1. Wrist Orthopaedic Tests

2. Anterior Aspect Flexor Tendons Flexor carpi ulnaris Palmaris longus
Flexor digitorum profundus
Flexor digitorum superficialis
Flexor pollicis longus
Flexor carpi radialis

3. Flexor Tendons

4. Carpal Tunnel
The median nerve and the finger flexion tendons lie within the carpal tunnel.
This is a common site of compression neuropathy.

5. Carpal Tunnel

6. Guyon’s Canal (Ulnar Tunnel)
The ulnar nerve and artery lie within Guyon’s tunnel.
This is also a common site of compression neuropathy.

7. Guyon’s Canal (Ulnar Tunnel)

8. Posterior Aspect
The ulnar styloid process is at the posterior aspect of the wrist proximal to the fifth digit.
The radial tubercle is at the posterior aspect of the wrist proximal to the thumb.
Pain the the tubercle may indicate Colle’s fracture.
Pain at the ulnar styloid process may indicate a distal ulnar fracture.

9. Ulnar Styloid Process and Radial Tubercle

10. Posterior Aspect
There are six fibro-osseous tunnels at the posterior aspect of the wrist.
The extensor tendons to the hand pass through these tunnels.
They are bound by an extensor retinaculum superficially.

11. Extensor Tendons Tunnels and associated tendons
Tunnel 1 Adductor pollicis longus, extensor pollicis brevis
Tunnel 2 Extensor carpi radialis longus and brevis
Tunnel 3 Extensor pollicis longus
Tunnel 4 Extensor digitorum and extensor indexes
Tunnel 5 Extensor digiti minimi
Tunnel 6 Extensor carpi ulnaris

12. Extensor Tendons

13. Carpal Tunnel Syndrome
Carpal tunnel syndrome is a compression neuropathy of the median nerve.
Compression occurs under the flexor retinaculum at the wrist.

14. Carpal Tunnel Syndrome

15. Carpal Tunnel Syndrome
Clinical Signs and Symptoms
Loss of sensation of the tips of the first three fingers
Hand and wrist pain
Weakness of grip

16. Tinel’s Wrist Sign
Procedure: Patient’s hand supinated. Stabilize the wrist with one hand. With your opposite hand, tap the palmar surface of the wrist with a neurological reflex hammer.
Rationale: Tingling along the distribution of the medial nerve indicates carpal tunnel syndrome. The cause could be any of the following: inflammation of the flexor retinaculum, anterior dislocation of the lunate bone, arthritic changes, or tenosynovitis of the flexor digitorum tendons.

17. Tinel’s Wrist Sign

18. Phalen’s Test
Procedure: Flex both wrist and approximate them towards each other. Hold for 60 seconds.
Rationale: When both wrists are flexed, the flexor retinaculum provides increased compression of the medial nerve in the carpal tunnel. Tingling in the distribution of the median nerve (thumb, index finger, middle finger, and medial half of ring finger) indicates carpal tunnel syndrome.

19. Phalen’s Test

20. Reverse Phalen’s Test
Procedure: Instruct the patient to extend the affected wrist and have him grip your hand. With your opposite thumb, press on the carpal tunnel.
Rationale: Extending the hand and providing pressure over the carpal tunnel further constricts the tunnel. Tingling may indicate compression of the medial nerve.

21. Reverse Phalen’s Test

22. Ulnar Tunnel Syndrome
The ulnar nerve travels through the tunnel of Guyon and innervates the muscles of the little and ring fingers.
Ulnar nerve syndrome is a compression neuropathy of the ulnar nerve.

23. Guyon’s Canal (Ulnar Tunnel)

24. Ulnar Tunnel Syndrome Clinical Signs and Symptoms
Pain over the little and ring finger
Weakness of grip
Difficulty with finger spreading
Claw hand

25. Ulnar Tunnel Triad
Procedure: Inspect and palpate the patient’s wrist, looking for tenderness over the ulnar tunnel, clawing of the ring finger, and hypothenar wasting.
Rationale: All of these signs are indicative of ulnar nerve compression possibly in the tunnel of Guyon.

26. Ulnar Tunnel Triad

27. Stenosing Tenosynovitis
Stenosing tenosynovitis in the wrist affects the tendon and sheath of the abductor pollicis longus and extensor pollicis brevis.
It is also termed de Quervain’s or Hoffman’s disease.
Swelling of the tendons and thickening of the sheaths that they pass through is due to an overuse condition of the wrist and thumb.

28. Stenosing Tenosynovitis
Clinical Signs and Symptoms
Painful wrist and thumb during movement
Swelling over the radial styloid
Tendons and sheath tender to palpation

29. Stenosing Tenosynovitis

30. Finkelstein’s Test
Procedure: Instruct the patient to make a fist with the thumb across the palmar surface of the hand and to stress the wrist medially.
Rationale: Making a fist and stressing it medially will stress the abductor pollicis longus and extensor pollicis brevis tendons. Pain in the distal styloid process of the radius indicates stenosing tenosynovitis of the tendons (de Quervain’s disease).

31. Finkelstein’s Test