CME

Examination of the Wrist

Patrick L. Reavey, M.D., M.S.

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Learning Objectives: After reading this article and reviewing the supplemental
Warren C. Hammert, D.D.S.,
videos, the participant should be able to: 1. Identify common wrist conditions
M.D.
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that may be encountered on evaluation. 2. Describe provocative maneuvers

Rochester, N.Y. used to confirm a diagnosis of wrist disorder. 3. Develop a systematic approach
to examination of the wrist. 4. Determine appropriate diagnostic maneuvers for
radial, central, and ulnar wrist pain.
Summary: The wrist is a complex structure, and providers caring for hand
and upper extremity conditions need to have an understanding of the wrist
examination and provocative maneuvers for conditions that are encountered.
Fractures, tendonitis, arthritis, and instabilities are all commonly encountered,
and the provider should have an idea of the diagnosis based on clinical exam-
ination and use imaging as needed to confirm or stage a diagnosis.  (Plast.
Reconstr. Surg. 147: 284e, 2021.)

W
09/16/2022

rist pain is a frequent complaint encoun- of dorsal prominence in patients but is usually eas-
tered by hand, orthopedic, and plastic ily visualized and palpable. The distal radioulnar
surgeons. The complexity of the wrist joint can be palpated as a “soft spot” between the
with multiple associated ligaments, joints, ten- head of the ulna and the dorsal radius.
dons, and neurovascular structures can make The abductor pollicis longus and extensor
diagnosis of wrist abnormalities difficult. However, pollicis brevis tendons lie within the first dorsal
with a good understanding of anatomy and care- compartment over the radial styloid. With the
ful provocative maneuvers, an experienced clini- thumb abducted, these tendons can be visualized
cian can often narrow the differential diagnosis passing to the base of the thumb, along with the
and formulate a treatment plan without the need more ulnar extensor pollicis longus tendon from
for advanced imaging. Common wrist conditions the third dorsal compartment. The space between
and key examination maneuvers are discussed to these two compartments forms the “anatomical
aid the surgeon caring for these patients. snuffbox” within which the midscaphoid can be
palpated. The scapholunate interval can be gener-
ally palpated ulnar to the extensor pollicis longus
WRIST ANATOMY
tendon, with the lunate found slightly more ulnar
The wrist includes the anatomical area from to that location, and the triquetrum distal to the
the distal radius to the base of the metacarpals. ulnar head.
Pertinent anatomy for common abnormalities is On the volar aspect of the wrist, landmarks
discussed along with key examination maneuvers are not usually visualized but can still be palpated.
in subsequent sections. Key external anatomy to The distal pole of the scaphoid is located as a volar
orient the examiner is presented here (Fig. 1). prominence proximal and ulnar to the base of the
The distal radius can easily be palpated on thumb, in line with the flexor carpi radialis ten-
its dorsal surface. A notable dorsal prominence don. The palmaris longus is ulnar to the flexor
(Lister tubercle) is a reliable external landmark. carpi radialis tendon, although this is absent in
The radial styloid can also be palpated extending approximately 15 percent of the population. The
distally and volarly. The radiocarpal (scapholu- median nerve is located deep and between these
nate) joint is approximately 1 cm distal to the Lister tendons. The scaphotrapeziotrapezoid joint is just
tubercle. The head of the ulna has variable degrees

From the Divisions of Plastic and Reconstructive Surgery Disclosure: The authors have no financial or other
and Hand and Wrist, Department of Orthopedic Surgery, conflicts of interest to disclose.
University of Rochester Medical Center.
Received for publication March 19, 2020; accepted September
15, 2020. Related digital media are available in the full-text
Copyright © 2021 by the American Society of Plastic Surgeons version of the article on www.PRSJournal.com.
DOI: 10.1097/PRS.0000000000007520

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 Volume 2, Number 147 • Examination of the Wrist
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Fig. 1. Key external wrist anatomy. T, triquetrum; L, lunate; S, scaphoid; asterisk, Lister
tubercle; P, pisiform; H, hook of hamate; black arrows, trapeziometacarpal joint; red arrow,
flexor carpi radialis.

distal to the scaphoid tubercle, with the trapezium The examination is performed sitting across
radial and the trapezoid (which is more difficult from the patient, using an examination table, with
to palpate) located ulnar to the ulnar of the trape- the arms or elbows placed on the table (Fig.  2).
zium. The trapeziometacarpal joint is most easily The examination begins with visual inspection of
palpated on its most radial aspect. the appearance and resting posture of the arm
The pisiform is identified at the proximal aspect and hand, including areas of swelling, soft-tissue
of the hypothenar eminence at the same level as the compromise, or deformity; skin texture, color,
scaphoid tubercle. Slightly radial and distal to the and integrity; and previous scars. Motion of the
pisiform is the hook of the hamate. Between the wrist/forearm should be measured in flexion/
pisiform and hook of the hamate lies the Guyon extension, radial/ulnar deviation, and pronation/
canal containing the ulnar neurovascular bundle. supination (Fig.  3). Although a comprehensive
examination is good practice, many complaints
are specific enough that a focused examination
HISTORY AND PHYSICAL will give the diagnosis. Generally, we perform any
EXAMINATION maneuvers likely to cause the patient pain last. In
Evaluating a patient with a wrist complaint the case of trauma or suspected bony or ligamen-
requires a detailed history and physical exami- tous injuries/conditions, standard wrist radio-
nation. The anatomical area of the complaint graphs with additional views as needed based on
(radial, ulnar-side, or dorsocentral) can be help- the differential diagnosis (e.g., scaphoid view for
ful to narrow the differential diagnosis and focus scaphoid fracture, a Robert view for trapeziometa-
the history and examination. The history may be carpal arthritis) should be obtained.
brief for an acute trauma and longer for a non- Neurovascular conditions (e.g., carpal tun-
traumatic complaint but should be organized to nel syndrome) can cause wrist pain but are not
narrow the differential diagnosis. The patient discussed, as the associated symptoms would also
should also be asked to localize any symptoms incite a complete neurologic examination, which
(e.g., pain) as much as possible, and to point to is outside the scope of this article. Arthritis is com-
a location with a single finger or move their hand mon in the wrist and can affect any or multiple
or wrist into the inciting position to focus the joints. Diagnosis is based on radiographs and is not
subsequent examination. With acute trauma, the always symptomatic. Treatment is based on symp-
position of the wrist/forearm (flexion/extension, toms rather than radiographic findings. Table  1
pronation/supination) and direction of force demonstrates common location of tenderness with
during the injury should be considered. palpation based on the location of arthritis.

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 Plastic and Reconstructive Surgery • February 2021
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Fig. 2. Positioning for proper hand examination.

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Fig. 3. Measuring wrist range of motion.

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 Volume 2, Number 147 • Examination of the Wrist

Table 1.  Joints and Areas of Palpation for Wrist Table 2.  Differential Diagnosis of Radial-Side Wrist Pain
Arthritis
Acute traumatic
Joint Point of Tenderness  Distal radius fracture
  Radial styloid or Lister tubercle tenderness
Trapeziometacarpal Volar or dorsal  Scaphoid fracture*
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Scaphotrapezial trapezoid Volar    Snuffbox tenderness*

Radioscaphoid Radial or dorsal radial   Distal tubercle tenderness*
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Midcarpal Dorsal    Axial thumb compression*

Radiolunate Dorsal Chronic degenerative/traumatic
DRUJ Dorsal  TM arthritis*
Pisotriquetral Volar or ulnar    Grind test*
CMC Dorsal over affected joint   Thumb extension test*
Pancarpal Dorsal   Thumb adduction test*
DRUJ, distal radioulnar joint; CMC, carpometacarpal joint.    Lever test*
 STT arthritis
  STT tenderness, radial grind test†
Radial-Side Wrist Pain  Scaphoid nonunion
   Snuffbox tenderness
There are many causes of radial wrist pain  Radioscaphoid arthritis
(Table  2). Although the provocative maneuvers   Synovitis and pain in radioscaphoid joint
Chronic overuse
are discussed under each diagnosis, many of them  de Quervain tenosynovitis*
are performed in sequence to rule in or rule out   Pain over first dorsal radial compartment*
particular abnormalities.    Finkelstein test*
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 Intersection syndrome*
First Dorsal Compartment (de Quervain)    Pain in distal forearm, pain with wrist extension*
 FCR tendonitis
Tenosynovitis   Pain over FCR tendon, wrist flexion
De Quervain tenosynovitis is a common condi- TM, trapeziometacarpal; STT, scaphotrapeziotrapezoid; FCR, flexor
tion involving inflammation of the abductor pol- carpi radialis
*Conditions and maneuvers discussed in detail in the text.
licis longus and extensor pollicis brevis tendons †Wu JC, Calandruccio JH. Evaluation and management of scaph-
within the first dorsal compartment. Patients typi- oid-trapezium-trapezoid joint arthritis. Orthop Clin North Am.
cally complain of radial wrist pain exacerbated with 2019;50:497–508. DOI: 10.1016/j.ocl.2019.05.005.
movement of the thumb, especially with lifting,
grasping, or twisting. Swelling, crepitus, and ten-
Intersection Syndrome
derness over the radial styloid may also be noted.
Intersection syndrome is a tendinopathy
The Finkelstein maneuver is considered the
involving the radial wrist extensors at the point
pathognomonic sign of this condition. However,
where the muscles bellies of the abductor pollicis
this has been incorrectly perpetuated in the litera-
longus and extensor pollicis brevis cross over, or
ture for decades.1,2 The true Finkelstein maneuver
“intersect” with them. Symptoms can be similar to
is performed by grasping the patient’s thumb and
those of de Quervain tenosynovitis but are more
then quickly ulnarly deviating the wrist, rather
severe with wrist flexion and extension. The con-
than placing the patient’s thumb in their clenched
dition is more common in young manual laborers
fist and then ulnarly deviating the wrist (Fig. 4).
and those involved in specific sport activities, such
The commonly misconceived clenched fist
as rowing, canoeing, racket sports, weight lifting,
maneuver was actually described by Eichoff, who
and skiing.4 On examination, the patients may
noted it was uncomfortable in most normal sub-
have some visible swelling accompanied by pain
jects and thought it explained the propensity for
and possibly crepitus in the distal forearm (approx-
developing de Quervain tenosynovitis.2 In addi-
imately 4  cm proximal to the radiocarpal joint)
tion, in a comparative study between the two tests,
with wrist flexion and extension.5 Ultrasound can
Wu et al. found that the Finkelstein test was 100
be helpful in confirming the diagnosis.4
percent specific, whereas the Eichoff test may
result in false-positives for de Quervain tenosy- Trapeziometacarpal Arthritis
novitis.1 Another provocative maneuver for de The thumb metacarpal articulates with the
Quervain tenosynovitis is the “wrist hyperflexion trapezium on a biconcave, saddle-shaped joint
abduction of the thumb” maneuver, which has that provides the thumb with a wide arc of multi-
been described as an additional diagnostic tool planar motions. The joint has little inherent osse-
with better sensitivity (0.99 versus 0.89) and speci- ous stability and as such is the most common site
ficity (0.28 versus 0.14).3 [See Video  1 (online), of symptomatic arthritis in the hand.6 Arthritis is
which demonstrates provocative maneuvers to more common in women and with increasing age,
diagnose first dorsal compartment tendonitis (de and 90 percent of people older than 80 years have
Quervain tendonitis).] some degree of trapeziometacarpal arthrosis on

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 Plastic and Reconstructive Surgery • February 2021
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Fig. 4. Maneuvers for de Quervain tenosynovitis. (Left) This demonstrates the true Finkelstein maneuver, where the examiner
grasps the thumb and ulnarly deviates the wrist. Pain over the radial styloid is a positive test. (Right) The clasped thumb maneuver
is frequently mislabeled, but is properly attributed to Eichoff and is often positive in patients without de Quervain tenosynovitis .
09/16/2022

radiography.7 Patients often complain of a throb- placing pressure on the dorsal aspect of the meta-
bing pain in the radial aspect of their hand or wrist carpal head and bringing the thumb metacarpal
or in the thenar eminence, often exacerbated by parallel to the index with adduction. The exten-
pinch, grip, or twisting, such as opening jars or sion test is performed similarly except the pressure
doors. Advanced cases may have a characteristic is on the radial aspect of the metacarpal, extend-
deformity of the trapeziometacarpal joint with ing it until it is in a plane parallel with the palm
dorsoradial prominence of the thumb metacarpal or an endpoint is reached (Fig. 5). Finally, in the
base (known as shoulder sign) with concomitant lever maneuver, the metacarpal is held just distal
flexion and/or adduction of the metacarpal. to the basal joint and shucked radially and ulnarly.
The close relationship of the trapeziometacar- For all maneuvers, pain reproduced at the trape-
pal joint to other possible causes of radial wrist ziometacarpal joint is considered a positive result.
pain make the examination important, with sev- Although the grind test is the most com-
eral maneuvers described. These include the monly taught and used by most hand surgeons,6
grind test, adduction stress test, extension test,6 it has been demonstrated to have a sensitivity of
and lever test.8 approximately 0.40,6,8 indicating that it will miss
The grind test is performed by compressing some patients with trapeziometacarpal arthri-
the metacarpal on the trapezium and rotating tis. The lever test has a sensitivity and specific-
the metacarpal. The adduction stress test involves ity of approximately 0.82 and 0.81,8 respectively,

Fig. 5. Basal joint arthritis maneuvers. (Left) In the adduction test, the examiner pushes the patient’s thumb into a position parallel
with the index metacarpal. (Right) In the extension test, the examiner pushes the patient’s thumb into the plane of the palm. The
arrows demonstrate the direction of force. Pain at the trapeziometacarpal joint with either test is indicative of basal joint arthritis.

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 Volume 2, Number 147 • Examination of the Wrist

whereas the extension and adduction tests have and scaphoid (ulnar deviated) views. If there is
sensitivities and specificities above 0.9.6 A combi- suspicion for a scaphoid fracture, but the images
nation of these maneuvers is best used to diagnose do not demonstrate a fracture, repeated imaging
symptomatic trapeziometacarpal arthritis. [See in a couple of weeks is warranted. Alternatively, a
Video 2 (online), which demonstrates provocative magnetic resonance imaging scan can be obtained
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maneuvers for clinical diagnosis of trapeziometa- and is more sensitive and specific for diagnosis of
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carpal (basal joint, thumb carpometacarpal joint) a scaphoid fracture.11 Computed tomography can
arthritis.] be helpful in determining displacement and sur-
gical planning.12
Scaphoid Fracture
In more advanced wrist arthritis, the
The scaphoid is the most commonly fractured
radioscaphoid joint may be involved, often result-
carpal bone. It usually occurs from a high-energy
ing in synovitis and a prominence between the
fall on an outstretched wrist. Unrecognized frac-
extensor pollicis longus and abductor pollicis
tures can go on to malunion, nonunion, or avascu-
longus tendons at the level of the radioscaphoid
lar necrosis, and subsequent radiocarpal arthritis.
joint. Although much less common than the dor-
Plain radiographs have 65 to 85 percent sensitivity
sal wrist tendonitis, flexor carpi radialis tendonitis
to detect scaphoid fractures.
may occur and is the result of irritation of the ten-
The classic finding of a scaphoid fracture is
don as it passes through the trapezial tunnel, deep
pain in the anatomical snuffbox (Fig. 6) and has
to the trapezial ridge.
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been demonstrated to have high sensitivity but

variable specificity.9 It should be noted that the
Central Wrist Pain
orientation of the scaphoid is dependent on the
wrist position. The snuffbox palpation should be Patients with “central” wrist pain will often
performed in neutral extension and ulnar devia- indicate the dorsal aspect of the wrist as the loca-
tion, which presents over six times more of the tion of their symptoms. Radiocarpal arthritides
dorsal scaphoid for palpation in the snuffbox often present with central wrist pain and decreased
when compared to radial deviation.10 Pain on range of motion. Radiographs will confirm the
direct palpation of the scaphoid tubercle is also diagnosis. Common causes of central wrist pain
a highly sensitive test for a more a distal scaphoid are listed in Table 3.
fracture.9 Scapholunate Ligament Injury
Radiography should be performed as an ini- The scapholunate interosseous ligament is a
tial examination. Radiographs include posteroan- complex consisting of dorsal and volar ligaments
terior, lateral, pronated and supinated oblique, and a proximal membranous extension facing the
radius. The dorsal portion of the scapholunate lig-
ament is the strongest portion and considered the
“key “ portion of the ligament.13 Complete disrup-
tion of the scapholunate and secondary stabilizers

Table 3.  Differential Diagnosis of Central Wrist Pain

Acute traumatic
 Distal radius fracture
  Radial styloid or Lister tubercle tenderness
 SL ligament injury*
  Dorsal SL tenderness*
  Watson scaphoid shift*
Chronic degenerative/traumatic
 Occult ganglion
  Dorsal wrist tenderness without mass
 Kienböck disease*
   Snuffbox tenderness*
 SLAC/SNAC wrist
  Radiocarpal tenderness, decreased ROM
 Radiolunate arthritis
  Pain at radiolunate joint, decreased ROM
Chronic overuse
 Extensor tendinopathy
  Swelling, pain with finger ROM
Fig. 6. Anatomical snuffbox. Black arrow, first dorsal compart-
SL, scapholunate; SLAC, scapholunate advanced collapse; SNAC,
ment; red arrow, extensor pollicis longus; box, anatomical scaphoid nonunion advanced collapse; ROM, range of motion.
snuffbox. *Conditions and maneuvers discussed in detail in the text.

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 Plastic and Reconstructive Surgery • February 2021

will result in widening of the scapholunate inter- [See Video  3 (online), which demonstrates the
val and, if untreated, likely result in characteris- provocative maneuver, the scaphoid shift, also
tic progressive carpal malalignment and arthritis known as the Watson maneuver, to aid in diagno-
known as a scapholunate advanced collapse wrist. sis of scapholunate instability.]
Patients often injure their scapholunate ligament As discussed by Watson, there are a variety
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in a similar manner to a scaphoid fracture—a of findings from this examination, and it should
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high-energy fall on an extended wrist. be considered a provocative maneuver and not

The scapholunate interval can be palpated a “test.” In addition, up to 36 percent of normal
approximately 1  cm distal and slightly ulnar to wrists can have some degree of positive results and
the Lister tubercle. The scaphoid shift maneu- may not be pathologic.15 A concerning examina-
ver14 is the classic provocative maneuver to dem- tion is usually followed up with advanced imag-
onstrate scapholunate instability. The patient’s ing (magnetic resonance imaging) or diagnostic
elbow is supported on an examination table and arthroscopy.
the examiner places the thumb on the volar dis-
tal pole of the scaphoid with the fingers on the Kienböck Disease
dorsal wrist (Fig. 7). The wrist is placed in ulnar Kienböck disease is an idiopathic avascular
deviation and slight extension, and the examiner necrosis of the lunate. Disruption of the arterial
moves the hand into radial deviation and slight supply or venous outflow to the lunate, increased
flexion. Lack of space available in the radial fossa mechanical load across the radiolunate joint
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moves the scaphoid into flexion, and the exam- because of negative ulnar variance, and systemic
iner will feel the scaphoid “push” against their factors have all been implicated in the pathogen-
thumb. The examiner then repeats the motions esis. Patients are often young men (aged 20 to
but applies force against the distal pole to pre- 40 years) and present with progressive pain and
vent it from flexing. With a complete scapholu- weakness in the affected wrist without a history
nate ligament injury, the scaphoid will sublux of trauma.16 On examination, dorsal swelling and
dorsally out of the scaphoid fossa. As thumb synovitis over the dorsal wrist may be present. In
pressure is relieved on the scaphoid, it will move advanced cases, palpation of the lunate may elicit
back into its normal position with a characteristic pain. Wrist motion is often decreased with pain
“clunk” as it falls over the dorsal rim of the radius. at the end of the extension arc. The affected side
More subtle findings include “laxity” and pain dur- often has decreased grip strength. In advanced
ing motion when compared to the opposite side. stages, radiographs will demonstrate sclerosis

Fig. 7. Scaphoid shift test. The examiner places their thumb on the distal pole of the
scaphoid and moves the wrist between ulnar and radial deviation.

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 Volume 2, Number 147 • Examination of the Wrist

Table 4.  Differential Diagnosis of Ulnar-Side Wrist

Pain
Acute traumatic
 TFCC injury*
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  DRUJ instability (piano key test)*

   Fovea sign*
 LT ligament injury*
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  Reagan shear test*

  Kleinman shuck test*
   LT ballottement*
 Ulnar styloid fracture
  Pain at ulnar styloid
 Triquetral fracture
  Pain over dorsal triquetrum
 Hook of hamate fracture
  Pain at hook of hamate
 Base of fifth metacarpal fracture
  Pain at base of fifth metacarpal
Chronic degenerative/traumatic
 Ulnar impaction syndrome*
  Ulnocarpal stress test*
 Pisotriquetral arthritis* Fig. 8. Triangular fibrocartilage complex (TFCC). On this mag-
  Pisotriquetral shuck test* netic resonance imaging scan, the triangular fibrocartilage
 DRUJ arthritis complex can be clearly seen originating from the radius and
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  Pain to palpation over DRUJ, or DRUJ manipulation

 DRUJ instability inserting at the fovea at the base of the ulnar styloid (arrow).
  DRUJ instability, pain
 ECU tendon subluxation
  ECU snapping with pronation/supination ulnar fovea (at the base of the ulnar styloid),
Chronic overuse respectively, playing a crucial role in stabilizing
 ECU tendonitis*
  ECU synergy test* the distal radioulnar joint during forearm rota-
 FCU tendonitis tion18 (Fig. 8).
  Pain over distal FCU, pisiform
The distal radioulnar joint is examined sit-
TFCC, triangular fibrocartilage complex; DRUJ, distal radioulnar
joint; LT, lunotriquetral; ECU, extensor carpi ulnaris; FCU, flexor ting across from the patient with the elbow
carpi ulnaris. flexed and the hand toward the ceiling and the
*Conditions and maneuvers discussed in the text. examined wrist in pronation, supination, and
neutral rotation. Stability is subjective, and the
and/or fracture of the lunate. Magnetic reso- opposite wrist should be examined for com-
nance imaging is helpful to confirm the diagnosis, parison. The examiner stabilizes the ulna and
especially in early cases.16,17 pushes the radius toward the patient. If the
ulna is able to be displaced from the sigmoid
Ulnar-Side Wrist Pain notch, the examiner may feel a clunk, indicative
Common causes of ulnar-side pain are listed of complete tear or avulsion of the foveal fibers
in Table 4. Many of these overlap in terms of pre- of the triangular fibrocartilage complex. A lax
sentation and examination findings because of distal radioulnar joint with pain on this maneu-
the intimate relationships between the ligamen- ver may indicate partial tear or injury. The wrist
tous and osseous structures. The diagnosis of a is then pronated and the maneuver repeated.
particular condition on history and examination This stressing of the radial ulnar ligaments
is comparatively more difficult than radial-side specifically tests the deep foveal fibers.18 [See
pain. Advanced imaging to confirm the diagnosis Video 4 (online), which demonstrates provoca-
is often helpful. tive maneuvers for examining the distal radioul-
nar joint for instability, secondary to triangular
Triangular Fibrocartilage Complex Injuries fibrocartilage complex tear.]
The triangular fibrocartilage complex is the The “foveal sign” as described by Dr. Richard
primary stabilizer of the distal radioulnar joint. Berger is a more specific examination maneuver
It consists of an articular disk, ulnocarpal liga- to evaluate the foveal attachments of the triangular
ments, dorsal and volar radioulnar ligaments, fibrocartilage complex. The forearm and wrist are
and the extensor carpi ulnaris tendon sheath. positioned in neutral. The examiner then deeply
The radioulnar ligaments have superficial and presses in the “soft spot” just distal to the ulnar
deep portions that originate from firm attach- head, between the ulnar styloid and the flexor carpi
ments on the medial border of the distal radius ulnaris volarly (Fig. 9). Pain indicates a positive sign.
and insert into the ulnar styloid and into the This test has been demonstrated to be 95.2 percent

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 Plastic and Reconstructive Surgery • February 2021
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Fig. 9. The fovea can be assessed by placing direct pressure in the space distal to the
ulnar head, volar to the ulnar styloid and dorsal to the flexor carpi ulnaris.

sensitive and 86.5 percent specific for a foveal dis- Extensor Carpi Ulnaris Tendonitis
ruption or ulnar-triquetral ligament injury.19 The powerful extensor carpi ulnaris attaches
The ulnocarpal stress maneuver involves on the ulnar side of the small finger metacarpal
ulnarly deviating the wrist and placing an axial and causes wrist extension and/or ulnar devia-
load across the wrist while passively pronating and tion, depending on the position of the forearm.
supinating the forearm. Pain indicates a positive The tendon runs in a grove in the distal ulna and
test and, although sensitive to intraarticular ulnar- has a dense subsheath that stabilizes it during pro-
side abnormalities, it is not very specific and can nation and supination—as it moves from volar
be indicative of a variety of conditions.20 A positive ulnar to dorsal, respectively. Ruptures or tears of
test is an indication to pursue additional workup. the extensor carpi ulnaris subsheath can cause
[See Video  5 (online), which demonstrates pro- ulnar-side wrist pain or characteristic snapping of
vocative maneuvers to evaluate the foveal inser- the extensor carpi ulnaris tendon during prona-
tion of the triangular fibrocartilage complex and tion/supination as the tendon subluxes out of the
maneuvers to diagnose ulnar impaction.] ulnar groove.
Ulnar Impaction It can be difficult to pinpoint the cause of
Ulnar impaction is a common cause of ulnar- chronic ulnar-side wrist pain on examination
side wrist pain, and patients will often complain because of the complex relationships of the ulnar
of pain with extension and loading, such as tendons and ligaments in the triangular fibro-
doing push-ups. The ulnocarpal stress maneu- cartilage complex. The extensor carpi ulnaris
ver as described above will often reproduce the synergy maneuver will isolate the extensor carpi
pain. In addition, extension and axial load to ulnaris without stressing the deeper intraarticular
the pronated wrist will cause discomfort. Zero portions of the triangular fibrocartilage complex
rotation posterior anterior and lateral x-rays, by activating the extensor carpi ulnaris without
along with a pronated grip view, can determine ulnar deviation of the wrist. The patient’s elbow is
ulnar variance and may show changes consistent placed at 90 degrees and the forearm in full supi-
with ulnar impaction. Magnetic resonance imag- nation, with all of the fingers extended. The exam-
ing can also be used for further evaluation and iner then compresses the thumb and long finger
may show changes in the proximal ulnar aspect and asks the patient to radially abduct the thumb
of the lunate, confirming the diagnosis. Central against resistance (Fig. 10). [See Video 6 (online),
triangular fibrocartilage complex tears are com- which demonstrates the provocative maneuver
mon with ulnar impaction. (extensor carpi ulnaris synergy maneuver) to

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Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 2, Number 147 • Examination of the Wrist

the pisiform volarly and “shucking” the triquetrum

volarly and dorsally against the lunate. Because of
the manipulation of the pisotriquetral joint with
this maneuver, the pisotriquetral joint should
first be evaluated to make sure pisotriquetral dis-
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ease does not give a false-positive result. Finally,

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the Kleinman shear test is performed similarly to

the shuck test but with the examiner compress-
ing the dorsal lunate and the volar triquetrum by
means of the pisiform. Varying amounts of force
can be applied to create “shear” between the
lunate and triquetrum and potentially more spe-
cifically evaluate the lunotriquetral joint.18,22 [See
Video 7 (online), which demonstrates provocative
maneuvers to demonstrate lunotriquetral insuffi-
ciency, including lunotriquetral shear, shuck, and
compression.]
Pisotriquetral Arthritis
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Pisotriquetral arthritis is an underappreci-

ated cause of ulnar wrist pain. Patients will often
Fig. 10. Extensor carpi ulnaris synergy test. The patient abducts the describe vague discomfort along the volar ulnar
fingers and the thumb and radially deviates the wrist against resis- wrist. They will have discomfort with compression
tance from the examiner on the thumb. This offloads the intraarticu- of the pisiform against the triquetrum. Supinated
lar portion of the triangular fibrocartilage complex but will activate oblique radiograph of the wrist will demonstrate
the extensor carpi ulnaris tendon. Pain over the extensor carpi ulna- narrowing of this joint, confirming the diagnosis.
ris tendon is a positive test for extensor carpi ulnaris tendonitis.
CONCLUSIONS
diagnose extensor carpi ulnaris tendonitis.] The The diversity of abnormalities that result in
extensor carpi ulnaris and flexor carpi ulnaris ten- wrist pain can be daunting to the hand surgeon.
dons contract to stabilize the wrist (synergy), and Using common provocative wrist examination
pain along the extensor carpi ulnaris tendon is maneuvers, the differential diagnosis can often
considered positive for extensor carpi ulnaris ten- be narrowed. Imaging is often required to con-
dinopathy. This has high sensitivity and specificity firm a particular abnormality. However, it is also
and may eliminate the need for additional imag- important to remember that findings on imag-
ing if it is positive.21 ing might not be a source of discomfort and do
not necessarily need treatment. The history and
Lunotriquetral Ligament Injury physical examination are often more important to
Lunotriquetral ligament injuries commonly guiding care. Although many of the provocative
occur with the hand/forearm positioned in exten- maneuvers may not be required in all patients pre-
sion and radial deviation at the time of axial load. senting to the clinic, it is helpful to incorporate
Complete lunotriquetral ligament injuries will many of them into a standard wrist examination.
result in the scaphoid and lunate progressing into When performed regularly, they add little time to
flexion. Partial ligament injuries can be more dif- the overall examination and the surgeon will get a
ficult to diagnose on examination and standard better understanding of “normal,” thus increasing
radiographs. Three examination maneuvers can the sensitivity of their examination.
be used to evaluate abnormalities in the lunotri-
quetral interval. Warren C. Hammert, D.D.S., M.D.
4901 Lac de Ville Boulevard, Building D
The lunotriquetral ballottement test involves Rochester, N.Y. 14618
pushing on the ulnar portion of the triquetrum
and rocking it radially against the lunate. Pain on
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 Plastic and Reconstructive Surgery • February 2021

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