Wrist Examination OSCE — Systematic Approach, Special Tests, and Common Conditions

Why Wrist Examination Is Examined

Wrist injuries and conditions are common in both acute and outpatient settings. OSCEs examine wrist examination as part of the upper limb MSK suite — alongside hand, elbow, and shoulder. Examiners mark the systematic LOOK, FEEL, MOVE framework and specific special tests for the conditions most likely in the given history: scaphoid fracture in a young adult after a fall, carpal tunnel syndrome in a pregnant woman or middle-aged female, De Quervain's in a new parent.

Anatomy Revision — Key Structures

Bones: 8 carpal bones arranged in two rows (proximal: scaphoid, lunate, triquetrum, pisiform; distal: trapezium, trapezoid, capitate, hamate). The scaphoid is the most commonly fractured.

Joints:

• Radiocarpal joint (wrist proper)
• Distal radioulnar joint (DRUJ) — forearm rotation
• Intercarpal joints

Key structures at risk:

• Median nerve — through carpal tunnel (carpal tunnel syndrome)
• Ulnar nerve — through Guyon's canal
• Triangular fibrocartilage complex (TFCC) — on ulnar side
• Scaphoid — supplied by retrograde blood flow (risk of AVN)

Systematic Examination — LOOK, FEEL, MOVE

LOOK

Inspect from front, back, and sides with wrist flat on table:

• Swelling — generalised (synovitis/RA), localised (ganglion, DRUJ swelling, scaphoid fracture haematoma)
• Deformity — Colles' fracture (dinner fork deformity), Smith's fracture, ulnar head prominence (DRUJ disruption)
• Muscle wasting — thenar (median nerve/CTS), hypothenar (ulnar nerve)
• Scars — surgical (carpal tunnel decompression, previous ORIF)
• Skin changes — inflammation, psoriatic plaques

FEEL

Temperature and synovitis:

• Dorsal surface — warmth, boggy synovitis in RA

Bony tenderness — systematic palpation:

MOVE

Active movements first, then passive if restricted:

Compare bilaterally. Document as reduced, full, or painful arc.

Special Tests

Carpal Tunnel Syndrome

Phalen's test:

• Hold wrists in maximal flexion for 60 seconds (prayer position reversed)
• Positive: tingling/numbness in median nerve distribution (thumb, index, middle finger, radial half of ring finger)
• Sensitivity 68%, specificity 73%

Tinel's sign:

• Tap over carpal tunnel (midline, distal flexor crease)
• Positive: tingling or electric sensation in median nerve distribution
• Sensitivity 50%, specificity 77%

Compression test (Durkan's):

• Apply direct pressure over carpal tunnel for 30 seconds
• Positive: reproduces paraesthesia
• Sensitivity 89%, specificity 96% — most sensitive and specific

Scaphoid Fracture

Anatomical snuffbox tenderness:

• Gold standard clinical test
• Sensitivity 90%, specificity 40%
• High sensitivity means: negative test effectively rules out scaphoid fracture

Scaphoid compression test:

• Axial compression of thumb along the axis of the first metacarpal
• Positive: pain at the base of the thumb/scaphoid area

De Quervain's Tenosynovitis

Finkelstein's test:

• Patient wraps fingers around thumb, then actively ulnar deviates the wrist
• Positive: sharp pain over radial styloid/first dorsal compartment
• Highly sensitive and specific

Affects APL (abductor pollicis longus) and EPB (extensor pollicis brevis) in their shared sheath at the radial styloid. Common in new parents, repetitive gripping activities.

DRUJ Stability (Ballottement)

• Stabilise the radius with one hand
• Translate the ulnar head anteriorly and posteriorly relative to the radius
• Compare with contralateral side
• Increased translation with pain = DRUJ instability (often associated with TFCC injury)

Watson's Test (Scapholunate Instability)

• Pressure on scaphoid tubercle while moving wrist from ulnar to radial deviation
• Positive: clunk or pain as scaphoid subluxes

Presenting Your Findings

*"On examination of Mr Smith's right wrist, I note generalised swelling over the dorsum with a dinner-fork deformity consistent with a Colles' fracture. There is tenderness in the anatomical snuffbox and over the scaphoid tubercle. Wrist extension is reduced to 20 degrees (normally 70-90). Scaphoid compression test is positive. My findings are consistent with a distal radius fracture with possible associated scaphoid injury, and I would request AP and lateral wrist X-rays along with a scaphoid series."*

Frequently Asked Questions

"What is the anatomical snuffbox and what structures bound it?"

The anatomical snuffbox is the triangular depression on the radial (thumb) side of the dorsal wrist, visible when the thumb is fully extended. Boundaries: radially — extensor pollicis brevis (EPB) and abductor pollicis longus (APL); ulnarly — extensor pollicis longus (EPL); floor — scaphoid and trapezium; roof — skin and dorsal branch of radial nerve. The radial artery passes through its floor.

"What nerve is at risk in a distal radius fracture?"

The median nerve (carpal tunnel compression from haematoma or oedema), radial nerve (dorsal sensory branch — numbness over dorsum of first web space), and anterior interosseous nerve (a branch of the median nerve running deep to the forearm flexors — causes weakness of FPL and FDP to index). Carpal tunnel decompression may be required acutely if there is acute median nerve compression.

"What are the differential diagnoses for wrist pain in a young athlete?"

Scaphoid fracture (most important to exclude), scapholunate dissociation, TFCC tear, DRUJ instability, De Quervain's tenosynovitis, ganglion cyst, Kienböck's disease (avascular necrosis of the lunate), stress fracture of the distal radius. A normal X-ray does not exclude any of these except displaced fractures.

"How does carpal tunnel syndrome present and what are the risk factors?"

CTS causes pain, tingling, and numbness in the median nerve distribution (thumb, index, middle, and radial half of ring finger), classically worse at night and on activities that maintain wrist flexion. Late features: thenar wasting and weakness of thumb opposition. Risk factors: female sex, pregnancy, hypothyroidism, obesity, rheumatoid arthritis, diabetes, repetitive wrist flexion activities, previous distal radius fracture.

"What is the difference between Colles' and Smith's fractures?"

Both are extra-articular distal radius fractures. Colles' fracture results from a fall on an outstretched hand (FOOSH) — the distal fragment displaces dorsally and radially, producing the classic dinner-fork deformity. It is the most common fracture in the elderly, associated with osteoporosis. Smith's fracture (reverse Colles') results from a fall onto the back of the hand or forced wrist flexion — the distal fragment displaces volarly (garden spade deformity). Smith's fractures are less common and more unstable.

Related Posts

• Hand Examination OSCE — examination of the small joints, tendons, and nerves distal to the wrist
• Elbow Examination OSCE — completing the upper limb examination
• Musculoskeletal History OSCE — history taking for wrist and upper limb complaints