EXAMINATIO

N OF WRIST

SANDRA A P
ROLL NO. 136
  Patients usually present with either pain, swelling as caused by ganglion
HISTORY cyst or deformity such as tuberculous affection of the wrist or more
commonly of the joints of the fingers
 1) Position.— In all affections of the wrist joint this joint will remain in flexed
position and characteristic ulnar deviation is noticed in wrist and the finger
joints particularly in rheumatoid arthritis.

2) Swelling.— Swelling may be due to effusion of the wrist joint which is rather
uncommon and should be differentiated from effusion of the tendon sheaths.
 In the latter condition the effusion extends upwards and downwards
beyond the extent of the joint and along the corresponding tendon sheath,
INSPECTION while the former is limited within the extent of the joint and is seen both
anteriorly and posteriorly.
 In rheumatoid arthritis the metacarpophalangeal joints become swollen
with prominent knuckles. In tuberculous tenosynovitis of the ulnar bursa
(compound palmar ganglion), a swelling is present on the palmar aspect
and extends both proximally and distally beyond the flexor retinaculum.
 A small circumscribed swelling either on the dorsal (more common) or on
the ventral aspect of the wrist is nothing but a ganglion.
INSPECTION

 3) Deformity.— Obvious deformities of the wrist are

rare and barring rheumatoid arthritis they are mostly
congenital deformities e.g. radial club hand, Madelung's
deformity etc.
 4) Sinus.— In tuberculosis of the wrist joint sinus
formation is not uncommon
 A. INSPECTION
1. Deformity:-
o Colle's fracture – dinner fork deformity – dorsal prominence one inch above the level of the wrist, slight radial deviation making the
head of the ulna prominent
o Dislocation of the lunate bone – abnormal slight anterior projection at the wrist – following fall on the dorsiflexed hand
o Galeazzi fracture – fracture of lower third of the radius with inferior radio-ulnar dislocation
o Madelung's deformity or manus valgus – dorsal subluxation with prominence of lower end of the ulna in an adolescent girl, hand is
deviated laterally
o Bennett's fracture-dislocation – typical abnormal lateral projection at the base of the first metacarpal bone
o Metacarpal fractures – when asked to make a fist, line of knuckles may not on be the normal line
o Fracture of phalanges – mallet finger(rupture of the extensor tendon at its insertion at the base of terminal phalanx – persistent flexion
of the terminal phalanx)
o Dislocation of the IP and MCP joints- anterior projection of the head of the phalanx or head of the metacarpal would be obvious
B. PALPATION

 Palpate neighboring bones systematically to elicit

a) Local bony tenderness

b) Bony irregularity
c) Displacement
d) Unnatural mobility
e) Crepitus
1) Swelling.-
 Is the swelling fluctuant? Effusion of the wrist, ganglion and the
compound palmar ganglion are all fluctuant swellings.
 In effusion of the wrist joint cross fluctuation on both anterior
and posterior aspects of the joint can be elicited. Similarly in
compound palmar ganglion cross fluctuation can be elicited
above and below the flexor retinaculum.
PALPATION
 In ganglion, which is often a tense swelling fluctuation can be
seldom elicited. Sometimes it is felt as hard as a bone.
 The ganglion becomes fixed as soon as the concerned tendon is
made taut due to its intimate connection with the tendon sheath.
2) Tenderness.— Tenderness exactly on the joint line indicates
arthritis.
 Tenderness along the tendon sheath indicates tenosynovitis
PALPATION
3) Deformity.— By palpation the actual deformity is noted
A. PALPATION

1. Lower third of the radius:-

 In suspected fracture, follow the outer border and the dorsal aspect of the bone for any irregularity and tenderness
 Normally the lower third of the radius is smoothly concave in the front – feel for this concavity
 Springing the radius may be of some help to diagnose fracture of the lower third of radius above the typical site of
colle's fracture which is surrounded by muscles and tendons and hence not available for direct palpation
 In this case, squeezing upper part of radius and ulna elicits pain at the site of fracture
2. Lower third of the ulna:-
 Associated fracture of styloid process of ulna in Colle's fracture and dislocation of head of ulna in Galeazzi fracture
 Ulna being a subcutaneous bone, fracture of the ulna will elicit tenderness and bony irregularity

3. Relative position of radial and ulnar styloid processes:-

 Normally, the tip of the radial styloid process is about 1 cm lower than the tip of the ulnar styloid process (use two
fingers to locate the tips of styloid processes in the pronated forearm of the patient)
 A diagnostic feature of Colle's fracture – the radial styloid process will remain at a higher level than normal, in fact
they may remain in the same line
4. Carpal bones:-
 Scaphoid fracture – may be misdiagnosed as a simple sprain and the patient suffers pain and disability for a longer time ,
also notorious for non-union and avascular necrosis of the proximal fragment – hence requires prolonged immobilization
 Scaphoid is palpated at the anatomical snuff-box with the wrist bent medially to expose the bone for palpation
 Patient complains of pain immediately as pressure is applied over the anatomical snuff box in case of scaphoid fracture
 Lunate bone – may be dislocated anteriorly – made out by careful palpation

5. Metacarpals and phalanges:-

 Palpate the full length of the metacarpal or phalanx
  The wrist joint, like the elbow has got two components : (i) the
radiocarpal and (ii) the inferior radioulnar joint.
 Pronation and supination movements occur at the inferior radioulnar
joint. All other movements i.e. flexion, extension, adduction and
MOVEMENTS abduction occur in both the radiocarpal and the midcarpal joints.
 Extension and adduction mostly occur in radiocarpal joint, whereas
flexion and abduction take place in midcarpal joint.
 Normal range of flexion is about 60°, that of extension is about 70°,
adduction about 35° and abduction about 25°.
  Flexion and extension can be tested in the following way :

 To determine the range of extension the patient is asked to place his palms
and fingers of both the hands in contact (Indian method of salutation).
 Now he is asked to lift both the elbows gradually as far as he can keeping
the hands firmly in apposition.
 The angle formed by the hand and the forearm of the affected side is
MOVEMENTS compared with that of the sound side. This angle is the range of extension
movement.
 To determine the range of flexion the backs of the hands are placed in
contact and the elbows are lowered as far as possible.
 The angle between the hand and forearm is the range of flexion
movement.
 In arthritis of the wrist joint all the movements of the wrist are painful
and limited.
C. MOVEMENTS

 Movements of the affected part will obviously be painful and limited

 Restriction of movement of the wrist in Colle's fracture and MCP joint in metacarpal fracture

 Movement of IP joint is painful and restricted in fracture of the phalanges