Scaphoid shift test

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keywords: scaphoid shift test, wrist pain, os scaphoid and wrist.

Purpose

The scaphoid shift test is a provocative manoeuvre used to examine the dynamic stability of the scaphoid and reproduce a patient's symptoms. The test is found helpful during the examination of the wrist and more specifically the scaphoid. Beside the stability the examiner will also be able to reflect the quality of the adjoining articular surfaces. (1,3)

Clinically Relevant Anatomy

The ligaments that are thought to provide the principle support to the scaphoid are the radioscaphocapitate ligament, the scaphoid-trapezoid-trapezium ligament and the scapholunate interosseous ligament. (7)

Technique

Video in which the test is preformed : http://www.youtube.com/watch?v=DGH-pHmeLnQ
To preform the scaphoid shift test the patient should rest his arm with his elbow on the table and his forearm lifted. The examiner sits across the table and places his arm next to the patient's arm (like in an arm wrestling position right to right or left to left). The patient's hand is slightly pronated and the examiner places his thumb on the palmar side of the scaphoid (on the scaphoid tubercule), his other fingers are wrapped around the back of the wrist at the distal part of the radius. This will allow the examiner to put pressure on the scaphoid with his thumb. With his other hand the examiner holds the patient's hand at the metacarpal level. (1,2)

The hand is put into ulnar deviation and in slight dorsal flexion; in this position the scaphoid lies almost 'in line' with the ulna (fig2). From this position the hand is moved passively by the examiner into radial deviation and slight palmar flexion. Meanwhile a constant pressure is given by the thumb on the scaphoid tubercule.
During the radial deviation and slight palmar flexion, the distal part of the scaphoid tilts forward (fig 3) and thereby pushes against the examiner's thumb (which is pushing in the opposite direction) causing stress on the joints. (1,2,5)
This stress is overcome in a normal wrist (minimal movement can be tolerated), but results in a dorsal displacement ('shift') of the scaphoid in relation to the other carpal bones in the wrist of a patient with ligamentous laxity (fig 3). When the thumb force is then abruptly taken away the shift will be reduced and the scaphoid will fall back in its normal position, this may result in a painful 'thunk'. (1,2,5)
It is important to preform this technique on both wrists and compare them.

Interpretation

The scaphoid shift test may be considered negative if the examiner can feel the scaphoid rotating and pushing his thumb away during radial deviation. The test may be considered positive when the pressure of the thumb prevented the scaphoid from tilting forward and results in a dorsal movement of the scaphoid out of the elliptic fossa of the radius. (1,8)
Though Watson HK. has described this test more as a provocative then a test with a positive and negative result. An experienced examiner should be able to conclude a variety of findings from this test, the mobility itself should not directly be considered pathological because it may be caused by hypermobility syndrome. Though unilateral hyper mobility is rather suspicious. Pain similar to the patients symptoms during a dorsal shift indicates a symptomatic subluxation of the scaphoid, pain which is less localised combined with normal or limited movement may point in the direction of periscaphoid arthritis or scapho-Iunate advanced collapse pattern. A gritty, clicking or smooth sensation gives you an idea about the state of the articular cartilage and bony form of the joint. (1,2)
When there are doubts and to have clear results about the actual shift, a radioscopy and mostly a fluoroscopy are used to get clear images and information about the shift test. (3,4,6)

Diagnostic Procedures

1. MEDICAL DIAGNOSIS
A plain radiography or MRI is necessary to confirm the diagnose of a coccyx fracture. (level of evidence D)

2. CLINICAL DIAGNOSIS
The diagnose is made after rectal examination. (level of evidence D)iv By passing the finger up the rectum and then pressing the bone backwards and forward, the unnatural degree of motion will then be felt. Related to the age and sex of the patient must be remembered that in the female this bone naturally possesses more motion than in the male, and that in youth a degree of motion, that does not exist at a later period of life, is present, allowing the ossification being less complete. However the free motion of the bone is taken as a symptom. (level of evidence D)

Outcome Measures

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Examination

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Medical Management

1. COCCYGEOPLASTY
By applying the novel techniques that are used in vertebroplasty and sacroplasty, coccygeoplasty is introduced as a new percutaneous treatment modality for fractures of the coccyx. This procedure can be helpful for patients with refractory pain resulting from a fracture of the coccyx and can be performed quickly and safely with high-resolution c-arm fluoroscopy. The coccygeal fracture treated with an injection of polymethylmethacrylate cement can provide early symptom relief. Although the promising results, an experience with a larger patient population is warranted. ( level of evidence C)

2. COCCYGECTOMY
Literature reports suggest that coccygectomy, partial or total removal of the coccyx, has been beneficial with success rates as high as 60-91%. However, coccygectomy is a more invasive procedure, with a common complication rate as high as 22%, and is usually associated with perineal contamination of the wound. Other complications could include persistent bleeding from the hemorrhoidal venous complex of the rectum. (level of evidence C)ix

Physical Therapy Management

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Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 451-452, level of evidence D
YU-TSAI T., LI-WEN T., CHENG-HSIU L., SHIH-WEI C., The influence of human coccyx in body weight shifting, medicine and science in sport and exercise, 2011, Volume 43, Number 5, pag. 494-496, level of evidence B
MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 332, level of evidence D
HAARMAN H.J.Th.M., Klinische traumatologie, Elsevier gezondheidszorg, 2006, pag. 117, level of evidence D
MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 461, level of evidence D
TEKIN L. et al., Coccyx fracture in patients with spinal cord injury, European journal of physical and rehabilitation medicine, March 2010, Volume 46, Number 1, pag. 43-46, level of evidence C
RAISSAKI M.T.,Fracture dislocation of the sacro-coccygeal joint: MRI evaluation, Pediatric radiology, March 1999, pag. 642-643, level of evidence D
LONSDALE E.F., A practical treatise on fractures, Walton and Mitchell printers, 1838, pag. 269-270, level of evidence D
MIYAMOTO K. et al., Exposure to pulsed low intensity ultrasound stimulates extracellular matrix metabolism of bovine intervertebral dosc cells cultured in alginate beads, Spine, November 2005, level of evidence B
EBNEZAR J., Essentials of orthopaedics for physiotherapist, Jaypee, 2003, pag. 174, level of evidence D
DEAN L.M. et al., Coccygeoplasty : treatment for fractures of the coccyx, J. Vasc. Interv. Radiol, 2006, pag. 909-912, level of evidence C
COOPER G., HERRERA J.E., Manual of musculoskeletal medicine, Wolters kluwer, Lippincott Williams & Wilkins, 2008, pag. 144, level of evidence D