Hi, my name is Mike Henehan, and I'm a faculty member in the Stanford O'Connor Sports Medicine Fellowship Program. Wrist injuries are very common in sports medicine. And there's three that I think of when a patient presents, either acutely or in the office. I think of a TFCC, or triangular fibro cartilage complex, a scaphalonate dissociation, or a scaphoid fracture. I start my physical exam just by having the patient mimic my movement. And so go ahead and do this with me. I have them start out with the wrist flat, and then I have them extend, flex, come back up to neutral, and then they can ulnar deviate and radial deviate. Come back down. It seems like a very simple test, but it's actually quite useful. If there's wrist pathology, definitely you'll see pain with those movements, or you'll see a decreased range of motion. That tips you off that you have something that's happening. So let's take a look at how to examine those three structures in the wrist. I'm going to use my marker here. And if you're worried about a scaphoid fracture, this is the area of the wrist that you're going to be examining. If you're looking at scaphalonate problems, you're going to be more in this area. And then for the triangular fibrocartilage complex, you're going to be focusing on this area. So let's start first with the scaphoid. Certainly if you have a strong history of injury that would suggest a scaphoid fracture, and there's any focal tenderness as you come in here into what they call the anatomical snuff box, which is right at the base of the thumb between the two tendons there. And if there's focal tenderness, then you're suspicious of a scaphoid fracture. The other test I like to do is a grind test, where I just put a little axial load compressing the scaphoid. And if that's tender, again, that would raise my suspicion of a scaphoid fracture. Now we're going to demonstrate how to examine for scaphalonate dissociation. You palpate on the dorsum of the wrist, isolating Lister's tubercle is a good landmark that you're in the right area. You want to palpate in any tenderness, or sometimes you can feel a gap. That's an important physical exam component to note. Then to do Watson's test to look for scaphalonate instability, you have the patient position palm up, place your thumb at the base of their thumb. And you're going to add a slight extension and ulnar deviation. And then you move with a slight flexion and into radial deviation. And then release your thumb. And if you palpate clunk or movement of the scaphoid, or sometimes you can hear that, that would be suggestive of scaphalonate dissociation. To check for the triangular fibril cartilage complex, you want to palpate over the ulna. Just distal to it at the junction of the carpal bones and feeling for any tenderness in that area. And then you can do a grind test where you use ulnar deviation, load that area, and then move the wrist back and forth. And a positive test would be pain on that maneuver.

2nd Edition, CASE 17

2nd Edition

Hand and Wrist

wrist injuries

TFCC

scaphoid fracture

scapholunate dissociation

sports medicine