Examination of the Wrist Mr P R Stuart FRCS Freeman Hospital Newcastle upon Tyne HAND SURGERY REVISION COURSE - QMC Nottingham

(‘clunk, click every trip’) OR

Remember! Not all that clicks or clunks is abnormal most wrists don’t have ‘interesting’ instabilities investigation of the wrist is clinical - investigations add little knowledge of surface anatomy critical

Radial Side Styloid De Quervain’s - Finkelstein (JBJS 12A; 509, 1930) Wartenbergs Intersection

Radial Side Snuffbox swelling articular / non-articular pain –scaphoid #’s –impingement, (malunion) –scapho-styloid OA

Dorsal Radial Lister’s tubercle -> SL interval –occult ganglia –instability Lunate - Keinbocks

Dorsal Central Carpal boss Extensor compartments –extensor manus brevis –tenosynovitis - moves with tendons –ganglia –PIN neuritis –lunate + capitate #’s

Dorsal Ulnar DRUJ –compression, translation, piano key, dimple TFC Luno-triquetral, triquetro-hamate Ulnar carpal impaction - pronation + UD

Dorsal Ulnar ECU instability –supination, UD, flexion 4th + 5th CMC OA Mid-carpal instability

Palmar Radial scaphoid - tuberosity #’s STT - common, ganglia 1st CMC FCR tendonitis / trapezial ridge fractures PCB neuroma

Palmar Ulnar FCU tendonitis Piso-triquetral OA - compression Hook of Hamate - fist in UD hypothenar hammer syndrome Guyon’s canal compression pillar pain

Provocative Testing Scaphoid shift Finger extension test Midcarpal clunk L-T shuck test DRUJ –grind –pain at extremes

Lax, loose, wobbly or unstable Like the shoulder there is a range of normal most mid-carpal joints can be subluxed (pushed into VISI) most clunks and abnormal movements can only be considered pathological if they occur during normal use and / or are painful the ‘lax’ wrist is often painful without being ‘unstable’

Scaphoid shift - Watson’s test Qualitative assessment of scaphoid instability 10% normal wrists have positive test - take care!

Finger extension test Resisted finger extension in full passive wrist flexion +ve in DWS, SLAC, SLD, RSS, MCI, Kienbock’s

Articular - nonarticular Periscaphoid synovitis, SLAC, instability, non-union

Catch-up clunk Proximal row flicking suddenly from volar flexion to dorsiflexion normal smooth transition from one to other under influence of capsular and intracarpal ligaments