The wrist

Look

Skin

 Look for scars, particularly over the palmar side of the wrist. The thin scar of a carpal tunnel release may be almost invisible unless carefully looked for.

  Soft tissue

Swelling and wasting. Swelling is visible mainly on the dorsal side, or over the radial styloid (De Quervain’s tenosynovitis). Wasting can occur in the thenar or hypothenar eminence. It can also be seen between the metacarpals in the dorsum of the hand. Thenar eminence wasting can best be seen by putt­ing the two hands side by side, thumb upwards, and looking down at the thumbs from above. Any slight difference in shape can then be clearly seen (Fig. 20.34).

Bone

Look for prominence of the ulna styloid and for radial drift of the wrist characteristic of rheumatoid arthritis.

Feel

Skin

Test sensation in the hand by comparing the sides. The median nerve can be tested over the palmar surface of the thumb and the index finger, the ulna nerve over the little finger. The sensory distribution of the radial nerve is a patch over the dorsum of the base of the thumb.

Soft tissue

Feel for the radial pulse and capillary filling at the fingertips. Synovial thickening can be felt in the wrist either dorsally

or on the palmar side.

Tinel’s test. This is a test for inflammation in the median nerve. This is usually caused by compression in the carpal tunnel. Lay the patient’s hand on the table, palm upwards, and tap with the tip of your index finger over the median nerve at the wrist crease. Tingling or lightning pains into the fingers suggest that the median nerve is being compressed.

De Quervain’s tenosynovitis. The extensor tendons to the thumb can become inflamed from overuse. The tendon sheath is tender and it is sometimes possible to feel crepitus in the tendon if it is moved gently while palpating over it.

Bone

Scaphoid fracture. The waist of the scaphoid can be felt in the anatomical snuff box and the proximal pole can be felt anteriorly at the front of the base of the thumb.

Carpal instability. Trauma to the wrist can produce tears in the carpal ligaments. Chronic tears can be tender to palpation.

Move

Active

Extension is tested by the patient pushing their two hands together into a ‘prayer’ position but with the elbows raised so that the forearms are in line with each other (Fig. 20.35). If there is loss of extension the palms will not be able to meet together and/or one forearm will tend to be dropped. Palmar flexion is performed in the same way, but with the hands pointing down and the backs of the hands in contact.

Passive

Ulna and radial deviation are tested by taking the patient’s hand in your own and forcing the hand into these positions, comparing the two sides.

Stability and resisted movement

The stability of the wrist is not easy to test, but checking power grip tests the power of the finger flexors, the wrist extensors and the stability of the wrist.