Physical Examination of the Wrist: Useful Provocative Maneuvers

Clinical and Radiographic Evaluation of Ulnar-Sided Wrist Pain

PURPOSE OF REVIEW

Ulnar-sided wrist pain is a challenging diagnostic workup. A thorough and complete physical examination followed by appropriate radiographic studies can help the clinician diagnose and treat these conditions.

RECENT FINDINGS

Recent research has been focused on diagnostic modalities such as arthroscopy and high-resolution MRI. Ulnar-sided wrist pain is a challenging clinical workup that must be approached systematically with the aid of adjunctive diagnostic modalities.

Visualization of wrist ligaments with 3D and 2D magnetic resonance imaging at 3 Tesla

BACKGROUND

Wrist ligaments are challenging to visualize using magnetic resonance imaging (MRI). Injuries involving the scapholunate ligament (SLL), the lunotriquetral ligament (LTL), and the triangular fibrocartilage complex (TFCC) are common and difficult to diagnose, often requiring diagnostic arthroscopy.

PURPOSE

To compare the visualization of wrist ligaments on a three-dimensional (3D) sequence with two-dimensional (2D) sequences on 3-T MRI.

MATERIAL AND METHODS

Eighteen healthy volunteers were examined with a 3D SPACE (sampling perfection with application optimized contrasts using different flip angle evolution) sequence and 2D coronal, axial, and sagittal proton density-weighted (PD) sequences. Four musculoskeletal radiologists graded the anatomical visibility of the SLL, LTL, TFCC, and the image quality, using five grades in a visual grading characteristics (VGC) evaluation. After Bonferroni correction, a P value ≤0.005 was considered statistically significant.

RESULTS

The 3D images were graded significantly better than the 2D images in the visualization of the dorsal and palmar parts of the SLL and the LTL. Regarding the TFCC, the 3D images were graded significantly better for visualization of the foveal attachment. 2D imaging was not found significantly superior to 3D imaging in any aspect.

CONCLUSION

The 3D SPACE sequence was scored as superior to the 2D sequences at 3 T in the assessment of the SLL, the LTL, and the foveal attachment of the TFCC. Thus, 3D SPACE can replace 2D PD sequences when these ligaments need to be assessed.

Examination of Ulnar-sided Wrist Pain

This article reviews the pertinent history and physical examination maneuvers necessary to arrive at the proper diagnosis of patients with ulnar-sided wrist pain. Surface anatomy is stressed along with provocative maneuvers for maximal efficacy.

Ulnar-sided wrist pain: a prospective analysis of diagnostic clinical tests

BACKGROUND

Identifying the cause of pain on the ulnar side of the wrist can be challenging. The outcome and recovery following surgery can be unpredictable. The aim of this study was to document and analyse the clinical tests used to evaluate the cause of ulnar-sided wrist pain and determine their diagnostic relevance.

METHODS

This is a prospective evaluation of 110 patients who presented with pain on the ulnar side of the wrist. The clinical evaluation and results from radiological investigations were documented and analysed.

RESULTS

There were 17 different diagnoses. Eighty-five percent of the diagnoses were triangular fibrocartilage complex (TFCC) injuries, ulnocarpal abutment syndrome (UCAS), pisotriquetral arthritis (PTA), triquetral fracture or non-union, distal radioulnar joint arthritis (DRUJ OA) and extensor carpi ulnaris (ECU) pathology. The ulnocarpal stress test and ulnar foveal sign were positive in several diagnoses. The ulnar foveal sign had a sensitivity and specificity of 89% and 48% for TFCC injuries, and 85% and 37% for UCAS, respectively. The sensitivity and specificity of pisotriquetral shear test for PTA was 100% and 92%, respectively. Patients with PTA or ECU pathology localised their pain better on the patient's pain localisation chart.

CONCLUSION

Diagnosis of TFCC injuries, UCAS, DRUJ OA and ECU injuries are challenging as the clinical symptoms and signs for the four diagnoses were similar and required either magnetic resonance imaging or computed tomography for diagnostic confirmation after clinical examination. The ulnocarpal stress test and the ulnar foveal sign were not sufficiently specific.

Visualization of wrist anatomy-a comparison between 7T and 3T MRI

OBJECTIVE

Injuries to the wrist are, due to its small size and complex anatomical structures, difficult to assess by MR, and surgical interventions such as diagnostic arthroscopy are often necessary. Therefore, improved visualization using non-invasive methods could be of clinical value. As a first step of improvement, the purpose of this study was to evaluate visualization of anatomical structures at 7T compared with 3T MR.

METHODS

Eighteen healthy volunteers (three males and three females from each age decade between 20 and 49 years) were examined with 7T and 3T MR. Four musculoskeletal radiologists graded 2D and 3D images on a five-level grading scale for visibility of ligaments, cartilage, nerves, trabecular bone, and tendons, as well as overall image quality (i.e., edge sharpness, perceived tissue contrast, and presence of artefacts). Statistical analysis was done using a visual grading characteristics (VGC) analysis.

RESULTS

Visibility of cartilage, trabecular bone, tendons, nerves, and ligaments was graded significantly higher at 7T with an area under the curve (AUC_VGC) of 0.62-0.88 (95% confidence interval [CI] 0.50-0.97, p = < 0.0001-0.03) using either 2D or 3D imaging. Imaging with 3T was not graded as superior to 7T for any structure. Image quality was also significantly superior at 7T, except for artefacts, where no significant differences were found.

CONCLUSIONS

Tendons, trabecular bone, nerves, and ligaments were all significantly better visualized at 7T compared to 3T.

KEY POINTS

• MRI of the wrist at 7T with a commercially available wrist coil is feasible at similar acquisition times as for 3T MRI. • The current study showed 7T to be superior to 3T in the visualization of anatomical structures of the wrist, including ligaments, tendons, nerves, and trabecular bone. • Image quality was significantly superior at 7T, except for artefacts, where no significant differences were found.

Examination of the Wrist

LEARNING OBJECTIVES

After reading this article and reviewing the supplemental videos, the participant should be able to: 1. Identify common wrist conditions that may be encountered on evaluation. 2. Describe provocative maneuvers used to confirm a diagnosis of wrist disorder. 3. Develop a systematic approach to examination of the wrist. 4. Determine appropriate diagnostic maneuvers for radial, central, and ulnar wrist pain.

SUMMARY

The wrist is a complex structure, and providers caring for hand and upper extremity conditions need to have an understanding of the wrist examination and provocative maneuvers for conditions that are encountered. Fractures, tendonitis, arthritis, and instabilities are all commonly encountered, and the provider should have an idea of the diagnosis based on clinical examination and use imaging as needed to confirm or stage a diagnosis.

Osteoid osteoma of the wrist misdiagnosed as de Quervain's tenosynovitis due to normal X-ray at the first visit: A case report

INTRODUCTION

Osteoid osteomas are benign bone tumors that can occur in various bones throughout the body but are mainly found in the long bones.

PRESENTATION OF THE CASE

We report the case of a patient who had been treated for more than three years for a case of de Quervain's tenosynovitis due to tenderness in the first compartment of the right wrist joint. An X-ray on his first visit to a clinic was normal, but it was eventually discovered that he had an osteoid osteoma of the wrist.

DISCUSSION

The age of onset and gender proclivity of each disease should be considered. An X-ray should be taken in cases such as this, even to diagnose tendonitis. When any symptom, such as pain, has lingered for a long time and resisted treatment, we must reconsider the diagnosis. In patients with a low risk of tendonitis, it is essential to consider the possibility of other diseases if there is no improvement after treatment. As this patient's tumor was missed on the initial X-ray, it grew to a mature case of osteoid osteoma in three years.

CONCLUSION

We experienced a very educational case of osteoid osteoma of the wrist misdiagnosed as de Quervain's tenosynovitis.

Biomechanical Evaluation of Distal Radioulnar Joint Instability and Adams Procedure

PURPOSE

Distal radioulnar joint (DRUJ) instability may occur after an injury, resulting in pain and reduced strength. When primary repair is not possible or initial fixation has failed, chronic instability may result, requiring a reconstructive procedure such as the Adams procedure. The first purpose of this study was to evaluate the role of the triangular fibrocartilage complex and various components of the interosseous membrane as they were sectioned. The second purpose was to evaluate the Adams procedure in stabilizing the forearm.

METHODS

Eight fresh cadaver forearms were dynamically moved through an average range of 56.8° pronation to 54.8° supination and tested first with the forearm intact and then after sectioning each of the following structures: the dorsal (DRUL) and palmar radioulnar ligaments (PRUL), the distal interosseous membrane, and the central band. Finally, they were tested after reconstruction using the Adams procedure. During each forearm motion and provocative shuck, the motion of the radius and ulna were measured and the locations of the radial attachments of the DRUL, PRUL, and sigmoid notch and ulnar fovea were computed.

RESULTS

Significant increases in the gap between the ulnar fovea and the attachment sites of the DRUL and PRUL were observed with incremental sectioning, most notably after sectioning of the central band. Reconstruction significantly reduced the gap at the DRUL and PRUL sites during dynamic motion.

CONCLUSIONS

This study reinforces the concept that DRUJ stability depends on more than the radioulnar ligaments, ulnocarpal ligaments, and triangular fibrocartilage complex, but is also significantly affected by the distal and central interosseous membrane. Reconstruction reduces gapping.

CLINICAL RELEVANCE

These results suggest that the Adams reconstruction is a reasonable option to address DRUJ instability but may be an incomplete solution in the setting of a ruptured interosseous ligament.

Surgical Techniques for the Treatment of Acute Carpal Ligament Injuries in the Athlete

The treatment of athletes with carpal ligament injuries provides many challenges. Our initial goals remain to make a timely and accurate diagnosis, provide treatment options, and create an environment for shared decision making. To optimize outcomes and facilitate return to play, early surgical intervention may be warranted. This article reviews common carpal ligament injury patterns in the athlete with a focus on both classic and newer surgical techniques.

Nonsurgical Treatment for Acute Posttraumatic Distal Radioulnar Joint Instability: A Case Series

Purpose

We investigated the clinical outcomes of patients with acute posttraumatic distal radioulnar joint (DRUJ) instability who were treated with our nonsurgical protocol.

Methods

The electronic database of our community-based orthopedic practice was queried to identify patients with posttraumatic wrist pain and DRUJ instability who presented for treatment less than 6 weeks after injury. Medical records review defined a cohort of 16 patients treated between November, 2000 and December, 2016 with immobilization of the wrist and elbow for 6 weeks and gradual return to full activity at 6 months after injury. Data from the medical records were compiled and analyzed to assess short-term outcomes. Eight patients with a minimum 2-year follow-up completed questionnaires and underwent a wrist-focused examination to assess long-term outcomes. We used Wilcoxon signed-ranks exact test and McNemar chi-square exact test to confirm the statistical significance of observed trends in key outcome measures.

Results

At a mean long-term follow-up of 6.7 years, there was statistically significant improvement in ulnar-sided wrist pain and all eight subjects examined demonstrated a negative dorsopalmar stress test indicating improved DRUJ stability. Analysis of the entire cohort showed that 11 of 16 patients (69%) were overall improved with respect to wrist pain and DRUJ stability at final follow-up evaluation. Ulnar-positive variance was a relative contraindication to nonsurgical treatment.

Conclusions

Prompt above-elbow immobilization of patients with acute posttraumatic DRUJ instability may result in a good clinical outcome without operative treatment.

Type of study/level of evidence

Therapeutic IV.

[Carpus and distal radioulnar joint : Clinical and radiological examination]

A precise medical history and specific symptom-oriented clinical tests of the wrist joint should always precede any radiological, computed tomography (CT) or magnetic resonance imaging (MRI) diagnostics. In many cases, specific clinical tests of the wrist joint allow at least a preliminary diagnosis, which can be supported by standard radiography using correct projections. A systematic approach is recommended covering the radiocarpal, midcarpal, ulnocarpal and distal radioulnar joints. Exact identification of the palpable anatomic landmarks is mandatory for correct application and interpretation of the various clinical tests. The results of the clinical tests in combination with radiological imaging can often detect precisely ruptures of distinct wrist joint ligaments and localized arthritis.

Scapholunate and perilunate injuries in the athlete

PURPOSE OF THE REVIEW

Scapholunate and perilunate injuries can be difficult to diagnose and treat in the athlete. In this review article, we present the mechanism of injury, evaluation, management, and outcomes of treatment for these injuries.

RECENT FINDINGS

Acute repair of dynamic scapholunate ligament injuries remains the gold standard, but judicious use of a wrist splint can be considered for the elite athlete who is in season. The treatment of static scapholunate ligament injury remains controversial. Newer SL reconstructive techniques that aim to restore scapholunate function without compromising wrist mobility as much as tenodesis procedures show promise in athlete patients. Acute injuries to the scapholunate ligament are best treated aggressively in order to prevent the sequelae of wrist arthritis associated with long-standing ligamentous injury. Acute repair is favored. Reconstructive surgical procedures to manage chronic scapholunate injury remain inferior to acute repair. The treatment of lunotriquetral ligament injuries is not well defined.