Evaluation of Acute Wrist Injury

Differential Diagnosis

Most Common

1. Distal Radius Fractures

2. Scaphoid Fractures

3. Wrist Joint Sprain

4. Intercarpal Ligament sprain / tear

Less Common

1. Fracture of the hook of hamate

2. Triangular fibrocartilige complex Tear

3. Distal radioulnar joint instability

4. Scapholunate Disassociation

Not To Be Missed

1. Anterior dislocation of the Lunate

2. Perilunate Dislocation

3. Traumatic Ulnar Artery Aneurysm or Thrombosis (karate)

History

• Precise mechanism of Injury

• Site of pain, diagnosis may be divided into Dorsal vs Volar Pain

Examination

Always remember to examine the joint above (Elbow)

Inspection

1. Scars or stretch marks

2. Wasting of muscles

3. Obvious Deformity

4. Swelling in region of scaphoid

Palpation

1. Distal Forearm

2. Radial Snuffbox (this is the area surrounded by Extensor Pollicis Longus, Extensor Pollicis Brevis, and Abductor Pollicis Longus)

3. Base of metacarpals

4. Lunate: Palpated as a bony prominance proximal to the capitate sulcus on the dorsal aspect. On the radial side of the lunate lies the scapholunate joint.

5. Head of Ulna

6. Radio-Ulnar Joint

7. Scapholunate Joint

8. Triangular Fibrocartilage

9. Hamate: Hook of Hamate is 1cm distal and radial to the Pisiform.

10. Pisiform: Palpated at the flexor crease of the wrist on the Ulnar side.

Motion

Note that range of movement is measured determined actively first, if there is a deficiency, move on to passive range of motion. Any deficits should be measured with a goniometer. Note should be made of discrepence between active and passive movement.

Muscles

Measurement of muscle strength using the Oxford (MRC) Scale.

1. Flexion

2. Extension

3. Radial Deviation

4. Ulnar Deviation

NeuroVascular

1. Check and Grade reflexes (biceps (C5), brachioradialis (C6), and triceps (C7)

2. Check Pulses.

3. Sensation in radial / ulnar / median nerve

4. Strength in radial / ulnar / median nerve

Special Tests

1. Watson's Test to ascertain Scapholunate Injury

2. Stress Test of Fibrocartilage Complex

Investigations

1. Plain Films: Should be obtained for any trauma. Note that the proximal pole of the lunate fits into the concavity of the distal radius. In turn, the convex head of the capitate fits into the distal concavity of the lunate. These bones must line up with the third metacarpal.

2. Scaphoid Views:

3. Bone Scan: may be necessary to rule out subtle fractures.

4. CT scanning: particularly useful for evaluation of the distal radio-ulnar joint and the hamate / trapezium.

5. MRI

6. Arthrography: may be useful for ligamentous injury and triangular fibrocartilage tears.

7. Arthroscopy: Excellent for early scapholunate ligament tears. May be diagnostic and therapeutic.

Appendix

Wrist Joint Mechanics

Index

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