Wrist Joint Examination
Inspection (look):
While observing the patient and viewing the forearms, wrists, and hands from both the anterior
and posterior aspects, the examiner should note the patient’s willingness and ability to use the
hand doing activities such as removing a jacket, opening a door, weight-bearing on armrests
while sitting down or standing up, taking something out of a pocket, and writing.
• Fingers: the fingers are progressively more flexed as one moves from the radial side of
the hand to the ulnar side.
• bone and soft- tissue contours: the forearm, wrist, and hand should be compared for both
upper limbs, and any deviation should be noted.
• normal skin creases.
• muscle wasting:
o Thenar Eminence (median nerve)
o hypothenar eminence (ulnar nerve)
• localized swellings: seen on the dorsum of the hand
o In the wrist and hand, effusion and synovial thickening are most evident on the
dorsal and radial aspects.
o Swelling of the metacarpophalangeal and interphalangeal joints is most obvious on
the dorsal aspect.
• hypertrophy of the fingers.
• Skin color changes: give an indication of the state of the vascular system to the hand
o Hyperemia may be the result of infection.
o shiny skin may indicate systemic disease.
• wounds or scars: may indicate recent surgery or past trauma
o Are they new or old?
o Are they healing properly?
o Is the scar red (new) or white (old)?
Palmar scars may interfere with finger extension and Web space scars may interfere
with finger separation and metacarpophalangeal joint flexion.
Palpation (Feel):
Palpation should also follow a system. Work across the wrist initially on its dorsal aspect and
then volarly. Palpation should be aimed at specific anatomical landmarks.
• dorsal aspect from radial to ulnar:
o Is there fullness in the anatomical snuffbox? (Scaphoid pathology.)
o Does the area around the radial styloid and first extensor compartment look
swollen? (De Quervain’s disease.)
o Is there a swelling on the dorsum and, if so, what structure might this be overlying?
• Scaphoid Fracture: scaphoid fracture should be considered in a patient who falls on an
outstretched hand and presents with radial side pain.
• De Quervain’s Disease: Swelling and pain are localized to the first extensor
compartment (overlying the radial styloid).
• Kienböck’s Disease: Theres very specific tenderness over the lunate.
• Hamate Fracture/Non-union: Tenderness over the hook of the hamate (distal and radial
to the pisiform) may indicate an under lying fracture or non-union.
• Surface Anatomy Landmarks:
o Radial Styloid Process
o Ulnar Styloid Process
o Scaphoid (anatomical snuffbox)
o Lunate (just distal to Lister’s tubercle)
o Triquetrum (ulnar side, distal to ulnar styloid)
o Pisiform (volar side)
o Trapezium (proximal to base of 1st metacarpal)
o Capitate (distal to lunate, at the base of the third metacarpal)
o Hamate (palpate hook of hamate on volar aspect)
Range of Motion (ROM)(Move)
• Flexion/Extension: Both palmar and dorsiflexion measure about 75°.
o Extension can be assessed by placing the palms of the hands together and lifting up
the elbows.
o Flexion can be measured in a similar way with the dorsum of both hands in
apposition.
• Radial/ulnar deviation: assessed with the wrists in pronation and the elbows to the
sides. Typically, radial deviation is slightly less than ulnar deviation (20° and 35°,
respectively).
• Pronation/supination are measured with the elbows to the sides. with a comparison of
right and left (about 80°for both pronation and supination).
Resisted Isometric Movements:
The resisted isometric movements to the forearm, wrist, and hand are done with the patient in
the sitting position. The movements must be isometric and must be performed in the neutral
position.
• Pronation of the forearm
• Supination of the forearm
• Wrist abduction (radial deviation)
• Wrist adduction (ulnar deviation)
• Wrist flexion
• Wrist extension
Special test:
1. Finkelstein’s Test:
• Purpose: to identify De Quervain’s Disease.
• Procedure: The examiner supports the forearm with one hand. On the other hand, the
thumb is adducted and the wrist ulnarly deviated to put tension on the APL and EPB
tendons.
• Positive test: A positive test will elicit pain over the inflamed area in the region of the
radial styloid.
2. Scaphoid Shift Test (Kirk Watson):
• Purpose: to identify Scapholunate Instability.
• Procedure: The examiner uses one hand to grasp the wrist, placing the fingers
dorsally. The thumb is placed over the scaphoid tubercle volarly. With the examiner’s
other hand, the patient’s wrist is moved from ulnar into radial deviation whilst
maintaining pressure on the scaphoid tubercle.
• Positive test: A positive test occurs when a ‘click’ is felt by the examiner.
3. Murphy’s Sign:
• Purpose: to identify lunate dislocation.
• Procedure: The patient is asked to make a fist.
• Positive test: If the head of the third metacarpal is level with the second and fourth
metacarpals.
4. Sweater Finger Sign:
• Purpose: ruptured flexor digitorum profundus tendon.
• Procedure: The patient is asked to make a fist.
• Positive test: the distal phalanx of one of the fingers does not flex.
5. Phalen’s Test:
• Purpose: to identify carpal tunnel syndrome caused by pressure on the median nerve.
• Procedure: The examiner flexes the patient’s wrists maximally and holds this position
for 1 minute by pushing the patient’s wrists together.
• Positive test: tingling in the thumb, index finger, and middle and lateral half of the ring
finger (median nerve distribution).
6. Tinel Sign:
• Purpose: to identify carpal tunnel syndrome caused by pressure on the median nerve.
• Procedure: The examiner taps over the carpal tunnel at the wrist.
• Positive test: tingling in the thumb, index finger, and middle and lateral half of the ring
finger (median nerve distribution).
7. Allen Test:
• Purpose: This test determines the patency of the radial and ulnar arteries and
determines which artery provides the major blood supply to the hand.
• Procedure: The patient is asked to open and close the hand several times as quickly
as possible and then squeeze the hand tightly. The examiner’s thumb and index finger
are placed over the radial and ulnar arteries, compressing them. The patient then opens
the hand while pressure is maintained over the arteries. One artery is tested by
releasing the pressure over that artery to see if the hand flushes. The other artery is
then tested in a similar fashion.
• Positive test: if the hand takes more than 6vseconds to flush.
