Wrist Examination: Central-Dorsal Region

Christos Karagiannopoulos, PT, PhD, ATC, CHT

Assistant Professor, DeSales University

Doctor of Physical Therapy Program

Anatomy

• Osseous structures

– Dorsal rim of the distal radius

– Lister’s Tubercle

– Lunate

– Scapho-lunate interval

– Capitate

– Base IInd and IIIrd MC

Anatomy

• Soft tissue structures: – ECRB/ECRL (2nd Comp)

– EPL (3rd comp)

– EDC/EIP (4th Compartment)

– Posterior Interosseous Nerve

Palpation

• Dorsal rim of distal radius – Dorsal - central from radial styloid

– Radio-carpal OA: Osteophytes

– Scaphoid impingement with wrist extension

• Listers Tubercle – Prominence over mid-dorsal distal radius

– Demarks

• S-L interval

• Scaphoid /lunate fossa

• 3rd ext compartment

• EPL tendon

Palpation

• Lunate – Distal and ulnar to Lister’s Tubercle

– Wrist flexed

– Rounded prominence

– Clinical implications • Keinbock’s Disease:

– Avascular necrosis of lunate

– Peri-lunate joint OA

– Carpal collapse

Palpation

• Scapho-lunate Interval – Distal to Lister’s tubercle

– Between EPL and EDC

• Swelling, Tenderness, Clicking

– Clinical implications: • Occult ganglion

• Dorsal wrist syndrome: Isolated joint synovitis

• S-L instability

Palpation

• Capitate – Prox → dorsal IIIrd MC base

– Small depression

– Distal to lunate

– Clinical implications: • Mid-carpal instability

• SLAC wrist: – End-stage degenerative

– Altered carpal bone alignment

– Proximal capitate migration » SL, SC, STT, LT instability

Palpation

• 2nd and 3rd MC bases

• CMC Joints

• Clinical implications – CMC joint sprain: Forced wrist flexion

– ECRL/B insertional tendinosis

– Carpal boss: Bony prominence

• CMC Joint/tendon/bone hypertrophy

– Joint sprain

– Degenerative process

– Trauma - Osteophites

Palpation

• ECRL/ECRB – 2nd ext compartment

– Radial and distal to Lister’s tubercle

• EDC – 4th Ext compartment

– Ulnar to EPL and Lister’s tubercle

Palpation

• Posterior Interosseous Nerve (PIN) • Motor nerve to deep dorsal compartment

• Innervates dorsal wrist capsule

• Wrist proprioceptive feedback

– Symptoms: • Tenderness

• Radiating pain at dorsal proximal wrist

– Clinical implication: • PIN Neuritis

• Post surgical neuromas

• Dorsal wrist ganglion

Clinical Test

• Resisted Middle Finger Extension Test: – Resisted long finger extension

– Wrist flexed

– Pain is provoked over the S/L interval

– Clinical significance:

• Dorsal wrist syndrome

– S/L synovitis

– S/L ligament strain or instability

Clinical Test

• Scaphoid Shift Test (Watson’s Test) (Watson et al., 1988)

– Step 1: Pressure over volar scaphoid tubercle

• Scaphoid sublux stress

– Step 2: Passive UD/Ext → RD/Flex

• Pressure is released

• (+) Reproduction of painful “Click or Thunk”

– Scaphoid volar shift

– Grades: 0 No shift, +1 Mild “click”, +2 Audible “clunk”

• LR+ = 2.76, LR- = 0.25 (Valdes K, 2013)

– Clinical Significance: • SL laxity or instability

• Volar scaphoid subluxation

Clinical Test

• Scapho-lunate Ballottement Test – Stabilization of lunate with one hand

– Shifting scaphoid in volar-dorsal direction with other hand

– Clinical Significance: • Reproduction of pain & “click”

• Scapho-lunate instability

Clinical Test

• Best 5 confirmatory clinical signs for S/L dissociation

– S/L interval tenderness – Scaphoid tenderness – STT joint tenderness – Watson’s test – Resisted middle finger extension

Watson et al., 1988

Clinical Tests

• Linscheid Test – Detect ligament or instability at II & III MCP joints

– Support MC shafts with one hand

– Press MC heads in palmar and dorsal direction

• Clinical significance: – (+) Pain provoked at CMC joints

Clinical Tests

• Tenosynovitis: – Pain reproduction

– EDC resist or AROM • Resist MCP Extension

– ECRB/ECRL • Resist wrist extension

– Lumbricals • Resist PIP/DIP Ext