March – Wrist

[Laura Thornton]

A 21 year old collegiate male golfer presents to the clinic with one year history of ulnar-sided wrist pain and recurrent swelling of one year duration. He describes his pain as sharp initially, but can linger as a deep ache after activity. Aggs include golf, especially when hitting off center or during the end of his rounds, picking up moderate to heavy objects with his right hand, (>5#), and weight-bearing through his hand. He is currently in season and unable to play or workout due to pain, but wants to return to play as soon as possible.

Please discuss further relevant subjective questions and objective testing that would lead you to your differential diagnosis list.

What are some key clinical examination tools that you would use or have used with similar patients?

Have a read of the following two articles to help review. Both are from the Journal of Hand Therapy – Special Issue Wrist in 2016.

Attachments:

You must be logged in to view attached files.

[Erik Kreil]

Hey Laura,

Interesting case here. I’d be interested in the following additional questions…

About the patient:
– Is he right handed?
– How long has he been golfing?
– Did he ever take a break when experiencing pain, or just push through it?
– What exercises during workouts?

About the sxs:
– Does he have concurrent neck or elbow pain?
– When does the swelling occur? Where? For how long?
– Easing factors? It sounds quick to aggravate, how quick to dissipate?
– What has the trend of his sxs been since initial onset over 1 year ago? No particular MOI it sounds like?
– More details on the location of his sxs
– History of Kienbock disease in his family?

About his function:
– Can he discern what part of the swing is bothersome? (at least which 1/3rd?)
– Is it the act of picking up a heavier object, or just carrying it?
– Does it matter how he weight bears? (e.g orientation of the wrist or forearm)
– I’d like to see him hold a golf club

Objective features:
– Clear: CS, nerve, elbow
– Observation of willingness to move, skin changes, and bony prominences
– A/PROM of wrist and pronation/supination
– MMT
– Palpation of carpal and distal ulnar/radial joints, possible compression in cardinal or quadrant planes
– Ulnar foveal sign
– Grip strength

I haven’t come across many wrist/hand cases, but it sounds like from the 2 review articles that a well though-out subjective history and methodical objective examination to rule out structures is necessary for adequate diagnosis and subsequent treatment. I’d be interested to know what has worked with you guys to develop a clear picture for treatment!

[Matt Fung]

Hey Laura, thanks for posting the case and articles. These articles provided me with great guidance on how to approach an evaluation of the wrist systematically. I have treated one patient with complaints of localized ulnar sided wrist pain worse with weight bearing and carrying activities at the gym. In this particular case local wrist structures did not reproduce his symptoms. With help from Kristin we looked up the chain and were able to help him resolve his symptoms by addressing 1st rib mobility on his affected side.
For this case I’d like to know if there was a direct MOI a year ago when his symptoms presented? Are there any easing factors? Which hand is involved, is it his dominant hand? Is he a righty or lefty when if comes to golfing (top hand vs. bottom hand when gripping the club)? How long does the deep ache last after activity? Is there any clicking associated with his pain or clicking with rotational motion? Has he had any PMH of any injuries to the neck, affected shoulder, elbow, or wrist? Does he have any decreased sensation or strength in the hand, n/t? Does position of hand (neutral/pronated/supinated) affect his ability to pick up/carry moderate to heavy weights? Has he had any treatment in the past year (injections, splinting, PT)? Why does he believe his wrist hurts?
As of right now without more information my DDx would be centered on localized structures including TFCC partial tear, DRUJ instability, ligamentous tear (UT lig), ulnar impaction, then potentially looking up the chain.
Objectively I would watch him as he walked through the door, does he favor the wrist/hand with simple tasks such as opening a door, WB while sitting down, writing etc. I would proceed to perform an assessment of his quality and quantity of wrist motion in all planes comparing the unaffected to the affected side. Direct palpation of local structures of the wrist may help identify potential sources of his symptoms. I would also look at his grip strength and his golf swing (not that I am a golf pro). Additionally I would take a look up the chain at resting posture, ROM quality and quantity as well as strength to determine if other structures may be involved.
In regards to key clinical examination tools I would use with this patients or patients in the future, I would work systematically attempting cluster findings to help me to rule in/out suspected diagnoses. After reading these articles I believe assessing resting position of the DRUJ and quality/quantity of pronation and supination could provide useful information in the assessment of static and dynamic stabilizers of the wrist and forearm. I would also make sure not to focus in on the wrist itself and be sure to examine joints up the chain for potential involvement.
Being a young clinician in the outpatient setting it is easy to overcomplicate patients who may present to us with wrist pain since it is not the most common area we treat on a day to day. I received great advice this past week while shadowing Stacy (CHT) over at UVA HS. She told me that the hand/wrist is just like any other joint in the body and it needs to be treated as such. As I have not treated many patients with wrist pathologies to this point I am definitely interested to see how everyone else would go about the evaluation.

[Jon Lester]

Subjective Questions:
– MOI or insidious?
– Swing right or left handed?
– numbness/tingling/weakness
– any other location of pain/symptoms?
– symptom trend? Worsening, improving, stable
– eases?
– clicking/popping?
– Isolated TTP?

Objective Tests: All would be based off of the subjective responses
– Observation
– neck/shoulder/elbow clearing if appropriate
– neuro screen and tinel’s if appropriate
– APRs w/ quadrants if appropriate (wrist and possibly fingers/elbow)
– Joint mobility testing if appropriate
– Distraction/compression
– Palpation of TFCC, carpal bones, distal ulna
– grip strength
– golf swing, picking up 5+ lb weight, and “WB through joint”

What are some key clinical examination tools that you would use or have used with similar patients?
– I have only worked with one patient with a wrist pathology, which was a diagnosed fracture, so I really don’t have many clinical pearls or habits with this pt population to be honest. However, I agree with your comment Matt regarding the wrist just being another joint. Evaluation of the wrist/hand is the same as the other joints that we deal with every day. APRs and subjectives will drive the rest of the objective exam and isolate areas to treat. Have any of the other residents seen wrist/hand pathologies more frequently?

[jeffpeckins]

Subjective Questions
– More specific location of symptoms – dorsal or palmar side?
– MOI? Gradual, traumatic, insidious, increase in activity?
– Numbness or tingling?
– Weakness in hand? Change in grip strength or poor fine motor skills?
– Any elbow, shoulder, or neck pain?
– Hand dominance?
– Joint noises?
– Stiffness?
– Any pain in morning or night?

Objective:
– Functional Assessment of Aggravating Factors: lifting box, WB through UE (does it matter how he WBs?), swinging golf club or demonstrating with something else (does it matter how he holds the club, is it during a specific part of the swing?)
– Screen out cervical and elbow
– APR examination: wrist flex/ext/RD/UD, elbow flex/ext, forearm pron/sup
– Grip strength
– Palpation
– Joint assessment of carpal bones
– Distraction vs compression
– Special tests depending on subjective and objective info, however would guess I would want to do:
— TFCC grind test and press test
— Ligamentous testing
— Instability testing
— Shear testing

I have no clinical pearls of wisdom to share unfortunately. I’m hoping I’ll be able to see some more elbow, wrist, and hand pathologies in the second half of my residency. As an inexperienced hand/wrist clinician, the article with the flow chart that Laura posted would be extremely helpful in deciding which special tests to do based off which objective findings, which would hopefully help with diagnosis and treatment. One of the articles stated that the wrist and hand have a much less likelihood of referred pain compared to other regions, so I would rely heavily on palpation to guide my differential diagnosis.

[Cameron Holshouser]

Love the pictures in the articles.

Subjective:
– MOI and events surrounding the time of injury
– Imaging (XR)
– Paresthesia
– Weakness
– Hand atrophy
– How has he tried to manage pain for the past year? (bracing?)
– Bruising, clicking, popping,
– Golf specific questions (R vs L hand, driver/iron/putting/sand
– ROM limitations (pronation/supination vs flexion/extension)
– What is his training/competition schedule for golf?

Objective:
– Observations (atrophy, swelling, overall posture)
– C/S screen
– Peripheral nerve vs nerve root (ulnar vs C8) tests
– Local, proximal and distal soft tissue palpation (FCU/ECU/pronator teres)
– Palpation (hook of hamate / pisiform / TFCC / ulna)
– Joint assessment: DRUJ, radiocarpal joint, mid-carpal, inter-carpal, MCP
– MMT: wrist/hand/elbow
– Special tests: ulnar foveal sign, ligamentous stress tests, TFCC compression, Wartenberg, froment, spurlings, hand and thumb handheld dynometer)
– Golf swing analysis (backswing, impact, follow through positions)
– Carry / lift 5# dumbbell

My guess would be a potential hamate fracture vs TFCC tear. My asterisks signs: location, competitive golfer, compression, swelling. I would want an X-ray to rule out a fracture before proceeding with treatment. You would think a fracture would be healed by one year, but if he is still having persistent swelling, repetitive impact with golf, and sensitivity to compression – I would still like to rule out a fracture. I would think potential short-term immobilization (brace) might be the best for this patient. I have not evaluated a wrist/hand in clinic yet, so I am not sure what would be appropriate. Despite my lack of experience, I like your take on it Matt – looking at the wrist/hand the same way you look at any other joint.

[Laura Thornton]

Nice start with the compilation of subjective and objective lists – there’s obviously a lot of structures at play.

Let’s say his pain is in his left hand and he is a right dominant player. Denies pain in his elbow, shoulder, or neck. Initial MOI happened last spring when he swung and hit a tree root with his club. He initially played it off, pain subsided within a few days, but has noticed pain and mild localized swelling returns throughout the year if he’s playing tired, at contact when he hits a ball off-center, if he tries push ups or chest press at the gym, or if he tries to pick up his golf bag with his left hand.

Let’s get more specific with the major diagnoses you guys listed – how would you differentiate between a TFCC injury and a fracture, ligamentous injury, and/or ECU involvement?

[Jon Lester]

Here’s how I would attempt to differentiate from those possible differentials.

TFCC:
– isolated tenderness to TFCC
– joint assessment of the DRUJ could be painful/lax/restricted because of stabilization relationship
– compression in UD will be painful
– press up from chair likely painful but might be for other injuries also
– supination lift test

Fracture:
– isolated tenderness to a specific carpal bone or ulna
– maybe tuning fork
– guarded movements disproportionate to other structures

Ligamentous Injury:
– differentiating between laxity vs pain with ROM
– resisted testing might not be painful if it’s an isolated ligament injury (non-contractile)
– isolated tenderness to a specific ligament
– excessive motion?
– end feel

ECU Involvement:
– TTP to mm belly or tendon
– Possible subluxation could be palpable or reproducible with AROM
– strength testing and testing in lengthened position
– atrophy might be noted

[Caseylburruss]

TFCC is a structure to withstand load transmission. I think is a big part of where I can use both my subjective and objective questions to tease out. There was a sudden rotary injury that occurred here. The subject mentioned in this case would definitely fit this case, with a precipitating MOI and aggravating factors of hitting a golf ball and WB through that arm. The press test would be helpful to rule out TFCC if negative 100% sensitivity for a TFCC tear, however when performing this myself you definitely need to compare sides! There is also some good metrics to use ultrasound to assess ulnar displacement compared to the uninvolved side with reports of 88% sensitivity and 81% specificity (Hess et al., 2012)

Fracture: Likelihood small in my opinion. I think ruling out fracture would be relatively easy with palpation thinking the quality of pain and the other tests Jon mentioned. I did find however interesting metrics of concern for TFCC or instability complications relative to the location of a radial fracture. ” 22 patients in whom the fracture was within 7.5 cm of the distal radius’ articular surface, 12 were associated with intraoperative DRUJ instability. While 18 patients whose fracture was greater than 7.5 cm from the radius’ articular surface, 1 patient had intraoperative DRUJ instability after open reduction and internal fixation of the radial shaft fracture.”

Ligamentous: I agree with what Jon has presented, using passive and resistive testing might be helpful as it is a noncontractile tissue. Using the table or supportive base under wrist during testing should allow for less contractile tissues to be contributing and may be helpful. I think using distraction versus compression, in this case, could potentially be helpful to assess ligamentous integrity/pain generator. There was a study done that showed when all soft tissue constraints were intact, despite sectioning to the radioulnar ligament and TFCC DRUJ kinematics were normal.”the investigators concluded that the radioulnar ligaments and TFCC are not essential for maintaining normal DRUJ kinematics as long as the remaining soft tissues are intact. Therefore, when true instability is recognized, there is likely a concomitant injury to multiple structures.” Therefore with the patients’ complaint of pain with fatigue and lifting heavy items requiring increased stabilization with heavy lifting makes me think the stability of that joint is compromised via ligamentous or TFCC complaints.

In my search, I found that ulnar displacement in full pronation was common in patients with instability. “Instability is dorsal displacement of the ulna with respect to the radius, and the loss of congruity will be most pronounced in pronation” Therefore when considering static stability of the wrist noticing differences between nonaffected hand and involved hand in pronation/supination would be helpful.

ECU: tension on the subsheath is greatest during activities involving supination and holding the wrist in a flexed and/or ulnarly deviated position. Active testing in this position is consistent with our patients MOI wrist position and should be tested in this manner. Looking for tendon subluxation would be sound as the ECU tendon does change its angle of pull or dynamic support in different positions. ECU synergy test is a described maneuver proposed to help differentiate ECU pathology from other intraarticular diagnoses. “The test is performed with the patient’s arm resting on the table and elbow flexed to 90° with the wrist in supination. The patient is asked to radially abduct the thumb against resistance. Reproduction of pain in the ECU is a positive test. The test is based on the theory that there is isometric activation of the ECU during resisted thumb abduction” Ruland et al, 2008. There is also another test I found to help identify ECU involvement called the “ice cream scoop” test. “This test is performed with the patient’s wrist in pronation, ulnar deviation, and extension. The examiner palpates the ECU tendon and has the patient proceed with a scooping motion. Any subluxation of the tendon is noted as a positive exam finding” (Ng C et al, 2013)

[jeffpeckins]

I think that Casey and Jon both have sound clinical reasoning for how they would rule-in/out the competing diagnoses.

I would begin by palpatating his wrist and try to identify if there was isolated tenderness or if it the pain more widespread. More localized pain could implicate fracture, ligamentous injury, or TFCC injury, depending on the location. If there was TTP to a carpal bone, I would combine this with quality of pain, and tuning fork, to make sure that fracture is ruled out. I agree with Casey that fracture would be low on my list since it only occurs when he is tired or with certain WB positions. And I wouldn’t think him carrying a golf bag would aggravate a carpal bone fracture.

I would next perform APR exam on the patient’s wrist, forearm, and hand. Pain with AROM into wrist extension and/or wrist ADD would increase likelihood of ECU, however doesn’t necessarily rule out the other structures. PROM into flexion and/or wrist ABD would further increase likelihood of ECU or possibly ligamentous. The most important finding to me would be resisting wrist ext and ADD in their lengthened position, if resistance increases the patient’s pain, that would increase the likelihood of ECU.

Next I would see if compression or distraction aggravated his symptoms. I would expect distraction to increase the patient’s pain only if it was a ligamentous injury, so if distraction increased his pain, this would help me rule this in.

Lastly, I would use special tests to try and rule in my primary diagnosis or rule out any competing diagnoses. I would use STs such as the supination lift test, the ice cream scoop test or ECU synergy test that Casey describes for ECU involvement, or diagnostic US for TFCC involvement. The press test would be a great test to use to rule out TFCC, as it is 100% SN.

[Erik Kreil]

Hey guys,

Casey, I love the excerpt you used from article to get a better idea of the TFCC’s relationship to its surrounding soft tissue structures. From the information presented, I’m generating a different conclusion. The explanation says the TFCC is stressed when the muscles are fatigued, but he’s not fatigued necessarily when he’s picking up his bag or if it’s the first repetition of a push-up, for instance. More specific information about the activity limitations would obviously sway the needle more accurately.. Would you mind providing a link to the article referenced?

Further, I’d be uncertain that compression vs distraction testing is as useful as we hope. Push-ups and chest press provide compressive load, however if the theory is that use of surrounding soft tissue is lacking then picking up a golf bag should generate a distracting force… Gripping is definitely a consistent factor in his functional limitations, as is pronation. Pronator quadratus and flexor digitorum profundus travel along the ulnar aspect as well.

[Matt Fung]

Hey all,

Erik interesting take on the information presented. To your point about picking up his golf bag with the proposed theory your mentioned, I think we need to consider hand position and how forces distributed about the wrist may change when attempting to carry a cumbersome golf bag. If surrounding soft tissues are compromised then to perform the activity we may load structures differently than normal. From my experience these bags are often large and unbalanced and we are typically carrying them with slight ulnar deviation (inc compression of TFCC).

Everyone thus far has provided sound reasoning to help differentiate structures and diagnoses. For me I would start with palpation as well to help identify potential areas of isolated or localized tenderness. Fracture would also be lower on my list at this point due to chronicity of symptoms and description of symptoms. I believe all the tests mentioned prior are appropriate for ruling in or out fracture for this patient.

TFCC: being the “meniscus” of the wrist we would expect increased symptoms with compressive/axial loads with torsional and shearing forces. We have a battery of special tests to assess this structure but as mentioned the press test should be utilized based on its metrics to rule out potential involvement.

ECU: I agree that in order to rule in/out potential ECU involvement we need to perform an APR exam for the wrist to see if these active and restive tests reproduce the patients symptoms.

Ligamentous laxity: A passive wrist exam coupled with compression, distraction, and joint mobility would provide useful information for determining potential ligamentous involvement. Casey I love the information you presented in regards to the study performed. Speaking from personal experience, I had a torn ligament in my wrist and we were unable to identify its involvement in my wrist pain without advanced imaging as all surrounding structures were intact. If instability was present during examination I would definitely consider a potential multifactorial cause to the patients symptoms.

[Cameron Holshouser]

I think everyone has done a great job describing how they would differentiate these structures.

TFCC:
– I like Matt’s comparison of the meniscus in the knee to the TFCC. However, the TFCC is much more complex than just the meniscus in the knee. The triangular fibrocartilage complex includes structures such as the triangular fibrocartilage disc, ulnocarpal meniscus, dorsal/volar radioulnar ligaments, sheath of the extensor carpi ulnaris, UCL, and ulnolunate and ulnotriquetral ligaments. The TFCC has different functions as well including stabilizing the DRUJ and the ulnar carpal bones, but also transmits load between the ulnar and carpal bones. Due to the many structures within the TFCC and different functions, saying that you have a TFCC injury is similar to saying I have subacromial impingement syndrome in the shoulder – there are too many different structures that make up this complex, and it is hard to tease out which might be the structure at fault. Because of this I would think that you would want to see if this is a compressive issue vs a stability issue or a combination of both when talking about TFCC injuries.
– There are two classifications of TFCC injury type 1 (traumatic) and type 2 (degenerative). Going back to the knee meniscus analogy, an acute meniscus tear can present very differently than a degenerative tear in the meniscus. It was interesting to note that degenerative TFCC injuries can occur as young as 30 years old based on their history. Our individual has been a competitive golfer for a long time but did have a specific traumatic compressive/rotational mechanics that caused his pain, so he could have a presentation of both traumatic and degenerative symptoms.

– TFCC Tests:

o General:
– + pain with Palpation (distal ulna, TFCC – most common), also assess the other surrounding ligaments in that complex
– – atrophy / sensory changes
– + Edema
o Compression/rotation injury
– + press test (compression)
– + Compression / rotation /shearing of TFCC
– + Catching/clicking
– distraction
o Ligamentous TFCC Injury
– DRUJ motion laxity
– Carpal laxity
– Supination test
– Piano key test
– Pain with Distraction, better with compression?
– Shuck test – lunotriquetral ligament injuries

Fracture:
– Intense pain with palpation over bony prominence (hamate, pisiform, triquetrum, distal radius, ulnar styloid process, lunate)
– Tuning fork
– Imaging (XR/MRI)
– Edema

ECU involvement
– APR
– ECU synergy
– Palpation

[Caseylburruss]

Erik- I had extreme difficulty finding the exact article I pulled my excerpt from but this is the one I found that most related. I will continue to look and get back to you

Soft-tissue stabilizers of the distal radioulnar joint: an in vitro kinematic study
Gofton, Wade T et al.
Journal of Hand Surgery, Volume 29, Issue 3, 423 – 431

[Laura Thornton]

Well done with the thorough differentials.

Thanks for the reference Casey – I attached the article link.

I think this article is a great example of bridging the gap – can we take a controlled, laboratory-based study like this and make any connection to our patient care.

Any additional thoughts about the study?

Attachments:

You must be logged in to view attached files.

[jeffpeckins]

I thought that this was an interesting article, but very dense and anatomically based. I wish they expanded more on how the findings of the article may dictate how we treat patients in the clinic, however this may be out of the scope of the intent of the article. My takeaway from the article was the complexity of the DRUJ, and how there are numerous structures that need to be accounted for.

The results from the article suggest that the soft-tissue stabilizers can help preserve the kinematics of the DRUJ. I believe this is where we as PTs can help the most, working on improving strength, stability, and proprioception of the soft tissue both locally and then moving further up the chain.

Another finding that I thought was interesting was that the kinematics of the DRUJ were maintained with prox to distal sectioning until the final cut (RULs and TFC). This was evident with both pronation and supination, but only significant with active supination. I would argue that if these structures have been affected by an injury, I would make it my priority to improve the function of these structures before progressing my treatment. Another way of looking at this is that if I felt like these structures were affected by an injury, I may want to get imaging or send them to an orthopedic physician to ensure they are a rehab candidate, because if these structures aren’t functioning, we may not be able to improve the stability of the joint.

[Cameron Holshouser]

Despite the article being laboratory based, I agree with Jeff that this article has clinical value. My take away from this article was that both the passive (TFCC and radioulnar ligaments) and active (extensor carpi ulnaris sub-sheath, pronator quadratus) systems work together to provide stability for normal kinematics at the wrist. If one system is impaired, the other still can provide stability at the DRUJ. If there was a true instability at the DRUJ, then you would think both systems would be impaired and may require surgical intervention.

[Erik Kreil]

One thing that I like is how we as PT’s can use the DRUJ as an example in our practice. The strength of this joint comes from a see-saw effect, demonstrating balance in stabilization from an active source when passive stability is lost. How many patients have asked us “What can you do to help me, when I know the ___ (ligament, disc, etc) is damaged?” Can this help my education? How can I apply a generalized truth from the DRUJ to other joints in the body to better my practice?

[Matt Fung]

I agree that this article has clinical value and can be applied to our practice. My greatest takeaway mimics Cam’s in the fact that we might not be able to detect true instability unless both passive and dynamic stabilizers are compromised. Knowing this if patients are presenting with DRUJ symptoms it increases the importance of our ability to differentiate these different structures to determine the best POC for our patients. As Erik mentioned if we determine loss of passive joint stability we can educate patients about how we can help them improve the dynamic stability of the joint so that normal kinematics can be maintained.

[Author]

Posts