Musculoskeletal problems of the wrist and hand physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• Range of Motion
  • Radiocarpal joint flexion and extension
  • Normal flexion 90°, extension 80°
  • Mild pain/stiffness + normal ROM- sprain or mild arthritis
  • Moderate pain/stiffness + 20% loss ROM- arthritis
  • Severe pain/stiffness + 50% loss ROM- acute gout, fracture (navicular/distal radius), dislocation
  • Refusal to move- septic joint, fracture
  • Loss of ROM in only one direction (due to pain)
    • Tendon injury or inflammation
    • Pain with passive stretching of tendon (opposite direction)
• Grip Strength
  • Indirect measure of strength/integrity of forearm muscles
  • Can be measured objectively using rolled up partly inflated blood pressure (BP) cuff (patient grip measured in mmHg)
  • Reduced grip strength
    • Disuse atrophy, arthritis (hand or wrist), CTS, DeQuervain’s, osteonecrosis
    • May also be reduced in C8 radiculopathy, severe epicondylitis

• Palpation of the Radiocarpal Joint Line
  • • Junction of distal radius, scaphoid & lunate
    • At intersection of index finger extensor tendon & distal radius
  • Mild tenderness- simple sprain
  • Moderate tenderness- osteoarthritis (OA)
  • Severe pain- crystal-induced arthritis, Colles’ fracture, scaphoid fracture, perilunate dislocation
  • Swelling- mild swelling will fill the depression over the navicular (severe swelling causes a bulge)
  • Loss of ROM- significant loss (45° flexion / extension) with advanced disease
• Palpation of the Scaphoid Bone
  • Scaphoid forms floor of anatomical snuff box (distal radial styloid + base of thumb + abductor pollicis longus + extensor pollicis longus)
  • Tenderness in anatomical snuff box = scaphoid pathology (fracture, osteonecrosis, arthritis)
• Palpation of the Radial Styloid
  • Pain suggests DeQuervain’s tenosynovitis (friction-induced irritation of anatomic snuffbox tendons)
  • Confirmatory testing
    • Pain aggravated by thumb extension or abduction against resistance
      • (Abduction = movement of thumb perpendicular to palm)
    • Pain worse with passive stretch of tendons over radial styloid via thumb flexion
      • (Finkelstein’s test)
• Compression of the Base of Thumb
  • Screen for CMC arthritis (or strain)
  • Pain with compression of the CMC joint in the ante partum (AP) plane suggests CMC arthritis
  • Pressure applied from the snuffbox is much less painful
  • Swelling best seen with wrist turned radial-side-up
  • Crepitation with forcible rotation of metacarpal against trapezium (mortar & pestle sign)
  • Bony protuberance of metacarpal or thenar atrophy- late stages
• Palpation of Metocarpophalangeal Joint
  • Detect gamekeeper’s thumb (ulnar collateral ligament injury)
  • Local tenderness/swelling along ulnar side of MP joint suggests diagnosis
  • Instability or pain of MP joint with valgus stress (examiner’s thumb at MP joint, index finger at interphalangeal (IP) joint)
  • Loss of MP flexion (normal = 90°) and pinch strength can occur with acute symptoms/swelling
• Tests for Nerve Compression
  • CTS
  • Sensory loss in the first 3 fingertips- two-point discrimination, light touch, pain decreased
  • Weakness of thumb opposition- best detected when pt holds thumb + 5th finger together
  • Tinel Sign
    • Vigorous tapping over transverse carpal ligament with wrist in extension
    • Positive if reproduces pain and paresthesia
  • Phalen Sign
    • Both wrists held in extreme volar flexion for 30-60 seconds
    • Positive if symptoms reproduced
  • Pronator Teres Compression
    • If no compression detected at wrist, test for proximal compression
    • Apply pressure to forearm 1 to 2 inches distal to antecubital fossa
    • Positive if symptoms reproduced with compression
    • Sensitivity increased by resisting forearm pronation
  • Note- Tests can be totally normal despite significant compression (symptoms vary over time)
    • Sensitivity and specificity of provocative tests low
• Transillumination
  • Distinguishes between ganglion (transilluminates) and solid mass
  • Ganglion cyst should be highly mobile and fluctuant, not adherent; ROM should be full
  • Aspiration of cyst yields thick, colorless fluid

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