Dorsum, side, palmar- palmar flex wrist to exacerbate dorsal swellings
Deformity e.g. radial deviation after colles, prominent ulna
Swellings e.g. ganglion
Scars, muscle wasting
Start radial side & move in a circle around wrist;
Palpate for tenderness of :
- APL, EPL- de Quervain's
- Anatomical snuffbox- scaphoid
- Distal Radioulnar joint
- lunate- locate by dorsiflexing wrist
- ulnar styloid
- Hook of hamate
- Pisiform- pisiform triquetral degen
- Guyons canal
- Over median nerve
Dorsiflexion- palms together, lift up elbows. Normal 75 degrees
Palmar flexion- Dorsum of hands in contact, drop elbows. Normal 75 degrees
Radial deviation- in neutral pron-sup. Normal 20 degrees
Ulnar deviation- Normal 35 degrees
Pronation-supination-elbows by sides ask patient to hold pen, measure angle between vertical and pen
-pronation 75 degrees
-supination 80 degrees
Hold patients hand in right hand and forearm with left, normal wrist clunks on palmar displacement of hand on forearm. Nonspecific test1. Piano key sign- for instability = balottment of ulnar head, (prominence of ulna)
2. squeeze and turn test- the examiner stabilises the patient's forearm with one hand while with the other hand, he grasps the patient's hand as if for a vigorous handshake. When the patient resists forced passive rotation, or when there is active rotation against resistance, pain usually is elicited. If the pain is caused by compressing the ulna against the radius, it is mostly suggestive of chondromalacia.
For TFCC - shake hands with patient; ulnar deviate wrist whilst rotating the forearm. Pain = positive.Matrise Orthopaedics - Physical Examination of Wrist Instabilities
A. Scapholunate instability
1.scapholunate ballotment - using both index fingers and both thumbs, stabilise the lunate between thumb and index finger of one hand and the scaphoid between the thumb and index finger of the other; the scaphoid pushed in a volar to dorsal direction; discomfort in this area suggests the possibility of injury to the Scapholunate Ligament (SLL).
2.Kirk Watson's scaphoid shift test- examiner opposite patient, both elbows on table as if arm wrestling ipsilateral arms. Examiners thumb on scaphoid tubercle, index finger on scapholunate ligament to palpate clunk. SLL initiates scaphoid flexion on radial deviation of wrist. Completion of flexion of scaphoid caused by pressure from surrounding bones.
Normal- can feel scaphoid flexing in radial deviation, thumb pushed away
SLL injury- pressure of examiner's thumb prevents initiation of flexion of scaphoid , then Clunk occurs on sudden pressure from bones. Patient may withdraw hand with pain 'apprehension test'
Must compare to opposite wrist.
N.B. 20 % of normal people have positive test
[Watson HK, Ashmead D4, Makhlouf MV : Examination of the scaphoid. J Hand Surg Am. 1988; 13: 657-660.]
Original Description by Watson:
'The patient is approached by the examiner as if to engage in arm wrestling, face to face across a table with diagonally opposed hands raised (right to right or left to left) and elbows resting on the surface in between. With the patient's forearm slightly pronated, the examiner grasps the wrist from the radial side, placing his thumb on the scaphoid tuberosity (as if pushing a button to open a car door) and wrapping his fingers around the distal radius. The examiner's other hand grasps at the metacarpal level, controlling the wrist position. Starting in ulnar deviation and slight extension, the wrist is moved radially and slightly flexed with constant thumb pressure on the scaphoid. This radial deviation causes the scaphoid to flex. The examiners thumb pressure opposes this normal rotation, causing the scaphoid to shift in relation to the other bones of the carpus. This scaphoid shift may be subtle or dramatic. A truly positive test requires both pain on the back of the wrist (not just where you are pressing on the scaphoid tuberosity), and comparison with the opposite wrist is essential.'
B. Lunotriquetral instability [Back To Top]
1. Reagan test (Lunotriquetral ballotment test) - stabilise the lunate between thumb and index finger of one hand and the triquetrum between the thumb and index finger of the other;the pisiform and triquetrum are pushed in a volar to dorsal direction; discomfort in this area suggests the possibility of injury to lunotriquetral interosseous ligament
[Reagan D.S., Linscheid R.L., Dobyns J.H. Lunotriquetral sprains: J Hand Surg Am 1984; 9:502-514.]
2. Kleinman shear test (shuck test)- Examiner opposite patient, contralateral thumb over dorsum of lunate, index finger over pisiform. Attempt to squeeze thumb and index finger together. Pushing the pisiform dorsal arouses pain in the lunotriquetral joint.
(Examiner's thumbs used in this illustration instead of index finger & thumb)
3. Linscheid's test (ulnar snuff box compression test) - This test may be the least specific according to Kleinman (Figure 25). The thumb placed on the ulnar side of the triquetrum exerts an axial pressure directed toward the lunate, which arouses pain.
[Linscheid RL : Scapholunate ligamentous instabilities. Annales de Chirurgie de la Main. 1984; 3: 323-330]
Tests to distinguish causes of radial pain (to be done early if tenderness on radial side of wrist)
De Quervain's tenosynovitis- Finkelstein's test- ulnar deviation,thumb in palm
Thumb CMC joint- Press over CMC joint and circumduct thumb with axial pressure
STT joint- Resisted pronation causes pain
Wartenburg's (superficial radial nerve irritation) Tinel's test
Phalen's, Tinel tests and Median nerve compression test
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