Clinical Examinationof the

Hand and Wrist

A.MazaherinezhadMD. Sportsmedicine Department,

Assistant professor, IUMS

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OBJECTIVES

Review the clinical anatomy and physical exam of the wrist and handFormulate a pathoanatomic diagnosis in the clinical settingDiscuss common clinical conditions that can be elicited from the physical exam

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INTRODUCTION: Hand and Wrist

Series of complex, delicately balanced jointsFunction is integral to every act of daily livingMost active portion of the upper extremity

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INTRODUCTION

The least protected joints Extremely vulnerable to injuryDifficult and complex examination Diagnosis often vague

If no fracture = “wrist strain or sprain”

Bilateral comparison useful

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Bony AnatomyPhalanges: 14Sesamoids: 2Metacarpals: 5Carpals

Proximal row: 4Distal row: 4

Radius and Ulna

Lister’s tubercle IUMS

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HISTORY

AgeHandednessChief complaintOccupationPrevious injuryPrevious surgery

Sx related to specific activitiesWhat exacerbatesWhat improvesFrequencyDuration

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HISTORY

4 principle mechanisms of injury

ThrowingWeight bearingTwistingImpact

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EXAMINATION OF THE HANDS, FINGERS AND WRIST

INITIAL STEPS

INSPECTION PALPATION RANGE OF MOTION

SWELLINGREDNESS

ATROPHY

TENDERNESSWARMTH

FLEXIONEXTENSION

COMPARE OPPOSITE SIDE

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PHYSICAL EXAM

InspectionPalpationRange of MotionNeurologic ExamSpecial Tests

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INSPECTION

Observe upper extremity as patient enters roomExamine hand in functionDeformitiesAttitude of the hand

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INSPECTIONPalmar Surface

CreasesThenar and Hypothenar EminenceArched FrameworkHills and ValleysWeb Spaces

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Cascade sign

Assure all fingers point to scaphoid area when flexed at PIPs

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INSPECTION of Dorsal Hand and Wrist

Hills and ValleysHeight of metacarpal headsFinger nails

Pale or white=anemia or circulatorySpoon shaped=fungal infectionClubbed=respiratory or congenital heart

DeformitiesIUMS

Ganglion

Cystic structure that arises from synovial sheathDiscrete massDull acheDorsal or Volar aspect

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Boutonniere Deformity

Tear or stretch of the central extensor tendon at PIPNote: unopposed flexion at PIPExtension at DIPTrauma or inflammatory arthritis

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Swan Neck Deformity

Contraction of intrinsic muscles (trauma, RA)NOTE: Extension at PIP

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Osteoarthritis

Heberden’s nodes: DIP

Bouchard’s nodes: PIP

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Rheumatoid Arthritis

MCP swellingSwan neck deformitiesUlnar deviation at MCP jointsNodules along tendon sheaths

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Mallet Finger

Hyperflexion injuryRuptured terminal extensor mechanism at DIPIncomplete extension of DIP joint or extensor lagTreatment:

stack splint

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Dupuytren’s Contractures

Palmar or digital fibromatosisFlexion contracturePainless nodules near palmar creaseMale> FemaleEpilepsy, diabetes, pulmonary dz, alcoholism

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RANGE OF MOTION

Active range of motionPassive range of motion if unable to actively move jointBliateral comparison

To determine degrees of restriction

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RANGE OF MOTIONWrist

FlexionExtensionRadial deviationUlnar deviation

Ulnar deviation is greater than radial

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Mobility : (pronosupination)

To test pronosupination, the patient is asked to keep his or her elbows close to the body and to turn the palm up and down alternatively. One arm of the goniometer is placed parallel to the axis of the humerus, and the other along the distal part of the forearm (Figure 1 & 2). One should avoid measuring pronosupination with a stick in the patient's hands, as the pronosupination mobility is increased by the passive rotatory mobility of the carpus, which may be as high as 40°. If the neutral prono-supination position is defined as zero (with the elbow flexed and maintained against the chest, the thumb must be raised up):

Normal pronation varies between 60 and 90°, Normal supination, between 45 and 80°.

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Figure 1:Measurement of pronation: The vertical arm of the goniometer is placed in the axis of the arm and the horizontal arm on the dorsal surface of the wrist, but not the hand.

Figure 2:Measurement of supination. The horizontal arm is placed on the volar surface of the wrist.

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Flexion-extension

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Flexion-extension mobility is measured by placing the goniometer on the palm for wrist extension, and along the dorsum of the hand for wrist flexion, over the axis of the third metacarpal bone (figure 3 & 4).

Normal values vary among individuals and may reach 85° of flexion or extension.

Both inclinations are measured with one arm of the goniometer along the axis of the forearm, and the other along the axis of the third metacarpal, with the wrist in the neutral position of flexion or extension. These methods are simple and reproducible.

Ulnar inclination varies between 30 and 45°,Radial inclination, between 15 and 25°.

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Figure 4:

Masurement of extension: The goniometer is placed anteriorly on the wrist.

Measurement of strength

This should be done with a Jamar dynamometer, which is considered an international reference. Measurements should be done, either using each of the five handle positions, which is time-consuming, or using only one handle position, with three successive measurements. There are no standard values, and the contralateral hand serves as reference. The mean of three different measurements with maximum muscular contraction is noted. Usually, the curve for a single handle position is horizontal or slightly descending. Rapid alternating measurements changing from one hand to the other prevent patients from controlling their contraction and may reveal the absence of maximum contraction.

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The dominant hand is usually 5 to 10% stronger than the non-dominant hand.

RANGE OF MOTIONFingers

Flexion/extension at MCP, PIP, DIPTight fist and openDo all fingers work in unison

ABDuction/ADDuction at MCPSpread fingers apart and then back together

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CLINICAL EXAMINATION OF THE WRISTThe normal wrist :

The key to correct examination of the wrist is precise location of the symptoms relating to the underlying anatomical structures, i.e., bones, articular spaces, ligaments or tendons.

As in all clinical examinations, the most painful area is examined last. Comparative wrist examination is the rule, as there are no criteria of normality

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PALPATION of Skin

Warmth?Dryness?

Anhydrosis= nerve damage

Scars

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PALPATION of Wrist Dorsum

Radial StyloidScaphoid1st MC/Trapezium jtLunateLister’s Tubercle

Ulnar StyloidTFCCTriquetrumPisiformHook of HamateGuyon’s Tunnel

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Conditions of examination :

The wrist must be examined with the forearm free of clothing and jewelry. For a satisfactory examination, the patient and the examiner should be comfortably seated. The ideal solution is to place the patient's forearm on a narrow examination table whose height may vary.In clinical practice, the easiest solution is to sit very close to the patient so that his or her hand rests on the examiner's knee, with the patient's elbow resting on his thigh.

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A "practical" position for wrist examination

Physical examination usually begins on the dorsal surface of the wrist, with pronation of the forearm and wrist flexion, whereas the ulnar surface of the wrist is examined during maximum elbow flexion.

For palpation, the examiner stabilizes the wrist with both hands and uses his (her) thumbs to palpate the anatomical structures.

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Cutaneous projection of the anatomical structures

A beauty (the richness) of wrist examination is due to the fact that almost all bony, articular, tendinous or vascular structures may be palpated through the skin that covers it.

To be compete, the physical examination should be methodical and whichever structure is examined first, the examination should cover the entire wrist.

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Dorsal surface: Proximal to the wrist, proceding from the radius to the ulna it is easy to identify the radial styloid. One cm proximal you will palpate the sharp bony ridge which limits the first extensor compartment.

More ulnar is a dorsal bump on the distal radius which is Lister's tubercle, around which passes ulnarly the extensor pollicis longus tendon (figure 6 & 7).Closer to the ulna and ulnar to Lister`s tubercle, one can feel the flat dorsal surface of the radius and the ulnar head which protrudes in pronation.

On the ulnar side of the wrist, the ulnar styloid can be palpated dorsally in supination, at the ulnar and volar surfaces in pronation and on the ulnar side of the wrist in neutral rotation.

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Ulnar Styloid palpationLister’s Tubercle palpation

Ulnar styloid

Figure 6:

To examine a wrist correctly, one should mentally project the bones onto the skin.

Figure 7:

Main palpable bony structures on the dorsal surface of the wrist (redrawn after.)

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At the level of the carpus, the anatomical snuffbox is easy to locate radially: it is limited

radially by the extensor pollicis brevis and the abductor pollicis longus and ulnarly by the extensor pollicis longus.

The scaphoid lies at the bottom of the snuffbox, with the radial artery crossing over it.

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In radial deviation the scaphoid disappears dorsally and one can palpate the scaphotrapezial joint palmarly (figures 8 & 9).

Dorsally, at the distal end of the scaphoid there is a groove in which the examiner can place an index finger to palpate the trapezoid along the axis of the second metacarpal, and the trapezium along the axis of the first metacarpal .

Radial Styloid palpation Scaphoid Bone palpation

Radial styloid

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1st MC/Trapezium joint palpation

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Figure 9:

The cutaneous projection of the anatomical snuffbox.

Figure 8:

The scaphoid lies at the bottom of the anatomical snuffbox and distal to it lies the scaphotrapezial joint. Palpation of bony structures varies during radial and ulnar deviation.

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The radial part of this groove, just ulnar to the extensor pollicis longus tendon, is what is termed the STT entry point (scaphotrapeziotrapezoidal) for mid-carpal arthroscopy.

Figure 10:

The midcarpal joint can be palpated through the groove between the scaphoid and the trapezium and trapezoid bones.

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In the middle of the dorsal surface of the carpus, one centimeter distal to Lister's tubercle, lies the scapholunate interval.

the scapholunate interval can be palpated just distal to the dorsal rim of the radius at the level of Lister`s tubercle, with flexion of the wrist.

Flexion moves the lunate dorsally out of the lunate fossa as shown figure 5. Just radial to that point, the proximal pole of the scaphoid can be palpated if the wrist is in flexion.

Lunate Bone palpation

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Ulnar and distal to the scapholunate space lies a concavity which corresponds to the neck of the capitate .

Figure 11: The posterior surface of the waist of the capitate is palpable through a depression easily found in the midportion of the dorsal surface of the wrist.

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(French anatomists use the term “the crucifixion groove” as it represents the place where you should place your nails if you plan to crucify somebody...) When the wrist is flexed, the lunate and the head of the capitate are more easily palpable.

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Figure 12:

Wrist flexion allows palpation of the head of the capitate and the posterior horn of the lunate.

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Slightly radial to the neck of the capitate and one cm distal to the scapholunate interval is the radial entry point of the midcarpal space.

The prominence of the third metacarpal base, the third metacarpal styloid, is located one to one and a half cm distal to that point, between the capitate and the trapezoid. It is more or less developed depending on the individual and may sometimes be hidden by the insertion of the extensor carpi radialis brevis tendon.

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When the wrist is in neutral position, with the third metacarpal in the axis of the radius i.e. without flexion or extension or radial or ulnar deviation:

the ulnar head, triquetrum, hamate and fifth metacarpal

form a continuous line on the ulnar side of the wrist

Figure 8:

The scaphoid lies at the bottom of the anatomical snuffbox and distal to it lies the scaphotrapezial joint. Palpation of bony structures varies during radial and ulnar deviation.

Figure 9:The cutaneous projection

of the anatomical snuffbox.

Figure 10:

The midcarpal joint can be palpated through the groove between the scaphoid and the trapezium and trapezoid bones.

Figure 11: The posterior surface of the waist of the capitate is palpable through a depression easily found in the midportion of the dorsal surface of the wrist.

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Triquetrum Bone palpation

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The triquetrolunate joint and triquetrum

may be palpated during radial deviation of the wrist. The triquetrum is palpated just distal to the ulnar head and disappears with ulnar deviation.

The triquetrohamate space whose mobility can be appreciated lies distal to the dorsal tubercle of the triquetrum (Figure 13).

On the ulnar side of the wrist lies the "ulnar snuffbox" between the extensor and the flexor carpi ulnaris tendons. At the base of this snuffbox one can palpate the triquetrum during radial inclination, as well as the triquetrohamate joint distal to it, which is a drainage portal for mid-carpal arthroscopy (Figure 14).

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Figure 13: The ulnar "anatomical snuffbox".

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PALPATIONPalmar Aspect

Pisiform and HamateTunnel of GuyonUlnar ArteryCarpal TunnelFlexor Carpi RadialisFlexor Carpi Ulnaris

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The palmar surface :

The bony structures on this surface are too deep to be palpated.

However, it is possible to palpate not only the radial and ulnar styloid processes but also, radially, the trapezial ridge which lies at the base of the thenar eminence, as well as the scaphotrapezial space and proximal to the distal tuberosity of the scaphoid.

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pisiform

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when the wrist is in extension (Figure 15). Ulnarly, the pisiform is easily palpated, just distal to the distal wrist crease.

Figure15:

Main palpable bony structures on the anterior side of the wrist (redrawn after)

Pisiform and Hamate palpationTunnn

el of Guyon

The hamate hook (hamulus ossi hamatum)

Figure 16:

The hamulus ossi hamatum (hook of the hamate) is palpated deeply, 2 cm below the pisiform bone, on a line joining the pisiform to the head of the

second metacarpal bone.04/19/23 64

lies just along the radial edge of the pisiform, on a line from the pisiform to the second metacarpal head.

The articular spaces of the carpus are not accessible to palpation, but the radiocarpal joint is located at the level of the middle part of the proximal wrist flexion crease, while the midcarpal joint is located at the level of the middle of the distal flexion wrist crease.

Tunnel of Guyon

Depression between pisiform and hook of hamateContains ulnar nerve and arterySite of compression injuries

unusually tender if pathology is present

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Volar flexor tendons

Flexor carpi ulnaris

Palmaris longus

Flexor carpi radialis

Thumb CMC Joint Arthritis

Painful pinch or grasp“Grind Test”

Axial pressure to thumb while palpating CMC joint

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Scapholunate Dissociation

Diagnosis often missedPain, swelling, and decreased ROMPressure over scaphoid tuberosity elicits painGreatest pain over dorsal scapholunate area, accentuated with dorsiflexionX-ray shows widening of scapholunate joint space by at least 3 mm

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Triangular Fibro-Cartilage Complex palpation (TFCC)

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Triangular Fibrocartilage Complex Injuries(axial load test)

Ulnar sided wrist pain, swelling, loss of grip strength“Click” with ulnar deviationPoint tenderness distal to ulnar styloidTFCC load test

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PALPATION of HANDBone

Metacarpals - 5Phalanges - 14Palpate for swelling, tendernessAssess for symmetry

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PALPATIONSoft tissue6 Dorsal Compartments

Transport extensor tendons

2 Palmar TunnelsTransport nerves, arteries, flexor tendons

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1st Dorsal Compartment

Abductor Pollicis Longus and Extensor Pollicis BrevisRadial border of Anatomic Snuff BoxSite of stenosing tenosynovitis

De Quervain’s TenosynovitisFinkelstein’s Test

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DeQuervain’s Tenosynovitis

Inflammation of EXT Pollicis Brevis and ABD Pollicis Longus tendonsTenderness - 1st Dorsal CompartmentFinkelstein’s Test

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5 FINKELSTEINS TEST.mpg

DeQuervain’s Tenosynovitis

2nd Dorsal Compartment

Extensor Carpi Radialis Longus and Extensor Carpi Radialis BrevisMake fist—becomes prominent

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Intersection Syndrome(Squeaker Wrist)

Similar to DeQuervain’s tenosynovitisPeritendinitis related to bursal inflammation at the junction of the 1st and 2nd dorsal compartmentsOveruse of the radial extensor of the wrist

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Intersection Syndrome(Squeaker Wrist)

Seen in gymnasts, rowers, weightlifters, racket sportsProximal to DeQuervain’s- 4-6 cm from radiocarpal jointCrepitation or squeaking can be heard with passive or active ROM

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3rd Dorsal Compartment

Extensor Pollicis LongusUlnar side of Anatomic Snuff BoxCan rupture secondary to Colles’ Fracture or Rheumatoid ArthritisExtensor Pollicis Longus Tenosynovitis

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4th Dorsal Compartment

Extensor Digitorum Communis and Extensor IndicisPalpate from the carpus to the metacarpophalangeal jointsFrequent site of ganglion cysts

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5th Dorsal Compartment

Extensor Digiti MinimiMay become involved in rheumatoid arthritisMay be subject to attrition

friction due to dorsal dislocation of the ulnar headsynovitis

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6th Dorsal Compartment

Extensor Carpi UlnarisTendinitis -repetitive wrist motion or snap of wrist

May dislocate over the styloid process of the ulna

Seen with Colles’ fracture with associated fracture of the distal ulnar styloidAudible snap

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Carpal Tunnel

Deep to palmaris longusContains median nerve and finger flexor tendonsMost common overuse injury of the wrist

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Carpal Tunnel Syndrome

Entrapment of the median nervePhalen’s and Tinel’s Test2 point discrimination

SymptomsAching in hand and armNocturnal or AM paresthesias“Shaking” to obtain relief

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Carpal Tunnel Tests

Neurologic examMedian nerve sensation and motor

Phalen’s Test:both wrists maximally flexed for 1 minuteTinel’s Test

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PALPATIONPalm of Hand

Thenar Eminence3 muscles of thumbAtrophy seen in carpal tunnel syndrome

Hypothenar Eminance3 muscles of little fingerAtrophy with ulnar nerve compression

Palmar AponeurosisDupuytren’s Contracture

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PALPATION of Fingers

Finger Flexor TendonsTrigger Finger- sudden audible snapping with movement of one of the fingers

Extensor TendonsTufts of Fingers

Felon- local infectionParonychia- hangnail infection

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SPECIAL TESTSLong Finger Flexor Test

Flexor Digitorum Superficialis TestFlex finger at PIPThe only functioning tendon at the PIP

Flexor Digitorum Profundus TestFlex at DIP

Inability to flex= tendon cut or denervated

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Flexor Tendon Injury“Jersey Finger”Avulsion injury from rapid passive extension of the clenched fistLoss of flexion at PIP and/or DIP

“+” sublimus or profundus tests

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Trigger Finger

Stenosing flexor tenosynovitisPainful snap or lockPalpate nodule as digit flexed and extended

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Flexor Tenosynovitis

Tendon sheath infectionUsually due to a puncture woundBacterial skin floraRelative surgical emergency

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Flexor Tenosynovitis 4 Cardinal Signs of Kanavel

Uniform swelling of the fingerSensitivity along the course of the tendon sheathsPain upon passive extensionFingers held in flexion

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RANGE OF MOTIONThumb

Thumb flexion/extension at MCP and IP

Touch pad at base of little finger

Thumb ABD/ADD at carpometacarpal jointOpposition

Touch tip of thumb to tip of each finger

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Skier’s ThumbGamekeeper’s Thumb

Ulnar Collateral Ligament rupture of the thumb MCP jointInstability, weak and ineffective pinchRadially directed stress at MCP joint-stable if opens <35 degrees

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NEUROLOGIC EXAM

Muscular assessment using grading systemSensation testingBilateral comparison

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NEUROLOGIC EXAMMuscle Testing

WRISTEXT C6FLEX C7

FINGERSEXT C7FLEX C8ABD T1ADD T1

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Sensation TestingDorsal hand Radial hand

C-5 NEUROLOGIC LEVEL

SHOULDER ABDUCTION

BICEPS

LATERAL ARM

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C-6 NEUROLOGIC LEVEL

WRIST EXTENSION

BRACHIORADIALIS

LATERAL FOREARM

108

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C-7 NEUROLOGIC LEVEL

WRIST FLEXION

FINGER EXTENSION

TRICEPS

MIDDLE FINGER

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C-8 NEUROLOGIC LEVEL

FINGER FLEXION

MEDIAL FOREARM

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T-1 NEUROLOGIC LEVEL

FINGER ABUCTION

MEDIAL ARM

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THE ALLEN TEST

PURPOSE – TO EVALUATE BLOOD SUPPLY TO THE HAND

METHOD – ASK PATIENT TO OPEN AND CLOSE THEIR WRIST (1)

WITH THE PATIENTS WRIST CLOSED, APPLY PRESSURE TO THE ULNAR AND RADIAL ARTERY (2)

ASK THE PATIENT TO OPEN THEIR HAND, RELEASE ONE OF THE ARTERIES (3), THE HAND SHOULD FLUSH IMMEDIATELY, IF NOT THEN THE ARTERY IS PARTIALLY OR COMPLETELY OCCLUDED (4)

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RADIOLOGIC STUDIES

AP and Lateral of hand and wristConsider Obliques and special views if fracture suspected but not seen on AP and Lateral

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EXAMINATION OF RELATED AREAS

Referred pain can be due to:

Herniated cervical discsOsteoarthritisBrachial plexus outlet syndromeElbow and shoulder entrapment syndrome

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Scapholunate instability:

The mechanism of scapholunate injury includes a fall onto a hyperextended wrist with the forearm in pronation and the impact point on the thenar eminence .

Radial pain and progressive loss of strength are usual . Loss of mobility appears much later. Patients may sometimes complain of a snapping wrist which usually occurs during the passage from radial deviation to neutral with the wrist in flexion.

In ulnar deviation, the snap represents the action of the scaphoid on the lunate bone and the sudden correction of the proximal carpal row into dorsiflexion.

With wrist flexion, a snap may represent penetration of the capitate into the scapholunate interval (rare), or the dorsal subluxation of the scaphoid on the posterior margin of the radius .

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1-The synovial irritation sign of the scaphoid.To elicit this sign, pain is induced by exerting pressure on the scaphoid through the anatomical snuffbox (Figure 19).

This sign is usually positive in patients with scaphoid instability, but its specificity is very low.

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(2) The scaphoid bell sign.

This is performed by palpation of the scaphoid tuberosity anteriorly through the radial groove while placing the index finger in the anatomical snuffbox. With ulnar deviation of the wrist, the anterior protrusion of the distal scaphoid tuberosity disappears and the proximal pole appears in the snuffbox. With radial deviation, the proximal pole disappears in the snuffbox and the protrusion of the distal scaphoid tuberosity reappears in the radial groove. Any disruption of this normal mechanism is suggestive of instability, but the sensitivity of this test seems very low .

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(3) The scapholunate ballottement test.

•This test is designed to highlight any abnormal motion between the scaphoid and lunate bones. •With one hand the examiner holds the scaphoid between his thumb (placed distally over the scaphoid tuberosity on the palmar side) and index finger .•(placed posteriorly and proximally over the proximal pole of the scaphoid). The other hand holds the lunate).

•The hands then move in opposite directions and appreciate the ballotement between the two bones.

•It may be difficult to appreciate instability as the normal laxity of the scapholunate joint varies greatly among individuals . •However, if the test induces pain, this is a good sign. •This test, as all tests, may be compared to the opposite wrist to appreciate normal variations.

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Scapholunate ballottement is more marked when the wrist is in slight flexion, and, in this position, dorsal protrusion of the second row is sometimes visible .Flexing the wrist also brings the lunate more dorsal and distal to the dorsal rim of the radius making it easier to palpate the lunate. Another technique to palpate the scapholunate interval is to place the index finger on the dorsal and distal pole of the lunate and then move the index finger radially while moving the wrist in flexion and extension.One can sometimes feel a groove corresponding to the scapholunate interval, or more often a slight protrusion of the proximal pole of the scaphoid. The limitations of these tests are connected with the difficulty to hold the lunate bone correctly.

(4) The wrist-flexion finger-extension

maneuver was described by Watson. With the elbow resting on the table, the wrist is placed in flexion and the patient is asked to extend the fingers. Application of pressure on the nails may reveal pain in the scapholunate interval.

Figure 21:The wrist-flexion finger-extension maneuver. This maneuver induces loads into the carpus that arouses pain at the scapholunate space.

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(5) Watson's test or the scaphoid shear test

The examiner and patient face each other as for arm wrestling. The examiner's fingers are placed dorsally on the distal radius, while the thumb is placed on the palmar distal tuberosity of the scaphoid. The other hand holds the metacarpals. Firm pressure is applied to the palmar tuberosity of the scaphoid while the wrist is moved in ulnar deviation which places the scaphoid in extension. While the wrist is moved in radial deviation the scaphoid cannot flex, as it is blocked from flexing by the examiner's thumb.

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In case of scapholunate tear, or in lax wrist patients, the scaphoid will move dorsally under the posterior margin of the radius and will reach the examiner's index finger, thus inducing pain (Figure 22). Sometimes this test may only be painful, without any perception of dorsal scaphoid displacement. When pressure on the scaphoid is removed, the scaphoid goes back into position with what Watson described as a "thunk" (a clunk)

In certain patients, the absence of normal mobility compared to the uninjured wrist may be due to swelling and/or synovitis. To avoid false-positive testing, the examiner should first place his fingers on the posterior surface of the scaphoid to detect spontaneous pain.Lane suggested modifying the Watson's test by moving the scaphoid only from an anterior to a posterior position (he called it the Scaphoid shift test). This modification would enhance the test's sensitivity by using simple movements.

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Figure 22: The Watson's test.

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Lunotriquetral instability:

Lunotriquetral instability may appear after a hyperpronation injury ,but more often after a hyperextension injury with an impact on the ulnar side. Ninety per cent of patients complain of ulnar pain, and lunotriquetral joint palpation is usually painful .Active prono-supination movements against resistance are painful if the resistance causes twisting of the carpus .

A feeling of instability or loss of strength is present in rare cases. A snap or clunk may be observed in half of the patients during ulnar deviation or extension .

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The lunotriquetral ballottement test or Reagan's test (also called the Shuck or shear test, depending on the authors):

as in the scapholunate ballottement test, the clinician holds the lunate bone between his thumb and index finger with one hand, and moves the triquetrum with the pisiform dorsal and palmar (Figure 23). The aim is to appreciate instability (very difficult) and above all the arousal of pain [30-32]. The sensitivity of this test varies from 33 to 100%, depending on the authors, and its specificity is still unknown.

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Figure 23:The lunotriquetral ballottement test (Reagan's test)

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Kleinman's shear test (which some authors call the shuck test!)

With the patient's forearm in a vertical position, the examiner places one finger on the posterior part of the lunate and with his contralateral thumb placed palmar, pushes the pisiform dorsal which arouses pain in the lunotriquetral joint. This test might be more sensitive and more specific than the Reagan's test.

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Figure 24:The Kleinman's test.

The ulnar snuff box compression test (Linscheid's test)

This test may be the least specific according to Kleinman The thumb placed on the ulnar

side of the triquetrum exerts an axial pressure directed toward the lunate, which arouses pain.

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The raised triquetrum test

was recently proposed by Zradkovic and Sennwald (personal communication). The examiner holds the patient's hand proximal to the wrist and places his thumb on the triquetrum. From the neutral position, without flexion or extension, he performs radial and ulnar deviation movements and appreciates the dorsal and palmar movements of the triquetrum, which should be compared to those of the other wrist (Figures 26 a,b,c).The sensitivity and specificity of this test are still unknown, as are the anatomical lesions which cause the test to be positive. As pointed out by Gilula, the triquetrum is very prominent or dorsal with radial deviation, and moves palmarly and may even disapear with ulnar deviation. On plain radiographs, the triquetrum is located "onto" or proximal on the hamate with radial deviation (superposed), and "lateral" or ulnar to it with ulnar deviation (juxtaposed) [Laredo, personal communication].

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The raised triquetrum test

In Fig 26a, the examiner places the wrist in radial deviation while palpating the triquetrum. He then moves the wrist in neutral (26b) and ulnar (26c) deviation to appreciate the depression of the triquetrum with ulnar deviation and prominence of the triquetrum with radial deviation that should be compared to the contralateral wrist.

Fig 26a (26b) (26c)

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Distal radioulnar joint (DRUJ) instability :

As the ulna is fixed, the radius is the dislocated bone, but we have kept the usual convention which describes "dislocation of the ulna". A traumatic movement in supination is responsible for anterior DRUJ instability, while posterior DRUJ instability follows a pronation injury. Dorsal ulnar dislocation is responsible for

loss of supination and protrusion of the ulnar head.

In case of dorsal ulna subluxation, the protrusion of the ulnar head may be clearly visible when viewed laterally, and unlike what occurs in the normal wrist, does not disappear if the injured wrist is flexed.Anterior ulnar dislocation

makes the dorsal skin depress and limits pronation.

In anterior subluxation, the usual protrusion of the ulnar head is reduced or disappears.

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Pain secondary to DRUJ instability is located on the ulnar side of the wrist and is intensified by pronation or supination. In such cases the examiner stabilizes the patient's forearm with one hand while with the other hand, he grasps the patient's hand as if for a vigorous handshake. When the patient resists forced passive rotation, or when there is active rotation against resistance, pain usually is elicited. If the pain is caused by compressing the ulna against the radius, it is mostly suggestive of chondromalacia . Patients may also complain of a snap which occurs during pronation or supination and corresponds to either dislocation of the ulnar head or to its reduction.

radioulnar ballottement test

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Radioulnar instability is tested by the radioulnar ballottement test, in which the patient's elbow is flexed, and the examiner uses his thumb and index finger to stabilize the radius radially and the ulnar head ulnarly (Figure 29). Normally, there is no mobility in the anterior or posterior direction in maximum pronation or supination. Pain or mobility is very suggestive of radioulnar instability. The ballottement test must not only be done during extreme motions of pronation and supination, but also in various intermediate pronation and supination positions, because instability may only appear in some of these positions.

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Figure 29:

The radioulnar ballottement test.

TFCC lesions are usually of degenerative origin, but may also constitute the first stage of radioulnar instability. Pain is always ulnar and is intensified by wrist movements but not necessarily by pronation or supination. It is usually aggravated by ulnar inclination or rotational loads: thus, in the screwdriver test, the examiner holds the patient's hand while performing screwing and unscrewing movements.

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Extensor carpi ulnaris tendon dislocation is not a ligamentous injury but occurs after combined hypersupination and ulnar inclination. Passive pronation and supination are usually painful and may be accompanied by a visible and palpable snap which can be reproduced by placing the wrist in flexion and supination.

Figure 30:

Displacement of the extensor carpi ulnaris is more visible when the wrist is placed in flexion and supination.

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