How to Examine a Wrist: Anatomy, Systematic Protocol, and Special Tests

How to examine a wrist?

Examining the wrist involves a systematic process encompassing observation, palpation, assessment of range of motion, and specific provocative tests to identify potential injuries, dysfunctions, or underlying conditions.

Introduction

The wrist is a complex anatomical structure, critical for the intricate movements of the hand and forearm, enabling everything from fine motor skills to powerful gripping. Given its constant use and exposure to various stresses, the wrist is susceptible to a wide range of injuries and conditions, from acute trauma like sprains and fractures to chronic issues like tendinitis, carpal tunnel syndrome, and osteoarthritis. A systematic approach to examining the wrist is essential for anyone seeking to understand or address wrist discomfort, whether for personal awareness, athletic performance analysis, or preliminary assessment in a fitness or educational setting. This guide provides a comprehensive, evidence-based protocol for a thorough wrist examination.

Anatomy of the Wrist

A foundational understanding of wrist anatomy is crucial for effective examination. The wrist joint, or radiocarpal joint, is formed by the distal ends of the radius and ulna bones of the forearm and the eight carpal bones of the hand.

• Bones:
  • Forearm: Distal radius (larger, on thumb side), distal ulna (smaller, on pinky side).
  • Carpals (Proximal Row): Scaphoid, Lunate, Triquetrum, Pisiform.
  • Carpals (Distal Row): Trapezium, Trapezoid, Capitate, Hamate.
• Joints: Radiocarpal, Ulnocarpal (via TFCC), Intercarpal, Carpometacarpal.
• Ligaments: Numerous strong ligaments stabilize the carpal bones and connect them to the forearm, providing stability and guiding motion (e.g., volar radiocarpal ligaments, dorsal radiocarpal ligaments, intercarpal ligaments, collateral ligaments).
• Tendons: Extensor tendons (dorsal aspect) and flexor tendons (palmar aspect) cross the wrist, enabling finger and thumb movements, as well as wrist flexion and extension.
• Nerves: The median, ulnar, and radial nerves pass through or near the wrist, innervating muscles and providing sensation to the hand. The median nerve passes through the carpal tunnel, and the ulnar nerve through Guyon's canal.
• Triangular Fibrocartilage Complex (TFCC): A critical structure on the ulnar side of the wrist, supporting the distal radioulnar joint and providing cushioning.

The Systematic Wrist Examination Protocol

A thorough wrist examination follows a structured sequence: Observation, Palpation, Range of Motion assessment, and Special Tests. Always compare the affected wrist to the unaffected side for baseline comparison.

Observation

Begin by visually inspecting the wrist and hand for any obvious abnormalities.

• General Appearance: Note any signs of trauma, such as bruising, swelling, or lacerations.
• Deformity: Look for bony deformities (e.g., "dinner fork" deformity characteristic of a distal radius fracture), dislocations, or abnormal angulation.
• Swelling: Localized or diffuse swelling can indicate inflammation, fluid accumulation, or fracture.
• Skin Changes: Observe for redness (erythema), warmth, rashes, scars, or trophic changes (e.g., changes in nail growth, skin texture) that might indicate nerve involvement or chronic conditions.
• Muscle Atrophy: Compare muscle bulk, particularly the thenar eminence (thumb base) and hypothenar eminence (pinky base), which can indicate nerve compression or disuse.
• Posture and Hand Position: Note any resting postures that suggest pain or neurological deficits (e.g., wrist drop).

Palpation

Carefully feel the structures of the wrist, noting any tenderness, warmth, crepitus (a grating or crackling sound/sensation), or abnormal masses.

• Bony Landmarks:
  • Radial Styloid: Palpate the prominence on the thumb side of the forearm.
  • Ulnar Styloid: Palpate the prominence on the pinky side of the forearm.
  • Anatomical Snuffbox: The triangular depression on the back of the hand at the base of the thumb, formed by extensor tendons. Tenderness here often indicates a scaphoid injury.
  • Distal Radius and Ulna: Palpate along the shafts and joint lines.
  • Carpal Bones: Systematically palpate each carpal bone, starting with the proximal row (scaphoid, lunate, triquetrum, pisiform) and then the distal row (trapezium, trapezoid, capitate, hamate), noting any focal tenderness.
• Soft Tissues:
  • Extensor Tendons: Palpate along the dorsal aspect of the wrist. Tenderness or swelling along specific compartments can indicate tendinopathy (e.g., De Quervain's tenosynovitis in the first dorsal compartment).
  • Flexor Tendons: Palpate along the palmar aspect.
  • Carpal Tunnel: Palpate over the carpal tunnel, located on the palmar side of the wrist, between the thenar and hypothenar eminences.
  • TFCC: Palpate just distal to the ulnar styloid in the depression. Tenderness here suggests TFCC involvement.

Range of Motion (ROM)

Assess both active (patient performs) and passive (examiner performs) range of motion, noting any limitations, pain, or crepitus. Compare to the contralateral side.

• Active ROM: Ask the patient to perform the following movements:
  • Wrist Flexion: Bend wrist forward (palm towards forearm). Normal: 80 degrees.
  • Wrist Extension: Bend wrist backward (back of hand towards forearm). Normal: 70 degrees.
  • Radial Deviation: Bend wrist towards the thumb side. Normal: 20 degrees.
  • Ulnar Deviation: Bend wrist towards the pinky side. Normal: 30 degrees.
  • Forearm Pronation: Rotate forearm so palm faces down. Normal: 80 degrees.
  • Forearm Supination: Rotate forearm so palm faces up. Normal: 80 degrees.
• Passive ROM: Gently move the patient's wrist through the same ranges of motion. This helps differentiate between muscular weakness/pain (active ROM limited) and joint stiffness/mechanical block (passive ROM also limited). Note the end-feel (e.g., firm, soft, empty).
• Resisted ROM (Strength Testing): Test muscle strength and pain provocation by having the patient resist your movements.
  • Wrist Flexors: Resist wrist flexion.
  • Wrist Extensors: Resist wrist extension.
  • Wrist Radial Deviators: Resist radial deviation.
  • Wrist Ulnar Deviators: Resist ulnar deviation.
  • Grip Strength: A dynamometer can be used for objective measurement, or a simple hand squeeze can provide a qualitative assessment.

Special Tests

These specific maneuvers help confirm or rule out particular conditions by provoking symptoms.

• Phalen's Test: Used to screen for Carpal Tunnel Syndrome. Patient flexes wrists fully and holds the backs of their hands together for 60 seconds. Numbness or tingling in the median nerve distribution (thumb, index, middle, and radial half of ring finger) is a positive sign.
• Tinel's Sign (at Wrist): Used for nerve compression. Gently tap over the median nerve at the carpal tunnel or the ulnar nerve at Guyon's canal. Tingling or electric shock sensation in the nerve's distribution is a positive sign.
• Finkelstein's Test: Used to diagnose De Quervain's Tenosynovitis. Patient makes a fist with the thumb tucked inside the fingers, then ulnar deviates the wrist. Sharp pain along the radial side of the wrist is a positive sign.
• Watson Scaphoid Shift Test (Scaphoid Shift Test): Used to assess scaphoid instability. While stabilizing the radius, the examiner grasps the scaphoid and applies pressure while moving the wrist from ulnar to radial deviation. A painful clunk or subluxation indicates instability.
• TFCC Load Test: Used to assess Triangular Fibrocartilage Complex injury. Apply an axial load through the wrist while performing ulnar deviation and circumduction. Pain or clicking on the ulnar side of the wrist is a positive sign.

When to Seek Professional Medical Attention

While this guide provides a framework for self-examination or preliminary assessment, it is not a substitute for professional medical diagnosis. You should seek immediate medical attention if you experience:

• Severe pain, especially after trauma.
• Obvious deformity or inability to move the wrist.
• Numbness, tingling, or weakness that persists or worsens.
• Significant swelling or bruising.
• Signs of infection (redness, warmth, pus, fever).
• Inability to bear weight through the hand or wrist.
• Pain that does not improve with rest and conservative measures within a few days.

Conclusion

A systematic examination of the wrist, integrating observation, palpation, range of motion assessment, and targeted special tests, provides a comprehensive approach to understanding wrist health. This structured methodology, grounded in anatomical and biomechanical principles, allows fitness enthusiasts, personal trainers, and student kinesiologists to gain valuable insights into potential wrist issues, guiding appropriate next steps, whether it's activity modification, rehabilitation exercises, or referral to a healthcare professional. Always prioritize safety and, when in doubt, consult with a qualified medical expert for accurate diagnosis and treatment.