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Wrist Pathology
Acknowledgments
The authors would like to thank the previous authors of this chapter, Owen L. Ala, MD and T. Shane Johnson, MD, for their contributions.
Physical Examination of the Wrist
When performing a physical examination of the wrist, it is helpful to approach the wrist in a systematic fashion based on anatomical regions. Knowledge of anatomical landmarks will help the practitioner develop a differential diagnosis, while several exam maneuvers can help in making the correct diagnosis. The importance of wrist palpation based on anatomical region cannot be understated. Imaging can then be used to aid in the diagnostic process. In this chapter, we will use an anatomical approach to the wrist to identify and better understand commonly seen wrist pathologies and their treatments.
Radial-Sided Wrist Pain
The bones, tendons, and ligaments that lie on the radial side of the wrist can all be sources of pain for the patient. The first extensor compartment contains the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons and can be a source of significant pain, known as De Quervain’s tenosynovitis. These tendons can be identified making up the lateral/radial border of the anatomical snuffbox at the level of the radial styloid. Pain with palpation over this compartment or a Finkelstein’s test – clasping the thumb in the palm with ulnar deviation of the wrist – will confirm the diagnosis. Pain elicited with this maneuver more proximal in the forearm can be the result of intersection syndrome. Palpating just distal to the radial styloid in the anatomical snuffbox can indicate scaphoid pathology. The distal pole of the scaphoid can be palpated at the base of the thenar eminence. This can be confirmed by ranging the wrist from radial to ulnar deviation and feeling the scaphoid flex and extend. Palpating just distal to the anatomical snuffbox can elicit tenderness in the scaphoid–trapezium–trapezoid (STT) or trapezium–metacarpal (carpometacarpal, CMC) joint of the thumb. Pain in this region is commonly seen in CMC arthritis.
Central Wrist Pain
Just ulnar to the anatomical snuffbox on the dorsal side of the wrist is the “soft spot,” which is the region of the scapholunate (SL) ligament. The Watson shift test can be performed to assess the integrity of the SL ligament; this is performed by moving the wrist from ulnar hyperextension to radial flexion while pressing on the scaphoid tubercle volarly and assessing for a “clunk.” The contralateral wrist should always be assessed for comparison. Pain in the dorsal midline of the wrist can also be the result of Kienböck’s disease. The distal radioulnar joint (DRUJ) is assessed more proximally. A radioulnar ballottement test can be used to test for congruency of the DRUJ.
Ulnar-Sided Wrist Pain
The ulnar-sided wrist exam should start by palpating the ulnar head and ulnar styloid. Pain with palpation of the ulnar soft spot or fovea can be an indication of triangular fibrocartilage complex (TFCC) pathology. Injury to the TFCC can be confirmed with magnetic resonance imaging (MRI) or arthroscopy. Pain elicited by pushing the distal ulna in a radial direction like a “piano key” is a sign of DRUJ instability or injury. Immediately dorsal to the ulnar soft spot lies the extensor carpi ulnaris (ECU) tendon. Pain and snapping while performing ulnar flexion and supination of the wrist indicates ECU tendinitis and subluxation respectively. Pain on the volar side of the ulnar wrist is likely due to injury to the pisiform or hook of the hamate. This can be seen from both arthritic and traumatic pathologies.
Kienböck’s Disease
Pest first described avascular necrosis of the lunate based on cadaveric dissections although the disease gets its name from radiologist Robert Kienböck. Despite Kienböck’s disease being described over 100 years ago, the etiology and natural history are not clearly understood and it is thought to result from a vascular etiology. Kienböck’s disease presents in patients as wrist pain, usually located centrally over the dorsum of the wrist, and is rarely bilateral. Pain is usually present with wrist motion, but as the disease progresses, pain at rest is frequent. This diagnosis is commonly seen in men 20–40 years of age. It was originally thought that trauma to the lunate likely results in Kienböck’s disease, although long‐term follow-up studies have shown that lunate fractures do not reliably develop avascular necrosis, even with an ulnar negative variance. Ulnar negative variance has been associated with Kienböck’s disease, prompting many to point to this anatomical feature as a possible etiology. Hulten’s classic study in 1928 showed an association between ulnar negative variance and Kienböck’s disease but more recent studies do not demonstrate a clear correlation.
Clinical Evaluation
The clinical evaluation of the patient with Kienböck’s disease starts with a thorough physical exam of the wrist. However, the exam findings for Kienböck’s disease are usually nonspecific. Dorsal wrist pain, often with motion or activity, is the main physical exam finding. Radiographic evaluation is followed by the physical exam. Kienböck’s disease can be diagnosed by correlating the physical exam with radiographs, however imaging using MRI is often necessary for definitive diagnosis. Radiographs are evaluated for sclerosis of the lunate and negative ulnar variance.
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