Evaluation of the painful wrist and hand begins with a thorough history and physical examination, with the history alone often leading the physician to the diagnosis, whereas the examination serves as a confirmation. The history begins consistently with a review of demographics relevant to use of the hand, specifically age, sex, handedness, and occupation. The nature of the primary symptom is then ascertained with evaluation of character, location, onset, timing, and alleviating and aggravating factors. It is often helpful to have the patient point with one finger to the specific location of maximum symptomatology. Any pain should be evaluated through an analog scale to aid later comparisons. Associated symptoms may include paresthesias or numbness, weakness, color or temperature changes, snapping, popping, and decrease in coordination. Details are obtained regarding the mechanism of onset, including any history of trauma, change in activity levels or overuse, prior injury, and prior treatment.

A complete medical and surgical history with a full review of systems should be obtained at the first encounter and updated at each subsequent visit. Diabetes, vascular, cardiac, pulmonary, and renal dysfunction can all play a role in hand conditions, and any rheumatologic or dermatologic conditions should be noted. Social history involves smoking, alcohol and substance abuse, HIV and/or hepatitis status, and any hobbies or sports in addition to the basic demographic information listed previously. Family history may be relevant in many nontraumatic conditions.

After this initial survey of the history and character of the symptoms, most problems will easily stratify into one of four groups: acute traumatic, acute nontraumatic, chronic posttraumatic, and chronic nontraumatic (Table 14.1). Some patients may have sustained a past trauma, which was felt to be insignificant at the time but led to delayed symptoms (i.e., an undiagnosed scapholunate sprain leading to later degenerative changes). However, initial examination and imaging will often reveal signs of a past trauma and help to place the patient into one of the four groups. This process of stratification leads the examiner to additional relevant aspects of the history, guides the physical examination, and helps to narrow the differential diagnosis.

Once the history has been taken, the physical examination serves to confirm or refute the physician’s initial impression. A systematically performed examination of the neck and entire upper extremity will allow for precise localization of symptoms and any functional deficits of the wrist or hand while revealing any proximal or systemic causes that might be overlooked in an overly focused examination. By establishing a routine order of examination, the entire extremity can be evaluated in a thorough yet efficient manner. The examination proceeds through inspection, sensibility testing, range of motion, palpation and instability examination, grading of motor function, and finally provocative maneuvers so that trust between the patient and physician can be gradually established while potentially painful maneuvers are saved for the end of the examination. Comparison to the contralateral extremity is often helpful in detecting subtle changes from normal.

Inspection begins with a general review of the patient, ascertaining physiological age, general health status and mobility, posture, and gait. The skin of the hands is evaluated for any wounds, erythema, rashes, or swelling. Skin color, temperature, trophic changes, and rapidity of capillary refill may reveal problems with vascular perfusion. Muscular atrophy may be readily apparent on inspection. Alteration in the resting position of the wrist or normal cascade of the digits can be an indirect sign of tendon dysfunction or injury. One should note the location of any old scars or previous incisions.

In the office setting, sensibility is tested by moving light touch, pin prick, and two-point discrimination. The median nerve is tested at the volar tip of the index finger, whereas the ulnar nerve is tested at the volar tip of the small finger. The radial nerve is tested at the dorsal first web space. Bilateral symptoms or symptoms not conforming to typical peripheral nerve distributions should prompt a search for a more proximal nerve compression or injury at the brachial plexus or cervical root level.

Active and passive ranges of motion of the upper extremities are then evaluated. First the patient performs neck flexion, extension, and lateral rotation with the neck extended as a quick screen for cervical root compression. Any pain or decreased range of motion noted when the patient raises his or her arms straight up and then places his or her hands behind his or her head and then behind his or her back can reveal shoulder pathology that may play a part in the patient’s pain. Elbow motion is tested in flexion and extension. Forearm pronation and supination is an essential part of wrist evaluation that is often neglected. The wrist is tested in flexion, extension, radial deviation, and ulnar deviation and fingers are tested through flexion and extension at each joint. Ranges are compared with the opposite extremity. Differences between active and passive range are of particular importance. Take note of any sounds produced by range of motion, including crepitance, snapping of tendons, or the clunking of carpal instability.

As a result of the compact anatomy of the hand and wrist, palpation should be performed very precisely and systematically to match areas of tenderness to specific anatomic structures. The size, contour, and mobility of any masses can be appreciated and differentiated from areas of edema, tenosynovitis, or fluctuance. It is helpful to palpate the joints of each finger and to stress the joints if instability is a concern. Examine the flexor and extensor mechanisms of each digit for tenderness or subluxation. The wrist is best divided into four zones for a complete evaluation. A stepwise examination of each zone can ensure that all relevant structures have been examined and remind the examiner of the differential diagnosis during the process (Fig. 14.1).

Palpation of the radial aspect of the wrist proceeds from the volar aspect around to the dorsal side. The flexor carpi radialis (FCR) is easily traced distally from the forearm and is tender in FCR tendonitis. At its distal extent, the trapezial ridge is palpable and is tender in trapeziometacarpal arthritis. Just proximal to the trapezial ridge is the distal pole of the scaphoid, which is most prominent during radial deviation. A mass proximal to this may represent a volar ganglion cyst or radial artery aneurysm. The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) of the first extensor compartment are identified at the base of the thumb metacarpal and are tender as they pass over the radial styloid in DeQuervain’s tenosynovitis. Dorsal to the EPB within the distal aspect of the “anatomic snuffbox” one can palpate the dorsal aspect of the trapeziometacarpal joint. Just proximal to this is the scaphoid waist, and any tenderness here should elicit suspicion for a scaphoid fracture, even if initial radiographs are negative. The next most proximal structure is the radial styloid, which will be tender if fractured, followed by the crossing of the APL and EPB over the radial wrist extensor tendons of the second extensor compartment. Tendonitis here is known as “intersection syndrome” (1).

Proceeding to the dorsal zone of the wrist, the extensor pollicis longus (EPL) is palpable as it curves around Lister’s tubercle, a bony prominence on the dorsal distal radius. This is a common site of tendon rupture as a sequelae of distal radius fracture (2). One centimeter distal to Lister’s tubercle is the scapholunate joint, the most common site of intercarpal ligament injuries and a common site of ganglion cysts (3). Dorsal ganglia may become more prominent with flexion of the wrist or may remain occult. With the wrist flexed, the proximal pole of the scaphoid is easily felt to the radial side and the lunate is felt to the ulnar side. Lunate tenderness may raise suspicion of Kienböck’s avascular necrosis of this bone. The finger extensors may be tender as they emerge from under the extensor retinaculum in tenosynovitis secondary to overuse or rheumatoid arthritis. Distally, the bony ridge of the second through fifth carpometacarpal (CMC) joints may be tender in acute fractures or dislocations or in degenerative arthritis (CMC bossing).

Palpation of the ulnar side of the wrist proceeds from dorsal to volar. The most prominent feature of the dorsal ulnar side of the wrist is the ulnar head. Just radial to this one can palpate the distal radioulnar joint (DRUJ). By stabilizing the radius and translating the distal ulna in the dorsal–volar plane, one can determine whether any pathologic instability exists, indicating ligament injury or disruption. Comparison to the contralateral wrist is usually necessary. This maneuver should be repeated in full pronation, neutral rotation, and full supination to fully assess for instability. One centimeter distal to the DRUJ, the lunotriquetral joint is palpable and is another potential site of intercarpal injury and instability. Translation of the triquetrum relative to the lunate is known as the lunotriquetral ballottement test and is a sign of instability (4). Just distal to this joint, the dorsal aspect of the hamate is palpable and is a potential site of avulsion fractures seen in association with CMC dorsal dislocation. The extensor carpi ulnaris (ECU) is the next most ulnar structure and should be palpated along its length for tenderness indicating tendonitis and for subluxation during active wrist supination and flexion. Just volar to the ECU, the ulnar styloid is prominent within the “ulnar snuffbox” between

the ECU and flexor carpi ulnaris (FCU). This may be tender in acute fracture or nonunion. The triangular fibrocartilage complex (TFCC) is a structure analogous to the meniscus of the knee and may be palpated distal to the ulnar head and styloid on both sides of the ECU. Tenderness here may indicate a tear in the setting of an acute injury or may indicate degeneration of this structure secondary to impingement between the lunate and a prominent ulnar head (ulnar impaction syndrome) (5). The FCU may be traced distally from the forearm to its insertion on the pisiform at the base of the hypothenar eminence. Tenderness here may indicate FCU tendonitis or pisotriquetral arthritis. Arthritis is distinguished from tendonitis by pain and crepitance with ballottement or radioulnar translation of the pisiform over the triquetrum. The ulnar artery and nerve curve around the radial aspect of the pisiform. A pulsatile mass could indicate an aneurysm of the ulnar artery, and tenderness in association with paresthesias or numbness of the ulnar two digits can point to entrapment of the ulnar nerve within Guyon’s canal. Distal and radial to the pisiform and in line with the ring finger, the hook of the hamate can be palpated. Tenderness here, especially after a checked golf or baseball swing, may indicate a fracture of the hook.

The last zone to examine is the palmar zone, which includes the digital flexors and the median nerve as they pass through the carpal canal. Tenderness over the transverse carpal ligament, which runs between the trapezium radially and the hamate hook and pisiform ulnarly, may indicate compression of the median nerve in carpal tunnel syndrome or tenosynovitis of the flexor tendons from overuse or rheumatoid arthritis, which frequently leads to secondary carpal tunnel syndrome. Reproduction of paresthesias into the median nerve distribution with a gentle tapping (Tinel’s sign), direct pressure (carpal compression test), or wrist flexion for up to 30 seconds (Phalen’s test) is indicative of median nerve dysfunction secondary to entrapment, especially if all three tests are positive (6).

Muscle groups of the hand and wrist can be divided based on whether the muscle originates purely within the hand (intrinsic) or from the elbow or forearm (extrinsic). Additionally, they can be divided by the peripheral nerve, which innervates them. Median nerve extrinsic function can be tested by resisted proximal interphalangeal (PIP) flexion (flexor digitorum superficialis), digital interphalangeal (DIP) flexion of the index and long fingers (flexor digitorum profundus), thumb interphalangeal (IP) flexion (flexor pollicis longus), and wrist flexion with radial deviation (flexor carpi radialis). Median nerve intrinsic function can be tested by placing the thumb into opposition and having the patient resist pressure on the thumb from one of the examiner’s fingers as another palpates the opponens muscle for tone. Ulnar extrinsic function is tested through resisted DIP flexion of the ring and small fingers, whereas intrinsic function is tested by placing the index finger into abduction and having the patient resist an adduction force on the index finger from one of the examiner’s fingers as another palpates the tone of the first dorsal interosseous muscle. The radial nerve does not innervate any intrinsic muscles; therefore, its function is tested by resisted extension of the wrist and the metacarpophalangeal (MCP) joints. The examiner should be aware that extension of the IP joints can occur through the ulnar nerve-innervated intrinsic muscles even in the total absence of radial nerve function. Finally, objective strength measurements can be obtained through commercially available grip and pinch dynamometers.

By this point in the examination, the physician has evaluated the integrity of the skin and vascularity with inspection; the bony and ligamentous structures with range of motion tests and palpation; the sensory nerves with sensibility tests; and the motor nerves, muscles, and tendons with manual motor tests. Finally, there are a number of provocative maneuvers that attempt to isolate and stress specific areas of the hand and wrist confirm or refute the suspected diagnosis. These are discussed individually as each disorder is reviewed throughout the Chapter.