure 9 Testing for carpal tunnel syndrome with the wrists flexed. Direct pressure is applied over the tunnel with the examiner’s thumb for 60 seconds.
Comparison of tests for carpal tunnel syndrome
Figure 7 a) Finkelstein’s test. The examiner grasps the patients thumb and quickly ulnarly deviates. The examiner stabilizes the wrist with their other hand. (b) Eichhoff’s test. The patient grips their own thumb in the palm and ulnarly deviates. The point of maximal pain is indicated by the examiner’s right index finger. (c) WHAT test. The patient’s wrist is hyper-flexed, and the thumb is abducted. The examiner stabilizes the wrist with one hand, and asks the patient to abduct and extend the thumb against resistance.
Test
Sensitivity
Specificity
Tinel’s test Phalen’s test Durkan’s test Compression and flexion
41e64% 59e85% 42-89% 96%
56e99% 33e95% 18e96% 80%
Table 2
Central symptoms therefore the case definition varies. This has implications when comparing quoted sensitivity and specificity for different clinical tests from different studies e there is a very wide range. Abnormal clinical findings from provocative testing may be less apparent in advanced disease.8 It is also important to consider alternative causes of the symptoms, and one should always examine the patients elbow and neck. It may not be possible to identify what nerve is affected by the history alone, and the radial and ulnar nerves should also be evaluated in the setting of suspected carpal tunnel syndrome.
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Midcarpal instability Midcarpal instability is a subtype of carpal instability nondissociative (CIND). It is characterized by instability between the proximal and distal carpal row caused by extrinsic ligament dysfunction or laxity. There is usually no history of trauma and patients often have generalised ligamentous laxity. Patients present with subluxation, which may or may not be painful, and complain of the wrist ‘giving way.’ They may have a wrist clunk on certain movements when the wrist is under axial load. First, examine for signs of generalized ligamentous laxity.
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midcarpal joints. Progressive arthritis e SLAC wrist e is the end result. Patients with a scapholunate ligament deficiency present with pain or clicking in the wrist and may have swelling over the dorsal surface of the wrist and tenderness over the scapholunate ligament interval, found just distal to Lister’s tubercle. Scaphoid instability is demonstrated by Watson’s scaphoid shift test. This provocative manoeuvre is performed by exerting a dorsally directed load to the scaphoid tubercle as the wrist is taken from ulnar to radial deviation (Figure 11). Dorsal displacement of the scaphoid is noted, but the test is only considered positive if this is associated with pain. The sensitivity is 16.7% and specificity is 88.5%.11 The low sensitivity potentially reflects the difficult interpretation. Patients with a SLAC wrist have focal tenderness, which corresponds to their disease stage. Tenderness is initially limited to the radial styloid, as discussed above. Subsequently, in stage two and three disease the tenderness is more extensive along the scaphoid facet of the distal radius and then involves the capitolunate joint. The radiolunate joint is characteristically spared. Tenderness is accompanied by a reduction in wrist range of movement and weakness in grip strength.
Figure 10 Lichtman’s test for midcarpal instability (see text for description).
Try to bend the thumb to contact the patient’s forearm. The gap averages 4.5 cm in 17-year-olds and increases with age. Lichtman described the midcarpal shift test for midcarpal instability. To perform this on the patient’s left wrist the examiner first stabilises the patients pronated forearm with their right hand. The examiner presses on the capitate with the left thumb to apply a volarly directed force to the distal carpal row. This pressure should be maintained, then the wrist is deviated in an ulnar direction (Figure 10). The test is positive if there is a clunk, which may or may not be painful. Beware that the patient may be asymptomatic from their midcarpal instability and may have an alternative source for pain.
€ ck’s disease Kienbo €ck’s disease, is a rare Osteonecrosis of the lunate, or Kienbo condition that leads to progressive wrist pain and disability. Its aetiology remains poorly understood, but vascular and mechanical factors have both been implicated. Patients present with central wrist pain. Inspection reveals swelling over the dorsal surface of the wrist and there is focal tenderness over the lunate to palpation. A detailed understanding of wrist surface anatomy is again important here. Patients have a reduced range of motion in flexion and extension, with pain at the end of range and there is also reduced grip strength on the affected side.
Scapholunate dysfunction and SLAC wrist The scapholunate ligament is essential for the maintenance of carpal stability. Disruption of the ligament, from either an acute injury or degenerative rupture, leads to abnormal wrist biomechanics and ultimately advanced arthritis. A chronic scapholunate ligament injury causes the scaphoid to flex and the lunate to extend due to the unopposed extension force of the triquetrum transmitted through an intact lunotriquetral ligament. This results in dorsal intercalated segment instability (DISI) and resulting abnormal forces across the radiocarpal and
Ulnaredorsal symptoms Lunotriquetral instability The spectrum of lunotriquetral (LT) ligament injury ranges from partial tears with variable pain and weakness to complete
Figure 11 Watson’s scaphoid shift test. Force is applied to the scaphoid tubercle as the wrist is taken from ulnar (a) to radial deviation (b).
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dissociation with static collapse, causing a fork-like deformity of the wrist and prominence of the distal ulna (advanced VISI deformity). The dorsal intercarpal ligament may also be damaged, which acts as a secondary restraint of the lunotriquetral joint. Patients may or may not recall a hyperextension injury to the wrist and present with ulnar sided pain that is worse with pronation and ulnar deviation. When the LT ligament is disrupted the lunate and scaphoid flex and the triquetrum extends. This may be visible on inspection, as the carpus appears flexed compared to the distal radius. Pain may be present on direct palpation of the joint. The lunotriquetral ballottement test (Reagan’s test) is performed by grasping the pisotriquetral unit between the thumb and index finger of one hand and the lunate between the thumb and index finger of the other (Figure 12). If the test is positive, pain and increased anteroposterior laxity will be noted during manipulation of the joint. It is highly specific, but has poor sensitivity.11
Figure 13 Piano key test for distal radioeulnar joint instability.
ECU tendonitis and instability The tendon of extensor carpi ulnaris (ECU) runs through the sixth extensor compartment on the dorsal surface of the wrist. A spectrum of pathology can occur, ranging from tendonitis to instability. Patients with ECU tendonitis have focal tenderness over the tendon on the volar and ulnar aspect of the wrist. The classically described provocation test is asking the patient to perform resisted wrist extension and ulnar deviation. However, this manoeuvre also loads the TFCC and lunotriquetral ligament and compresses the distal ulna against the carpus. Consequently, a false-positive finding can occur if the pathology is within these areas of the wrist. The ECU synergy test has been advocated to avoid the false positive results associated with resisted wrist extension and ulnar deviation. The test exploits the synergistic activation of ECU with resisted thumb abduction. It is performed by resting the patient’s elbow on an examination table and flexing their elbow to 90 with the forearm in full supination. The examiner palpates the ECU tendon with one hand whilst the other grasps the patient’s thumb and middle finger. The patient then abducts the thumb against resistance. ECU muscle contraction is confirmed by appreciating bowstringing of the tendon. A positive finding includes the reproduction of pain over the dorsal and ulnar aspect of the wrist.12 ECU subluxation results from attenuation or rupture of the ECU subsheath. On examination, the tendon subluxes with supination and reduces into its groove during pronation. This can be associated with a painful snap.
DRUJ osteoarthritis and instability A variety of acute wrist injuries can result in DRUJ instability, which can then present with late symptoms, depending on how the initial injury was managed. DRUJ dysfunction is a common cause of ulnar-sided wrist pain and there will often be an associated triangular fibrocartilage complex (TFCC) injury. Patients with instability will usually have a history of injury and present with pain, stiffness and clicking associated with pronation and supination. Examine for a restricted range of pronation and supination. DRUJ instability can be assessed with the piano key test. The patient’s wrist is supported in pronation and a force is applied to the head of the ulna by the examiner’s thumb (Figure 13). The test is positive if the ulnar head returns back to its normal anatomical position, similar to the movement of a piano key when pressure is released. Later, patients develop osteoarthritis of the DRUJ. There may be deformity of the wrist or forearm visible on inspection, resulting from incongruency of the DRUJ and subsequent degeneration. Again, patients have pain and stiffness on pronation and supination. The ulnar compression test is performed by pressing the ulnar head onto the radius, thereby compressing the DRUJ, producing pain when positive.
Ulnarevolar symptoms TFCC tear The TFCC is composed of the dorsal and volar radioulnar ligaments, a central articular disc, the ulnar collateral ligament, the ECU subsheath and the origin of the ulnolunate and ulnotriquetal ligaments. Injuries to the complex can be classified into either type 1 (traumatic) or type 2 (degenerative), the latter of which is associated with positive ulnar variance and ulnocarpal impaction. Patients have a positive fovea sign on examination. This is performed by palpating the soft spot between the ulnar styloid, the FCU tendon, the volar surface of the ulnar head and the pisiform, with pain representing a positive test. The ulnar grind test is conducted with the wrist held in dorsiflexion and the
Figure 12 Regan’s test for lunotriquetral instability.
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Figure 14 Nakmura’s ulnar stress test for ulnar sided wrist pathology. The ulnarly deviated and pronated wrist is axially loaded from extension (a) into flexion (b).
forearm fixed. Axial load is applied and the wrist is rotated and deviated in ulnar direction. The test is positive when pain and crepitation occurs during this manoeuvre. The correlation between arthroscopy findings and clinical tests is generally low for both tests; they demonstrate poor specificity.11,13
Ulnar nerve compression Ulnar nerve compression at the wrist is uncommon and symptoms and signs of ulnar neuropathy should prompt examination of the elbow, brachial plexus and neck, since compression in the cubital tunnel or at the C8-T1 nerve roots is more common. In or near Guyon’s canal (through which the ulnar nerve transits into the hand, between the pisiform and hook of hamate) it divides into a superficial sensory and a deep motor branch. Therefore, signs and symptoms vary depending on which part of the nerve is compressed. Compression can be caused by hook of hamate fractures (does the patient have a history of trauma?) and ganglia, which give rise to point tenderness over Guyon’s canal. Ulnar artery aneurysm or thrombosis can cause an isolated compression of the superficial sensory branch. Altered sensation in the ulnar nerve distribution, wasting of the hypothenar eminence and wasting of the interosseous muscles should alert the examiner towards ulnar nerve compression. A detailed neurological examination should be performed.
Ulnocarpal abutment syndrome Ulnocarpal abutment syndrome is caused by excessive impact stress between the ulna and carpal bones (mainly the lunate). It occurs in patients with a positive ulnar variance, which can be seen in the setting of scapholunate dissociation, TFCC tears and lunotriquetral ligament tears. Careful examination of these structures needs to be undertaken in any patient with ulnocarpal abutment. Ask the patient about previous wrist injuries that lead to positive ulnar variance, such as distal radius fracture. They may complain of dorsoulnar sided wrist, pain which is worse on axial loading and ulnar deviation. Examination should assess the DRUJ and TFCC. Nakmura’s ulnar stress test was designed to detect abutment, but may also be positive with TFCC injury. The patient’s wrist is first deviated in an ulnar direction and pronated. The examiner then axially loads the wrist, whilst flexing and extending it (Figure 14). A positive test produces pain. This test is good at detecting patients with ulnar sided wrist pathology, but is not good at delineating the exact cause (it has low specificity).14
Pisotriquetral arthritis Degenerative osteoarthritis of the joint between the pisiform and the triquetrium leads to pain deep to the hypothenar eminence. The pisiform is the most ulnar and volar carpal bone and is a sesamoid within the FCU tendon. It can be palpated by tracing the FCU tendon distally into the palm. Patients present with ulnar pain in the palm, exacerbated by direct compression and wrist flexion (such as often occurs when playing racquet sports). Clinically, there will be tenderness on direct compression of the joint. Note that even in the normal wrist direct pressure over the pisiform bone can be uncomfortable.
Flexor carpi ulnaris tendonitis Flexor carpi ulnaris (FCU) tendonitis is a degenerative tendonosis of the FCU tendon. It differs from FCR tendonitis because the FCU does not have a synovial sheath at the wrist and hence is more similar in pathological terms to tennis elbow. Tendon calcification may also occur.15 Inspection may reveal swelling and/or erythema overlying the tendon.15 The patient will have tenderness over the FCU approximately 3 cm proximal to the pisiform and pain on resisted flexion and ulnar deviation of the wrist that is localized to the FCU tendon (Figure 8). This condition should be differentiated from the more common pisotriquetral osteoarthritis, were the pain is maximal when compressing directly over the pisiform.
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Conclusion By dividing the wrist up into five zones as described, a systematic approach to the clinical examination is facilitated for the wide range of pathologies that occur in this small anatomical space. The zone in which the pain occurs should be the cornerstone of the thought process from which the examination is tailored. By developing a working diagnosis based on a thorough history and examination, the chances of identifying the correct, clinically relevant pathology are much increased and, depending
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on the examination findings, treatment can be planned subject to confirmatory radiological or other testing. History and clinical examination are pivotal to the identification of what is actually troubling the patient and hence developing the correct management strategy. A
8 Mondelli M, Passero S, Giannini F. Provocative tests in different stages of carpal tunnel syndrome. Clin Neurol Neurosurg 2001; 103: 178e83. 9 D’Arcy CA, McGee S. The rational clinical examination. Does this patient have carpal tunnel syndrome? J Am Med Assoc 2000; 283: 3110e7. 10 Wiesman IM, Novak CB, Mackinnon SE, Winograd JM. Sensitivity and specificity of clinical testing for carpal tunnel syndrome. Can J Plast Surg J Can Chir Plast 2003; 11: 70e2. 11 Ruston J, Konan S, Rubinraut E, Sorene E. Diagnostic accuracy of clinical examination and magnetic resonance imaging for common articular wrist pathology. Acta Orthop Belg 2013; 79: 375e80. 12 Ruland RT, Hogan CJ. The ECU synergy test: an aid to diagnose ECU tendonitis. J Hand Surg 2008; 33: 1777e82. 13 Schmauss D, Pohlmann S, Lohmeyer JA, et al. Clinical tests and magnetic resonance imaging have limited diagnostic value for triangular fibrocartilaginous complex lesions. Arch Orthop Trauma Surg 2016; 136: 873e80. 14 Nakamura R, Horii E, Imaeda T, et al. The ulnocarpal stress test in the diagnosis of ulnar-sided wrist pain. J Hand Surg Edinb Scotl 1997; 22: 719e23. 15 Torbati SS, Bral D, Geiderman JM. Acute calcific tendinitis of the wrist. J Emerg Med 2013; 44: 352e4.
REFERENCES 1 Haara MM, Heliovaara M, Kroger, et al. Osteoarthritis in the carpometacarpal joint of the thumb. Prevalence and associations with disability and mortality. J Bone Jt Surg Am 2004; 86eA: 1452e7. 2 Gelberman RH, Boone S, Osei DA, Cherney S, Calfee RP. Trapeziometacarpal arthritis: a prospective clinical evaluation of the thumb adduction and extension provocative tests. J Hand Surg 2015; 40: 1285e91. 3 Choa RM, Parvizi N, Giele HP. A prospective case-control study to compare the sensitivity and specificity of the grind and tractionshift (subluxation-relocation) clinical tests in osteoarthritis of the thumb carpometacarpal joint. J Hand Surg Eur Vol 2014; 39: 282e5. 4 Finkelstein H. Stenosing tendovaginitis at the radial styloid process. J Bone Jt Surg 1930; 12: 509e40. 5 Eichhoff E. Zur pathogenese der Tendovaginitis stenosans. Bruns Beitrage Z Klin Chir 1927; CXXXIX: 746e55. 6 Goubau JF, Goubau L, Van Tongel A, et al. The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff’s Test. J Hand Surg Eur Vol 2014; 39: 286e92. 7 Sato J, Ishii Y, Noguchi H. Clinical and ultrasound features in patients with intersection syndrome or de Quervain’s disease. J Hand Surg Eur Vol 2016; 41: 220e5.
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Acknowledgements We would like to extend our gratitude to Pamela Palphreyman for proofreading the article and to Olivia Mennie for helping with the hand examination figures.
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Clinical examination of the wrist
General history A focused history will guide clinical examination. Ask about hand dominance, occupation, sporting level and previous injuries. There are four main symptoms that should be explored in some detail: 1. pain; 2. stiffness; 3. weakness; 4. clicking. Pain is important and enquiry should be made about its site (radial, central or ulnar; dorsal or volar), onset (insidious, following trauma), character (dull ache, sharp on movement), radiation (forearm, hand), exacerbating factors (particular movements), relieving factors (rest, analgesia), and severity (preventing work or self-care). The location of the pain is a strong guide towards the diagnosis, and this helps focus the clinical examination. The most common site of pain for a variety of pathologies is detailed in Figure 1.
Ashley W Newton David H Hawkes Vijay Bhalaik
Abstract Accurate clinical assessment of the wrist can be difficult, due to the large number of structures that are found in a confined space, which give rise to a range of pathologies. It is therefore essential that clinicians develop a thorough and systematic technique of examination to elucidate the cause of the patient’s wrist symptoms. This paper outlines key points for the clinical assessment of the symptomatic wrist. This is followed by an overview of the potential pathologies in each anatomical wrist zone, their typical symptoms and the pertinent examination findings the surgeon should seek to elicit. Thinking of the wrist as a series of five zones facilitates identification of the pathology. The described zones are radialedorsal, radialevolar, ulnar edorsal, ulnarevolar and central. Tips for the interpretation of each test are also included, along with an assessment of the sensitivity and specificity of relevant tests and its implications. Often, the better the clinical examination, the more productive the radiological examination.
General examination Positioning The examination should be conducted with the examiner sitting directly opposite the patient (so the patient can be observed for signs of discomfort) with a table between upon which the patient can rest their elbow. This position facilitates comfort and allows forearm rotation to be controlled (Figure 2). Both hands, wrists and forearms need to be exposed to allow comparison with the contralateral side. The examination should then follow the standard orthopaedic format of ‘look, feel, move’ followed by special/provocative tests.
Keywords carpus; clinical assessment; examination; wrist
Inspection (look) Look at the hand and wrist, paying particular attention to skin condition, swellings, muscle atrophy and deformity. Specific signs to seek on inspection are listed in Box 1. Diagnoses such as rheumatoid arthritis should be obvious at this stage of the examination.
Introduction The wrist is a complex anatomical arrangement, with multiple interconnected structures in a relatively confined space. This can make identification of the pathology responsible for particular symptoms potentially difficult. It is necessary to adopt a systematic approach to examination in order to narrow the wide differential diagnosis. This requires a sound knowledge of not only wrist anatomy, but the potential pathologies and the provocative tests which help delineate them from each other. This article will deal with general considerations concerning systematic examination of the wrist, then explore common causes of wrist symptoms and how to examine for them. The focus is on sub-acute and elective conditions in the adult.
Palpation (feel) Elicit tenderness, instability, crepitus, and clicking by palpation. Determine if masses are superficial or deep, fixed or mobile, hard or fluctuant. The different zones for palpation are considered later in this article in reference to each pathology and are summarised in Box 2. It is important to consider the dorsal and volar surface anatomy during palpation (Figure 3). Pulses of the radial and ulnar artery are palpated and sensation in the distribution of the median, ulnar, and superficial radial nerves is checked. Range of motion (move) The wrist has multiple points of articulation, which produce a variety of movements including flexion, extension, radial and ulnar deviation, pronation and supination which should be compared with the contralateral side (Figure 4). Flexion and extension originate from the radiocarpal and midcarpal joints and loss of this motion suggests pathology in these joints. Supination and pronation occur at the distal radioulnar joint (DRUJ) and disease of this joint leads to decreased rotation. In addition to assessing movements in isolation, a useful measure of combined functional motion is the ‘dart throwing motion’ (Figure 5).
Ashley W Newton MBChB MRes MRCS PGCTLCP FHEA Specialty Registrar, Trauma and Orthopaedic Surgery, North West (Mersey) Deanery, Health Education England, Liverpool, UK. Conflict of interest: none declared. David H Hawkes MBChB MPhil MRCS Specialty Registrar, Trauma and Orthopaedic Surgery, North West (Mersey) Deanery, Health Education England, Liverpool, UK. Conflict of interest: none declared. Vijay Bhalaik MBBS MRCS FRCS Consultant Hand and Upper Limb Surgeon, Wirral University Teaching Hospital, Arrowe Park Hospital, Wirral, UK. Conflict of interest: none declared.
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DORSAL st 1 CMC joint arthritis STT joint arthritis Radial styloid arthritis De Quervain’s Tenosynovitis Intersection syndrome Wartenberg syndrome ECRL/ECRB tendonitis
Lunotriquetral instability DRUJ osteoarthritis DRUJ instability ECU tendonitis ECU instability
CENTRAL Midcarpal instability Scapholunate dysfunction RADIAL ULNAR Keinbock’s disease SLAC wrist Carpal tunnel syndrome st 1 CMC joint arthritis FCU tendonitis FCR tendonitis Ulna nerve compression Scaphoid non-union Pisotriquetral arthritis Carpal tunnel syndrome TFCC tear Ulnocarpal abutment VOLAR Figure 1 Wrist pathology listed by site of pain. CMC, carpometacarpal; DRUJ, distal radioulnar joint; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; SLAC, scapholunate advanced collapse; STT, scaphotrapezial trapezoid; TFCC, triangular fibrocartilage complex.
refers to the ability of a test to correctly identify those without the condition. A reminder about interpreting sensitivity and specificity is found in Box 3. A number of the tests relating to wrist pathology have either a limited sensitivity or specificity and it is clearly essential that we understand these limitations if the correct diagnosis is to be established.
Special tests The numerous special tests for wrist pathology vary in their reported sensitivity and specificity. No single test is completely pathognomonic, hence several features must be interpreted in the clinical context of each individual patient to arrive at a diagnosis; a process of pattern recognition. Whilst it is clearly evident clinicians should understand how to correctly perform these special tests is it equally important to have an understanding of the psychometric properties of each test. Sensitivity describes the ability of a test to correctly identify those patients with a particular condition. Conversely, specificity
Radialedorsal symptoms Thumb carpometacarpal joint osteoarthritis Osteoarthritis of the first carpometacarpal (CMC) joint e often referred to as base of thumb arthritis e is a very common
Figure 2 Positioning for clinical examination of the wrist. The examiner sits opposite the patient with a small arm table between them.
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other hand is used to stabilize the wrist. A positive result is pain, with or without crepitus. The traction shift (subluxation-relocation) test is an alternative, which is performed by applying longitudinal traction to the thumb, followed by alternating volar and dorsal pressure to the base of the first metacarpal. This provokes subluxation and relocation of the joint and is positive if there is pain. Both of these tests are easy to perform and have high quoted specificity. Higher sensitivity has been reported for the adduction test. In the adduction test the patient places the affected hand on the examination table with the elbow flexed 90 and the forearm in neutral rotation. The examiner places his or her ipsilateral hand such that the examiner’s thumb rests over the head of the thumb metacarpal dorsally. The examiner’s contralateral hand supports the ulnar side of the patient’s hand to maintain the patient’s wrist in a neutral position in order to prevent ulnar deviation of the patient’s wrist. The examiner firmly directs an adduction force downward onto the patient’s metacarpal head until the patient’s thumb metacarpal lies parallel to the mid axis of the index metacarpal or until a firm end point is reached (Figure 6). Pain at the first CMC joint represents a positive test. Sensitivity and specificity estimates are detailed in Table 1.2,3 It is worth noting that point tenderness over the joint has both good sensitivity and specificity. Pitfalls in the examination of base of thumb arthritis include inconsistent correlation between clinical findings and radiological features, which may account for some of the low reported sensitivity rates. A patient with severe degenerative changes on radiographs may have little or no pain.
Signs to look for on inspection C
C C C C
Swelling, e.g. over extensor carpi ulnaris tendon, first extensor compartment Masses, e.g. ganglia, rheumatoid nodules Deformity, e.g. radial deviation, Z thumb Scars, e.g. previous distal radius fixation, carpal tunnel release Muscle wasting, e.g. thenar eminence, first dorsal interosseous
Box 1
Suggested order for palpation of the whole wrist
Radial side: C C C C C C C
First carpometacarpal joint Scaphotrapezial trapezoid joint Radial styloid First extensor compartment Second extensor compartment Scaphoid Flexor carpi radialis tendon
Central C C C
Lunate Scapholunate joint Carpal tunnel
STT joint arthritis Patient’s with scaphotrapezial trapezoid (STT) joint arthritis usually report a history of deep thenar eminence pain and base of thumb pain. Test the patient’s dart throwing motion (see Figure 5), which will often be painful and have reduced range. On examination, there is tenderness over the surface landmark of the joint, which is just distal and ulnar to the anatomical snuff box (Figure 3). The final stage of base of thumb arthritis is pantrapezial arthritis (Eaton-Littler stage IV) in which the STT joint is involved. As such the two conditions described above commonly co-exist.
Ulnar side C C C C C C C
Hook of hamate Pisotriquetral joint Lunotriquetral joint Distal radioulnar joint Ulnar soft spot Extensor carpi ulnaris tendon Flexor carpi ulnaris tendon
Palpation of these structures can be supplemented by special tests as described in the text
De Quervain’s tenosynovitis This is a stenosing tenosynovial inflammation of the first extensor compartment, which contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. Women are affected more commonly than men and patients typically present between the ages of 30 and 50, with the gradual onset of pain over the first extensor compartment at the level of the radial styloid process. Firstly, look for swelling over the first dorsal compartment and palpate for point tenderness. Caution must be taken with the nomenclature of the provocative tests for de Quervain’s e errors in how the tests are performed have propagated through the literature and into text books. The Finkelstein manoeuvre4 is performed by the examiner grasping the patient’s thumb and quickly deviating the hand in an ulnar direction, which provokes pain over the radial styloid (Figure 7a) when positive. The Eichhoff manoeuvre5 (which is often erroneously called Finkelstein’s) is performed by asking the
Box 2
condition with a prevalence of 8% in the general population.1 Patients typically present with pain on the radial side of the dorsum of the wrist, centred over the thumb CMC joint. Pain is worst on activity. Weakness or difficulty with pinch may be marked and activities, such as opening bottles, cause difficulty. Inspection may show swelling over the joint. ‘Squaring’ of the base of the thumb may be seen in later disease, followed by adduction of the thumb metacarpal and compensatory hyperextension of the metacarpophalangeal joint. With advanced disease this gives the characteristic ‘Z’ thumb appearance. Palpation is likely to elicit joint tenderness and crepitus. The range of motion at the CMC joint is restricted. The grind test is performed by rotating the patient’s first metacarpal whilst applying axial compression. The examiners
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Figure 3 Dorsal (left) and volar (right) wrist surface anatomy. CMC, carpometacarpal; DRUJ, distal radioulnar joint; SL, scapholunate.
The WHAT test6 (wrist hyperflexion and abduction of the thumb) is an active test, which stresses the APL and EPB tendons. The patient is examined with the wrist flexed, thumb abducted and metacarpophalangeal and interphalangeal joints of the thumb in extension. Resisted thumb abduction/extension is then tested and a positive result is reported pain over the first extensor compartment (Figure 7c). This isolates the tendons of the first extensor compartment. Contrary to tests for base of
patient to clench their own thumb into a fist and then deviate in an ulnar direction (Figure 7b). When positive this leads to pain, which is relieved once the thumb is extended, even when the wrist remains ulnarly deviated. Due to the passive nature of both of these tests (i.e. the tendons of the first extensor compartment are not active during the tests) other pathology of the radial border of the wrist can also cause pain and give a false-positive result.
Figure 4 Normal range of motion of the wrist. Pronation 75 (a) and supination 80 (b) flexion 75 (c) and extension 75 (d) radial deviation 20 (e) and ulnar deviation 35 (f).
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Figure 5 The dart throwing movement. A composite movement of the wrist from supination-radial deviation-extension (left), to pronation-ulnar deviation-flexion (right). This assesses functional wrist movement.
thumb arthritis, tests for de Quervain’s have high sensitivity but low specificity. In other words, patients with de Quervain’s are very likely to have a positive test, but patients with a positive test do not necessarily have de Quervain’s tenosynovitis (Table 1).6
Sensitivity and specificity e definition and worked example Sensitivity e probability of a positive result in patients with the disease (true positive rate) i.e. the probability of detecting the disease if the patient truly has it. Specificity e probability of a negative test in patients without the disease i.e. correctly determining that they don’t have the disease. Example interpretation: A patient has radial sided wrist pain and you suspect they have first carpometacarpal (CMC) joint arthritis. You examine them with the grind test, which has 30% sensitivity and 92% specificity. C
If the patient has first CMC joint arthritis, there is a 30% chance the test will be positive i.e. 30% chance of testing positive if they do have first CMC joint arthritis This means that even if the test is negative, the patient may well still have first CMC joint arthritis (this test isn’t very sensitive at detecting cases of first CMC joint arthritis)
C
If the patient does not have first CMC joint arthritis, there is a 92% chance the test will be negative i.e. 92% chance of test being normal if they don’t have first CMC joint arthritis This means if the test is positive, there is a good chance the patient has first CMC joint arthritis (the test is specific, i.e. it is not usually positive in other wrist pathology)
Radial styloid arthritis Radial styloid arthritis is the first stage of scapholunate advanced collapse (SLAC) wrist. Care must be taken to differentiate base of thumb arthritis and de Quervain’s from this condition, as all have point tenderness in a similar region. This should be done using knowledge of surface anatomy in conjunction with the appropriate provocative tests. Intersection syndrome Intersection syndrome is a less common phenomenon caused by inflammation at the point of crossover of the first (abductor pollicis longus and extensor pollicis brevis) and second (extensor carpi radialis longus (ECRL) and brevis (ECRB)) extensor compartments.7 It is associated with repetitive wrist extension and is relatively more common in rowers and weight lifters. Patients have point tenderness and swelling over the intersection, which can be palpated on the dorsal forearm 4 cm proximal to Lister’s tubercle (refer to Figure 3). Some patients will have crepitus on flexion and extension at the same point. Wartenberg syndrome Wartenberg syndrome is a rare compression neuropathy of the superficial sensory branch of the radial nerve. The nerve is compressed by a scissoring action of the brachioradialis and ECRL tendons during forearm pronation. Patients present with ill-defined dorsoradial wrist pain, paraesthesia or numbness. These symptoms can be exacerbated by movements, which increase traction on the nerve, including repetitive wrist flexion and ulnar deviation. Tinel’s sign is commonly positive, either over the radial styloid (type 1) or just distal to the brachioradialis muscle belly, which is 9 cm proximal to the radial styloid (type 2) or a combination of the two (type 3). Pronation of the forearm with ulnar deviation exacerbates symptoms. There is an association with de Quervain’s tenosynovitis. This is problematic because provocative tests for de Quervain’s
Important note: Sensitivity and specificity alone cannot be used to calculate the percentage chance of a patient who tests positive actually having first CMC joint arthritis (positive predictive value). This varies depending on how common first CMC joint arthritis is in the patients being tested (i.e. the prevalence)
Box 3
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Figure 6 Thumb adduction test. The examiner stabilizes the ulnar side of the patient’s wrist with one hand (a) and adducts the thumb by pressing over the first metacarpal head (b).
tenosynovitis can also exacerbate the symptoms of Wartenberg syndrome e and this needs to be considered during assessment.
(radial side of scaphoid affected early). Grip strength and pinch strength are both reduced. On examination a scaphoid non-union may be tender to axial compression. The examiner palpates the scaphoid between their thumb (on the scaphoid tubercle volarly) and index finger (in the anatomical snuffbox dorsally). If the patient is developing SNAC, inspection may reveal swelling of the dorsoradial aspect of the wrist related to a combination of osteophytes and focal synovitis. There will be tenderness to palpation of the radioscaphoid articulation. Extension and radial deviation will be decreased and/or painful.
Radialevolar symptoms FCR tendonitis Flexor carpi radialis (FCR) tendonitis is a relatively uncommon condition linked to repetitive wrist flexion. Pathologically it is characterized by inflammation within the tendon’s synovial sheath, which causes pain on the volar and radial aspect of the wrist. Look for swelling over the tendon (Figure 8). There is tenderness to palpation over the volar and radial forearm along the course of the FCR tendon at the level of the distal wrist flexion crease. The provocation manoeuvre is resisted wrist flexion and radial deviation with palpation of the FCR tendon.
Carpal tunnel syndrome Carpal tunnel syndrome is a constellation of symptoms and signs that result from median nerve compression within the carpal tunnel, beneath the transverse carpal ligament. It is the most common compressive neuropathy. It is associated with diabetes, hypothyroidism, rheumatoid arthritis, pregnancy and amyloidosis. The assessment of patients with suspected carpal tunnel syndrome centres around the history, followed by an assessment of median nerve sensory and motor function. Patients classically present with radial-sided hand pain and paraesthesia that wakes them from sleep. The numbness is in the distribution of the median nerve e the radial three and a half digits. Clumsiness is a feature if the recurrent motor branch to the thenar eminence is involved. Inspection may reveal thenar atrophy; test for weakness of resisted abduction. Altered sensation should be examined for in the median nerve distribution using graduated monofilaments. Tinel’s, Phalen’s and Durkan’s tests are often used in the diagnosis of carpal tunnel syndrome. Tinel’s test is performed by tapping over the patient’s median nerve at the distal wrist crease and is positive if it provokes paraesthesia in the median nerve distribution. Phalen’s test requires the patient to flex both wrists to 90 for 60 seconds and is positive if this produces paraesthesia in the median nerve distribution. Durkan’s pressure provocation test requires the examiner to press over the patient’s carpal tunnel with their thumb for 60 seconds and is positive if this produces paraesthesia in the median nerve distribution. A combination of wrist flexion (Phalen’s) with pressure applied (Durkan’s) for 60 seconds (Figure 9) gives good sensitivity (96%) and specificity (80%). Sensitivity and specificity values for a range of tests are shown in Table 2.8e10 There are many clinical tests for carpal tunnel syndrome, but there are no gold standard diagnostic criteria e
Scaphoid non-union In the early stages of this condition patients may present with few or no symptoms. Over time, chronic non-union leads to scaphoid collapse and progressive arthritis (scaphoid non-union advanced collapse (SNAC) wrist). This occurs in a characteristic pattern; firstly radial side of scaphoid and radial styloid, then scaphocapitate arthrosis, and finally periscaphoid arthrosis. However, the lunocapitate joint may remain relatively unaffected. Patients present with a history of progressive pain, stiffness and weakness. They may or may not recall previous wrist trauma. There is a reduced range of wrist flexion and extension. The stiffness is most marked in extension and radial deviation
Comparison of tests for first carpometacarpal joint arthritis and de Quervain’s disease Test
Sensitivity
Specificity
Grind Traction shift Thumb adduction Point tenderness Eichhoff test WHAT test
30e44% 66.7% 95% 94% 89% 99%
92e97% 100% 93% 81% 14% 29%
Table 1
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Figure 8 Flexor carpi radialis (bottom of image) and flexor carpi ulnaris (top of image) S indicates the scaphoid tubercle position, and P indicates the position of the pisiform.
Figure 9 Testing for carpal tunnel syndrome with the wrists flexed. Direct pressure is applied over the tunnel with the examiner’s thumb for 60 seconds.
Comparison of tests for carpal tunnel syndrome
Figure 7 a) Finkelstein’s test. The examiner grasps the patients thumb and quickly ulnarly deviates. The examiner stabilizes the wrist with their other hand. (b) Eichhoff’s test. The patient grips their own thumb in the palm and ulnarly deviates. The point of maximal pain is indicated by the examiner’s right index finger. (c) WHAT test. The patient’s wrist is hyper-flexed, and the thumb is abducted. The examiner stabilizes the wrist with one hand, and asks the patient to abduct and extend the thumb against resistance.
Test
Sensitivity
Specificity
Tinel’s test Phalen’s test Durkan’s test Compression and flexion
41e64% 59e85% 42-89% 96%
56e99% 33e95% 18e96% 80%
Table 2
Central symptoms therefore the case definition varies. This has implications when comparing quoted sensitivity and specificity for different clinical tests from different studies e there is a very wide range. Abnormal clinical findings from provocative testing may be less apparent in advanced disease.8 It is also important to consider alternative causes of the symptoms, and one should always examine the patients elbow and neck. It may not be possible to identify what nerve is affected by the history alone, and the radial and ulnar nerves should also be evaluated in the setting of suspected carpal tunnel syndrome.
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Midcarpal instability Midcarpal instability is a subtype of carpal instability nondissociative (CIND). It is characterized by instability between the proximal and distal carpal row caused by extrinsic ligament dysfunction or laxity. There is usually no history of trauma and patients often have generalised ligamentous laxity. Patients present with subluxation, which may or may not be painful, and complain of the wrist ‘giving way.’ They may have a wrist clunk on certain movements when the wrist is under axial load. First, examine for signs of generalized ligamentous laxity.
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midcarpal joints. Progressive arthritis e SLAC wrist e is the end result. Patients with a scapholunate ligament deficiency present with pain or clicking in the wrist and may have swelling over the dorsal surface of the wrist and tenderness over the scapholunate ligament interval, found just distal to Lister’s tubercle. Scaphoid instability is demonstrated by Watson’s scaphoid shift test. This provocative manoeuvre is performed by exerting a dorsally directed load to the scaphoid tubercle as the wrist is taken from ulnar to radial deviation (Figure 11). Dorsal displacement of the scaphoid is noted, but the test is only considered positive if this is associated with pain. The sensitivity is 16.7% and specificity is 88.5%.11 The low sensitivity potentially reflects the difficult interpretation. Patients with a SLAC wrist have focal tenderness, which corresponds to their disease stage. Tenderness is initially limited to the radial styloid, as discussed above. Subsequently, in stage two and three disease the tenderness is more extensive along the scaphoid facet of the distal radius and then involves the capitolunate joint. The radiolunate joint is characteristically spared. Tenderness is accompanied by a reduction in wrist range of movement and weakness in grip strength.
Figure 10 Lichtman’s test for midcarpal instability (see text for description).
Try to bend the thumb to contact the patient’s forearm. The gap averages 4.5 cm in 17-year-olds and increases with age. Lichtman described the midcarpal shift test for midcarpal instability. To perform this on the patient’s left wrist the examiner first stabilises the patients pronated forearm with their right hand. The examiner presses on the capitate with the left thumb to apply a volarly directed force to the distal carpal row. This pressure should be maintained, then the wrist is deviated in an ulnar direction (Figure 10). The test is positive if there is a clunk, which may or may not be painful. Beware that the patient may be asymptomatic from their midcarpal instability and may have an alternative source for pain.
€ ck’s disease Kienbo €ck’s disease, is a rare Osteonecrosis of the lunate, or Kienbo condition that leads to progressive wrist pain and disability. Its aetiology remains poorly understood, but vascular and mechanical factors have both been implicated. Patients present with central wrist pain. Inspection reveals swelling over the dorsal surface of the wrist and there is focal tenderness over the lunate to palpation. A detailed understanding of wrist surface anatomy is again important here. Patients have a reduced range of motion in flexion and extension, with pain at the end of range and there is also reduced grip strength on the affected side.
Scapholunate dysfunction and SLAC wrist The scapholunate ligament is essential for the maintenance of carpal stability. Disruption of the ligament, from either an acute injury or degenerative rupture, leads to abnormal wrist biomechanics and ultimately advanced arthritis. A chronic scapholunate ligament injury causes the scaphoid to flex and the lunate to extend due to the unopposed extension force of the triquetrum transmitted through an intact lunotriquetral ligament. This results in dorsal intercalated segment instability (DISI) and resulting abnormal forces across the radiocarpal and
Ulnaredorsal symptoms Lunotriquetral instability The spectrum of lunotriquetral (LT) ligament injury ranges from partial tears with variable pain and weakness to complete
Figure 11 Watson’s scaphoid shift test. Force is applied to the scaphoid tubercle as the wrist is taken from ulnar (a) to radial deviation (b).
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dissociation with static collapse, causing a fork-like deformity of the wrist and prominence of the distal ulna (advanced VISI deformity). The dorsal intercarpal ligament may also be damaged, which acts as a secondary restraint of the lunotriquetral joint. Patients may or may not recall a hyperextension injury to the wrist and present with ulnar sided pain that is worse with pronation and ulnar deviation. When the LT ligament is disrupted the lunate and scaphoid flex and the triquetrum extends. This may be visible on inspection, as the carpus appears flexed compared to the distal radius. Pain may be present on direct palpation of the joint. The lunotriquetral ballottement test (Reagan’s test) is performed by grasping the pisotriquetral unit between the thumb and index finger of one hand and the lunate between the thumb and index finger of the other (Figure 12). If the test is positive, pain and increased anteroposterior laxity will be noted during manipulation of the joint. It is highly specific, but has poor sensitivity.11
Figure 13 Piano key test for distal radioeulnar joint instability.
ECU tendonitis and instability The tendon of extensor carpi ulnaris (ECU) runs through the sixth extensor compartment on the dorsal surface of the wrist. A spectrum of pathology can occur, ranging from tendonitis to instability. Patients with ECU tendonitis have focal tenderness over the tendon on the volar and ulnar aspect of the wrist. The classically described provocation test is asking the patient to perform resisted wrist extension and ulnar deviation. However, this manoeuvre also loads the TFCC and lunotriquetral ligament and compresses the distal ulna against the carpus. Consequently, a false-positive finding can occur if the pathology is within these areas of the wrist. The ECU synergy test has been advocated to avoid the false positive results associated with resisted wrist extension and ulnar deviation. The test exploits the synergistic activation of ECU with resisted thumb abduction. It is performed by resting the patient’s elbow on an examination table and flexing their elbow to 90 with the forearm in full supination. The examiner palpates the ECU tendon with one hand whilst the other grasps the patient’s thumb and middle finger. The patient then abducts the thumb against resistance. ECU muscle contraction is confirmed by appreciating bowstringing of the tendon. A positive finding includes the reproduction of pain over the dorsal and ulnar aspect of the wrist.12 ECU subluxation results from attenuation or rupture of the ECU subsheath. On examination, the tendon subluxes with supination and reduces into its groove during pronation. This can be associated with a painful snap.
DRUJ osteoarthritis and instability A variety of acute wrist injuries can result in DRUJ instability, which can then present with late symptoms, depending on how the initial injury was managed. DRUJ dysfunction is a common cause of ulnar-sided wrist pain and there will often be an associated triangular fibrocartilage complex (TFCC) injury. Patients with instability will usually have a history of injury and present with pain, stiffness and clicking associated with pronation and supination. Examine for a restricted range of pronation and supination. DRUJ instability can be assessed with the piano key test. The patient’s wrist is supported in pronation and a force is applied to the head of the ulna by the examiner’s thumb (Figure 13). The test is positive if the ulnar head returns back to its normal anatomical position, similar to the movement of a piano key when pressure is released. Later, patients develop osteoarthritis of the DRUJ. There may be deformity of the wrist or forearm visible on inspection, resulting from incongruency of the DRUJ and subsequent degeneration. Again, patients have pain and stiffness on pronation and supination. The ulnar compression test is performed by pressing the ulnar head onto the radius, thereby compressing the DRUJ, producing pain when positive.
Ulnarevolar symptoms TFCC tear The TFCC is composed of the dorsal and volar radioulnar ligaments, a central articular disc, the ulnar collateral ligament, the ECU subsheath and the origin of the ulnolunate and ulnotriquetal ligaments. Injuries to the complex can be classified into either type 1 (traumatic) or type 2 (degenerative), the latter of which is associated with positive ulnar variance and ulnocarpal impaction. Patients have a positive fovea sign on examination. This is performed by palpating the soft spot between the ulnar styloid, the FCU tendon, the volar surface of the ulnar head and the pisiform, with pain representing a positive test. The ulnar grind test is conducted with the wrist held in dorsiflexion and the
Figure 12 Regan’s test for lunotriquetral instability.
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Figure 14 Nakmura’s ulnar stress test for ulnar sided wrist pathology. The ulnarly deviated and pronated wrist is axially loaded from extension (a) into flexion (b).
forearm fixed. Axial load is applied and the wrist is rotated and deviated in ulnar direction. The test is positive when pain and crepitation occurs during this manoeuvre. The correlation between arthroscopy findings and clinical tests is generally low for both tests; they demonstrate poor specificity.11,13
Ulnar nerve compression Ulnar nerve compression at the wrist is uncommon and symptoms and signs of ulnar neuropathy should prompt examination of the elbow, brachial plexus and neck, since compression in the cubital tunnel or at the C8-T1 nerve roots is more common. In or near Guyon’s canal (through which the ulnar nerve transits into the hand, between the pisiform and hook of hamate) it divides into a superficial sensory and a deep motor branch. Therefore, signs and symptoms vary depending on which part of the nerve is compressed. Compression can be caused by hook of hamate fractures (does the patient have a history of trauma?) and ganglia, which give rise to point tenderness over Guyon’s canal. Ulnar artery aneurysm or thrombosis can cause an isolated compression of the superficial sensory branch. Altered sensation in the ulnar nerve distribution, wasting of the hypothenar eminence and wasting of the interosseous muscles should alert the examiner towards ulnar nerve compression. A detailed neurological examination should be performed.
Ulnocarpal abutment syndrome Ulnocarpal abutment syndrome is caused by excessive impact stress between the ulna and carpal bones (mainly the lunate). It occurs in patients with a positive ulnar variance, which can be seen in the setting of scapholunate dissociation, TFCC tears and lunotriquetral ligament tears. Careful examination of these structures needs to be undertaken in any patient with ulnocarpal abutment. Ask the patient about previous wrist injuries that lead to positive ulnar variance, such as distal radius fracture. They may complain of dorsoulnar sided wrist, pain which is worse on axial loading and ulnar deviation. Examination should assess the DRUJ and TFCC. Nakmura’s ulnar stress test was designed to detect abutment, but may also be positive with TFCC injury. The patient’s wrist is first deviated in an ulnar direction and pronated. The examiner then axially loads the wrist, whilst flexing and extending it (Figure 14). A positive test produces pain. This test is good at detecting patients with ulnar sided wrist pathology, but is not good at delineating the exact cause (it has low specificity).14
Pisotriquetral arthritis Degenerative osteoarthritis of the joint between the pisiform and the triquetrium leads to pain deep to the hypothenar eminence. The pisiform is the most ulnar and volar carpal bone and is a sesamoid within the FCU tendon. It can be palpated by tracing the FCU tendon distally into the palm. Patients present with ulnar pain in the palm, exacerbated by direct compression and wrist flexion (such as often occurs when playing racquet sports). Clinically, there will be tenderness on direct compression of the joint. Note that even in the normal wrist direct pressure over the pisiform bone can be uncomfortable.
Flexor carpi ulnaris tendonitis Flexor carpi ulnaris (FCU) tendonitis is a degenerative tendonosis of the FCU tendon. It differs from FCR tendonitis because the FCU does not have a synovial sheath at the wrist and hence is more similar in pathological terms to tennis elbow. Tendon calcification may also occur.15 Inspection may reveal swelling and/or erythema overlying the tendon.15 The patient will have tenderness over the FCU approximately 3 cm proximal to the pisiform and pain on resisted flexion and ulnar deviation of the wrist that is localized to the FCU tendon (Figure 8). This condition should be differentiated from the more common pisotriquetral osteoarthritis, were the pain is maximal when compressing directly over the pisiform.
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Conclusion By dividing the wrist up into five zones as described, a systematic approach to the clinical examination is facilitated for the wide range of pathologies that occur in this small anatomical space. The zone in which the pain occurs should be the cornerstone of the thought process from which the examination is tailored. By developing a working diagnosis based on a thorough history and examination, the chances of identifying the correct, clinically relevant pathology are much increased and, depending
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on the examination findings, treatment can be planned subject to confirmatory radiological or other testing. History and clinical examination are pivotal to the identification of what is actually troubling the patient and hence developing the correct management strategy. A
8 Mondelli M, Passero S, Giannini F. Provocative tests in different stages of carpal tunnel syndrome. Clin Neurol Neurosurg 2001; 103: 178e83. 9 D’Arcy CA, McGee S. The rational clinical examination. Does this patient have carpal tunnel syndrome? J Am Med Assoc 2000; 283: 3110e7. 10 Wiesman IM, Novak CB, Mackinnon SE, Winograd JM. Sensitivity and specificity of clinical testing for carpal tunnel syndrome. Can J Plast Surg J Can Chir Plast 2003; 11: 70e2. 11 Ruston J, Konan S, Rubinraut E, Sorene E. Diagnostic accuracy of clinical examination and magnetic resonance imaging for common articular wrist pathology. Acta Orthop Belg 2013; 79: 375e80. 12 Ruland RT, Hogan CJ. The ECU synergy test: an aid to diagnose ECU tendonitis. J Hand Surg 2008; 33: 1777e82. 13 Schmauss D, Pohlmann S, Lohmeyer JA, et al. Clinical tests and magnetic resonance imaging have limited diagnostic value for triangular fibrocartilaginous complex lesions. Arch Orthop Trauma Surg 2016; 136: 873e80. 14 Nakamura R, Horii E, Imaeda T, et al. The ulnocarpal stress test in the diagnosis of ulnar-sided wrist pain. J Hand Surg Edinb Scotl 1997; 22: 719e23. 15 Torbati SS, Bral D, Geiderman JM. Acute calcific tendinitis of the wrist. J Emerg Med 2013; 44: 352e4.
REFERENCES 1 Haara MM, Heliovaara M, Kroger, et al. Osteoarthritis in the carpometacarpal joint of the thumb. Prevalence and associations with disability and mortality. J Bone Jt Surg Am 2004; 86eA: 1452e7. 2 Gelberman RH, Boone S, Osei DA, Cherney S, Calfee RP. Trapeziometacarpal arthritis: a prospective clinical evaluation of the thumb adduction and extension provocative tests. J Hand Surg 2015; 40: 1285e91. 3 Choa RM, Parvizi N, Giele HP. A prospective case-control study to compare the sensitivity and specificity of the grind and tractionshift (subluxation-relocation) clinical tests in osteoarthritis of the thumb carpometacarpal joint. J Hand Surg Eur Vol 2014; 39: 282e5. 4 Finkelstein H. Stenosing tendovaginitis at the radial styloid process. J Bone Jt Surg 1930; 12: 509e40. 5 Eichhoff E. Zur pathogenese der Tendovaginitis stenosans. Bruns Beitrage Z Klin Chir 1927; CXXXIX: 746e55. 6 Goubau JF, Goubau L, Van Tongel A, et al. The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff’s Test. J Hand Surg Eur Vol 2014; 39: 286e92. 7 Sato J, Ishii Y, Noguchi H. Clinical and ultrasound features in patients with intersection syndrome or de Quervain’s disease. J Hand Surg Eur Vol 2016; 41: 220e5.
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Acknowledgements We would like to extend our gratitude to Pamela Palphreyman for proofreading the article and to Olivia Mennie for helping with the hand examination figures.
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Please cite this article in press as: Newton AW, et al., Clinical examination of the wrist, Orthopaedics and Trauma (2017), http://dx.doi.org/ 10.1016/j.mporth.2017.05.009