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

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Igo Goldberg M.D, Hand Surgeon Tel-Aviv, Israel

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Clinical Examination of the Wrist

Igo Goldberg M.D, Hand Surgeon

Tel-Aviv, Israel


MOST COMMON CAUSES OF WRIST PAIN - 1


MOST COMMON CAUSES OF WRIST PAIN - 2


What constitutes the first part of every thorough physical examination?

A thorough history


STEPS IN TAKING A PATIENT HISTORY


CLINICAL EXAMINATION

  • ROM active, passive

  • Grip - Jamar dynamometer (flat curve, rapid exchange grip strength, coefficient of variation)

  • Pinch - Pinchmeter

  • Circumference measurements

  • (Volumetric measurements)

  • Palpation

  • Provocative tests

  • Anaesthetic examination

  • DASH Questionnaire

  • Mayo evaluation score


The wrist is a key joint of the hand Starling Bunnel

Wrist movement occurs around three principal functional axes: yet all of them are complex and are not restricted to a fixed geometric axis.

Flexion-Extension : transverse axis, sagital plane

Radial-Ulnar deviation: sagital axis, coronal (frontal) plane

Pronation-Supination : longitudinal axis, horizontal plane

What is their relative contribution to the upper extremity (UE) function?

RANGE OF MOTION (ROM)


WRIST MOTION IMPAIRMENT - 1

The wrist functional unit represents 60% of the upper extremity (UE) function.

Flexion-Extension unit: 70% of wrist function:70%x60%=42% of UE function.

Radial-Ulnar deviation unit: 30% of wrist function: 30%x60%=18% of UE function

-

Normal ROM 20-30 R-U

Normal ROM 60-60 F-E

Wrist fusion:

10 extension

10 ulnar deviation

Functional ROM: 0-10 R-U

FunctionalROM: 10-10 F-E


WRIST MOTION IMPAIRMENT - 2

Pronation-Supination

Impairments of pronation-supination are ascribed to the elbow because the major muscles for this function are inserted about the elbow. This applies even if the loss of rotation results primarily from the wrist involvement in the presence of an intact elbow

The relative value of this motion unit

is 28% of the UE function

Normal ROM : 80-80 P-S

Functional position: 20 P


WRIST MOTION IMPAIRMENT - 3

The relative contribution of various motion units to the upper extremity (UE) function:

  • F-E 42%

  • P-S 28%

  • R-U 18%


How much wrist motion is required for most activities of daily living (ADL) ?


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- 10% [ 41(10)(')]

" " ()- 31% [ 44(2+3+4)]

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TOPOGRAPHIC ANATOMY OF THE WRIST

middle axis 4th finger

VOLAR

ulnar

central

radial

Ulnar border FCU

Ulnarborder FCR

Radial border 1st comp


TOPOGRAPHIC ANATOMY OF THE WRIST

Dorsal

Radial border

1st comp

Radial border

2nd comp

Ulnar border

4th comp

Ulnar border FCU

radial

central

ulnar


COMMON CAUSES OF WRIST PAIN ACCORDING TO TOPOGRAPHIC AREAS - 1


COMMON CAUSES OF WRIST PAIN ACCORDING TO TOPOGRAPHIC AREAS - 2


COMMON DIAGNOSTIC TESTS AND PROVOCATIVE MANEUVERS ACCORDING TO TOPOGRAPHIC AREAS - 1


COMMON DIAGNOSTIC TESTS AND PROVOCATIVE MANEUVERS ACCORDING TO TOPOGRAPHIC AREAS - 2


PROVOCATIVE TESTS


.

  • Dorsal wrist (DWS) test

  • Finger extension (FET) test

  • Articular/nonarticular (ANA) test

  • Scaphotrapeziotrapezoid (STT) test

  • Scaphoid shift maneuver (SSM)

  • Ballotment test (shear) test for SL


1.Dorsal wrist (DWS) test

S-L :

  • This joint is not painful to palpation.

    If painful, suspect:

  • S-L dissociation

  • Kienbocks disease

  • Dorsal wrist syndrome

    (S-L joint overloading with wrist pain secondary to S-L ligament synovitis and/or tear preceding evidence of rotary subluxation of the scaphoid)


2.Finger extension (FET) test(wrist-flexion finger-extension maneuver)

  • Usually not painful

  • If painful:

    • Periscaphoid inflammation

    • Radiocarpal or midcarpal instability

    • Symptomatic rotary subluxation of scaphoid

    • Kienbocks disease


3.Articular/nonarticular (ANA) test.

  • Always compare to the other side

  • If severe pain:

    • Periscaphoid synovitis

    • Scaphoid instability

    • SLAC changes


4.Scaphotrapeziotrapezoid (STT) test

  • Palpation of this joint is not painful

  • If painful, suspect:

    • Triscaphe synovitis

    • Triscaphe OA


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

  • If painful: rotary subluxation, periscaphoid arthritis


6. S- L shear test

Pressure on the scaphoid tubercle

Pressure on dorsal aspect of the lunate

Simultaneous pressure in opposite directions


7.Scapholunate ballottement test


.

Areas involved:

  • DRUJ

  • TFCC

  • Ulnar carpus


1.DRUJ

Decreased and/or painful pronosupination:

  • Degenerative disease

  • Subluxation

    Piano key sign: exaggeration of normal ulna head prominance.

  • Dorsal subluxation

  • Articular effusion


Ulnar impingement or impaction syndrome

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


2.TFCC

Suspected when:

  • Loss of forearm prosupination and wrist motion

  • Tenderness over TFCC dorsally

  • Palpable and/or audible click with forearm rotation or radioulnar deviation (Ulnar carpal abutment test)

    Necessitates: Three compartment arthrography


3.ULNAR CARPUS

LT compression test: direct pressure along ulnoradial axis by palpating within the ulnar snuffbox. (Linscheids test)

If painful:

  • LT instability

  • Synovitis

  • Degenerative disease

  • Partial synchondrosis


LT instability: Reagans test(L-T ballottement, shuck, shear)

Pressure on the lunate

Pressure on the triquetrum


LT instability: Masquelets test


LT instability: Masquelets test

Pressure on pisiformis

Pressure on dorsal aspect of the lunate

Simultaneous pressure in opposite directions


TH instability test

  • Grasping of the triquetrum

  • Stabilization of capitate and carpus with other hand

  • Volar and dorsal stressing of the triquetrum


TILT: Triquetral Impingement Ligament Tear syndrome

Triad of:

  • Localized triquetral pain

  • History of hyperflexion injury

  • Normal radiographs

    Mechanism: cuff of fibrous tissue that has become detached from the ulnar sling mechanism and chronically impinges on the triquetrum, resulting in synovitis, bony eburnation and pain.


.

Radiocarpal anteroposterior drawer test


The pivot shift of the mid-carpal joint

  • - 90


The pivot shift of the mid-carpal joint

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.

Midcarpal anteroposterior drawer test


.

CMC1 tests:

  • Grind test

  • Stress test

  • Adduction test


Carpal boss


.

  • Finkelsteins test

  • Wet leather sign

  • ECU problems: synovitis, subluxation, stenosis, partial rupture

  • Pisiformis problems: fractures, OA

  • Hook of hamate

  • FCR tendinitis

  • intersection syndrome

  • Substitution maneuvers


COMMON DIAGNOSTIC TESTS AND PROVOCATIVE MANEUVERS

List of publications and suggested readings

for download in:

www.goldberg-hand.co.il


Thank you !


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