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Wrist Examination & Pathology Module


TopicWrist Examination and Pathology
AuthorSegn Nedd
Duration2 hrs
Equipment requiredSplints, soft bandages, plaster of paris sets

  • Basics (10 minutes)
  • Main Session (2 x15 minutes) case discussions covering key points and evidence
  • Advanced  Session ( 2 x 20 minutes) case discussions covering diagnostic dilemma, advanced management
  • Sim scenario – (30 minutes) 
  • Quiz (5 minutes)
  • Infographic sharing (5 minutes): 5 take home learning points

(From TeachMeAnatomy and LITFL)

The wrist is a common place for injuries in children often occurring following a Fall Onto an OutStretched Hand (FOOSH). The wrist joint connects the hand to the forearm. It is made up of the radius and 8 carpal bones. Although commonly included, the ulna is not technically part of the wrist joint. The ulna articulates with the radius just proximal to the wrist at the radio-ulnar joint. It is separated from the carpal bones by a fibrocartilaginous ligament (articular disk). The wrist joint is a synovial joint. It therefore has a capsule. Its internal membrane secretes synovial fluid to lubricate the joint. 

When describing injuries of the wrist (and hand) for documentation or referral purposes it is important to know the terminology widely in use in order to convey an accurate description to others. Injuries present on the palmar surface would be described as Palmar or Volar. Injuries on the back of the hand are dorsal. The proximal part of the wrist is more towards the forearm, whereas the distal end is towards the fingers. The thumb lies on the radial side and the little is the ulnar side. 

Anatomy: (from Radiopedia, NYSORA & teachme anatomy)

In order to understand what you are examining and the associated pathologies that need to be considered it is important to have knowledge of the underlying structures that form the wrist. The wrist and hand have a complex anatomy with bony structures surrounded by a matrix of soft tissues including, muscles, tendons and ligaments. It additionally has an intricate blood and nerve supply. We will focus on the structures most important when assessing paediatric wrists in the emergency department.


The radius is on the side of the thumb, the ulna on the side of the little finger. A good mnemonic to remember the position of the carpal bones is to describe them starting from the base layer thumb to little finger, followed by the top layer little finger to thumb.

So             Long     To                 Pinky,     Here       Comes    The            Thumb

Scaphoid, Lunate, Triquestrum, Pisiform, Hamate, Capitate, Trapezoid, Trapezium

Ligaments: (from Radiopedia)

There are multiple ligaments of the wrist. These play a vital role in the stability of the wrist joint. They are specifically important in holding the carpal bones together. Those most clinically important in wrist joint stability are labelled as above. Ligaments of the wrist are not visible on X-ray and to be fully examined are best assessed with a dedicated wrist MRI. However, increases in the spacing between bones on plain X-rays can indicate a ligament injury with clinical correlation. 

The Nervous System: (from NYSORA)

The ulnar, median, and radial nerves innervate the hand. The course of these nerves traverse the wrist. They therefore have the potential to be damaged following wrist injuries. The median, anterior interosseous nerve (a branch of the median) and the ulnar nerve specifically although rare can be compromised following wrist fractures. The nerves of the wrist and hand also have an important role in functionality of the wrist (and hand). The radial nerve facilitates extension of the wrist and metacarpophalangeal joints. The ulnar nerve facilitates movement of the small muscles of the hand. The median nerve supports finger extension and anterior interosseous branch enables thumb flexion at the interphalangeal joint and flexion of the index finger at the distal interphalangeal joint.

The corresponding dermatomal innervation of the wrist and hand is illustrated below.

Vasculature: (from teachmeanatomy)

Arising from bifurcations of the brachial artery in the cubital fossa are the radial and ulnar arteries (and their branches) to supply blood to the forearm, wrist and hand. These two arteries merge in the hand forming the superficial palmar and the deep palmar arch. The radial artery supplies the posterolateral aspect of the forearm and is important in contributing to the blood supply of the carpal bones. The ulnar artery supplies the anteromedial aspect of the forearm. It mostly supplies blood to the elbow joint, but its branches do however help supply some of the deeper structures in the forearm.

Examination: From Geeky Medics 

The look, feel, move & function approach is generally used to examine the hand and wrist. Always offer analgesia prior to your examination of a child with an injury.

As functions involve both areas they are often examined together

1Perform general inspection
2Inspect the dorsum of the hands
3Inspect the palms of the hands and elbow

Careful note should be taken to ensure that full inspection is undertaken. This may identify any bruising, overlying skin changes, swelling or deformity. Remember also to always examine the joint above and the joint below.

1Asses and compare temperature of wrist and small joints of hand
2Palpate radial and ulnar pulse & check capillary refill
3Palpate thenar and hypothenar eminence
4Asses median nerve sensation
5Asses ulnar nerve sensation
6Asses radial nerve sensation
7Perform MCP squeeze
8Bimanually palpate hand and finger joints
9Palpate anatomical snuff box
10Bimanually palpate the wrist joints

It is important not to miss any neurovascular compromise when examining the wrist and hand. Findings to suggest compromise may include colour change, coolness to touch, prolonged capillary refill time and altered sensation.

1Assess finger extension
2Assess finger flexion
3Assess active wrist extension
4Assess active wrist flexion
5Assess wrist/finger extension against resistance (radial nerve)
6Assess index finger ABduction against resistance (ulnar nerve)
7Assess thumb ABduction against resistance median nerve)

Where possible movements should be actively undertaken by the patient. Take notice of any movements that are undertaken with difficulty or cause pain in undertaking.  

1Assess power grip
2Assess pincer grip
3Assess picking up small objects
4Supination and pronation- twisting key movement or ‘turning the key’

An 8 year old boy is brought to ED with his father. He had been outside roller-skating but fell over onto the concrete patio within the last hour. He is complaining of pain in his wrist and has difficulty moving it. An x-ray was done following triage: and it’s a buckle fracture

What would be your approach to examining his injury?

What type of fracture do you suspect and how would you differentiate on x-ray?

What type of immobilisation would you use?

What would be your approach to examining this injury?

What type of fracture do you suspect?

What type of immobilisation would you use?

A 12 year old girl is brought to ED with her mother. She was jumping on her trampoline but fell out. She had immediate pain and has not been able to use her left hand since.  Her mum gave her some paracetamol and ibuprofen prior to arrival. An  x-ray was then done and is as follows:

What does this fracture show?

How  would you further classify this type of fracture?

How would you manage these fractures?

Mum asks you if she should let her 6 year old daughter use the trampoline. What is your advice?

What does this fracture show?

How would you classify it?

How would you manage this?

Are trampolines ok?

A 14 year old boy was skateboarding and dismounted, landing on his outstretched hand. He had significant pain in his wrist around the distal radius. Following analgesia in the emergency department an x-ray was undertaken. No fracture was identified and he was reassured that he had sustained a soft tissue injury. He was discharged with RICE advice. 

Four weeks later he is still in pain – the original x-ray is re-reviewed – a scaphoid fracture is seen.

What are thoughts surrounding soft tissue injuries in children and how should they be defined and managed ?

Are there any other pathologies you should consider when x-rays appear normal

How do we decide between a soft tissue injury and suspicion of a scaphoid injury?

What other pathology should we consider with a normal x-ray?

How to manage scaphoid injuries

A 13 year old girl is brought to ED following a fall from a tree she has significant pain, swelling and deformity of the distal shaft of the radius. Analgesia is given and she is taken to x-ray:

Case courtesy of Radswiki, From the case rID: 12221

What type of fracture has occurred?

How would you manage this fracture?

What type of fracture is this?

How should this be managed?

What is a Galeazzi fracture-dislocation?

Depending on the experience of the learners in your group please choose and adapt the following practical elements

  1. Role play hand examinations in pairs. Identifying techniques to follow and signs to exclude. Can be done in OSCE format. 
  2. Removable casts – demonstration by facilitator of rigid casts and soft bandages available in your department alternatively videos from below could be used prior to a learner practice session:
  3. Plaster of Paris hard cast application- demonstration by facilitators or alternatively videos from below be used prior to a learner practice session:

Question 1

Answer 1

Question 2

Answer 2

Question 3

Answer 3

  1. video series on hand and wrist injuries
  7. Slaar A, Walenkamp MM, Bentohami A, et al. A clinical decision rule for the use of plain radiography in children after acute wrist injury: development and external validation of the Amsterdam Pediatric Wrist Rules. Pediatr Radiol. 2016;46(1):50‐60. doi:10.1007/s00247-015-3436-3
  8. Davidson AW. Rock-paper-scissors. Injury. 2003;34(1):61‐63. doi:10.1016/s0020-1383(02)00102-x
  15. Elvey M, Patel S, Avisar E, White WJ, Sorene E. Defining occult injuries of the distal forearm and wrist in children. J Child Orthop. 2016;10(3):227‐233. doi:10.1007/s11832-016-0735-7
  18. Little, Jason & Klionsky, Nina & Chaturvedi, Abhishek & Soral, Aditya & Chaturvedi, Apeksha. (2014). Pediatric Distal Forearm and Wrist Injury: An Imaging Review. Radiographics : a review publication of the Radiological Society of North America, Inc. 34. 472-90. 10.1148/rg.342135073. 
  21. Shaterian A1, Santos PJF1, Lee CJ1, Evans GRD1, Leis A1. Management Modalities and Outcomes Following Acute Scaphoid Fractures in Children: A Quantitative Review and Meta-Analysis. Hand (N Y). 2019 May;14(3):305-310. PMID: 29078712.
  22. Porter J, Porter R, Chan KJ. Scaphoid Fractures in Children: Do We Need to X-ray? A Retrospective Chart Review of 144 Wrists. Pediatr Emerg Care. 2018 Mar 12. PMID: 29538268.
  24. Al-Ajmi TA, Al-Faryan KH, Al-Kanaan NF, et al. A Systematic Review and Meta-analysis of Randomized Controlled Trials Comparing Surgical versus Conservative Treatments for Acute Undisplaced or Minimally-Displaced Scaphoid Fractures. Clin Orthop Surg. 2018;10(1):64‐73. doi:10.4055/cios.2018.10.1.64
  27. Clinical Anatomy –hand, wrist (palmar aspect/flexors) Armando Husudungan 

Please download our Facilitator and Learner guides


  • Segn is a Paediatric Registrar in London who’s second home is the Paeds ED. She loves teaching and is also passionate about improving diversity & cultural competence in Medicine. When she’s in her real home she enjoys cooking up some Caribbean flavours and chilling with her husband and toddler.


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