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Wrist and Hand


Clinical Summary and Recommendations

Patient History
Complaints

  • Overall subjective complaints do not appear useful in identifying carpal tunnel syndrome. Only reports of “dropping objects” and “shaking hand improves symptoms” statistically altered the probability of the diagnosis and then only minimally (+LR [likelihood ratio] = 1.7 to 1.9, −LR = .34 to .47).

Physical Examination
Screening

  • Physical examination cannot accurately rule in scaphoid fracture, but the absence of snuffbox tenderness can substantially reduce the probability of scaphoid fracture (+LR = 1.5, −LR = 0.15).

  • Clinical prediction rules for identifying wrist fractures in adults and children based on eight variables (age, sex, swelling of the wrist, swelling of the anatomical snuffbox, visible deformation, distal radius tender to palpation, pain on radial deviation, and painful axial compression of the thumb) can be useful to screen patients with acute wrist trauma (app and calculator available at http://www.amsterdamwristrules.nl/ ).

Range-of-Motion, Strength, and Sensation Assessments

  • Measuring wrist range of motion appears to be highly reliable but is of unknown diagnostic utility. Measuring finger and thumb range of motion is less reliable, even when it is performed by the same examiner.

  • Assessing strength with dynamometry has consistently been shown to be highly reliable but, again, is of unknown diagnostic utility. Manual muscle testing of the abductor pollicis brevis muscle does not appear to be very helpful in identifying carpal tunnel syndrome.

  • Sensory testing of the hand is of poor to moderate reliability. Only sensory loss at the pad of the thumb appears helpful in identifying carpal tunnel syndrome, and then only minimally (+LR = 2.2, −LR = .49).

Special Tests

  • Evidence for the diagnostic utility of the Tinel sign, Phalen test, and carpal tunnel compression test is highly variable. The highest-quality studies of each suggest that none of the three tests is particularly helpful in identifying carpal tunnel syndrome. Additionally, one study found all three tests to be both more sensitive and more specific in identifying tenosynovitis than carpal tunnel syndrome.

  • The ulnar fovea sign appears to be very useful at ruling in or ruling out foveal disruption of the distal radioulnar ligaments and ulnotriquetral ligament injuries (+LR = 7.1, −LR =.06).

  • The metacarpal adduction (+LR = 13.4, −LR = .06) and extension provocation maneuvers (+LR = 18.8, −LR = .06) appear to be useful at ruling in or ruling out trapeziometacarpal arthritis.

Combinations of Findings

  • Although not yet validated, a clinical prediction rule appears to be very effective at identifying carpal tunnel syndrome. The presence of five variables (a Hand Severity Scale score of more than 1.9, a wrist ratio index higher than .67, a patient report of shaking the hand for symptom relief, diminished sensation on the thumb pad, and age over 45 years) was found to be associated with a +LR of 18.3.

Anatomy

Osteology

Figure 11-1, Carpal bones.

Figure 11-2, Bones of wrist and hand.

Arthrology

Figure 11-3, Wrist joint.

Joints Type and Classification Closed Packed Position Capsular Pattern
Radiocarpal Synovial: condyloid Full extension Limitation equal in all directions
Intercarpal Synovial: plane Extension Limitation equal in all directions
Carpometacarpal (CMC) Synovial: plane, except for first CMC, which is sellar Full opposition Limitation equal in all directions
Metacarpophalangeal (MCP) Synovial: condyloid Extension except for first digit Limitation equal in all directions
Interphalangeal (IP) Synovial: hinge Extension Flexion greater than extension

Ligaments

Palmar Ligaments of the Wrist

Figure 11-4, Palmar ligaments of wrist.

Ligaments Attachments Function
Transverse carpal Hamate and pisiform medially, and scaphoid and trapezium laterally Prevents bowstringing of finger flexor tendons
Palmar radiocarpal (radioscapholunate and radiocapitate portions) Distal radius to both rows of carpal bones Reinforces fibrous capsule of wrist volarly
Palmar ulnocarpal (ulnolunate and ulnotriquetral portions) Distal ulna to both rows of carpal bones Reinforces fibrous capsule of wrist volarly
Palmar radioulnar Distal radius to distal ulna Reinforces volar aspect of distal radioulnar joint
Radial collateral Radial styloid process to scaphoid Reinforces fibrous capsule of wrist laterally
Ulnar collateral Ulnar styloid process to triquetrum Reinforces fibrous capsule of wrist medially
Pisometacarpal Pisiform to base of fifth metacarpal Reinforces fifth CMC joint
Pisohamate Pisiform to hook of hamate Maintains proximity of pisiform and hamate
Capitotriquetral Capitate to triquetrum Maintains proximity of capitates and triquetrum
Palmar CMC Palmar aspect of carpals to bases of metacarpals 2 to 5 Reinforces volar aspect of CMC joints 2 to 5
Palmar metacarpal Attaches bases of metacarpals 2 to 5 Maintains proximity between metacarpals

Posterior Ligaments of the Wrist

Figure 11-5, Posterior ligaments of wrist.

Ligaments Attachments Function
Dorsal radioulnar Distal radius to distal ulnar Reinforces dorsal aspect of distal radioulnar joint
Dorsal radiocarpal Distal radius to both rows of carpal bones Reinforces fibrous capsule of wrist dorsally
Dorsal CMC Dorsal aspect of carpals to bases of metacarpals 2 to 5 Reinforces dorsal aspect of CMC joints 2 to 5
Dorsal metacarpal Attaches bases of metacarpals 2 to 5 Maintains proximity between metacarpals

Metacarpophalangeal and Interphalangeal Ligaments

Figure 11-6, Metacarpophalangeal and interphalangeal ligaments.

Ligaments Attachments Function
Collateral ligaments of IP joints Sides of distal aspect of proximal phalanx to proximal aspect of distal phalanx Reinforces medial and lateral capsules of IP joints
Deep transverse metacarpal ligaments Connects adjacent MCP joints Reinforces MCP joints
Palmar ligament (volar plate) Individual plates attach to palmar aspect of MCP and IP joints Reinforces palmar aspect of MCP and IP joints

Muscles

Extensor Muscles of the Wrist and Digits

Figure 11-7, Extensors of wrist and digits.

Muscles Proximal Attachments Distal Attachments Nerve and Segmental Level Action
Extensor carpi radialis longus Lateral supracondylar ridge of humerus Base of second metacarpal Radial nerve (C6, C7) Extends and radially deviates wrist
Extensor carpi radialis brevis Lateral epicondyle of humerus Base of third metacarpal Deep branch of radial nerve (C7, C8) Extends and radially deviates wrist
Extensor carpi ulnaris Lateral epicondyle of humerus Base of fifth metacarpal Radial nerve (C6, C7, C8) Extends and ulnarly deviates wrist
Extensor digitorum Lateral epicondyle of humerus Extensor expansions of digits 2 to 5 Posterior interosseous nerve (C7, C8) Extends digits 2 to 5 at MCP and IP joints
Extensor digiti minimi Lateral epicondyle of humerus Extensor expansion of fifth digit Posterior interosseous nerve (C7, C8) Extends fifth digit at MCP and IP joints
Extensor indicis Posterior aspect of ulna and interosseous membrane Extensor expansion of second digit Posterior interosseous nerve (C7, C8) Extends second digit and assists with wrist extension
Abductor pollicis longus Posterior aspect of ulnar, radius, and interosseous membrane Base of first metacarpal Posterior interosseous nerve (C7, C8) Abducts and extends thumb
Extensor pollicis brevis Posterior aspect of radius and interosseous membrane Base of proximal phalanx of thumb Posterior interosseous nerve (C7, C8) Extends thumb
Extensor pollicis longus Posterior aspect of ulnar and interosseous membrane Base of distal phalanx of thumb Posterior interosseous nerve (C7, C8) Extends distal phalanx of thumb at MCP and IP joints

Flexor Muscles of the Wrist and Digits

Figure 11-8, Flexors of wrist and digits.

Muscles Proximal Attachments Distal Attachments Nerve and Segmental Level Action
Flexor carpi radialis Medial epicondyle of humerus Base of second metacarpal bone Median nerve (C6, C7) Flexes and radially deviates hand
Flexor carpi ulnaris Medial epicondyle of humerus and olecranon and posterior border of ulna Pisiform, hook of hamate, and fifth metacarpal Ulnar nerve (C7, C8) Flexes and ulnarly deviates hand
Palmaris longus Medial epicondyle of humerus Distal aspect of flexor retinaculum and palmar aponeurosis Median nerve (C7, C8) Flexes hand and tightens palmar aponeurosis
Flexor digitorum superficialis (humeroulnar head) Medial epicondyle of humerus, ulnar collateral ligament, coronoid process of ulna Bodes of middle phalanges of digits 2 to 5 Median nerve (C7, C8, T1) Flexes digits at proximal IP joints 2 to 5 and at MCP joints 2 to 5
Flexor digitorum superficialis (radial head) Superoanterior border of radius
Flexor digitorum profundus (median portion) Proximal anteromedial aspect of ulnar and interosseous membrane Bases of distal phalanges of digits 2 to 5 Ulnar nerve (C8, T1) Flexes digits at distal IP joints 2 to 5 and assists with flexion of hand
Flexor digitorum profundus (lateral portion) Median nerve (C8, T1)
Flexor pollicis longus Anterior aspect of radius and interosseous membrane Base of distal phalanx of thumb Anterior interosseous nerve (C8, T1) Flexes phalanges of first digit

Intrinsic Muscles of the Hand

Figure 11-9, Intrinsic muscles of hand.

Muscles Proximal Attachments Distal Attachments Nerve and Segmental Level Action
Opponens pollicis Flexor retinaculum, scaphoid, and trapezium Lateral aspect of first metacarpal Median nerve (C8, T1) Opposes and medially rotates thumb
Abductor pollicis brevis Lateral aspect of base of proximal phalanx of thumb Abducts thumb and assists in thumb opposition
Flexor pollicis brevis Flexes thumb
Adductor pollicis (oblique head) Bases of metacarpals 2 and 3 and capitates Medial aspect of base of proximal phalanx of thumb Deep branch of ulnar nerve (C8, T1) Adducts thumb
Adductor pollicis (transverse head) Anterior aspect of third metacarpal
Abductor digiti minimi Pisiform Medial aspect of base of proximal phalanx of fifth digit Abducts fifth digit
Flexor digiti minimi Hook of hamate and flexor retinaculum Flexes proximal phalanx of fifth digit
Opponens digiti minimi Medial aspect of fifth metacarpal Draws fifth digit at MCP joints and extends IP joints
Lumbricals (lateral) Tendons of flexor digitorum profundus Lateral sides of extensor expansions 2 to 5 Median nerve (C8, T1) Flexes digits at MCP joints and extends IP joints
Lumbricals (medial) Deep branch of ulnar nerve (C8, T1)
Dorsal interosseous Adjacent sides of two metacarpals Bases of proximal phalanges 2 to 4 and extensor expansion Deep branch of ulnar nerve (C8, T1) Abducts digits and assists with action of lumbricals
Palmar interosseous Palmar aspect of metacarpals 2, 4, and 5 Bases of proximal phalanges 2, 4, and 5 and extensor expansion Adducts digits and assists with action of lumbricals

Figure 11-10, Intrinsic muscles of hand (continued).

Nerves

Median Nerve

Figure 11-11, Median nerve.

Nerve Segmental Level Sensory Motor
Median nerve C6, C7, C8, T1 Palmar and distal dorsal aspects of lateral
3 1 2
digits and lateral palm		 Abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, lateral lumbricals

Ulnar Nerve

Figure 11-12, Ulnar nerve.

Nerve Segmental Level Sensory Motor
Ulnar nerve C7, C8, T1 Palmar and distal dorsal aspects of medial
1 1 2
digits and medial palm		 Interosseous, adductor pollicis, flexor pollicis brevis, medial lumbricals, abductor digiti minimi, flexor digiti minimi brevis, opponens digiti minimi

Radial Nerve

Figure 11-13, Radial nerve.

Nerve Segmental Level Sensory Motor
Radial nerve C5, C6, C7, C8, T1 Dorsal aspect of lateral hand, excluding digits No motor in hand

Patient History

Initial Hypotheses Based on the Patient History

Reliability of the Historical Examination

History Initial Hypothesis
Pain over radial styloid process with gripping activities Possible de Quervain syndrome
Reports of an insidious onset of numbness and tingling in first three fingers; may complain that pain is worse at night Possible carpal tunnel syndrome
Reports of paresthesias over dorsal aspect of ulnar border of hand and fingers 4 to 5 Possible ulnar nerve compression at canal of Guyon , ,
Patient reports inability to extend MCP or IP joints Possible Dupuytren contracture
Possible trigger finger
Reports of falling on hand with wrist hyperextended; complains of pain with loading of wrist Possible scaphoid fracture ,
Possible carpal instability

History and Study Quality Population Interexaminer Reliability
Most bothersome symptom is pain, numbness, tingling, or loss of sensation? 82 patients presenting to primary care clinic, orthopaedic department, or electrophysiology laboratory with suspected cervical radiculopathy or carpal tunnel syndrome κ = .74 (.55, .93)
Location of most bothersome symptom? κ = .82 (.68, .96)
Symptoms intermittent, variable, or constant? κ = .57 (.35, .79)
Hand swollen? κ = .85 (.68, 1.0)
Dropping objects? κ = .95 (.85, 1.0)
Entire limb goes numb? κ = .53 (.26, .81)
Nocturnal symptoms wake patient? κ = .83 (.60, 1.0)
Shaking the hand improves symptoms? κ = .90 (.75, 1.0)
Symptoms exacerbated with activities that require gripping? κ = .72 (.49, .95)

Diagnostic Utility of Patient History in Identifying Carpal Tunnel Syndrome

History and Study Quality Population Reference Standard Sens Spec +LR −LR
Age over 45 years 82 patients presenting to a primary care clinic, orthopaedic department, or electrophysiology laboratory with suspected cervical radiculopathy or carpal tunnel syndrome Needle electromyography and nerve conduction studies .64 (.47, .82) .59 (.47, .72) 1.58 (.46, 2.4) .60 (.35, 1.0)
Most bothersome symptom is pain, numbness, tingling, or loss of sensation .04 (−.04, .11) .91 (.83, .98) .42 (.05, 3.4) 1.1 (.94, 1.2)
Location of most bothersome symptom .35 (.16, .53) .40 (.27, .54) .58 (.33, 1.0) 1.6 (1.1, 2.5)
Symptoms intermittent, variable, or constant .23 (.07, .39) .89 (.81, .97) 2.1 (.74, 5.8) .87 (.69, 1.4)
Reports of hand becoming swollen .38 (.20, .57) .63 (.50, .76) 1.0 (.57, 1.9) .98 (.68, 1.4)
Dropping objects .73 (.56, .90) .57 (.44, .71) 1.7 (1.2, 2.5) .47 (.24, .92)
Entire limb goes numb .38 (.20, .57) .80 (.69, .90) 1.9 (.92, 3.9) .77 (.55, 1.1)
Nocturnal symptoms wake patient .73 (.56, .90) .31 (.19, .44) 1.1 (.79, 1.4) .86 (.41, 1.8)
Shaking hand improves symptoms .81 (.66, .96) .57 (.43, .70) 1.9 (1.3, 2.7) .34 (.15, .77)
Symptoms exacerbated with activities that require gripping .77 (.61, .93) .37 (.24, .50) 1.2 (.91, 1.6) .62 (.28, 1.4)
Age 40 years or older 110 patients referred to laboratory for electrophysiologic examination Nerve conduction tests .80 .42 1.38 .48
Nocturnal symptoms .77 .28 1.07 .82
Bilateral symptoms .61 .58 1.45 .67

Figure 11-14, Carpal tunnel syndrome.

Diagnostic Utility of Signs and Symptoms in Identifying Wrist Fractures

Test and Study Quality Description and Positive Findings Population Reference Standard Sens Spec +LR −LR
Amsterdam Wrist Rules Eight variables (age, sex, swelling of the wrist, swelling of the anatomical snuffbox, visible deformation, distal radius tender to palpation, pain on radial deviation, and painful axial compression of the thumb) determine the probability of a fracture. Available at http://www.amsterdamwristrules.nl/ 395 consecutive adult patients presenting to emergency department with pain or tenderness secondary to acute wrist trauma Radiographic confirmation of wrist fracture 98.2 (95.1, 99.4) 21.0 (15.4, 27.9) 1.24 ∗ .09 ∗
Amsterdam Pediatric Wrist Rules Seven variables (age, sex, swelling of the distal radius, visible deformation, distal radius tender to palpation, anatomical snuffbox tender to palpation, and supination is tender) determine the probability of a fracture. Available at http://www.amsterdamwristrules.nl/ 379 children between 3 years and 18 years old, presenting at the emergency department with pain or tenderness secondary to acute wrist trauma 96.0 (92.0,98.0) 37.0 (31.0, 44.0) 1.52 ∗ .11 ∗
Pershad Pediatric Wrist Rules Perform radiograph if both clinical findings are present:

  • 1.

    Point tenderness over the distal radius

  • 2.

    Decrease of more than 20% in grip strength compared to the normal hand

94.0 (89.0, 97.0) 26.0 (20.0, 33.0) 1.27 ∗ .23 ∗
Webster Pediatric Wrist Rules Perform radiograph if at least one of the following clinical findings is present:

  • 1.

    Radial tenderness

  • 2.

    Focal swelling

  • 3.

    Reduction in range of supination and pronation

99.0 (95.0, 100.0) 11.0 (7.0, 17.0) 1.11 ∗ .09 ∗
Rivara Pediatric Wrist Rules Perform radiograph if at least one of the following clinical findings is present:

  • 1.

    Gross deformity

  • 2.

    Point tenderness

96.0 (91.0, 98.0) 22.0 (16.0, 28.0) 1.23 ∗ .18 ∗

∗ Values were calculated by the authors of this text.

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