Kleinman's 2015 Current Concepts article presents the biomechanical rationale and step-by-step technique for provocative physical examination of the wrist. It focuses on diagnosing partial interosseous ligament injuries — SL, LT, midcarpal, and DRUJ/TFCC — in patients with chronic wrist pain and normal radiographs. The article argues that physical examination is underused and, when properly performed, is more reliable than advanced imaging for these injuries.
A patient presents with months of wrist pain, normal x-rays, and point tenderness over the dorsal SL ligament — a frustratingly common scenario. MRI and CT have inconsistent specificity for partial ligament tears, and ordering them reflexively adds cost without reliably changing management.
This paper gives you a structured, anatomy-based examination framework. When you see dorsal SL tenderness with normal films, run through the four-diagnosis differential and apply the Watson test. When you see ulnar-sided wrist pain after a rotational injury, use the shear test rather than the ballotment test. The shear test titrates load precisely and avoids the false positives that plague ballotment.
For DRUJ/TFCC evaluation, remember that the deep fibers (ligamentum subcruentum) are what matter. Stress the wrist in full pronation to test palmar deep fibers and in full supination to test dorsal deep fibers, always comparing to the contralateral side.
One practical caveat the author emphasizes: the pisotriquetral joint must be examined and confirmed healthy before performing either the shuck sign or the shear test, or the result is uninterpretable.
Kleinman's 2015 Current Concepts article presents the biomechanical rationale and step-by-step technique for provocative physical examination of the wrist. It focuses on diagnosing partial interosseous ligament injuries — SL, LT, midcarpal, and DRUJ/TFCC — in patients with chronic wrist pain and normal radiographs. The article argues that physical examination is underused and, when properly performed, is more reliable than advanced imaging for these injuries.
A patient presents with months of wrist pain, normal x-rays, and point tenderness over the dorsal SL ligament — a frustratingly common scenario. MRI and CT have inconsistent specificity for partial ligament tears, and ordering them reflexively adds cost without reliably changing management.
This paper gives you a structured, anatomy-based examination framework. When you see dorsal SL tenderness with normal films, run through the four-diagnosis differential and apply the Watson test. When you see ulnar-sided wrist pain after a rotational injury, use the shear test rather than the ballotment test. The shear test titrates load precisely and avoids the false positives that plague ballotment.
For DRUJ/TFCC evaluation, remember that the deep fibers (ligamentum subcruentum) are what matter. Stress the wrist in full pronation to test palmar deep fibers and in full supination to test dorsal deep fibers, always comparing to the contralateral side.
One practical caveat the author emphasizes: the pisotriquetral joint must be examined and confirmed healthy before performing either the shuck sign or the shear test, or the result is uninterpretable.