Disorders of the wrist

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23

Disorders of the wrist

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Lesions at the wrist often have a traumatic cause – either a single injury or overuse – and are localized. Usually the patient can locate the lesion precisely because wrist and hand disorders seldom cause referred pain. If the symptoms appear spontaneously and are diffuse over the entire wrist, arthritis, usually of the rheumatoid type, is very likely. Further data obtained from the history include pain at rest, pins and needles, twinges and functional loss. The interpretation of the functional examination is classic and encompasses inert structures (capsular, non-capsular and ligamentous lesions) and contractile structures.

Disorders of the inert structures

Limited range: capsular pattern

The capsular pattern is an equal degree of limitation of flexion and extension (Fig. 23.1). In advanced arthritis, fixation of the wrist in the neutral position takes place.

Traumatic arthritis

The discovery of a capsular pattern following a trauma should always induce further examination. Uncomplicated traumatic arthritis is rare and the finding of a post-traumatic capsular pattern is highly suggestive of a fracture. The radiographic picture is unreliable because it may take up to several weeks for radiological evidence of a fracture to be conclusive.1 This delay may be responsible for serious complications because failure to diagnose and immobilize carpal fractures often leads to non-union and avascular necrosis.2,3 However, the clinical picture is so evident that the diagnosis should not be missed: any case of traumatic arthritis of the wrist lasting for longer than 2 days should be considered as a fracture.

image Warning

A capsular pattern lasting for more than 2 days after trauma makes fracture, either of a carpal bone or of the epiphysis of the radius, a strong possibility.

History and examination

The history is that of an injury, varying from a simple thrust to a fall onto the outstretched and dorsiflexed hand. There is instant and severe pain that prevents hand movement. Initially the pain is localized but spreads over the entire wrist later on.

Inspection shows swelling of the wrist. On examination, a capsular pattern is found: passive flexion and extension are very painful and limited. The end-feel is that of a vibrant twang caused by a protective muscle spasm. Passive deviation of the wrist towards the painful side also increases the pain – a compression phenomenon that provides further evidence of a bony lesion. Careful palpation of the bones reveals localized tenderness. Most often the scaphoid bone is involved.4 In this case, tenderness will be elicited in the anatomical snuffbox.5 This is often described as a classic sign of scaphoid fracture and has a reported sensitivity of 90% but a low specificity of 40%.6 The scaphoid compression test also has a high sensitivity but a better specificity for scaphoid fractures. This test is performed by grasping the thumb and applying an axially directed compressive force along the line of the thumb metacarpal; wrist pain indicates a positive result.7

The scaphoid bone spans the joint between the proximal and distal rows of carpal bones and is most vulnerable: scaphoid fracture comprises between 51 and 78% of all carpal fractures.8–11 Young males and persons between 10 and 19 years of age are at highest risk for scaphoid fracture.12–14

Scaphoid fractures occur most easily during loading of a hyperextended wrist, possibly in combination with ulnar deviation. This movement tightens the palmar ligaments (the radiocapitate and radioscaphoid ligaments), so stabilizing the scaphoid against the radius. As the proximal pole is strongly stabilized, further loading and extension of the wrist causes bending forces on the distal pole, which may result in fracture.15,16

Fractures may occur at any level in the scaphoid but the more proximal the fracture, the greater the chance of avascular necrosis of the proximal fragment.17,18 The main reason for this is the special nature of the scaphoid’s blood supply.19 The blood supply to the scaphoid can be divided into extraosseous and intraosseous sources. The extraosseous blood supply is primarily derived from a branch of the radial artery, the artery to the distal ridge of the scaphoid.20 The branches of this vessel enter the scaphoid through a foramen at the dorsal ridge at the level of the wrist (Fig. 23.2). These vessels then run proximally and palmarly within the medullary chamber, forming the intraosseous supply to the proximal pole.21 Since vascularity of the proximal pole is limited and dependent on intraosseous flow, acute proximal pole fractures have a potentially prolonged healing period, averaging 3–6 months, and there is higher incidence of non-union.

Because of the danger of avascular necrosis developing, it is important to recognize a scaphoid fracture as quickly as possible. Acute scaphoid fractures are often missed on initial plain radiographs. Therefore an initial negative radiograph does not alter the clinical diagnosis. When clinical suspicion of a scaphoid fracture is high and plain films are negative, the traditional recommendation is for these patients to be immobilized in a thumb spica splint or cast, with repeat radiographs after about 2 weeks.22

image Warning

It is important to diagnose a scaphoid fracture as soon as possible in order to avoid avascular necrosis. In post-traumatic arthritis lasting longer than 24 hours, the condition should be regarded as a fracture until the contrary has been established.

Alternative imaging modalities for diagnosis include bone scans and magnetic resonance imaging (MRI). A bone scan reportedly shows focally increased uptake within 72 hours and is very sensitive for detecting a fracture, but may not be extremely specific.23–25 MRI has been reported to have 95–100% sensitivity and almost 100% specificity for scaphoid fractures.26–28 Additional advantages of MRI include its potential to assess vascularity of the proximal scaphoid pole when a fracture is present.29

Treatment

Treatment consists of immediate immobilization of the wrist, which is protective and can decrease the incidence of non-union and avascular necrosis.30 The best position remains unclear. Several dissection studies have come to different conclusions.31–34 Immobilization seems to be best performed with a thumb–spica cast, holding the thumb in the palmar abducted position and the wrist in the mid-position but with an element of deviation towards the site of the fracture, which, for the scaphoid, would be radial deviation. This helps to press the fractured surfaces together and stimulates the healing process.15 The time needed for a scaphoid fracture to heal is variable, from a minimum of 6 weeks to as long as 9 months,35 but 90% of fresh fractures heal with adequate treatment.30

Fractures of the other carpal bones can occur. Frequently, multiple radiographic views and/or follow-up studies with tomograms or bone scans may be necessary for a definitive diagnosis.36 Displaced fractures may require open reduction and internal fixation.37,38

Rheumatoid arthritis

The wrist can become affected by any type of rheumatic disorder, such as systemic lupus erythematosus, progressive systemic sclerosis, psoriatic arthritis, gout and pseudogout, ankylosing spondylitis and sarcoidosis, but rheumatoid arthritis is one of the commonest, frequently affecting both wrists39 and often following involvement of the fingers. In the acute stage a capsular pattern is found on examination, together with swelling, warmth and synovial thickening. At this stage MRI can be a useful technique for reaching a diagnosis.40 Recently joint ultrasound has also proved to be an important tool to evaluate synovitis of the wrist.41 In addition to pain, the more chronic cases present with gross limitation of movement. At this stage, there is no longer any warmth and even the swelling has diminished; diagnosis is easily made on conventional radiographs.

In the acute stage, the patient can be treated locally by immobilization of the wrist for some weeks. In the subacute and chronic stages, triamcinolone is a much better approach. One infiltration of 20 mg of triamcinolone acetonide is given at all the different areas of synovial thickening and/or tenderness, which are first precisely identified by palpation. Although treatment is very painful, the results are spectacular and symptoms at the wrist tend not to recur.

Limited range: non-capsular pattern

Carpal subluxation

Subluxation of a carpal bone, most often the capitate, occurs quite frequently. The diagnosis is purely clinical and, once the condition is recognized, it can be dealt with successfully by conservative management. Recurrence is not at all uncommon and may ultimately cause problems.

History and examination

The patient complains of pain on certain movements at the dorsal aspect of the wrist, especially when weight is put on an extended wrist. The symptoms may come on spontaneously or as the result of a minor injury in flexion.

On examination, signs of internal derangement are found (Fig. 23.3): one movement, most often extension, is limited with – certainly in acute cases – an end-feel of muscle spasm. Other movements are full-range, although often painful – the result of overstretching the irritated ligaments (see p. 34). The bony subluxation may be visible and palpable if the wrist is held in flexion. There is local tenderness in the ligaments.

The radiograph is negative: the edge of the subluxated bone appears merged with the others and cannot be visualized separately on the radiograph, nor can its position be measured against the superimposed margins of the other bones (Cyriax:43 p. 184).

The clinical examination supplies the diagnosis: the joint is blocked in one direction only, (which is typical of internal derangement) and there is a visible displacement on inspection. Instant reduction during manipulation confirms the tentative diagnosis.

Palmar subluxation, mostly of the lunate bone, is very exceptional. It gives rise to (slight) limitation of flexion and may compress a palmar branch of the median nerve, causing paraesthesia in the corresponding territory (see online chapter Nerve lesions and entrapment neuropathies of the upper limb).

Treatment

Treatment consists of manipulative reduction, which restores extension. Because of the accompanying sprain of the dorsal ligaments, flexion often remains painful. A few sessions of deep transverse friction will resolve this problem. If the condition recurs, manipulation is repeated. Frequent recurrences indicate instability and should be treated with infiltration of a sclerosant solution into the ligaments attached to the subluxated bone.

Basic technique: manipulation for carpal subluxationimage

The patient sits on a couch, the arm held in abduction against the back of the couch. An assistant grasps the patient’s upper arm just proximally to the elbow and holds it firmly against the couch. One foot is placed forwards for the manipulator’s benefit: the latter will place a foot against it.

The manipulator stands level with the patient’s hip, between the couch and the patient’s arm, and places the ipsilateral foot against the assistant’s foot; later, this will enable the manipulator to lean sideways and use the body weight for the pull required to obtain traction on the wrist joint. With the ipsilateral hand, the patient’s forearm is grasped just proximally to the radiocarpal joint, with the thumb on the dorsal aspect of the forearm. With the contralateral hand, the patient’s wrist is held with the thumb dorsally on the subluxated bone.

The aim of the manipulation is to perform a gliding movement between the rows of carpal bones during traction. The technique is executed as follows. The manipulator leans sideways but makes sure that the pull is only carried out with the distal hand, so as to obtain traction on the wrist. After the slack has been taken up, both hands are moved vertically up and down in opposite directions (Fig. 23.4). The little finger of the contralateral hand is kept in the palm of the patient’s hand to control movement; the manœuvre should result in a pure gliding movement and flexion–extension should be avoided.

This gliding movement is performed several times in one manœuvre. The movements of the wrist are then re-examined and the manipulation repeated until a full range of extension has been restored or until no further benefit results. If there is no immediate result, the attempt should not be abandoned too quickly. It may sometimes help to slightly change the position of the patient’s hand during the manœuvre and to build in a bit more flexion, extension or radial or ulnar deviation.

When this technique does not lead to full recovery, the next manœuvre is tried.

Second technique: manipulation for carpal subluxationimage

This technique is never used first but is introduced only when the bone is partially reduced. The aim is to perform a squeezing of the wrist during traction.

The patient, assistant and manipulator maintain the same positions as in the previous technique. The manipulator’s distal hand is now moved slightly downwards, so that it grasps the patient’s hand at the level of the bases of the metacarpal bones. Using the other hand, the patient’s wrist is approached from above and encircled with thumb and index finger. The metacarpophalangeal joint of the index finger is placed on the subluxated bone. The manipulator’s forearm is held vertically (Fig. 23.5). The manipulator leans sideways, applying traction with the distal hand and, having taken up the slack, executes a short, sharp squeezing manœuvre.

Although the manipulative thrust is a pure squeezing, there is an involuntary downwards movement of the hand, which helps reduction. This technique can be repeated several times.

Alternative technique: manipulation for carpal subluxation

The patient stands next to the couch, with the forearm, stabilized by the other hand, placed on the couch, the distal part level with the edge. The manipulator stands in front of the patient and grasps the hand in such a way that one thumb, reinforced with the other, is placed dorsally on the subluxated bone, while one index finger, reinforced by the other, is placed on the palmar aspect of it. The little fingers are placed in the palm of the patient’s hand, in order to prevent flexion–extension movements during the manipulation (Fig. 23.6).

Traction is applied with both hands and, after having taken up the slack, an anteroposterior glide is performed with emphasis on downward movement. Several movements are performed and the patient is re-examined after each manœuvre.

Other joint problems

The four following disorders, all visible on radiograph, give rise to limited extension only.

Aseptic necrosis of the lunate bone (Kienböck’s disease)

Avascular necrosis of the lunate was first described by Peste in 1843.44 The condition was then forgotten until 1910, when Kienböck recorded lunatomalacia, which he assumed had a vascular traumatic aetiology.45 Despite recognition of this disease entity for the past 100 years, its cause is still debated. Some investigators relate it to a stress fracture that leads to devascularization of the major segment of the lunate. Other authors consider the avascular necrosis to be the result of interruption of the vascularization of the lunate bone following excessive shear forces caused by acute trauma or repeated microtrauma.46 This would happen more easily in those lunate bones that are supplied by a single volar or dorsal blood vessel.47 Others suggest that a vascular non-traumatic process, with a minor infarction pattern in the proximal subchondral area, may be nearer to the truth.48

Avascular necrosis usually affects the dominant hands of males between 20 and 40 years of age.49,50 The symptoms come on spontaneously or as the result of minor injury, and usually interfere very significantly with work-related activities. The initial symptoms are pain and stiffness, which may vary from moderate to severe and incapacitating. The patient may also mention reduced strength in the hand.51

Clinical examination in the initial stage shows a capsular pattern with muscle spasm, due to the accompanying synovitis. Later, painful limitation of passive dorsiflexion becomes obvious, together with pain at the end of range of the other movements – a clear non-capsular pattern.

The classification of Kienböck’s disease is based on its roentgenological appearance.52,49,53:

Treatment methods extend from immobilization to revascularization surgery on the affected bone. However, there is still no gold standard for the treatment of Kienböck’s disease.56 A recent systematic review showed that, to date, there are insufficient data to determine whether the outcomes of any intervention are superior to placebo or the natural history of the disease.57

Avascular necrosis in other carpal bones has been described but is rare.58,59

Full range

Although passive movements of the wrist show a full range of movement, they can be painful at the end of range, showing that a structure is either stretched (ligament) or pinched (impaction syndromes).

Ligamentous lesions

Ligamentous injuries range from minor sprains with no instability (which are discussed here) to complete rupture with gross instability (see p. 341).61

Sprain of the ulnar collateral ligament

This disorder is the result of an injury causing a fracture, either a Colles’ fracture or fracture of the styloid process of the ulna. The fracture has healed but pain remains at the ulnar aspect of the wrist. On inspection, the deformity of the radius is visible and passive radial deviation causes pain at the ulnar aspect of the wrist. The symptoms can be quickly relieved by an infiltration of triamcinolone.

Sprain of the radial collateral ligament

This rare disorder results in pain felt at the radial aspect of the wrist during passive ulnar deviation. A more common cause of these symptoms is a tendinous lesion in the extensor pollicis brevis and abductor pollicis longus tendons (see p. 354). Differential diagnosis is easy because, in tendinitis, resisted movements are also positive.

Radial collateral sprain responds well to treatment with either one infiltration of triamcinolone or several sessions of deep transverse friction.

Sprain of the dorsal ligaments

The most common minor lesions are usually the result of overuse but may also occur when long-standing carpal subluxation causes irritation of the overstretched ligaments.

Pain is felt at the dorsal aspect of the wrist on full passive flexion. Other tests are negative. Careful palpation reveals the exact site of the lesion. Most of the lesions are found in the lunate–capitate ligament but occasionally also in the radiolunate, capitate–third metacarpal or ulnar–triquetral ligament.

Treatment consists of several sessions of deep transverse friction, which should lead to complete cure, independently of how long symptoms have been present. In the rare case in which it is not clear whether the symptoms are caused by a pure ligamentous sprain or by irritation of the ligaments from carpal subluxation, manipulation may be tried. If it proves ineffective, deep transverse friction is substituted. Even in the chronic stage of a dorsal ligamentous lesion at the wrist, the only effective treatment is deep transverse friction. Other treatments, such as steroid injections, immobilization or operation, are of no use. In order to avoid permanent problems, and because these lesions are often multiple, friction must be given to all the sprained ligaments. Palpation should therefore be performed carefully until all the tender spots have been found.

Technique: deep transverse frictionimage

The patient sits with the hand over the edge of the couch. The therapist sits facing the patient’s wrist, which is flexed with one hand within the limits of pain. Friction is imparted with the other hand. The direction depends on the course of the ligamentous fibres: the radiocarpal and carpometacarpal ligaments are aligned in the same longitudinal axis as the forearm, while the intercarpal ligaments have a more or less transverse direction (Fig. 23.9). For a radiocarpal or carpometacarpal ligament, the direction of the friction is transverse on the ulnar–radial axis. Friction is given with either the index finger, reinforced with the middle finger (Fig. 23.10), or with the thumb. As the lesion is very localized, the therapist must make sure that the finger remains deep between the extensor tendons and does not pass over them.

An intercarpal ligament is given friction with the thumb and in a proximo–distal direction (see Fig. 23.9).

Wrist impaction syndromes

Dorsal and/or ulnar-sided wrist pain may be caused by periosteal bruising that results from impaction between the carpus and the radioulnar border.

Ulnar impaction syndrome

Ulnar impaction syndrome, also known as ulnar abutment or ulnocarpal loading, is a degenerative condition characterized by ulnar wrist pain related to excessive load bearing across the ulnar aspect of the wrist. Chronic impaction between the ulnar head and ulnar carpus results in periostitis and degeneration of the lunate bone, triquetral bone and distal ulnar head, and degenerative tears of the triangular fibrocartilage complex (Fig. 23.11).62

The clinical manifestation of ulnar impaction syndrome generally consists of chronic or subacute ulnar wrist pain, often exacerbated by activity such as loading in extension and relieved by rest. Functional examination shows dorsal pain on passive extension. If the triangular fibrocartilage complex is involved, there will also be pain on forearm rotations.

Radiographic changes include subchondral sclerosis and cystic changes in the ulnar head, ulnar aspect of the proximal lunate bone, and proximal radial aspect of the triquetral bone. MRI is helpful in detecting occult disease in the early stage.63

Treatment will depend on the severity of the lesions. Periostitis responds well to local infiltration with 10 mg of triamcinolone acetonide, provided that further irritation is avoided. This can be done by avoiding the extremes of wrist movement in the loaded position or by the application of a splint or a cast. In more advanced cases or in lesions of the triangular fibrocartilage complex, arthroscopy and surgery will be needed.64,65

Ulnar styloid impaction syndrome

This ulnar-sided wrist pain is caused by impaction between an excessively long ulnar styloid process and the triquetral bone.66 The ulnar styloid process is a continuation of the prominent subcutaneous ridge of the shaft of the ulna, which projects distally towards the triquetral bone for a variable distance (2–6 mm).67 A single or repetitive impaction between the tip of the ulnar styloid process and the triquetral bone results in contusion, which leads to periostitis of the opposing surfaces. If a single-event trauma is forceful enough, fracture of the dorsal triquetral bone may occur.68

The diagnosis of this condition is made on the basis of pinching pain during ulnar deviation and radiographic evidence of an excessively long ulnar styloid process. MRI may show chondromalacia of the ulnar styloid process and proximal triquetral bone (Fig. 23.12).69

Treatment consists of a local infiltration with 10 mg of triamcinolone. In advanced cases, resection of all but the two most proximal millimetres of the styloid process is the treatment of choice.

Radial impaction syndrome

Pain at the dorsal aspect of the wrist may occur as the result of repetitive extension movements during weight bearing, as frequently happens in gymnastics or other high-energy sports; this may lead to periostitis at the distal epiphysis of the radius or the proximal carpal bones,70,71 described as ‘wrist impingement’ syndrome72 or ‘stress reaction’.73 The pain is elicited each time the patient puts weight on an extended wrist.

On examination, passive extension of the wrist is found to be full but painful, all other movements being negative. Careful palpation shows the lesion to lie at the inferior border of the radius or at the scaphoid and lunate bones.

Periostitis responds well to local infiltration with 10 mg of triamcinolone acetonide, provided that further irritation is avoided. This can be done by avoiding the extremes of wrist movement in the loaded position or by the application of a splint or a cast, if necessary. Surgery can be performed in recurrent cases or to avoid long-term complications.74

Repetitive compressive loading may result in stress fractures of the distal part of the radius, the scaphoid and the capitate bones. Scintigraphy and MRI are diagnostic and immobilization in a cast is therapeutic.75,76

Ganglion

A ganglion is a fluid-filled cavity that originates from the joint capsule or tendon sheath. It is very common at the wrist. It occurs dorsally, most often over the scapholunate joint, as well as at the palmar aspect, usually at the trapezioscaphoid joint.77 Its aetiology has been debated for many years and various hypotheses have been presented: retention cyst, herniation of tendon or capsular synovia, bursal transformation, neoplasia, or mucinous degeneration of fibrous tissue, the last of these being the most widely accepted theory.78

The main complaint is the presence of a swelling that was not there before. It may sometimes be painful either at rest or during movement. The size may vary and so does its consistency: it can be either very soft or quite hard, giving the impression of a bony structure. When the ganglion grows, the neighbouring tissues may become compressed and there may be pressure on nervous tissue as well (see online chapter Nerve lesions and entrapment neuropathies of the upper limb).

Many techniques have been used to treat this condition, varying from crushing the ganglion (e.g. pressure with the thumbs or a firm slap with a book) to aspiration and infiltration with a steroid or sclerosant solution. These measures usually lead to temporary cure but recurrences are frequent because the cause has not been treated. More consistent results are obtained by surgical removal, although the risks associated with surgery may be more undesirable than the minor symptoms associated with the presence of a ganglion.79

Excessive range

Ligamentous instability

According to Ekenstam, instability of the wrist is ‘a condition of altered joint kinematics in which one or several carpal bones are permitted abnormal patterns of motion as a result of bony abnormalities, ligamentous lesions or joint laxity’.80

Carpal instability remains a very controversial topic. Since 1943, when Gilford et al81 first mentioned instability of the wrist, many authors have worked on the subject. They have developed several hypotheses and proposed different methods of classification. This variability indicates the difficulty in reaching a consensus on such a vague topic as ‘instability’ in the complex area that is the wrist. There is still a lack of standardization in evaluation methods and in the findings and radiographic criteria. Arthroscopy, however, has helped to provide a clearer picture of the possible underlying mechanisms.82

Aetiology

Wrist instability is generally believed to be caused by post-traumatic stretching or rupture of one or several radiocarpal or intercarpal ligaments. The injury is usually hyperextension combined with radial or ulnar deviation and/or pronation or supination.83According to some authors, however, it can also be the result of anatomical changes and malalignment subsequent to radial or carpal fracture. Other possible causes of ligamentous laxity are degenerative and inflammatory conditions (i.e. crystal synovitis, rheumatoid arthritis), as well as iatrogenic causes.84

Epidemiology and classification

Epidemiological data on carpal instability are still not available, although wrist injuries occur in 28.6% of all accidents.85 Several methods of classification have been described.86

Taleisnik87,88 has proposed a theory based on the columnar concept of Navarro.89 This concept recognizes three vertical columns in the wrist: (a) the central (flexion/extension) column contains two blocks – one on the lunate bone and one on the trapezium, trapezoid, capitate and hamate bones; (b) the radial column comprising the mobile scaphoid bone; and (c) the ulnar (rotating) column,which includes the triquetral bone and the pisiform. Taleisnik therefore classifies wrist instability as being radial, ulnar or proximal.90

This concept does not mention the transverse or perilunar patterns (stages I–IV), which were later described by Mayfield et al,91 or the more recently discussed mid-carpal instability, proximal row instability and miscellaneous instability.

The Mayo Clinic proposes a classification, based on the work of Amadio, Cooney, Dobyns and Linscheid.92–96

The Lichtman classification97 deviates from the columnar wrist concept and the consequent longitudinal classification system. It is based on the ‘carpal ring concept’ – the distal and proximal rows are joined by two links: on the radial side the mobile scaphotrapezial joint and on the ulnar side the rotatory triquetrohamate joint. This concept includes the perilunate and mid-carpal instabilities.

Other classification systems – for example, the Barton classification – have also been proposed.

We consider Saffar’s classification86 to be a clinical and useful approach.

1. Static or dynamic instabilities

2. Location of instability

Proximal row instability is the most frequent type of instability:

Mid-carpal instability:

Proximal instability (radiocarpal) with the two Taleisnik stages:

Clinical diagnosis

Although post-traumatic wrist pain occurs frequently, instability does not. The patient is examined thoroughly, and only when the history and the physical findings are compatible with carpal instability should the diagnosis be made.

The patient has a history of past trauma with or without fracture or of past inflammatory disease. There is wrist pain mostly during or after activity, which may be accompanied by a feeling of weakness or of snapping during movement. Information about the type of injury should be obtained but the patient often does not recall such features.98 The localization of the pain is also very informative and points towards specific possibilities. The passive movements are full or even excessive in range and, although they are performed very gently, they may cause pain at the end of the movement.

Provocative tests can be performed:99

1. For scapholunate instability

• The scaphoid bell sign: the examiner grasps the patient’s scaphoid bone between thumb and index finger and controls its movement while the patient is actively moving from radial to ulnar deviation. The movement of the scaphoid should be smooth. If this is not the case, the test is considered positive.

• Watson’s test:100,101 the examiner puts the patient’s hand in ulnar deviation. With the other hand the scaphoid bone is grasped between thumb (on the tubercle) and index finger. The hand is then brought into radial deviation and resists flexion movement of the scaphoid by the thumb. In instability this results in the proximal pole shifting backwards, which can be felt at the dorsal aspect (Fig. 23.13).

• Lane’s test (the scaphoid shift test):102 the examiner assesses the anteroposterior gliding of the scaphoid.

2. For triquetrolunate instability

• Kleinman’s shear test:103 the examiner grasps the patient’s distal forearm and puts the fingers on the most distal and dorsal aspect of the ulna. The thumb is placed on the pisiform bone. The ulna is so stabilized and a posterior pressure exerted on the pisiform. Pain may be produced (Fig. 23.14).

• Linscheid’s test:104 the examiner grasps the patient’s distal forearm and puts the finger on the most distal and radial aspect of the radius. The thumb is placed at the ulnar aspect on the triquetral bone (Fig. 23.15). The radius is stabilized and pressure exerted laterally on the triquetrum. Pain may be produced.

3. For mid-carpal instability

• Mid-carpal shift test:105 the examiner exerts axial compression on the wrist via the hand and asks the patient to move the wrist actively. A painful click may be produced. The click will not be present when pressure is brought to bear on the pisiform or during active contraction of the hypothenar muscles.

• Apprehension test:106 when the capitate bone is glided in a posterior direction, pain and/or apprehension are produced.

• Metacarpal gliding:107 the wrist is placed in ulnar deviation and the metacarpals glided in a palmar direction. Pain may be elicited.

4. For radiocarpal instability

• Medial radiocarpal drawer test:108 pressure is exerted on the posterior aspect of the triquetral bone and counterpressure is on the radius. The test is positive when painful.

• Ulnar sag: the ulnocarpal sag has increased.

Technical investigations may include arthrography, arthroscopy, computed tomography (CT), MRI and scintigraphy.

Treatment

Treatment is still controversial and is very much surgeon-, physician- or therapist-related. Therapy varies from conservative treatment to a range of different surgical techniques. Asymptomatic or slightly symptomatic cases are usually treated conservatively, including immobilization, anti-inflammatory drugs and gradual physiotherapy. Clearly symptomatic, persistent or recurrent cases are often treated surgically. Therapeutic evidence should be looked for in the years to come.

The disorders of the inert structures of the wrist are summarized in Box 23.1.

Box 23.1   Summary of disorders of the inert structures of the wrist

Disorders of the contractile structures

Tendinitis and tenosynovitis of the wrist are often encountered. Their frequency is the consequence of the long course of the tendons over the wrist, the role played by these tendons in the mobilization and stabilization of the wrist, and overuse of the hand in daily life, as well as in professional and sporting activities.

Resisted extension

Pain

Pain on resisted extension indicates a lesion of either the wrist or the finger extensors. The movement hurts near the wrist, which shows that the distal part of either muscle group is implicated.

Differentiation between wrist and finger extensors can be made by testing extension first with the fingers relaxed and then actively flexed, which inhibits the action of the finger extensors. When an extensor of the wrist is at fault, it is possible to differentiate between the radial extensors and the ulnar extensor by testing resisted radial and ulnar deviation (Fig. 23.16).

Extensor carpi radialis longus and/or brevis

A lesion of the extensor carpi radialis longus and/or brevis (Fig. 23.17) is usually the result of overuse.109,110 The patient complains of local pain during activity.

Resisted extension and radial deviation of the wrist are painful at the dorsal and radial aspect of the joint. Full passive flexion may also cause pain but is usually negative.

On palpation (in full flexion) two different localizations can be found. Tenderness is elicited at the insertion of the tendons at the base of the second (longus) and/or third (brevis) metacarpal bones. Sometimes the lesion lies in the distal part of the tendon(s), level with the carpus.

Treatment consists of either deep transverse friction three times a week, in which case full recovery should be obtained within 2 weeks, or one or two infiltrations with triamcinolone suspension, provided the lesion is at the tenoperiosteal junction.

For the duration of treatment, the patient should avoid exertion that causes pain. Exercises, passive movements, immobilization and surgery are not indicated.

Extensor carpi ulnaris

The tendon is the second most common site of tendinitis in the upper limb.111,112 A tendinitis of the extensor carpi ulnaris (Fig. 23.20) usually develops after a strain or overuse. A tenosynovitis is a rheumatoid manifestation.

On examination, pain at the dorsal and ulnar aspect of the wrist is elicited by testing resisted extension and resisted ulnar deviation. Passive radial deviation may also cause pain at the ulnar side. Palpation is performed with the hand in radial deviation. In rheumatoid tenosynovitis the structure is warm to the touch and swollen or nodular. In an overuse disorder three possible localizations can be palpated. They are (in order of frequency): the tenoperiosteal junction at the base of the fifth metacarpal; the tendon body between the triquetral and the head of the ulna; and the tendon at the groove of the ulna. In the latter, pain is also elicited at the extreme of passive supination. This puzzling localizing sign is explained by Bowers as follows:

In mechanical tendinitis, either 2 weeks of deep transverse friction or one or two infiltrations with triamcinolone suspension will effect a cure. Infiltration is performed at the tenoperiosteal junction or between tendon and sheath. Mobilization, exercises or immobilization do not afford any help. Surgery is seldom necessary. Rheumatoid tenosynovitis is treated by infiltration of a steroid suspension between the tendon and its sheath.

Post-traumatic rupture of the subsheath or of the extensor retinaculum may result in recurrent subluxation of the tendon. The patient feels a sudden snap on certain movements – for example, active supination with the wrist slightly flexed.114 During the clinical examination, an attempt can be made to reproduce the instability using isometric stress in supination. Treatment is surgical reconstruction.115

Extensor digitorum

Tenosynovitis, either mechanical or rheumatoid, may occur at the level of the carpus – where the tendons lie in a common sheath – and gives rise to pain felt locally at the dorsum of the wrist. Resisted extension of the fingers provokes this symptom, as does passive flexion, which stretches the tendon. Rheumatoid tenosynovitis is characterized by a discrepancy between (pronounced) symptoms and (moderate) signs. Palpation shows the exact location and, in rheumatoid conditions, reveals swelling as well. Crepitus accompanies mechanical tenosynovitis.

The mechanical type responds to either infiltration with 10 mg of triamcinolone acetonide between the tendon and tendon sheath, or a number of sessions of deep transverse friction. In the rheumatoid type, triamcinolone injection is the only effective treatment.

Weakness

Painless weakness on resisted extension of the wrist should lead to a full neurological examination of the upper limbs. Combination with weakness of other muscle groups helps to determine the causative lesion. Although other conditions may cause painless weakness, those described below are the most common.

Unilateral weakness

Unilateral weakness of wrist extension may result from a lesion of either a nerve root or a peripheral nerve. Combination with weakness of other muscles provides more information: the cause lies at the C6–C8 nerve roots or at the radial nerve.

• C6 root palsy: in a C6 root palsy, flexion of the elbow is weak as well.

• C7 root palsy: weakness of extension of the wrist is exceptional in C7 root palsy but extension of the elbow and flexion of the wrist are normally found to be weak.

• C8 root palsy: this is suspected when the extensor carpi ulnaris and flexor carpi ulnaris are weak. Consequently, the hand deviates radially when resisted extension of the wrist is tested. Extension and adduction of the thumb are also weak.

• Radial palsy: pressure on the radial nerve in the arm gives rise to radial palsy. The causes may be pressure from a crutch in the axilla, the edge of a chair or, in acute circumstances, fracture of the humerus at mid-shaft (see online chapter Nerve lesions and entrapment neuropathies of the upper limb).

Resisted flexion

Pain

The first question that arises is: is there a lesion of either the flexors of the wrist or the flexors of the fingers, and, if a wrist flexor is at fault, is it the radial or the ulnar tendon? Radial and ulnar deviation, tested against resistance, as well as resisted flexion of each finger in turn, should define the affected structure (Fig. 23.23).

Flexor carpi radialis

Lesions of the flexor carpi radialis (Fig. 23.24) are not very common117 but typically occur in women (75% of cases)118 and are the outcome of overuse, either recreational or occupational. Pain is felt at the palmar aspect of the wrist during movements such as grasping and lifting with the fingers outstretched.

On examination, resisted flexion and resisted radial deviation of the wrist are painful. Tenderness can be palpated either over the whole distal extent of the tendon or at the insertion of the tendon at the base of the second metacarpal bone.119

Tenoperiosteal lesions respond well to both infiltration with triamcinolone acetonide and deep transverse friction, although friction through the thenar musculature is not easy, and is quite uncomfortable and time-consuming. Tendinous lesions are better treated with friction, as the lesion is usually too extensive.

Flexor carpi ulnaris

Tendinitis is more common at the ulnar flexor tendon (Fig. 23.27) than at the radial flexor tendon because of the greater mobility at the ulnar side.120 This lesion usually arises after a single excessive strain.

Usually, the patient can precisely locate the symptoms to the palmar and ulnar aspect of the wrist. Pain is elicited during resisted flexion and resisted ulnar deviations of the wrist. Palpation discloses the exact site of the lesion: distal to the pisiform bone – at the tenoperiosteal junction at the fifth metacarpal bone – or proximal to the pisiform bone in the body of the tendon.121

Both deep transverse friction (4–6 treatments) and infiltration with triamcinolone suspension are effective.

Pisotriquetral disorders

Disorders of the joint between the pisiform and the palmar surface of the triquetrum may occur and, because of the attachment of the tendon to the pisiform bone, give rise to the same signs as in flexor carpi ulnaris tendinitis.122 Disorders at the joint have been described as pisotriquetral arthritis123 and pisotriquetral instability.124 Direct pressure on the pisiform elicits pain. Side-to-side passive motion of the pisiform on the triquetrum will also lead to pain and crepitus. If pisotriquetral disorder is suggested, intra-articular steroid is required.125 In recurrent cases, surgical removal of the pisiform may be necessary.126,127

Flexor digitorum profundus

A lesion of the flexor digitorum profundus is either a mechanical tenosynovitis or a rheumatoid tenovaginitis. The former results from overuse. The pain is brought on by testing resisted flexion of the fingers. The lesion lies over an area 3–4 cm above the level of the carpus on the palmar aspect of the lower forearm. It is treated by deep transverse friction (see below) or by injection of a steroid suspension between the tendons.

A rheumatoid tenovaginitis is usually confined to one flexor tendon near the carpus. Early in its progress, diffuse swelling and local warmth on the palmar aspect of the forearm are the only signs.128 Later, tenderness of the tendon may be found over a greater extent than that which occurs in overuse. After a few weeks, the swelling becomes nodular and local warmth persists.

The symptoms abate after one or two infiltrations with triamcinolone.

Swelling on a digital flexor tendon may sometimes lead to compression of the median nerve distal to the carpal tunnel, thus causing a partial syndrome (see the online chapter Nerve lesions and entrapment neuropathies of the upper limb).

Weakness

Weakness of wrist flexion is frequently the result of a C7 or C8 nerve root lesion, as well as more general neurological conditions:

Disorders of the contractile structures are summarized in Box 23.2.

Box 23.2   Summary of disorders of the contractile structures

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