import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Wrist Examination The wrist examination requires systematic assessment of both carpal bones and the DRUJ. Key conditions include scaphoid fractures, scapholunate instability, TFCC injuries, and Kienbock's disease. ## Quick Reference One-Pager ## Introduction and Setup **Patient Positioning:** Seated opposite examiner with forearm resting on table or pillow **Exposure:** Both forearms exposed from elbow to fingertips **Consent Script:** "I'm going to examine your wrists. I'll look at both, feel around the joints, and test the movements. Please let me know if anything is painful." **Key Anatomy:** - 8 carpal bones in two rows - Scapholunate ligament critical for carpal stability - TFCC stabilizes DRUJ - Carpal tunnel transmits median nerve and 9 tendons ## Look (Inspection) - **Swelling**: Generalized (synovitis, RA), localized (ganglion, cyst) - **Deformity**: Dinner fork (Colles'), prominent ulna (DRUJ instability) - **Scars**: Previous surgery, trauma - **Extensor tendons**: Wasting, rupture (dropped fingers) - **Skin changes**: Thinning (steroid use), rheumatoid nodules - **Thenar eminence**: Wasting (median nerve/CTS) - **Hypothenar eminence**: Wasting (ulnar nerve) - **Scars**: Carpal tunnel release, tendon repairs - **Palmar fascia**: Dupuytren's nodules, cords - **Swelling**: Flexor tenosynovitis - **Radial styloid**: Prominence, swelling - **Anatomical snuffbox**: Fullness (scaphoid pathology) - **First CMC joint**: Squaring (OA) - **Alignment**: Radial inclination, volar tilt ## Feel (Palpation) **Dorsal Structures (Radial to Ulnar):** 1. **Radial styloid**: Bony landmark, de Quervain's 2. **Anatomical snuffbox**: Scaphoid tenderness 3. **Scaphoid tubercle**: Volar, distal to radial styloid 4. **Lister's tubercle**: Dorsal prominence on radius 5. **Scapholunate interval**: Just distal to Lister's tubercle 6. **Lunate**: Central, dorsal to capitate 7. **Capitate**: Central, base of 3rd metacarpal 8. **DRUJ**: Ulnar head prominence 9. **Ulnar styloid**: Ulnar side, TFCC attachment **Volar Structures:** 1. **Carpal tunnel**: Tinel's over flexor retinaculum 2. **Pisiform**: Ulnar, proximal to hook of hamate 3. **Hook of hamate**: 1cm distal and radial to pisiform 4. **Flexor tendons**: Crepitus, swelling **Special Palpation:** - DRUJ: Grasp distal radius and ulna, assess AP translation ("piano key") - Temperature: Compare with back of hand ## Move (Range of Motion) **Functional Wrist ROM:** Most activities require 40° flexion, 40° extension (dart-thrower's arc through radial extension to ulnar flexion is most functional). ## Special Tests ### Scaphoid and Carpal Instability ### DRUJ and TFCC ### Tendon Tests ### Carpal Tunnel Syndrome ## Neurovascular Assessment **Median Nerve:** - Sensory: Palmar thumb, index, middle, radial half ring finger - Motor: APB (thumb abduction against resistance) - Test: Thenar wasting, Phalen's, Tinel's **Ulnar Nerve:** - Sensory: Little finger and ulnar half ring finger - Motor: Finger abduction (1st dorsal interosseous) - Test: Froment's sign (FPL substitution for weak adductor pollicis) **Radial Nerve:** - Sensory: First dorsal web space - Motor: Wrist and finger extension - Rarely affected at wrist level ## Complete the Examination **Always state to the examiner:** "To complete my examination, I would like to: - Examine the **elbow** as the joint above - Examine the **hand** including individual fingers - Complete **neurological assessment** of the upper limb - Check for **cervical radiculopathy** - Obtain **X-rays** (PA, lateral, +/- scaphoid views if indicated)" ## Summary Presentation ## Common Conditions Table ## Examiner Tips