3 Wrist EX

Wrist Examination
The hand and wrist examination can be broken down into five key components:
look, feel, move, function and special tests.
Introduction
 Introduce yourself , explain what you are going to do .
 Gain consent.
 ……
1.Look
General inspection
As other….
Close inspection of the hand

Palmar aspect of the hand
1. Hand posture: note any evidence of abnormal hand posture (e.g. clawed
hand secondary to Dupuytren’s contracture).
2. Scars.
3. Swelling.
4. Dupuytren’s contracture.
5. Thenar/hypothenar wasting: isolated wasting of the thenar eminence is
suggestive of median nerve damage (e.g. carpal tunnel syndrome).
6. Elbows: inspect for evidence of psoriatic plaques or rheumatoid nodules.
7. Janeway lesions: non-tender, haemorrhagic lesions that occur on the thenar
and hypothenar eminences of the palms (and soles). Janeway lesions are
typically associated with infective endocarditis.
8. Osler’s nodes: red-purple, slightly raised, tender lumps, often with a pale
centre, typically found on the fingers or toes. They are typically associated
with infective endocarditis.
Dorsal aspect of the hand

1. Hand posture.
2. Scars.
3. Swelling.
4. Skin color: erythema of the soft tissue may indicate cellulitis or joint sepsis.
5. Bouchard’s nodes: occur at the proximal interphalangeal joints (PIPJ) and are
associated with osteoarthritis.
6. Heberden’s nodes: occur at the distal interphalangeal joints (DIPJ) and are
associated with osteoarthritis.
7. Swan neck deformity: occurs at the distal interphalangeal joint (DIPJ) with
clinical features including DIPJ flexion with PIPJ hyperextension. Swan neck
deformity is typically associated with rheumatoid arthritis.
8. Z-thumb: is associated with rheumatoid arthritis.
9. Skin thinning or bruising: can be associated with long-term steroid use (e.g.
common in patients with active inflammatory arthritis).
10. Psoriatic plaques.
11. Muscle wasting: can occur secondary to chronic joint pathology or
lower motor neuron lesions (e.g. median nerve damage secondary to carpal
tunnel syndrome).
12. Splinter hemorrhages: Causes include local trauma, infective
endocarditis, sepsis, vasculitis and psoriatic nail disease.
13. Nail pitting and onycholysis: associated with psoriasis and psoriatic
arthritis.
2.Feel
Palms up
1. Temperature
Increased temperature of a joint, particularly if also associated with swelling
and tenderness may indicate septic arthritis or inflammatory arthritis.
2. Radial and ulnar pulse
3. Thenar and hypothenar eminence bulk
wasting can be caused by disuse atrophy as well as lower motor neuron
lesions (e.g. ulnar and median nerve).
4. Palmar thickening
Support the patient’s hand and palpate the palm to detect the typical bands
of thickened palmar fascia associated with Dupuytren’s contracture.
5. Median and ulnar nerve sensation
1. Assess median nerve sensation over the thenar eminence and index finger.
2. Assess ulnar nerve sensation over the hypothenar eminence and little
finger.
Palms down (dorsum)

1)Radial nerve sensation.
2)Temperature.
3)Metacarpophalangeal joint squeeze
Gently squeeze across the metacarpophalangeal (MCP) joints and observe for
verbal and non-verbal signs of discomfort. Tenderness is suggestive of active
inflammatory arthropathy.
4)Bimanual joint palpation

Bimanually palpate the joints of the hand, assessing and comparing for
tenderness, irregularities and warmth:
1. Metacarpophalangeal joint (MCPJ).
2. Proximal interphalangeal joint (PIPJ).
3. Distal interphalangeal joint (DIPJ).
4. Carpometacarpal joint (CMCJ) of the thumb (squaring of the joint is
associated with OA).
5)Anatomical snuffbox
Palpate the anatomical snuffbox for tenderness which is suggestive of a
scaphoid fracture.
6)Bimanual wrist palpation

3.Move
Active movement
1)Finger extension
2)Finger flexion
3)Wrist extension
Normal range of movement: 90º
4)Wrist flexion
Normal range of movement: 90º
Passive movement
It’s important to feel for crepitus as you move the joint (which can be associated
with osteoarthritis) and observe any discomfort or restriction in the joint’s range
of movement. Repeat the above movements passively.
Motor assessment
The following screening test will allow you to quickly assess the motor function of
the radial, ulnar and median nerve.
Wrist and finger extension against resistance

Nerve assessed: radial nerve
Index finger ABduction against resistance

Nerve assessed: ulnar nerve
Thumb ABduction against resistance

Nerve assessed: median nerve
4. Special test
1.Power grip
Instructions: “Squeeze my fingers with your hands.”
2.Tinel’s test
Tinel’s test is used to identify median nerve compression and can be useful in the
diagnosis of carpal tunnel syndrome.
To perform the test, simply tap over the carpal tunnel with your finger.
Interpretation
If the patient develops tingling in the thumb and radial two and a half fingers this
is suggestive of median nerve compression.
Phalen’s test
If the history or examination findings are suggestive of carpal tunnel syndrome,
Phalen’s test may be used to further support the diagnosis.
Ask the patient to hold their wrist in maximum forced flexion (pushing the dorsal
surfaces of both hands together) for 60 seconds.
Interpretation
If the patient’s symptoms of carpal tunnel syndrome are reproduced then the test
is positive (e.g burning, tingling or numb sensation in the thumb, index, middle
and ring fingers).
Also, there are Reverse Phalen test

3.Durkans test
Carpal tunnel compression test for 30 s .
4.Piano-Key Sign Test

The Piano-Key Sign Test is a test carried out for the clinical assessment of wrist
instability. It is used as an indicator for distal radio-ulnar joint instability and tears
of the triangular fibrocartilage complex of the wrist.
Technique
In the Piano-key Sign Test, the wrist is supported in pronation and the hand is
stabilized in the neutral position. Force is applied to the head of ulna.
5.Finkelsteins test
To assess for tenosynovitis, wrist adduction.
6.Fovea test
The ulnar fovea sign is a clinical test used to specify the cause of ulnar-sided wrist
pain.
A positive ulnar fovea sign test is indicative of foveal disruption of the distal
radioulnar ligaments and ulnotriquetral ligament injuries.
7.ROM.
8.Allen test.
Thank the Patient……

3 Wrist EX

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Wrist Examination

Close inspection of the hand

Dorsal aspect of the hand

Palms down (dorsum)

4)Bimanual joint palpation

6)Bimanual wrist palpation

Wrist and finger extension against resistance

Index finger ABduction against resistance

Thumb ABduction against resistance

Also, there are Reverse Phalen test

4.Piano-Key Sign Test

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