Evaluation of the Wrist
The wrist is inspected for gross deformity, redness, and swelling (including focal swelling from a ganglion cyst) and is gently felt for warmth and to detect subtle swelling. Findings may be compared to the unaffected side.
The bones, the joint, and the soft tissues are palpated for tenderness. Tenderness at the anatomic snuffbox (an indentation between the extensor pollicis longus on the ulnar side and the abductor pollicis longus and the extensor pollicis brevis on the radial side) suggests a scaphoid injury. The snuffbox is best shown by having the patient extend the thumb like a hitch-hiker.
Complete range of motion is attempted, including extension and flexion and radial and ulnar deviation. Extension and flexion can be compared bilaterally by having patients put their elbows up, first with the palms together and then with the backs of the hands together.
If the patient's symptoms permit, provocative testing for tendinopathy and ligamentous laxity can be done. The Finkelstein test is done to look for De Quervain syndrome, which is tenosynovitis of the 1st extensor compartment. For this test, the patient makes a fist with the thumb inside the fingers, and then gentle passive ulnar deviation is applied; the test is positive if pain is elicited. To assess the stability of the distal radial-ulnar articulation, the examiner grasps the distal ulna with the fingers of one hand and the distal radius with the other and pulls them up and down in opposition to each other.
Needle entry occurs distal to the Lister tubercle and ulnar to the extensor pollicis longus tendon, with axial traction, 20 to 30° of flexion, and ulnar deviation applied to the hand to facilitate entry into the joint space. The extensor pollicis longus tendon can be identified more easily if the patient actively extends the wrist and thumb. A 25- to 30-gauge needle is used to place a wheal of local anesthetic over the needle entry site. A 1-inch (2.54 cm), 22-gauge needle is used to aspirate the joint. The skin is entered perpendicularly, and needle is advanced aiming toward the volar side of the wrist, with back pressure on the syringe plunger during the advance. Synovial fluid will enter the syringe when the joint is entered.