What should be included in the documentation of a normal wrist exam?

Documentation of a Normal Wrist Examination

A normal wrist examination should document inspection findings, range of motion measurements in all planes, palpation findings at specific anatomic landmarks, neurovascular status, and results of provocative maneuvers, following a systematic approach that includes observation, range of motion, palpation, and special tests. 1

Patient Positioning

• Sitting position with the hand positioned on top of the patient's thigh or on an examining table 2
• For dynamic examination, document active flexion and extension of the fingers 2
• Assess in multiple forearm positions (supination, neutral, pronation) as measurements vary significantly with forearm rotation 3

Inspection and Observation

• Document absence of: swelling, deformity, erythema, ecchymosis, muscle atrophy, or asymmetry compared to contralateral side 1
• Note skin integrity: no scars, lesions, or signs of trauma 1
• Alignment: normal carpal alignment without visible subluxation or malalignment 4

Range of Motion Documentation

Normal wrist ROM values vary by study methodology, but functional ranges are well-established:

Active Range of Motion (document bilaterally for comparison)

• Flexion: 60-74 degrees (functional minimum 40-54 degrees) 5, 6
• Extension: 60-73 degrees (functional minimum 30-40 degrees) 5, 7, 6
• Radial deviation: 15-20 degrees (functional minimum 10-17 degrees) 5, 7, 6
• Ulnar deviation: 30-40 degrees (functional minimum 15-40 degrees) 5, 7, 6
• Supination: 140 degrees 6
• Pronation: 60 degrees 6

Critical Documentation Points

• Measure ROM in neutral forearm position as the standard, but note that grip strength and ROM vary significantly with forearm rotation 3
• In males, wrist flexion is reduced in supination (63 degrees) compared to neutral (73 degrees), while extension is greater in pronation (70 degrees vs 65 degrees in supination) 3
• Document that motion is pain-free, smooth, and without crepitus throughout the arc 1

Palpation Findings

Document tenderness assessment at specific anatomic sites:

Dorsal Wrist Structures

• Lister's tubercle: non-tender 1
• Scapholunate interval: non-tender (located just distal to Lister's tubercle) 1
• Extensor tendons: no tenderness, thickening, or crepitus along their course 2

Volar Wrist Structures

• Scaphoid tubercle: non-tender (radial aspect) 1
• Median nerve at carpal tunnel: no tenderness or Tinel's sign 2
• Flexor tendons: no tenderness or triggering 2

Radial and Ulnar Aspects

• Radial styloid: non-tender 1
• First dorsal compartment (de Quervain's): non-tender 2
• Ulnar styloid and TFCC region: non-tender 2
• Distal radioulnar joint: stable, non-tender 2

Neurovascular Assessment

• Radial and ulnar pulses: 2+ and symmetric 1
• Capillary refill: less than 2 seconds in all digits 1
• Sensation: intact to light touch in median, ulnar, and radial nerve distributions 1
• Motor function: normal thumb opposition, finger abduction/adduction, and wrist extension strength 1

Special Tests (Document as Negative)

• Finkelstein's test: negative (no pain with ulnar deviation of wrist while thumb is flexed into palm) 2
• Watson's scaphoid shift test: negative (no clunk or pain with radial to ulnar deviation while applying pressure to scaphoid tubercle) 2
• Piano key test: negative (no excessive dorsal translation of ulnar head) 2
• Phalen's test: negative (no paresthesias after 60 seconds of wrist flexion) 2
• Tinel's sign at carpal tunnel: negative 2

Grip Strength

• Document bilateral grip strength using dynamometer in neutral forearm position 3
• Normal values in neutral position: males 51-56 kg (dominant), 46-51 kg (nondominant); females 27-29 kg (dominant), 26-27 kg (nondominant) 3
• Note that grip strength is weakest in pronation and strongest in neutral position 3

Common Pitfalls to Avoid

• Do not rely on single-position assessment: ROM and grip strength vary significantly with forearm rotation, particularly in males 3
• Do not skip bilateral comparison: subtle asymmetry may be the only finding in early pathology 1
• Do not forget dynamic assessment: some instabilities are only apparent with provocative maneuvers or weight-bearing 2
• Document negative findings explicitly: stating what is normal helps establish baseline and medicolegal documentation 1