What are the findings of a clinical wrist examination?

From the Guidelines

A comprehensive clinical wrist examination should begin with inspection for deformity, swelling, and skin changes, followed by palpation of key anatomical structures including the distal radius and ulna, scaphoid, lunate, and other carpal bones, as recommended by the most recent guidelines 1. The examination should assess range of motion in all planes (flexion, extension, radial and ulnar deviation, pronation, and supination), comparing with the unaffected side. Special tests should include:

• Watson's test for scaphoid instability
• Finkelstein's test for de Quervain's tenosynovitis
• The grind test for TFCC injuries Neurovascular assessment is essential, including:
• Allen's test for arterial patency
• Evaluation of median, ulnar, and radial nerve function Pain provocation tests like the DRUJ compression test can help identify specific pathologies. When performing this examination, maintain a systematic approach from inspection to specialized testing, and document findings clearly, as supported by the American College of Radiology Appropriateness Criteria 1. Understanding the complex anatomy of the wrist joint, with its eight carpal bones and intricate ligamentous structures, helps in accurately diagnosing conditions ranging from carpal tunnel syndrome to scapholunate dissociation, and is in line with the recommendations from the Journal of the American College of Radiology 1. Always compare findings with the contralateral wrist to establish baseline function and identify subtle abnormalities, as suggested by the evidence 1.

The clinical wrist examination is a crucial step in evaluating patients with chronic wrist pain, and its findings can guide further imaging and treatment, as outlined in the guidelines 1. The use of ultrasound (US) in the evaluation of chronic wrist pain is also supported by the evidence, particularly for examining extra-articular soft tissues and guiding therapeutic injections 1. However, the choice of imaging modality depends on the patient's presentation and the clinical questions being asked, and should be guided by the most recent and highest quality evidence 1.

In terms of specific conditions, the clinical wrist examination can help diagnose:

• Carpal tunnel syndrome
• Scapholunate dissociation
• De Quervain's tenosynovitis
• TFCC injuries
• Rheumatoid arthritis
• Ganglion cysts
• Tendon and soft tissue pathology The examination should be tailored to the individual patient's symptoms and presentation, and should be performed in conjunction with a thorough medical history and other diagnostic tests as needed, as recommended by the guidelines 1.

From the Research

Clinical Examination Findings

The findings of a clinical wrist examination can be summarized as follows:

• A detailed history alone may lead to a specific diagnosis in approximately 70 percent of patients who have wrist pain 2
• Palpation of the hand and wrist can help localize tenderness to a specific anatomic structure 2, 3, 4, 5
• Special tests, such as Finkelstein's test, the grind test, and Watson's test, can help support specific diagnoses 2, 4, 5
• Radiography, including posterior-anterior and lateral views, can help evaluate the bony architecture and alignment, joint spaces, and soft tissues 2

Diagnostic Approach

A systematic approach to clinical evaluation of the wrist can help identify the source of dysfunction and initiate an appropriate treatment plan 6

• The basic clinical examination (BCE) process can enable the hand therapist to identify conditions that are contraindicated for conservative care and require further physician intervention 6
• Combining findings from the patient's history, BCE, and special testing can help determine the underlying pathology and provide appropriate treatment 6
• Diagnostic imaging, such as ultrasonography, technetium bone scan, computed tomography, and magnetic resonance imaging, may be indicated when the diagnosis remains unclear or when the clinical course does not improve with conservative measures 2

Examination Techniques

The physical examination of the wrist requires knowledge of wrist anatomy and pathology to make a diagnosis or narrow the differential diagnosis 3

• A systematic approach includes observation, range of motion, palpation, and special tests 3, 5
• Localizing points of tenderness, testing for abnormal dorso-palmar shifts of the carpus and the ulnar head, and provoking catch up clunks by radio-ulnar movements of the clenched fist can help identify specific pathologies 4
• Comparing clinical diagnosis with arthroscopic findings can help evaluate the accuracy of the clinical examination 4