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.
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.