An evaluation of the wrist includes a physical examination Physical Examination of the Wrist An evaluation of the wrist includes a physical examination and sometimes arthrocentesis. (See also Evaluation of the Patient With Joint Symptoms.) In this view, the triquetrum overlaps (dorsal... read more and sometimes arthrocentesis Arthrocentesis of the Wrist An evaluation of the wrist includes a physical examination and sometimes arthrocentesis. (See also Evaluation of the Patient With Joint Symptoms.) In this view, the triquetrum overlaps (dorsal... read more . (See also Evaluation of the Patient With Joint Symptoms Evaluation of the Patient With Joint Symptoms Some musculoskeletal disorders affect primarily the joints, causing arthritis. Others affect primarily the bones (eg, fractures, Paget disease of bone, tumors), muscles or other extra-articular... read more .)
Physical Examination of the Wrist
The wrist is inspected for gross deformity, redness, and swelling (including focal swelling from a ganglion cyst Ganglia Ganglia are cystic swellings occurring usually on the hands, especially on the dorsal aspect of the wrists. Aspiration or excision is indicated for symptomatic ganglia. (See also Overview and... read more ) and is gently felt for warmth and to detect subtle swelling. Findings may be compared to the unaffected side.
The bones, the joint, and the soft tissues are palpated for tenderness. Tenderness at the anatomic snuffbox (an indentation between the extensor pollicis longus on the ulnar side and the abductor pollicis longus and the extensor pollicis brevis on the radial side) suggests a scaphoid injury Scaphoid (Navicular) Fractures Scaphoid fractures usually result from wrist hyperextension. They may not be visible on initial x-rays. Complications can be severe. (See also Overview of Fractures.) The scaphoid is the most... read more . The snuffbox is best shown by having the patient extend the thumb like a hitch-hiker.
Complete range of motion is attempted, including extension and flexion and radial and ulnar deviation. Extension and flexion can be compared bilaterally by having patients put their elbows up, first with the palms together and then with the backs of the hands together.
If the patient's symptoms permit, provocative testing for tendinopathy and ligamentous laxity can be done. The Finkelstein test is done to look for De Quervain syndrome De Quervain Syndrome De Quervain syndrome is stenosing tenosynovitis of the short extensor tendon (extensor pollicis brevis) and long abductor tendon (abductor pollicis longus) of the thumb within the first extensor... read more , which is tenosynovitis of the 1st extensor compartment. For this test, the patient makes a fist with the thumb inside the fingers, and then gentle passive ulnar deviation is applied; the test is positive if pain is elicited. To assess the stability of the distal radial-ulnar articulation, the examiner grasps the distal ulna with the fingers of one hand and the distal radius with the other and pulls them up and down in opposition to each other.
Arthrocentesis of the Wrist
Needle entry occurs distal to the Lister tubercle and ulnar to the extensor pollicis longus tendon, with axial traction, 20 to 30° of flexion, and ulnar deviation applied to the hand to facilitate entry into the joint space. The extensor pollicis longus tendon can be identified more easily if the patient actively extends the wrist and thumb. A 25- to 30-gauge needle is used to place a wheal of local anesthetic over the needle entry site. A 1-inch (2.54 cm), 22-gauge needle is used to aspirate the joint. The skin is entered perpendicularly, and needle is advanced aiming toward the volar side of the wrist, with back pressure on the syringe plunger during the advance. Synovial fluid will enter the syringe when the joint is entered.
Arthrocentesis of the wrist
Synovial fluid is withdrawn from the radiocarpal joint. To help identify the extensor pollicis longus tendon, the patient should actively extend the wrist and thumb. To puncture the joint, the wrist is flexed and ulnar-deviated about 20 to 30°. Traction is applied to the hand. Needle entry occurs just distal to the Lister tubercle, ulnar to the extensor pollicis longus tendon.