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
Look
- Dorsal swelling (synovitis, ganglion)
- Dinner fork deformity (Colles')
- Wasting of thenar/hypothenar eminence
- Scars, skin changes
Feel
- Anatomical snuffbox (scaphoid)
- Lister's tubercle
- Scapholunate interval
- DRUJ (piano key)
- Carpal tunnel (Tinel's)
Move
- Flexion 0-80°
- Extension 0-70°
- Radial deviation 0-20°
- Ulnar deviation 0-30°
- Pronation/supination
Special Tests
- Scaphoid shift (Watson)
- DRUJ stability
- Finkelstein's (de Quervain's)
- Phalen's/Tinel's (CTS)
Introduction and Setup
Before You Start
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
Feel (Palpation)
Systematic Palpation Sequence
Dorsal Structures (Radial to Ulnar):
- Radial styloid: Bony landmark, de Quervain's
- Anatomical snuffbox: Scaphoid tenderness
- Scaphoid tubercle: Volar, distal to radial styloid
- Lister's tubercle: Dorsal prominence on radius
- Scapholunate interval: Just distal to Lister's tubercle
- Lunate: Central, dorsal to capitate
- Capitate: Central, base of 3rd metacarpal
- DRUJ: Ulnar head prominence
- Ulnar styloid: Ulnar side, TFCC attachment
Volar Structures:
- Carpal tunnel: Tinel's over flexor retinaculum
- Pisiform: Ulnar, proximal to hook of hamate
- Hook of hamate: 1cm distal and radial to pisiform
- 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)
- normalRange
- 0-80°
- technique
- Prayer position, lower hands
- keyPoints
- Compare symmetry
- normalRange
- 0-70°
- technique
- Reverse prayer, raise hands
- keyPoints
- Limited in dorsal ganglion
- normalRange
- 0-20°
- technique
- Wrist flat, move thumb toward radius
- keyPoints
- Less than ulnar deviation
- normalRange
- 0-30°
- technique
- Wrist flat, move hand to ulnar side
- keyPoints
- Pain in TFCC injury
- normalRange
- 0-80°
- technique
- Elbow at 90°, palm down
- keyPoints
- DRUJ function
- normalRange
- 0-80°
- technique
- Elbow at 90°, palm up
- keyPoints
- DRUJ function
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
Special test
Scaphoid Shift Test (Watson)
Scapholunate instability
Technique
- 1Patient seated, forearm in neutral rotation
- 2Examiner places thumb on scaphoid tubercle (volar, distal pole)
- 3Move wrist from ulnar deviation and slight extension to radial deviation and slight flexion
- 4Apply dorsal pressure on scaphoid tubercle throughout
Positive Sign
Painful clunk as scaphoid subluxates dorsally, reduced pain when pressure released
Indicates
Scapholunate ligament injury, scapholunate instability
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Anatomical Snuffbox Tenderness
Scaphoid fracture
Technique
- 1Wrist in ulnar deviation to expose scaphoid
- 2Palpate floor of anatomical snuffbox (between EPL and EPB/APL tendons)
Positive Sign
Point tenderness in anatomical snuffbox
Indicates
Scaphoid fracture until proven otherwise
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Scaphoid Compression Test
Scaphoid fracture
Technique
- 1Apply axial compression along the thumb metacarpal
- 2Force transmitted through trapezium to scaphoid
Positive Sign
Pain in scaphoid region
Indicates
Scaphoid fracture
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
DRUJ and TFCC
Special test
Piano Key Test
DRUJ instability
Technique
- 1Forearm pronated, wrist in neutral
- 2Stabilize distal radius with one hand
- 3Apply dorsal-volar force to distal ulna
Positive Sign
Increased AP translation compared to other side, painful clunk
Indicates
DRUJ instability, TFCC injury
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Fovea Sign
TFCC injury
Technique
- 1Palpate between ulnar styloid and FCU tendon
- 2Deep palpation into the ulnar fovea
Positive Sign
Exquisite tenderness in fovea
Indicates
TFCC tear (foveal insertion)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Press Test
TFCC pathology
Technique
- 1Patient seated in chair with armrests
- 2Asks patient to push up from chair using wrists
Positive Sign
Ulnar-sided wrist pain on loading
Indicates
TFCC injury, ulnocarpal impaction
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Tendon Tests
Special test
Finkelstein's Test
de Quervain's tenosynovitis
Technique
- 1Patient makes fist with thumb tucked inside fingers
- 2Examiner stabilizes forearm
- 3Ulnar deviate the wrist passively
Positive Sign
Pain over first dorsal compartment (radial styloid area)
Indicates
de Quervain's tenosynovitis (APL, EPB)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Carpal Tunnel Syndrome
Special test
Phalen's Test
Carpal tunnel syndrome
Technique
- 1Patient holds wrists in maximal flexion (reverse prayer position)
- 2Maintain position for 60 seconds
Positive Sign
Paraesthesia in median nerve distribution (thumb, index, middle, radial half ring finger)
Indicates
Carpal tunnel syndrome
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Tinel's Sign (Carpal Tunnel)
Carpal tunnel syndrome
Technique
- 1Percuss over carpal tunnel (proximal wrist crease, between FCR and palmaris longus)
Positive Sign
Tingling or electric sensation radiating into median nerve distribution
Indicates
Carpal tunnel syndrome
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Durkan's Compression Test
Carpal tunnel syndrome
Technique
- 1Apply direct pressure over carpal tunnel with both thumbs for 30 seconds
Positive Sign
Reproduction of median nerve symptoms
Indicates
Carpal tunnel syndrome
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Neurovascular Assessment
Neurological Examination
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
“28-year-old male with radial wrist pain after falling onto outstretched hand 2 weeks ago.”
Common Conditions Table
- look
- Snuffbox swelling
- feel
- Snuffbox + tubercle tender
- move
- Painful grip
- specialTests
- Compression test +
- look
- May be normal
- feel
- SL interval tenderness
- move
- Weak grip
- specialTests
- Watson shift +
- look
- Ulnar swelling
- feel
- Fovea tenderness
- move
- Pain at end rotation
- specialTests
- Piano key +, Press test +
- look
- 1st compartment swelling
- feel
- Radial styloid tender
- move
- Pain on thumb movement
- specialTests
- Finkelstein's +
- look
- Thenar wasting late
- feel
- Normal bones
- move
- Normal ROM
- specialTests
- Phalen's +, Durkan's +
Examiner Tips
Do
- Know your carpal anatomy precisely
- Distinguish SL interval from snuffbox
- Test DRUJ stability routinely
- Assess all three major nerves
- Know the dart-thrower's motion concept
Don't
- Miss the fovea sign for TFCC
- Confuse Phalen's and reverse Phalen's
- Forget to check first CMC joint
- Miss dorsal ganglion
- Ignore thenar wasting