Name: Physical Examination of the Wrist
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Description: Physical Examination of the Wrist

Name: Physical Examination of the Wrist

Description: Physical Examination of the Wrist

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Segment:0 .
WILLIAM B. KLEINMAN: Physical diagnosis. Laying on of the hands is a critical part of your skills as a hand surgeon. When combined with a complete history from your patient, laying on of the hands by a well performed physical examination of the wrist can lead to a definitive diagnosis in the vast majority of your patients.
WILLIAM B. KLEINMAN: In this instructional course, I'll try to emphasize the key elements of the wrist physical examination with the hopes that it will become easier for you to make accurate diagnoses in the patients you treat with either acute or chronic wrist pain. We'll break the examination down into two components. The first will be extracapsular structures crossing the wrist and the second component will be examination of the intracapsular components of the wrist.
WILLIAM B. KLEINMAN: The extensor tendons across the wrist,
WILLIAM B. KLEINMAN: divided into six so-called dorsal compartments. The first dorsal compartment consists of the extensor pollicis brevis and the abductor pollicis longus, both of which pass through a very tight first dorsal compartment. In cases of tenosynovitis of the first dorsal compartment, the inflammatory conditions cause stenosis of these tendons. Inflammation of the parietal peritoneum and pain.
WILLIAM B. KLEINMAN: The first maneuver we'll talk about is the Finkelstein test, which is performed by stretching the first dorsal compartment tendons through the housing of the retinaculum of the first dorsal compartment by gently ulnarly deviating the wrist and then putting tension on the extensor pollicis brevis and abductor pollicis longus by hyper flexing the thumb across the palm. This creates tenderness and pain in the area of the first dorsal compartment, just proximal to the radial styloid.
WILLIAM B. KLEINMAN: Throughout this examination of the wrist, we'll find that the most important tool that the surgeon has is palpation. If you are knowledgeable about the anatomy and you put your finger directly on the site of maximum tenderness, that's usually where the pathology is, and in this case, tenderness directly over the first dorsal compartment in de Quervain's stenosing tenosynovitis is the hallmark of inflammatory changes within the contents of the first dorsal compartment.
WILLIAM B. KLEINMAN: The second dorsal compartment consists of the extensor carpi radialis longus and extensor carpi radialis brevis, both of which insert not on the dorsal aspect of the respective second and third metacarpals but on the dorsal radial aspect, thus making them radial deviators of the wrist in addition to being extensors of the wrist, so there's a component for radial deviation and extension because of the lever distance by insertion on the dorsal radial rather than the dorsal aspect of the metacarpal.
WILLIAM B. KLEINMAN: The extensor carpi radialis brevis and longus crossed from the forearm into the wrist under the muscle bellies of the first dorsal compartment muscles. So the ECRL and ECRB pass under the extensor pollicis brevis and the abductor pollicis longus as they come from their muscle origin in the proximal forearm. Right underneath this muscle, these muscle bellies, are the so-called outcrop muscles.
WILLIAM B. KLEINMAN: There's parietal parthenon around the ECRL and the ECRB, which allow them to glide under the fascial envelope of the first dorsal compartment muscles. If this is tight, if there is a leading edge or a trailing edge of enveloping fascia around the first dorsal compartment muscles that causes an irritation of the parietal peritoneum of the ECRL and ECRB, we wind up having inflammatory changes, tenderness at either the distal aspect of the outcrop of muscles, or the proximal aspect of the outcrop of muscles, which is called intersection syndrome.
WILLIAM B. KLEINMAN: It's the defining moment for inflammatory changes of the parietal peritoneum of the second dorsal compartment tendons by irritation from the either leading or trailing edge of the outcrop of muscles of the first dorsal compartment. Again, direct palpation will cause tenderness in the intersection syndrome by palpating that intersection of the first and second compartments either distally or proximally. Lister's tubercle defines the point of the change in angle of attack of the extensor pollicis longus as it comes paralleling the radius from the mid forearm,
WILLIAM B. KLEINMAN: around Lister's tubercle changing its angle 30 degrees to approach the thumb and become the extensor of the IP joint of the thumb. This change in angle of attack by 30 degrees gives the extensor pollicis longus a lifter capacity of the thumb, as well as a component of adduction, enabling the thumb to be brought towards the hand by the secondary abductor potential of the extensor pollicis longus.
WILLIAM B. KLEINMAN: Because of this angle change, in cases where there's stenosis under the retinaculum or tightness of the extensor pollicis longus, there can be inflammation of the parietal peritoneum of the EPL, create a situation where there is considerable tenderness directly ulnar to Lister's tubercle. In cases of distal radius fracture where there's fibrosis, callus formation, other inflammatory changes from the injury, there can actually be attritional changes
WILLIAM B. KLEINMAN: at Lister's tubercle and commonly seen after distal radius fractures is rupture of the extensor pollicis longus because of its change of angle of attack as it comes around the tubercle to approach the thumb. The fourth dorsal compartment consists of the extensor indicis proprius and the extensor digitorum communists going to all four fingers. The extensor digitorum commonest to the small finger is only present in less than 50% of the human hand
WILLIAM B. KLEINMAN: but the other tendons, the EIP and the EDC of index, middle and ring are present in all cases. They cross under the retinaculum and approach the individual fingers allowed a gliding by the parietal peritoneum that exists around all the tendons. In cases of inflammatory change of the extensor digitorum communists, there can be large swelling of the extensor compartment
WILLIAM B. KLEINMAN: with inflammatory swelling of the parietal peritoneum creating a large mass that mimics the dorsal carpal scapholunate ganglion. One of the things that's important in examination of the wrist is that the tuck sign should always be performed in an effort to differentiate parietal peritoneum and inflammatory changes in swelling from a dorsal carpal ganglion.
WILLIAM B. KLEINMAN: And in many cases, the two are extremely similar in the way they appear. Tender, swollen, round, firm etc, but totally different, one intracapsular and one extracapsular. One of the best ways to do that is with the tuck sign and what the patient is asked to do is to allow the wrist to flex like this, and with the wrist held in flexion by the patient.
WILLIAM B. KLEINMAN: They're asked to extend the fingers as hard as they can with the wrist held in flexion. Lifting the fingers as hard as they can be, and in a tuck sign with tenosynovitis of the fourth dorsal compartment, there will be an actual dimpling or tucking of the skin along the distal margin of the inflammatory change. This is pathognomonic of extensor digitorum commonest tenosynovitis and differentiates it from a ganglion. In a ganglion, which can be a similar mass coming from the carpus
WILLIAM B. KLEINMAN: intracapsular when the patient is asked to do the tuck sign, there'll be no dimpling ever with the dorsal carpal ganglion cysts only present with tenosynovitis of the extrinsic extensors of the fourth dorsal compartment. So that's an important sign to keep in mind as you examine the wrist. As we continue with extracapsular structures on the dorsal aspect of the wrist, the next is the fifth dorsal compartment consisting of the extensor digiti quinti proprius, which splits as it crosses the wrist into two tendon slips in the human hand.
WILLIAM B. KLEINMAN: And it's important to recognize that the location of the fifth dorsal compartment is directly over the distal radioulnar joint. So a good way to be able to identify to find the extensor digiti quinti proprius quickly at the wrist is to palpate the medial border of the radius or the distal head of the ulnar. Find the distal radioulnar joint and you know that the extensor digiti quinti proprius is directly over this spot
WILLIAM B. KLEINMAN: and you can feel it when the patient lifts the small finger. Just lift your small finger up. That's it. Hold it up. Small finger, alone and then down. Up, down. And when you do the examination, you can easily feel the EDQP going back and forth over the distal radioulnar joint, right over the capsule as the patient lifts the EDQP.
WILLIAM B. KLEINMAN: It's a good landmark to use for trying to establish exactly where the EDQP is. The EDQP can also be involved, albeit rarely with tenosynovitis as it comes through the retinaculum and as I mentioned before, if you put your finger directly where the patient is feeling the most pain and you can elicit tenderness right in that spot, undoubtedly that's where the patient's pain is coming from.
WILLIAM B. KLEINMAN: As we get into examination of the distal aspect of the ulnar, one of the things to immediately be eliminated in patient in the physical diagnosis is to make sure that the patient's EDQP is not inflamed in the vicinity of things like the triangular fibrocartilage and the lunotriquetral joint. Lastly, on the dorsal aspect of the wrist, the sixth dorsal compartment, the extensor carpi ulnaris
WILLIAM B. KLEINMAN: has its own sheath. It's an independent deep sub sheath, deep to the retinaculum that houses all six dorsal compartments. It's approximately 1 to 2in long, directly over the distal aspect of the ulnar, and it forms a pivot point for changing the action of the extensor carpi ulnaris from a predominantly extensor of the wrist to a predominantly ulnar deviator of the wrist
WILLIAM B. KLEINMAN: and let me explain what I mean. The presence of the sixth dorsal compartment locks the position of the extensor carpi ulnaris directly at the same position of the ulnar, regardless of what position of prono supination the forearm is in. So by locking the extensor carpi ulnaris in one single position when the hand forearm unit is in pronation,
WILLIAM B. KLEINMAN: the extensor carpi ulnaris position will be along the ulnar border of the ulnar. As all of us know, the ulnar is fixed to the humerus with respect to rotation, it's a ginglymus joint at the elbow, so it only flexes and extends, there's no rotation whatsoever. So with the ulnar fixed and the extensor carpi ulnaris fixed to the ulnar, the position of the ECU will always be the same
WILLIAM B. KLEINMAN: with respect to the ulnar. The entire radius, carpus and hand rotates back and forth around a fixed ulnar. So whatever position the radius, carpus and hand is in, the relationship between the extensor carpi ulnaris and the fixed ulnar will always be the same. So what that means is that with the hand forearm unit in pronation, the position of the ECU relative to the axis of rotation of the rate of the ulnocarpal joint makes it more of an ulnar deviator, more of an ulnar deviator than it is a wrist extensor.
WILLIAM B. KLEINMAN: It's almost a pure ulnar deviator of the carpus or of the hand on the forearm when it fires in pronation relative to its action in supination and when the hand forearm unit is fully supinated, now the position of the ECU remains constant with respect to the ulnar but with respect to the carpus, it now has a dorsal position so when the ECU fires with the hand forearm unit in supination, it becomes almost a, it becomes the predominant ulnar sided wrist extensor, but its function is almost pure extension and minimally ulnar deviation.
WILLIAM B. KLEINMAN: That's a very important concept to know in our knowledge of the biomechanics of the hand. Full supination, the ECU is a pure ulnar, pure wrist extensor and in full pronation, the ECU is almost a pure ulnar deviator only because of its anchored position relative to the changing position of the carpus as the hand forearm unit is pronosupinated. All of these six compartments
WILLIAM B. KLEINMAN: are held down close to the bone to prevent bow stringing by a very tight retinaculum that has its origin predominantly on the distal radius over the length of about 2 inches and the fibers sweep ulnarly and distally to converge in the vicinity of the triquetrum but pass all the way across the sixth dorsal compartment sub sheath all the way to the deep flexor retinaculum. As we continue our Odyssey from the dorsal aspect of the hand to those six compartments deep to the extensor retinaculum onto the flexor side, there is no retinaculum per se in maintaining the position of the flexor carpi radialis and the flexor carpi ulnaris.
WILLIAM B. KLEINMAN: The flexor carpi radialis takes its origin from the medial epicondyle, comes across the forearm surrounded by parietal peritoneum as it approaches the carpus and then changes its angle of attack from directly co-linear with the radius to a 30 degree angle as it plunges down into the hand to insert on the volar aspect of the second metacarpal. The actual apex of that change in direction of the flexor carpi radialis is the scaphoid,
WILLIAM B. KLEINMAN: so when you examine the wrist and palpate this bony prominence directly at the end of the flexor carpi radialis, that is not the scaphoid but the, but rather the crest of the trapezium. This bony prominence distal on the flexor carpi radialis is the prominence under which the FCR passes as it plunges towards the second metacarpal but the actual change in attitude of the FCR comes more proximal to the trapezium i.e. at the distal pole of the scaphoid which is palpated proximal to the trapezial crest.
WILLIAM B. KLEINMAN: Flexor carpi radialis tunnel syndrome once again is diagnosed by direct palpation for tenderness over the area of the inflamed parietal peritoneum of the distal FCR and right up against the crest of the trapezium where you can no longer palpate the FCR because it's diving towards the second metacarpal. Tunnel syndrome is a very common clinical entity, but can be confused with a variety of other pathology in the area of the radiocarpal or radial scaphoid joint.
WILLIAM B. KLEINMAN: One of the hallmarks of examining for FCR tunnel syndrome is the so-called rebound test. The rebound test is performed by coming away from the inflamed tissue, holding the hand forearm unit securely and then. ballotting strongly, the non tender area of the FCR, which gives it a tug distally and if there's inflamed tissue with the area of the interface between the trapezial crest and the parietal tenon, it'll tug on that tissue and cause significant pain to the patient when you palpate way outside the zone of inflammation.
WILLIAM B. KLEINMAN: That's called the rebound test and I believe it's pathognomonic for flexor carpi radialis tunnel syndrome. On the ulnar side of the wrist, the last tendon we'll mention, crossing the wrist is the flexor carpi ulnaris, also taking its origin from the distal humerus and the ulnar at the vicinity of the medial epicondyle of the humerus, and it courses in a straight line distally surrounded by parietal peritoneum.
WILLIAM B. KLEINMAN: But it's important to recognize that the origin of the flexor carpi ulnaris is the entire shaft of the ulnar all the way down to approximately 3 centimeters proximal to the pisiform. What that means is that when the flexor carpi ulnaris fires, it's very strong because of its cross-sectional area, but it has a very small excursion, so it pulls the hand forearm unit into ulnar deviation and volar flexion with a lot of strength, but not a lot of excursion of the tendon because of its enormous origin off the bone,
WILLIAM B. KLEINMAN: quite different from the flexor carpi radialis. The flexor carpi ulnaris swallows the sesamoid pisiform bone as it courses to the volar base of the fifth metacarpal and we'll talk more about pisiform, its relationship to the flexor carpi ulnaris and how to examine the pisiform when we get into the area of carpal examination. We've switched positions on the examining table so I can show you the contralateral hand for our examination of the carpus and the distal aspect of the forearm.
WILLIAM B. KLEINMAN: What I've done is drawn on the patient the radius, the ulnar. You remember, the ulnar is fixed as a ginglymus joint at the elbow, so it has no rotatory component and the radius, carpus and entire hand held together securely by struts and guy wires that hold it together as a unit, rotate back and forth in pronation and supination around a fixed ulnar. The examination of the wrist should be performed,
WILLIAM B. KLEINMAN: at least the bulk of it should be performed with the fingers towards the ceiling the same way that arthroscopy should be done, the same way that x-rays should be looked at so that the surgeon can gain a three dimensional, three dimensional perspective of the carpus that's consistent whether he's examining the wrist in the clinical situation, examining the X-rays or examining intra-articularly on X-ray.
WILLIAM B. KLEINMAN: Before we actually get into the carpus, let me spend a moment emphasizing the examination of the CMC joint, which most of us find in our patient population quite, quite commonly. Now, just like I emphasized before about examination of the extensor tendons, the physical sign that will lead you most commonly to the site of pathology is tenderness directly under the balloting or palpating finger.
WILLIAM B. KLEINMAN: As I mentioned before, first dorsal compartment tenderness for De Quervain stenosing tenosynovitis is the most common physical finding. If you press on the first dorsal compartment and it's sore, then you can assume that the tendons are inflamed, resulting in tenderness directly under the site of palpation. If you come up to the interface between the first metacarpal and the trapezium and press here, it's quite a distance from the first dorsal compartment and pretty easy to separate out synovitis and inflammatory change of the joint between the first metacarpal and the trapezium as being very different from the tenderness over the first dorsal compartment.
WILLIAM B. KLEINMAN: You've got about an inch and a half separation there. But a better way to examine the, the carpometacarpal joint is to support the patient's hand in your own non examining hand, grasp the borders of the first CMC joint with the thumb and the middle finger and then perform either circumduction or grind in an effort to stabilize the trapezium with your fingers and then allow the first metacarpal to move around without interfering with any other area around the CMC joint as possibly confusing your diagnostic findings.
WILLIAM B. KLEINMAN: I find this technique to be the most rewarding in terms of showing me subtle changes of tenderness and pain at the CMC joint in the early stages of degenerative arthritis of this joint. One of the more difficult examinations to perform is for stability of the first metacarpal relative to the trapezium. Instability, subluxation of the CMC joint is very commonly seen, particularly in patients who have ligamentous laxity.
WILLIAM B. KLEINMAN: I especially find it in my own patient population, in young women in their third decade of life when they're doing a lot of work with their hands and they find that instability leads to early synovitis and tenderness. The human hand is divided into two components grossly. There's a grasp side of the hand. The power grasp side involving the ring and small fingers, and then the precision side, which involves the thumb, index and middle finger.
WILLIAM B. KLEINMAN: You can use that basic breakdown of human hand function to examine the CMC joint of your patient's thumb for instability by using the power grasp side of the hand to hold the thumb, being able to put traction on the thumb by just holding on to it, anchoring it with the power grasp side, and then using the precision side of your hand to grasp the base of the thumb metacarpal while you're supporting securely the carpus and trapezium with the contralateral hand.
WILLIAM B. KLEINMAN: So you have power grasp putting a little distraction on precision side of the hand to support the base of the metacarpal.
WILLIAM B. KLEINMAN: That's the examining hand and then the stabilizing contralateral hand of the examiner to hold the trapezium and carpus while you can actually shuck the first metacarpal back and forth to demonstrate instability. I find that the radiographic examination techniques have been described in the literature are unrewarding in terms of demonstrating instability. They're inconsistent,
WILLIAM B. KLEINMAN: they don't really say very much but if you examine the hand in this way and of course compare it to the contralateral hand as well, but you can get excellent stability, put all of the energy of your examination technique into your precision, part of the examining hand and check for shuck or instability and it really gives you a good sense. It's not about the movement of the skin back and forth,
WILLIAM B. KLEINMAN: it's about your palpation of the instability of the basilar thumb joint itself. And in this patient, she has, I would call a 2 plus instability, but it's painless. The next technique I'd like to demonstrate for you is to isolate the examination of the wrist to the second and third, but particularly the second CMC joint. As we all know, the joint between the second metacarpal and the trapezoid and capitate and between the third metacarpal and capitate is a fully formed,
WILLIAM B. KLEINMAN: they're both fully formed diarthrodial joints with synovial lining. Complete capsules with short intrinsic ligaments, but an architecture of the joint surfaces and tightness of the ligament structures that keeps this joint from both of these joints from moving at all. So the CMC joint of the index and the CMC joint of the middle finger have absolutely no motion, zero. But there can be trauma or inflammatory degenerative changes or rheumatoid disease
WILLIAM B. KLEINMAN: etcetera at these joints, which can cause considerable pain and local tenderness on direct palpation. One of the provocative maneuvers that I introduced some time ago is I like to call the squeeze test, which is again, pathognomonic for inflammatory change at the second CMC joint. Not only is the patient quite tender, when you palpate the joint between the trapezoid and the second metacarpal, but if you take your examining hand again,
WILLIAM B. KLEINMAN: reduce the transverse arc of the distal palm by squeezing the patient's second metacarpal, rolling it into pronation passively, it torques the second CMC joint and creates considerable pain. That's why patients who have had traumatic injury or intra articular injury or synovitis at the second CMC joint always complain to the doctor that when patients shake their hands, it hurts, it hurts a lot.
WILLIAM B. KLEINMAN: So the squeeze test, I believe, is pathognomonic for inflammatory changes in the articular area of the second CMC joint. The reason it's so important is because if you remember back to when we examined the extensor carpi radialis longus, which inserts onto the dorso radial side of the second metacarpal extensor carpi radialis longus tendinitis is quite tender in the repetitious stress marketplace.
WILLIAM B. KLEINMAN: So a good way to differentiate tendonitis from intra articular pathology is by using the so-called squeeze test with cases of extensor carpi radialis longus tendonitis, the squeeze test will always be negative and with intra-articular pathology at the CMC joint of two, the squeeze test will always be positive. Most injuries to the radiocarpal relationship passing with energy dissipated through the carpus occur with the hand forearm unit in extension.
WILLIAM B. KLEINMAN: The in falls on the outstretched hand, the wrist is extended, and whether the impact load is on the base of the thumb, creating intercarpal supination or on the heel of the hand, creating intercarpal pronation will determine where the path of energy passes as the injury is created. As you can see in this slide, the injuries to the radial side of the carpus will occur with the hand forearm unit and ulnar deviation.
WILLIAM B. KLEINMAN: The strike of the ground being at the base of the thumb and with the wrist held in extension. Energy is dissipated along the radial side of the carpus into the area between the scaphoid and the lunate. On the other hand, if the hand forearm unit is held in radial deviation at the time of impact load, for example, in an automobile accident where the hand is gripping the steering wheel hard and the wheels are instantly shoved in one direction, spinning the steering wheel, the hand is in extended the hand forearm units in extension and energy will be dissipated into the relationship between the lunate and the triquetrum.
WILLIAM B. KLEINMAN: In this diagram from Mayfield and Johnson's classic 1981 work, progressive peri lunar instability, the amount of injury caused to the carpus will be dependent upon a variety of factors, including the exact position of the hand forearm unit at the time of impact load exactly where the point of entry for the energy bolus is, the age of the patient and the disease of the bone itself i.e. osteoporosis or a young healthy bone structure
WILLIAM B. KLEINMAN: and that will determine where the pathway of least resistance is for the entering bolus of energy. And all these factors are involved in determining what pathology takes place. Of course, the most significant factor is how much energy is being delivered into the system. In this X-ray from the laboratory, from Mayfield Johnson's cadaver work, you can see at the time of impact load, the hand forearm unit in their work is in severe ulnar deviation and the carpus is pulled up along its radial border with tension forces acting on the carpus and the radiocarpal relationship
WILLIAM B. KLEINMAN: as the energy bolus enters the carpus just distal to the radius. This X-ray is consistent with the results that we would call stage one progressive perilunar instability, and I'll explain that in just a minute. These diagrams drawn by Gary Schnitz, our medical illustrator, shows the results of a grade 1 low energy injury to the carpus with a hand forearm unit held in ulnar deviation.
WILLIAM B. KLEINMAN: The radial collateral ligament has been torn, the radial scaphoid capitate ligament has torn, but there's not enough energy to completely tear the ligament of testut i.e. the radial scapholunate ligament. And it's deflected off of the long radial lunate ligament, but with insufficient energy to tear the interosseous scapholunate ligament. So what happens is that we wind up with marked tenderness directly on palpation of the scapholunate relationship.
WILLIAM B. KLEINMAN: The examiner takes his finger and puts it directly over the scapholunate ligament, which can be found just distal to Lister's tubercle. That's the area of maximum tenderness with the hand forearm unit held in neutral position. In stage one progressive peri lunar instability, when we look at the patient's x-rays with load and without load, you'll see that the scapholunate relationship is entirely normal, both on the lateral projection where we see that the angle of the scaphoid is its normal 45 degree position and that the lunate sits squarely in the lunate fossa of the radius without any tilt into extension, as I'll explain in a minute.
WILLIAM B. KLEINMAN: Stage one progressive peri lunar instability results only because the energy bolus at the time of impact load was insufficient to cause damage resulting in carpal instability. The differential diagnosis of focal scapholunate. Tenderness and pain consists of dynamic scapholunate instability, secondary to a partial sprain or tearing of the scapholunate interosseous ligament.
WILLIAM B. KLEINMAN: Scaphoid impaction syndrome, occult dorsal carpal ganglion cyst and chronic dorsal carpal impingement syndrome or what I like to refer to as type I gymnast wrist. Type one gymnast wrist should be differentiated from type 2 as described by Kirk Watson, which is premature closure of the dorsomedial epiphyseal plate, leading to deformity of the wrist, secondary to repetitive trauma along the dorsal aspect of the distal radius.
WILLIAM B. KLEINMAN: This diagram shows dorsal scaphoid impaction syndrome, which comes from a single episode of fall on the outstretched hand, where the dorsal margin of the radius literally jams into distal dorsal neck of the scaphoid, creating either a trans chondral injury or an osteochondral fracture adjacent to the scapholunate ligament. These can be very deceptive when you try to examine and when the examiner palpates the area of the scapholunate ligament, you find that these can mimic scapholunate injury.
WILLIAM B. KLEINMAN: Dorsal occult ganglion cyst of the scapholunate ligament can also be quite tender, quite small and hidden. That's why they're called occult ganglions, but can also be manifest as marked tenderness directly over the scapholunate ligament. And the final diagnosis and the differential diagnosis of focal scapholunate pain is the so-called dorsal chronic carpal impingement syndrome or type 1 gymnast wrist where chronic repetitive loading of the hand forearm unit with the wrist and hyperextension.
WILLIAM B. KLEINMAN: A good example would be the athlete who performs on the pommel horse with chronic repetitive hyperextension, literally causing a chronic thickening and capsulitis on the dorsal aspect of the carpus. Quite tender, quite sensitive, no acute inflammatory changes, but marked irritability of the free nerve endings in the dorsal capsule. And if the examiner palpates directly over the scapholunate ligament, it will not only be thick and full, but also quite tender on palpation.
WILLIAM B. KLEINMAN: Examples of these from patients in the operating room can be seen first in this view of an occult dorsal carpal ganglion cyst sitting directly in the dorsal distal scapholunate ligament, just proximal to that critical 2 to 4mm of dorsal ligament that is primarily responsible for maintaining the position of the scaphoid and lunate. In this intraoperative photograph, we see a classic case of scaphoid impaction syndrome, a single episode where an osteochondral fragment has been taken by driving the dorsal aspect of the radius into the distal portion of the scaphoid directly adjacent to the scapholunate ligament often confuses the diagnosis on palpation.
WILLIAM B. KLEINMAN: So with the elbow flexed, the forearm rotated in neutral position and the hand forearm unit held securely by the examiner. We can easily find the scapholunate relationship by first palpating Lister's tubercle and then moving the examining finger directly distal to Lister's tubercle, which places it distal to the inter fossil ridge of the radius between the elliptical fossa and the spherical fossa, and directly between the scaphoid and the lunate for palpation.
WILLIAM B. KLEINMAN: In the normal rotational situation like this, with the forearm in neutral position, the lunate sits 2/3 on the spherical fossa of the radius and one third overhanging the triangular fibrocartilage complex. So the examiner should have a good 3 dimensional concept of where the lunate sits and then where the scaphoid is adjacent to this lunate. Lunate is 2/3 on, 1/3 off the radius.
WILLIAM B. KLEINMAN: By finding Lister's tubercle and moving it onto the scapholunate ligament, the examiner can easily palpate the scapholunate interval. As the wrist is flexed, the scapholunate relationship becomes more prominent and it actually becomes easier to palpate the scapholunate interval. In stage one progressive peri lunate instability, this area will be very tender
WILLIAM B. KLEINMAN: because of the partial damage that's been created to the scapholunate ligament. The examiner needs to remember that the differential diagnosis of tenderness directly over the scapholunate ligament and only consists of four things. So it's incumbent upon the examiner to rule out as many things as possible by physical diagnosis and then leave the laboratory to differentiate the remainder.
WILLIAM B. KLEINMAN: As more energy enters the system with the hand forearm unit held in ulnar deviation extension with a load coming through the base of the thenar eminence, there's an intercarpal torque and if the energy is sufficient, as you can see in this stage two, Mayfield and Johnson progressive peri lunar instability, the energy is dissipated through the radial collateral ligament, through the radial scaphoid capitate ligament, through the ligament of testut and then continues through all elements of the scapholunate ligament finally coming to rest within the space of Fourier between the distal carpal row and the proximal carpal row.
WILLIAM B. KLEINMAN: What results from this injury is a loss of anatomic connection between the scaphoid and the lunate. If there's a loss of anatomic connection, the internal force coupled within the scaphoid sitting at 45 degrees will cause a collapse of the scaphoid under load between the hand and the forearm, allowing the scaphoid to collapse into a more perpendicular attitude relative to the plane of the hand forearm unit.
WILLIAM B. KLEINMAN: When this occurs, the lunate and the triquetrum will then slide volarally on the radius because of its tilt and fall into an extended position that Linscheid and Dobyns, in their classic 1971 article on carpal instability referred to as dorsiflexion intercalated segment instability or DISI of the lunate. These next two X-rays show the classic progressive peri lunate instability quite well with a perpendicular scaphoid, a loss of carpal shift influence of the scaphoid on the lunate by opening up of a wide diastasis between the lunotriquetral unit and the scaphoid.
WILLIAM B. KLEINMAN: So-called scapholunate separation. And in the lateral projection, the scaphoid can be seen being pushed into a more perpendicular attitude as the radial lunate relationship allows the lunate to rock into a more extended or dorsiflexed posture. Scapholunate instability of Mayfield & Johnson stage two was an easy diagnosis to make, not just on the basis of the patient's complaints of pain, but on the basis of clear radiographic changes in the resting position, which we call static instability.
WILLIAM B. KLEINMAN: The problem for us as examiners is to understand how to make the clear diagnosis of dynamic instability in Mayfield & Johnson's stage one leading to stage two progressive peri lunate instability. And that's where the examination techniques of the wrist become very important. Kirk Watson deserves credit for describing one of the most successful examination techniques of the wrist in determining dynamic scapholunate instability or advanced stage one progressive peri lunar instability where there hasn't been enough energy dissipated to allow a complete blowout of the scapholunate ligament with loss of that relationship.
WILLIAM B. KLEINMAN: But normal x-rays, everything looks good on static projection but when energy is introduced into the system by provocative maneuvers, we can demonstrate some subtle instability, but real between the scaphoid and lunate. The Watson maneuver, or what some refer to as the scaphoid shift test, relies on normal anatomic changes that go on with movement of the hand forearm unit from ulnar deviation to radial deviation
WILLIAM B. KLEINMAN: and if we look at these cadaver sections, with X-rays that correlate to the position of the cadaver, you see that in ulnar deviation, the scaphoid is pulled up into a longitudinal attitude. Normally the scapholunate ligament exerts what we call a carpal shift influence of the scaphoid on the lunate as the scaphoid is pulled up longitudinally. There's a decompression or tension of load along the radial side of the carpus, and the entire lunotriquetral unit is pulled more onto the spherical fossa of the radius by the intact scapholunate ligament.
WILLIAM B. KLEINMAN: What happens when this is performed and the hand is forced into an ulnar deviated posture relative to the forearm, is that the hand as defined by the rigid distal carpal row the hand, as we can, see here on the medial side being the hamate is literally driven down the helicoidal triquetrum interface in a corkscrew fashion to engage the triquetrum and help coax it into an extended position.
WILLIAM B. KLEINMAN: So in ulnar deviation the scaphoid is extended, the lunate is extended and the triquetrum is extended. That position is enhanced by the driving nature, the active driving nature of the hamate, the ulnar side of the hand being driven down that helicoidal corkscrew interface, pushing the triquetrum into extension. As the hand forearm unit swings from ulnar deviation to radial deviation
WILLIAM B. KLEINMAN: as we see in this cadaver, the triquetrum joint dissociates, the hamate goes into what's referred to as the hamate high position that we can see on this X ray, completely disengaged from the triquetrum and allowing whatever active mechanics are taking place on the radial side of the carpus to allow the proximal carpal row to be forced into flexion. As the trapezium and trapezoid portion of the hand comes closer to the radius, making the space available for the scaphoid smaller and the triquetrum joint disengages allowing mechanics to take place driven by the radial side of the hand.
WILLIAM B. KLEINMAN: So if we go back to the ulnar deviation cadaver view, you can see active mechanics taking place on the ulnar side of the carpus, driving the proximal row into extension as the scaphoid is pulled into a longitudinal extended position and then swinging over to the radial side of the hand, the scaphoid being driven into a perpendicular attitude with the triquetrum hamate joint disengaged and not contributing to the posture of the proximal row.
WILLIAM B. KLEINMAN: Now Kirk Watson took this biomechanical information and designed the scaphoid shift test to add energy into the system by the examiner and demonstrate scapholunate instability dynamically that can't be seen on static x-rays. The exam is performed by putting the examiner's thumb directly under the distal pole of the scaphoid with the hand forearm unit held in ulnar deviation, supporting the scaphoid in its extended position and keeping the distal pole from flexing down as the hand is brought into radial deviation.
WILLIAM B. KLEINMAN: You can see in this AP view, the examiner's thumb is under the distal pole of the scaphoid, right at the distal neck and as the hand is passively brought into radial deviation, the examiner's thumb keeps the scaphoid from its normal falling position, holding it up into extension, keeping it from flexing, and thereby creating a situation where energy dissipated into the carpus by the passage from ulnar deviation to radial deviation has to manifest itself at the scapholunate relationship by demonstrating instability at the proximal pole.
WILLIAM B. KLEINMAN: If you look at the lateral projection hand forearm unit held in neutral rotation, the examiner's thumb in ulnar deviation placed under the distal neck and the examiner's thumb holding the scaphoid from coming down into a perpendicular attitude. As the hand forearm unit passes from ulnar deviation into radial deviation. You can see this on X-ray with the examiner's lead covered hand, holding the distal neck of the scaphoid up in ulnar deviation, and then the examiner passively moving the hand forearm unit from ulnar deviation to radial deviation with the thumb holding the neck of the scaphoid up so that the scaphoid can't come down into a more perpendicular attitude.
WILLIAM B. KLEINMAN: In this schematic, we can see the normal on the left side with the position of the scaphoid in ulnar deviation and the position of the scaphoid and radial deviation. You can see how it comes from an extended position to a flexed position and then doing the Watson maneuver loading force of radial deviation taking place, as the examiner's thumb holds the distal pole of the scaphoid where it is supposed to be.
WILLIAM B. KLEINMAN: The energy dissipated by the force of passive ulnar deviation, radial deviation forces all the load down to the proximal pole of the scaphoid, driving the proximal pole of the scaphoid out from the elliptical fossa and over the dorsal edge of the radius. This is associated with a marked amount of pain. It has to always be compared to the opposite side for a normal baseline, but it can consist of either a low frequency clunk sound, a subtle click.
WILLIAM B. KLEINMAN: If the energy dissipated is small enough and the ligaments stable enough to not allow the entire clunking of the proximal pole out and over the dorsal margin of the radius and definitely pain. It must be compared to the opposite wrist. The Watson maneuver is extremely useful in separating patients with dynamic scapholunate instability who can't be diagnosed in any other way.
WILLIAM B. KLEINMAN: So let me demonstrate it now in our patient, examining thumb goes right onto Lister's tubercle, comes up over the scapholunate ligament on the dorsal side. and on the volar side, the examiner's thumb goes right under the neck of the scaphoid holding it into extension. The medial four fingers of the examination, the examiner's hands support the radius
WILLIAM B. KLEINMAN: so it's entirely locked. And then the opposite hand of the examiner brings the hand forearm unit from ulnar deviation into radial deviation while the thumb continues to maintain the position of the scaphoid. When the examiner brings the hand from ulnar deviation to radial deviation, if there's instability at the scapholunate ligament, it will force the proximal pull of the scaphoid up and out over the dorsal margin of the radius at the elliptical fossa.
WILLIAM B. KLEINMAN: The Watson maneuver, as I mentioned, is extremely critical, extremely important to be able to be done well by the examiner and separates those patients out who have dynamic scapholunate instability. And remember, most importantly, as I keep mentioning through this video, patients all have tenderness at the scapholunate interval. If the patient has no tenderness at the scapholunate interval on direct palpation, then there is no justification for continuing to go forward with the Watson maneuver.
WILLIAM B. KLEINMAN: As I talked about before, the position of the hand forearm unit with respect to radial and ulnar deviation at the time of impact load, determines whether energy enters the system along the ulnar border or the radial border and the system always fails in tension, it thrives in compression. So if the hand forearm unit is in ulnar deviation, the force of energy will enter into the radial side of the hand forearm unit at the radial collateral ligament.
WILLIAM B. KLEINMAN: If the hand forearm unit is in radial deviation, it will enter along the ulnar side and be directed in a peri lunar fashion through the lunatotriquetral area. And patients who have sprains of the lunotriquetral ligament are very difficult to diagnose. They all will have tenderness on direct palpation of the lunatotriquetral ligament, which can be found, as I mentioned earlier, by thinking of the lunate in three dimensions with 2/3 of the lunate on the spherical fossa of the radius in neutral rotation and neutral deviation and one third off the radius over the triangular fibrocartilage.
WILLIAM B. KLEINMAN: So in this diagram, you can see how easy it is to find the lunatotriquetral joint and palpate it for tenderness. If the patient has complaints of tenderness in this area and X-rays of the lunatotriquetral relationship are normal, there are three diagnostic tools that the surgeon can use to introduce energy into the system by physical diagnosis and elicit a diagnosis of lunatotriquetral instability that occurs most commonly prior to complete tearing and dissociation of the lunatotriquetral joint, which we define as stage three, which leads to the classic VISI collapse deformity of the scaphoid and lunate with extension of the triquetrum.
WILLIAM B. KLEINMAN: Stage three LT instability is rare. It requires an enormous amount of energy to create that type of instability. On the other hand, stage one and stage two instabilities are very common and these provocative maneuvers help the examiner in isolating LT instability and making a definitive diagnosis. The most subtle and most rewarding of the
WILLIAM B. KLEINMAN: provocative maneuvers to determine lunatotriquetral instability, I like to refer to as the shear test. It creates controlled shear forces between the lunate and the triquetrum by application of pressure by both of the examiner's hands. The hand forearm unit is held in neutral rotation again, no deviation, no rotation of the forearm. One of the examiners thumbs is placed directly over the pisiform and compresses or loads the pisiform directly against the triquetrum.
WILLIAM B. KLEINMAN: The other examiner's hand stabilizes the dorsal body of the lunate, which is easy to find by putting the thumb directly distal to the medial distal side of the radius directly over the dorsal body of the lunate and giving a counterforce to the first thumb, pushing dorsally. So one thumb is pushing the dorsal body of the lunate volarlly, the other thumb is compressing the pisiform against the triquetrum and pushing it gently dorsally and as I'll demonstrate in our patient, this can be completely controlled and the energy titrated into the system in very subtle aliquots
WILLIAM B. KLEINMAN: so that diagnosis of even the smallest LT sprain or LT ligament inflammation can be diagnosed. You can see how one examiner's thumb compresses the pisiform against the volar body of the triquetrum pushing it dorsally while the other examiner's thumb pushes the dorsal body of the lunate volarlly, creating shear forces within the LT relationship. Thus, the name shear test. Forearm unit again held in neutral deviation, form not rotated into either supination or pronation held in neutral position.
WILLIAM B. KLEINMAN: And then the first thumb comes up along the medial border of the distal radius directly over the lunate and the second thumb compresses the pisiform against the triquetrum and you notice that both of my hands are supporting the forearm so that there's no rotational instability of the forearm while this maneuver is done.
WILLIAM B. KLEINMAN: And then aliquots of energy can be introduced by the examiner slowly, subtly, totally controlled the whole time, delivering a little bit of energy into the system or a lot of energy into the system based on what the requirements are and the patients, if they've had injury to the LT ligament or synovitis of the LT relationship, will have considerable pain when this is done. This test is pathognomonic for LT instability.
WILLIAM B. KLEINMAN: The examining technique puts it distal to the triangular fibrocartilage complex, so injuries to the LT relationship can be differentiated from TFC injuries, which we'll get to in a couple of minutes. That's the shear test. The shuck sign described by Doug Reagan and colleagues at the Mayo Clinic is grosser maneuver, but also has the same basic philosophy. In Doug Reagan's shuck test,
WILLIAM B. KLEINMAN: form is neutral again. The examiner squeezes with one hand, the relationship between the dorsal body of the triquetrum and the volar pisiform, grasps it securely, and then, with the other hand supporting the hand forearm unit, this two bone relationship is literally shucked back and forth relative to the remainder of the carpus in an effort to load the lenato triquetral ligament and cause pain.
WILLIAM B. KLEINMAN: It's a little bit more difficult to control the amount of energy that's going into the system when the shuck maneuver is performed relative to the shear test that we just described, but let me show you how this is done. Again, to demonstrate the shuck sign, form is in neutral position. Examining hand supports the relationship between the pisiform and the triquetrum.
WILLIAM B. KLEINMAN: And then this pisotriquetrum relationship with the hand forearm unit held securely by the other hand of the examiner is literally shucked back and forth, dorsal and palmar relative to the remaining portion of the carpus. And what this maneuver does is it puts a torque or load on the lenato triquetral ligament demonstrating pain when it's been injured. Problem with the shuck sign is that it's difficult to control the amount of energy that the examiner puts into the system by doing this.
WILLIAM B. KLEINMAN: It's a lot more subtle to support the lunate using the shear test by supporting the dorsal body of the lunate and creating subtle shear across that LT relationship in a manner that can be much more controlled. The last examination technique for the relationship is called the Ballotment test and was described by Ron Linscheid of the Mayo Clinic with a hand forearm unit held in neutral rotation, the examiner's hand and thumb come up along the medial border of the triquetrum and then the medial border of the triquetrum is literally pushed against the scapholunate relationship, creating compression at the LT relationship, which should be quite tender on direct palpation.
WILLIAM B. KLEINMAN: If there's inflammatory change or injury of any kind along the LT relationship, this maneuver will cause pain. Obviously because of the load produced not only at the LT joint but also along all of the extrinsic capsular ligaments that support the carpus to the forearm. It's the crudest of the three examination techniques for the LT relationship. However, I think all three should be done
WILLIAM B. KLEINMAN: if the clinician is concerned about primary or secondary instability, stage one or stage two, The Shear Test, The Shuck sign and the Ballotment examination should all be performed. It takes about 10, 15 seconds to perform all three, and you can glean an enormous amount of information about the health of the LT ligament by doing all three.
WILLIAM B. KLEINMAN: Of course, each one of these should be done after examination of the piso triquetral joint. If there's any inflammatory change at the pisiform and its relationship to the triquetrum, then it's very difficult, if not impossible, to either do the Shear test, the Shuck sign or the Ballotment examination. So first and foremost, before the LT ligament is examined by either of these three provocative maneuvers, the surgeon should palpate the piso triquetral joint for swelling or tenderness and perhaps even shuck the piso triquetral joint back and forth to make sure it's healthy and painless before embarking on any of these maneuvers.
WILLIAM B. KLEINMAN: So the Linscheid Ballotment examination is performed by first finding the styloid of the ulnar, moving the thumb just distal to the styloid so that it's on the ulnar body of the triquetrum and then pushing the triquetrum radially so that compressive forces are generated within the lunatotriquetral relationship, and if there's swelling, injury, synovitis at the relationship, it will be tender.
WILLIAM B. KLEINMAN: The Llinscheid Ballotment examination, obviously the crudest of the three maneuvers, the Reagan shuck sign, the second most useful, but also important and then the Shear test, shearing between the triquetrum and the lunate, the most sensitive of the three provocative maneuvers. Let's finish this instructional course on physical diagnosis of the wrist by focusing on the triangular fibrocartilage complex and the distal radioulnar joint.
WILLIAM B. KLEINMAN: Two extremely important areas for the clinician to know how to examine and actually quite easy to examine for a lot of useful information. We have learned a lot about the anatomy, the details of anatomy of this area over the last 15 or 20 years. Many orthopedic and plastic surgeons who do hand surgery, consider this area the Black box of hand surgery. I think over the past two decades, there's been a lot of illumination of this area
WILLIAM B. KLEINMAN: and hopefully the diagnostic maneuvers that I go through in the next few minutes will help the clinician in separating out some of the diagnoses of injury and disease in this area. The triangular fibrocartilage basically has two functions. The first and most important is to anchor the radius carpus and hand as one unit to the fixed ulna. As we discussed earlier in this instructional course, the ulna is fixed in a ginglymus relationship with the humerus at the elbow.
WILLIAM B. KLEINMAN: It flexes and extends, but there's no rotation. The radius, carpus and hand unit rotates as one free body in space around the fixed unit in pronation, all the way to supination. The principal structure that guides that rotation of the radius around the ulnar is the periphery of the triangular fibrocartilage complex. If you, as you can see in this diagram by Gary Schnitz, there are two components of the periphery, a superficial component, which you can see in green, taking its origin from the medial aspect of the distal radius and inserting on the ulnar styloid.
WILLIAM B. KLEINMAN: And a second component, which you see in blue, also taking its origin on the distal aspect of the medial radius, but inserting on the fovea of the distal ulna adjacent to the cartilaginous coverage of the distal pole of the ulnar, creating a situation where the angle of attack of the fibers of this deep blue portion of the triangular fibrocartilage which I've called the ligamentum subquantum, is much more obtuse than the more longitudinally and acutely angled fibers of the superficial green component that insert on the base of the styloid.
WILLIAM B. KLEINMAN: This difference in angles of the deeper tissue of the triangular fibrocartilage periphery, both dorsal and palmar, give it a better mechanical advantage to control rotation of the radius
WILLIAM B. KLEINMAN: carpus hand unit around the fixed ulnar. Both the green and the blue are important, but the blue fibers are much more important in stabilizing this relationship. As you can see in this diagram, the green and blue fibers of the periphery are oriented longitudinally between the radius and the ulnar, and they envelop a central portion of the triangular fibrocartilage referred to as the articular disc, which is responsible for the second function of the triangular fibrocartilage, which is to allow load transfer from the ulnar deviated medial portion of the carpus or hand through the central portion of the triangular fibrocartilage onto the distal pole of the ulnar.
WILLIAM B. KLEINMAN: So there are two distinct functions of this little piece of gristle the size of 4 or 5 stacked dimes, one being control of rotation of the radius carpus hand unit around the fixed ulnar and the other being load transmission through the central portion, the articular disk of the TFC. The periphery of the triangular fibrocartilage, the green and blue portion both are well vascularized
WILLIAM B. KLEINMAN: and nourished by oxygenated arterial blood, passing through the two vessels, one volar, one dorsal that come off the dorsal branch of the intra anterior interosseous artery of the forearm. The central portion, the white articular disk portion is nourished by synovial washings from the ulnocarpal joint itself. The normal arc of motion of the forearm is 90 degrees of supination
WILLIAM B. KLEINMAN: and 90 degrees of pronation. What happens during that arc of prono supination is that the radius carpus hand unit rotates around the fixed seat of the ulnar but in addition to rotation, it translates dorsally relative to the fixed ulnar seat so there's a combination of rotation and translation as the radius carpus hand unit rotates into supination.
WILLIAM B. KLEINMAN: The predominant structure that's responsible for maintaining stability of the radius to the seat of the ulnar as it rotates and translates is the deep portion of the triangular fibrocartilage, the so-called ligamentum subquantum. And as you can see in this diagram, it's actually the ever tightening dorsal portion of the deep ligamentum subquantum that's the primary check rein preventing hyper rotation or hyper supination and maintaining stability.
WILLIAM B. KLEINMAN: The relationship between the radius and the ulnar in maximum supination involves contact in only about 10% of the articular surface of the contact area between the seat of the ulnar and the sigmoid notch. So it keeps it from super physiologically translating is the increasing tightness of the ligamentum subquantum dorsal portion. As you can see in this diagram, the head of the ulnar becomes almost entirely exposed in maximum supination, thus rendering the volar portion of the superficial green component less and less and less effective as a primary stabilizer of the relationship of the radius and ulnar.
WILLIAM B. KLEINMAN: So if we come back to our patient. To examine the patient in supination as the forearm supinates to its maximum position, the ulnar stays stable, the radius carpus and hand rotates and translates more and more dorsal, and the dorsal portion of the ligamentum subquantum becomes the primary stabilizer
WILLIAM B. KLEINMAN: as the head of the ulnar becomes more and more prominent and less responsive to tightening of the superficial volar green ligament. We can elicit injuries to the deep portion of the triangular fibrocartilage, injuries to the ligamentum subquantum, the blue portion that you saw on that diagram, by introducing energy into the system, trying to create a super physiologic load to that relationship.
WILLIAM B. KLEINMAN: Now what I mean by that is if the patient is having pain in the area of the triangular fibrocartilage complex and if your clinical examination by direct palpation of the area distal to the pole of the ulnar demonstrates tenderness, then if we rotate the forearm into maximum supination and tighten that dorsal deep blue ligamentum subquantum, and then further tighten it by taking the hand forearm unit
WILLIAM B. KLEINMAN: and trying to super physiologically translate it more dorsal while we shove the ulnar even more volar, trying to create a situation where even less than 10% of the articular surface is in contact, really demonstrating instability and increasing load on the dorsal deep portion of the ligamentum subquantum, the patient will have considerable pain. So this maneuver is done by putting the patient in supination and then literally driving the fixed ulnar even more volarly, putting more tension on the potentially injured dorsal deep portion of the ligamentum subquantum.
WILLIAM B. KLEINMAN: This maneuver is pathognomonic for injuries, inflammation, disease of the dorsal fibers of the ligamentum subquantum. Conversely, if we roll the hand forearm unit into pronation, then the radius carpus hand is now rolling, rotating and translating volarly off of the fixed ulnar. And in this situation, it's the volar fibers of the ligamentum subquantum that are most responsible for maintaining the relationship of the radius to the ulnar.
WILLIAM B. KLEINMAN: If we take the situation in our patient who has triangular fibrocartilage pain, rotate the forearm into pronation, and then introduce a super physiologic stress against the ulnar, driving it even more dorsal this time in pronation and pulling the radius carpus in hand, even more volar. We're creating enormous loads, super physiologic loads on the volar aspect of the ligamentum subquantum.
WILLIAM B. KLEINMAN: This maneuver is pathognomonic for injuries, instability, diseases that involve the volar fibers of the deep portion of the triangular fibrocartilage. So these two maneuvers, as you can see in this diagram, by introducing a dorsal load to the distal ulnar with the hand held in supination, stresses the dorsal fibers of the ligamentum subquantum, creates instability if one exists, subtle instability but marked pain, and then to stress test the volar fibers of the ligamentum subquantum, the hand forearm unit is rotated and translated into pronation and a dorsal load is placed on the distal ulnar, trying to move it in a supra physiologic fashion
WILLIAM B. KLEINMAN: so that more load is placed on the volar ligamentum subquantum subjecting it to a higher degree of stress testing. And if there's injury, inflammation or disease of any kind in the volar ligamentum subquantum it will be very painful for the patient. So it's important to review these positions of the hand forearm unit. If you look at these two diagrams by Gary Schnitz, you'll see that in maximum supination
WILLIAM B. KLEINMAN: the tightening fibers of the deep, dorsal, blue ligament and subcordatum is what's most susceptible to injury in supination and the one that can be stress tested to see if it's intact or diseased or has failed. And conversely, in pronation, the radius rotates off of the ulnar with the carpus in the hand, stress testing the volar portion of the ligamentum subquantum.
WILLIAM B. KLEINMAN: The two maneuvers that increase super physiologic load to this area can be used to demonstrate if there's been any injury, any instability or any disease in these two components of the most important portion of the triangular fibrocartilage complex, the ligamentum subquantum. I just want to emphasize one more thing about palpation of the anatomy in any of these conditions that we mentioned during this instructional course,
WILLIAM B. KLEINMAN: we need to keep in mind that unless the tissue is tender on direct palpation, then there's no indication to go ahead and stress test any of the different components. If the triangular fibrocartilage has been injured, if we palpate Bergers point, which is the area between the extensor carpi ulnaris, flexor carpi ulnaris and the ulnar styloid just proximal to the body of the triquetrum
WILLIAM B. KLEINMAN: and this area is not tender at all. It's doubtful that there's been any injury to the triangular fibrocartilage to begin with. Somewhere on palpation of the TFC either dorsal or palmar or on the medial border at Berger's point, there should be some tenderness to indicate injury or micro instability of the distal radioulnar relationship. If there's some tenderness in this area
WILLIAM B. KLEINMAN: and we want to isolate injury to the deep portion of the triangular fibrocartilage relative to the superficial green fibers, then we need to do the provocative maneuvers that stress test the deep blue fibers of the ligamentum subquantum. Now, the reason for putting so much emphasis on stress testing the ligament subquantum is that diagnostic arthroscopy of the TFC to determine size and position of traumatic injuries to the periphery or central portion has no value whatsoever in being able to inspect the ligamentum subquantum. The arthroscope is introduced into the ulnocarpal joint.
WILLIAM B. KLEINMAN: It can see only the superficial component and the articular disc or central portion of the triangular fibrocartilage. The most important stabilizer of the distal radioulnar relationship through its arc of supination cannot be seen by direct diagnostic arthroscopy because the scope cannot see through the green, through the white, into the important blue fibers that take their insertion directly into the fovea, the most important rotational controlling anatomy. And finally, examination of the distal radioulnar joint should be performed again first by direct palpation to see if there's inflammation, synovitis, tenderness along the relationship between the distal seat of the ulnar and the sigmoid fossa.
WILLIAM B. KLEINMAN: And then this can be also added to by compression, the compression test where if there's inflammatory change, pain, tenderness at the distal end of the ulnar, the examiner's hand comes outside the area of inflammation down the shaft of the radioulnar relationship and then load and squeezing is introduced into the distal radioulnar relationship as the two bones are squeezed together by the examiner's hand in an effort to shear and shuck the seat of the ulnar back and forth against the sigmoid notch.
WILLIAM B. KLEINMAN: If there is chondromalacia or degenerative change exposed bone ebronated bone, this compression test of the radioulnar relationship will be extremely painful when the examiner performs it. I hope the points I have gone through in this instructional course on physical examination of the wrists are helpful to you and for your treatment of patients with acute or chronic wrist pain. Thanks so much for your attention, and good luck.
WILLIAM B. KLEINMAN:

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