Physical Examination of Wrist

1. Shamima Akter
B. Sc (Honors) in Occupational Therapy
& M. Sc in Rehabilitation Science
Assistant Professor,
Department of Occupational Therapy
Bangladesh Health Professions Institute (BHPI)
Centre for the Rehabilitation of the Paralysed (CRP)
Chapain, Savar

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4. 4
Carpal Bones

5. 5

6. 6

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9. Reference position for palpation
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- Place thumb upon the patient’s radial styloid
process (proximal to thumb).
- Then place your index and middle fingers
upon the ulnar styloid process (proximal to
little finger).
- From this position, palpation will proceed in a
linear fashion.

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11. Points to palpate bony prominence
area
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 Radial styloid process
 Ulnar styloid process
 Lister tubercle
 Carpal bones
 Scaphoid
 Lunate
 Triquetrum
 Pisiform
 Trapezium
 Trapezoid
 Capitate
 hamate

12. Radial Styloid process
 Truly lateral when hand
is in anatomical position
palm facing anteriorly).
 During palpation, the
distal trip, note the small
but distinct groove that
can be felt along the
lateral edge.
12

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14. Carpal bones
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 Carpal bones situated in two rows: proximal row and
distal row.
 The proximal carpal row from the radial to ulnar
contains the scaphoid/ navicular, lunate, triquetrium
and pisiform.
 The distal carpal row from radial to ulnar is composed
of the trapezium, trapezoid, capitates and hamate.

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17. Navicular/ Scaphoid
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 The navicular, also known as scaphoid bone,
is situated on the radial side of the carpus.
 It represents the floor of carpus.
 Ulnar deviation causes the navicular to slide
out from under the radial styloid process.

18. Traapezium
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 The trapezium is located on the radial side of
the carpus where it articulates with the first
metacarpal.
 Move distal to the anatomical snuffbox to
palpate the trapezium/ first metacarpal
articulation.

19. Tubercle of the radius/ Lister’s tubercle
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 Lister’s tubercle lies about one-third of the
way across the dorsum of the wrist from
the radial styloid process.
 It feels like a small, longitudinal bony
prominence or nodule.

20. Capitate
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 As move distal from lister’s tubercle, you will
encounter the base of third metacarpal bone.
 The capitates lies in the distal row in
between the third metacarpal base and the
tubercle of radius.
 When the wrist is in a neutral position, you will
find a small depression in the area of
capitate.

21. Lunate
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 The lunate is just proximal to the capitates.
 It is palpable just distal to radial tubercle.
 It is the 2nd most fractured bone at wrist.
 The lunate, capitates and the base of the third
metacarpal are in line with each other.

22. Ulnar styloid process
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Return to the basic position with your
fingers on the ulnar and radial styloid
process.

23. Triquetrium
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 The triquetrium lies just distal to the ulnar
styloid process, in the proximal carpal row.
 To facilitate the palpation, the hand must
be radially deviated so that the
triquetrum moves out from under the ulnar
styloid process.

24. Pisiform
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 As you probe the anterolateral region of
the triquetrium
 Feel a small sesamoid bone, the pisiform,
which is formed within the flexor carpi
ulnaris tendon.

25. Hook of hamate
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 The hook of hamate is situated slightly distal and radial
to the pisiform.
 To locate it, place the interphalangeal joint of thumb
upon the pisiform, pointing the tip of your thumb
toward the web space between the patient’s thumb and
index fingers,
 Then rest of the tip of thumb on the palm.
 The hook of the hamate lies directly under your
thumb tip, but since it is buried deep under the layers of
soft tissue
 Then must press firmly to find its rather shallow contour.

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27. Wrist: Zones
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 Wrist is divided into five (5) zones regarding
soft tissue palpation
Zone 1: Radial Styloid process
Zone 2: Lister Tubercle
Zone 3: Ulnar Styloid Process
Zone 4: Pisiform
Zone 5: Palmaris Longus & Carpal Tunnel

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Within the five zone of the wrist, there are-
 Six dorsal passage ways or tunnels: Which transport the
extensor tendons to the hand
 Two palmar passage ways or tunnels: Which transport
the nerves, arteries and flexor tendons to the hand.
These tunnels (and the structures within them) are
palpable, and each will be discussed in details under
its respective clinical zones.

29. Tunnels in the Wrist Zones
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Name of Wrist Zones Tunnels
Wrist is divided into five (5) zones regarding soft tissue
palpation
Dorsal
passage
Zone 1: Radial Styloid process Tunnel I
Zone 2: Lister Tubercle Tunnel II, III,
IV
Zone 3: Ulnar Styloid Process Tunnel V, VI
Palmar
assage
Zone 4: Pisiform Tunnel VII
Zone 5: Palmaris Longus &
Carpal Tunnel
Tunnel VIII

30. 6 Dorsal compartment/ tunnel/
passageway
30
Wrist
zones

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Wrist
Zone-
1,2,
3
6
Dorsal
Tunnels
Wrist
Zone
1 Wrist Zone 2
Wrist
Zone
3

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VII
VIII
Wrist Zone 4,5
2 Palmar Tunnels
Zone
4
Zone
5

33. Anatomical snuffbox
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 The anatomical snuffbox is a small depression located immediately
distal and slightly dorsal to the radial styloid process.
 It becomes outlined and is palpable when the patient extends
thumb laterally away from finger.
Structures
Radial border-
1) Abductor pollicis longus (APL)
2) Extensor pollicis brevis (EPB)
Ulnar border-
1) Extensor pollicis longus (EPL)
Floor- Scaphoid or navicular bone
TUNNEL 1
TUNNEL 3

34. Tunnel 1
Tunnel 3
Radial border
Ulnar border

35. Small (triangular)
depression

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Wrist: Zone 1- Radial styloid
process
Tunnel- I:
Location:
Radial styloid process
Content:
Its composed of-
1) Abductor pollicis longus
(APL)
2) Extensor pollicis brevis (EPB)
Palpation:
It becomes outlined at radial side
and is palpable when the patient
extends thumb laterally away
from finger.
Clinical significance:
Site for de quervain’s disease
Tunnel 1

38. ABDUCTOR POLLICIS LONGUS
 ORIGIN: Upper parts of the
posterior surface of the radius &
ulna and interosseous membrane.
 INSERTION: Base of the 1st
metacarpal bone
 ACTION: abducts, extends, lateral
rotates the thumb at
carpometacarpal joint, & abducts
the wrist.
 N.SUPPLY:PIN (c7,c8)

39. EXTENSOR POLLICIS BREVIS
 ORIGIN: Posterior surface of the
radius below the origin of abductor
Pollicis longus and from
interosseous membrane.
 INSERTION: Base of the proximal
phalanx of the thumb
 ACTION: Extends proximal phalanx
of the thumb at MC joint, ext.at 1st
carpometacarpal joint
 N.SUPPLY:PIN (c7,c8)

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De Quervain’s
Tenosynovitis:
A painful thickening and
inflammation of the tendon
sheath at thumb lateral
side containing Abductor
pollicis longus (APL) and
Extensor pollicis brevis
(EPB) are known as De
Quervain’s tenosynovitis.

41. Wrist Zone 2
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 Contents
Tunnel II
Tunnel III
Tunnel IV
Wrist Zone 2

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Wrist: Zone 2- Lister tubercle (Tubercle of radius/
Radial tubercle)
Tunnel II
Location
- Radial side of lister tubercle
Contains
- Extensor carpi radialis longus (ECRL)
- Extensor carpi radialis brevis (ECRB)
Palpation
- Ask the patient to clench his fist, and
then the tendon will stand out
slightly on the radial side of the
dorsal radial tubercle.
Clinical significance
- Used for tendon transplant

43. EXT.CARPI RADIALIS LONGUS
 ORIGIN: lateral supracondylar ridge of
humerus
 INSERTION: base of the 2nd MC bone
 ACTION: Extends and abducts the
hand
 N.SUPPLY: Radial .N (C6,C7)

44. EXTENSOR CARPI RADIALIS BREVIS
 ORIGIN: Lateral epicondyle of the
humerus
 INSERTION: Base of the 3rd
Metacarpal bone
 ACTION: Extends and abducts the
wrist
 N.SUPPLY: deep br.of radial .N(c7c8)

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Wrist Zone 2 continue…
Tunnel III
Location
- Ulnar side of lister tubercle
Contains
- Extensor pollicis longus
(ulnar border of anatomical
snuffbox)
Palpation
- During extension of thumb,
the extensor pollicis longus
tendon clearly visible as the
tendon takes 45⁰ turns
around the radial tubercle.
Clinical significance
- It can be ruptured during
colle’s fracture,

46. EXT.POLLICIS LONGUS
 ORIGIN: Posterior surface of
middle 1/3rd of ulna &
interrosseous membrane
 INSERTION: Base of the distal
phalanx of the thumb
 ACTION: Extends distal phalanx
of the thumb at MP joint, IP joint &
it can contribute abduction of the
thumb
 N.SUPPLY:PIN (c7,c8).

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Clinical significance
- It can be ruptured during
colle’s fracture,
rheumatoid arthritis.
- If condition worsen then
possible to develop
tendon attrition.
*A Colles fracture of the
wrist is a medical
condition where there is
a break in forearm bone
termed as the radius
(distal 1/3).

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Rheumatoid Arthritis
is a systemic and
inflammatory disease
characterized by
remissions and
exacerbations that
vary in duration and
severity among
people and may also
involve the lungs,
heart, blood vessels
and eyes (Radomski
and Latham 2008).

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Wrist Zone 2: Lister’s tubercle
Tunnel IV:
Location
Just ulnar to tunnel 3
Contains
1) Extensor digitorum communis
(EDC)
2) Extensor indicis (EI)
Palpation
1) When fingers (index, middle
and ring fingers) are extended,
extensor digitoroum communis
can be palpated
2) When index will move in flexion
and extension independently, you
can identify extensor indicis.

51. EXTENSOR DIGITORUM
 ORIGIN: lateral epicondyle of the
humerus
 INSERTION: Extensor Expansions
Of The Medial 4 digits
 ACTION: extension at MCP, IP
joints, ext of wrist when the fingers
are extended
 N.SUPPLY: PIN (c7,c8)

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Clinical significance
 Cystic, pea- sized
swelling (ganglion)
with a jelly-like
consistency may
develop on the dorsal
aspect of the wrist.
 This ganglia are not
usually fixed to the
connective tissues, nor
are they tender to
palpation.

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Wrist zone 3: Ulnar styloid process
Tunnel V
Location
- Overlies the distal ends of the
radioulnar articulation on the
dorsum of the wrist
Contains
1) Extensor digitiminimi tendon
Palpation
- Ask the patient rest his palm
upon a table or desk and ask
him to raise his little finger.
- The movement of the tendon
can be felt in the depression
radial to the ulnar styloid
process.
Clinical Signification
- Attrition due to RA

54. EXTENSOR DIGITI MINIMI
 ORIGIN:lat epicondyle of the humerus
 INSERTION:extensor expansion of the 5th digit
 ACTION: ext.of 5th digit at MC, PIP ,
ext of wrist when little finger in extension
 N.SUPPLY:PIN (c7,c8)

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- The extensor digitiminimi lies over
radioulnar articulation and may become
involved in Rheumatoid Arthritis of the joint.
- It may also be subject to attrition, either from
friction due to dorsal dislocation of the ulnar
head or from synovitis.

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Wrist Zone 3 continue…
Tunnel VI
Location
- Groove between the apex of
ulnar styloid process and ulnar
head.
Contains
1) Extensor carpi ulnaris
Palpation
- The extensor carpi ulnaris is
more palpable when the patient’s
wrist is extended and ulnarly
deviated.
Clinical significance
1) Can be rupture or displace
in addition to Rheumatoid
arthritis
2) Can cause pain due to
displacement caused by
colles’ fracture

57. EXTENSOR CARPI ULNARIS
 ORIGIN:2 heads
Lateral epicondyle of humerus,
Posterior border of ulna
 INSERTION: Medial side of the
base of the 5th Metacarpal
 ACTION: Extends and adducts the
hand
 N.SUPPLY:PIN (c7c8)

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60. Palmer aspect of wrist
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Wrist Zone 4
(Pisiform)
- Tunnel VII
Wrist Zone 5
(Palmaris Longus)
-Tunnel VIII

61. Wrist zone 4: Pisiform (Palmar
aspect)
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Location: Pisiform
Content
- Flexor Carpi Ulnaris
- Tunnel VII (Tunnel of guyon)

62. Wrist zone 4: Pisiform (Palmar aspect)
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Flexor Carpi Ulnaris
Location
The pisiform bone is enclosed by flexor carpi
ulnaris

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Tunnel VII (Tunnel of guyton)
Location
Depression between the pisiform and hook of
hamate
Structure
Anterior border: Palmar carpal ligament
Posterior border: Flexor retinaculum
Lateral border (radial side): Hook of hamate
Medial border (ulnar side): Pisiform

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Contains
1) Ulnar nerve
2) Ulnar artery
Clinical Significance
 Ulnar tunnel syndrome or Guyton’s canal
syndrome

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66. Wrist: Zone 5: Palmaris longus and
carpal tunnel
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Location: Palmaris longus
Content:
Palmaris longus
Flexor carpi radialis
 Carpal tunnel (Tunnel VIII)

67. Wrist: Zone 5: Palmaris longus and carpal tunnel
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Palmaris longus
Location: Anterior aspect of the wrist
Palpation: Flex wrist and touch the tips of thumb and
little finger together
Clinical Significance: Used during tendon graft to
replace severely traumatized flexor tendon of the
fingers.

68. PALMARIS LONGUS
 INSERTION: anterior aspect of
the distal flexor retinaculum and
palmar aponeurosis
 ACTION: flx. the wrist, and
tightens the palmar aponeurosis
 N.SUPPLY: Median. N (c6,c7)

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Flexor carpi radialis
Location: Radial to the Palmaris longus
Palpation: When the patient flexes wrist and
radially deviates his hand, the tendon
becomes prominent next to Palmaris longus.

71. FLX.CARPI RADIALIS
 INSERTION: base of the
2nd mc bone and slip to
the base of the 3rd MC
bone
 ACTION: flexion and
abduction of wrist
 N.SUPPLY: Median.N
(c6,c7)

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Tunnel VIII- Carpal tunnel
Location: Deep to the Palmaris longus
Border: Proximally, pisiform and tubercle of scaphoid
Distally, hook of hamate and tubercle of trapezium
Posteriorly, by carpal bone
Contents: It includes-
- Median nerve
- Flexor tendons from the forearm to hand
Clinical Significance
- Carpal tunnel syndrome

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- Carpal tunnel syndrome: Carpal Tunnel Syndrome
(CTS) is an entrapment neuropathy of the median
nerve at the wrist producing parathesias and
weakness in the hands.
- It is a disorder characterized by disturbances of
sensation in the area of the skin supplied by the
median nerve affecting the wrist and fingers.

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Carpal tunnel Syndrome

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Wrist Zones Tunn
el
Contents Clinical
Significance
Dorsal
Zone I
Radial
Styloid
process
T- I Abductor Pollicis Longus
Extensor Pollicis Brevis
De quervain’s
disease/
Tenosynovitis
Zone II
Lister
Tubercle
T- II Extensor carpi radialis
longus
Extensor carpi radialis
brevis
Used for tendon
transplant
T- III Extensor pollicis longus Rupture due to
Colle’s fracture
Rheumatoid arthritis
T- IV Extensor digitorum
communis
Extensor indicis
Cystic and pea sized
ganglion
Zone III
Ulnar
T- V Extensor digitiminimi Rheumatoid Arthritis
T- VI Extensor carpi ulnaris Rheumatoid Arthritis

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Palmar
Zone IV
Pisiform
T- VII Ulnar nerve &
artery
Ulnar tunnel
syndrome/
Guyton’s
tunnel
syndrome
Zone V
Palmaris Longus
& Carpal Tunnel
T- VIII Median nerve
& flexor
tendons
Carpal
Tunnel
Syndrome
(CTS)

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Tentative question pattern
 Write down the name of wrist zones with its location.
 Write the name of wrist zone five/ three/ two/four/one with its content and
palpation procedure.
 Which zone is located in lister tubercle/ radial styloid tuberosity/ ulner styloid
tuberosity/ pisiform/ palmaris longus- describe the palpation procedures.
 What are the other names of lister tubercle/ tubercle of radius/lister tuberosity?
 Describe the soft tissue palpation procedure of anatomical snuffbox/ carpal
tunnel/ tunnel of guyton with the corresponding clinical significance.
 What are the wrist zones of dorsal aspect- illustrate and describe.
 What are the wrist zones of volar/ palmer aspect- illustrate and describe.
 Describe the five wrist zones with its names, location, content and clinical
significance.
 Which wrist zones are prone to develop rheumatoid arthritis- describe.
 What do you understand by rheumatoid arthritis and de quervain’s disease?
 Describe the procedures of soft tissue palpation for the following wrist zones
with its name-

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