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Examination of the Wrist

HAND SURGERY REVISION COURSE - QMC Nottingham. Examination of the Wrist. Mr P R Stuart FRCS Freeman Hospital Newcastle upon Tyne. OR. (‘clunk, click every trip’). Remember!. Not all that clicks or clunks is abnormal most wrists don’t have ‘interesting’ instabilities

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Examination of the Wrist

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  1. HAND SURGERY REVISION COURSE - QMC Nottingham Examination of the Wrist Mr P R Stuart FRCS Freeman Hospital Newcastle upon Tyne

  2. OR (‘clunk, click every trip’)

  3. Remember! • Not all that clicks or clunks is abnormal • most wrists don’t have ‘interesting’ instabilities • investigation of the wrist is clinical - investigations add little • knowledge of surface anatomy critical

  4. Radial Side Styloid • De Quervain’s - Finkelstein (JBJS 12A; 509, 1930) • Wartenbergs • Intersection

  5. Radial Side Snuffbox • swelling • articular / non-articular pain • scaphoid #’s • impingement, (malunion) • scapho-styloid OA

  6. Dorsal Radial • Lister’s tubercle -> SL interval • occult ganglia • instability • Lunate - Keinbocks

  7. Dorsal Central • Carpal boss • Extensor compartments • extensor manus brevis • tenosynovitis - moves with tendons • ganglia • PIN neuritis • lunate + capitate #’s

  8. Dorsal Ulnar • DRUJ • compression, translation, piano key, dimple • TFC • Luno-triquetral, triquetro-hamate • Ulnar carpal impaction - pronation + UD

  9. Dorsal Ulnar • ECU instability • supination, UD, flexion • 4th + 5th CMC OA • Mid-carpal instability

  10. Palmar Radial • scaphoid - tuberosity #’s • STT - common, ganglia • 1st CMC • FCR tendonitis / trapezial ridge fractures • PCB neuroma

  11. Palmar Ulnar • FCU tendonitis • Piso-triquetral OA - compression • Hook of Hamate - fist in UD • hypothenar hammer syndrome • Guyon’s canal compression • pillar pain

  12. Provocative Testing • Scaphoid shift • Finger extension test • Midcarpal clunk • L-T shuck test • DRUJ • grind • pain at extremes

  13. Lax, loose, wobbly or unstable • Like the shoulder there is a range of normal • most mid-carpal joints can be subluxed (pushed into VISI) • most clunks and abnormal movements can only be considered pathological if they occur during normal use and / or are painful • the ‘lax’ wrist is often painful without being ‘unstable’

  14. Scaphoid shift - Watson’s test • Qualitative assessment of scaphoid instability • 10% normal wrists have positive test - take care!

  15. Finger extension test • Resisted finger extension in full passive wrist flexion • +ve in DWS, SLAC, SLD, RSS, MCI, Kienbock’s

  16. Articular - nonarticular • Periscaphoid synovitis, SLAC, instability, non-union

  17. Catch-up clunk • Proximal row flicking suddenly from volar flexion to dorsiflexion • normal smooth transition from one to other under influence of capsular and intracarpal ligaments

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