Introduction  

The wrist is one of the most complex anatomical structures and features eight bones that are collectively known as the carpus or carpal bones. The carpus is comprised of the scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, and hamate.
Moving distally, we will have the metacarpals and phalangeals, as well as the distal radius and ulna.

Epidemiology

Wrist and hand pain is reported to have a point prevalence of about 13% with women being almost twice as often affected as men across all age groups (Picavet et al. 2003).

Course

The Dutch GP Association reports on the course of wrist and hand pain (NHG 2010). The course of wrist and hand pain appears to be unfavorable as only 25% of patients recover after three months and 40% after one year. Prosser et al. (2012) report that patients who received arthroscopy for nonspecific wrist pain had a 50% chance to have moderate levels of pain and low levels of disability one-year post-surgery.

Prognostic factors (Artus et al. 2017, NHG 2010, Prosser et al. 2012)

The following prognostic factors are specifically described for the wrist and hand:

• old age
• female gender
• long duration (>3 months)
• somatisation (+ fracture = increased risk for CRPS)
• less control over pain and function
• baseline Patient-Reported Wrist and Hand Examination (PRWHE)

Furthermore, you should not forget the prognostic factors for general MSK complaints by Artus et al.:

• widespread pain
• high functional disability
• somatization
• high pain intensity
• presence of previous pain episodes

Red flags

There are several specific pathologies that count as red flags. These are:

Fractures

Common fractures are those of the scaphoid, distal ulna, and distal radius.
Distal radius fractures are:

• Smith fractures: distal head of the radius fractures with volar angulation of the fragment(s)
• Colles fractures: Most common after FOOSH (fall on an outstretched hand) trauma. Impact of the scaphoid on the distal radius leads to fracture and dorsal angulation of the radial fragment(s)

Karaca et al (2016) developed the Karadeniz Wrist Rule to screen for fractures of the wrist. Check the video below to learn how to do them.

Ligament Lesions

“Gamekeeper’s thumb/ski pole thumb” (Opposition trauma)

Signs & Symptoms include:

• Pain
• Ecchymosis of the thumb MCP
• Weakness of pinch grasp

Scapholunate (SL) ligament lesion

Signs & symptoms include:

• Clicking and pain on the dorsoradial aspect of the wrist
• Clear wrist trauma in history
• Swelling
• Diminished grip strength & reduced ROM

Vascularization issues / Decalcification

• SNAC: Scaphoid Non-Union Advanced Collapse (due to non-healed scaphoid fracture)
• SLAC: Scaphoid-Lunated Advanced Collapse (due to ruptured SL-ligament)

Signs and symptoms include:

• Wrist pain
• Dorsoradial swelling
• Limited ROM
• Tenderness of the radiocarpal and mid-carpal joint

Basic Assessment

Let’s start with active range of motion:

Standard values for the range of motion in different directions are as follows: 

AROM assessment is then typically followed by Passive Range of Motion Assessment (PROM) that you can watch with a click on the following video:

During PROM assessment, it’s important to compare the range of motion as well as the end-feel of the affected with the unaffected side.

Specific Pathologies in the Wrist & Hand

There are several pathologies that are commonly seen in the wrist & hand. For more information, click on the respective pathology (content will be added in the near future):

• Carpal Tunnel Syndrome
• De Quervain’s Disease
• Triangular Fibrocartilage Complex (TFCC) Lesions
• Intercarpal Instability
• Impaired Blood Flow & Vascularization

References

Artus, Majid et al. “Generic Prognostic Factors for Musculoskeletal Pain in Primary Care: A Systematic Review.” BMJ Open 7.1 (2017): e012901. PMC. Web. 6 Sept. 2018.

Cevik, Arif Alper, et al. “Evaluation of physical findings in acute wrist trauma in the emergency department.” Ulusal travma ve acil cerrahi dergisi= Turkish journal of trauma & emergency surgery: TJTES 9.4 (2003): 257-261.

Christensen, Thomas, et al. “Long-term outcomes of primary repair of chronic thumb ulnar collateral ligament injuries.” Hand 11.3 (2016): 303-309.

Herziening, Eerste. “NHG-Standaard Hand-en polsklachten.” Huisarts en wetenschap 1.2010 (2010): 22-39.

Karaca, Yunus, et al. “A study to develop clinical decision rules for the use of radiography in wrist trauma: Karadeniz wrist rules.” The American journal of emergency medicine 34.11 (2016): 2074-2078.

Picavet, H. S. J., and J. S. A. G. Schouten. “Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC3-study.” Pain 102.1-2 (2003): 167-178.

Prosser, Rosemary, et al. “Prognosis and prognostic factors for patients with persistent wrist pain who proceed to wrist arthroscopy.” Journal of Hand Therapy 25.3 (2012): 264-270.

Shah, C. M., & Stern, P. J. (2013). Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist arthritis. Current reviews in musculoskeletal medicine, 6(1), 9-17.