Upper Extremity — Palpation Landmarks

Palpation Landmarks

Lateral Epicondyle of the Humerus

• How to find it: With the client seated and the elbow flexed to 90 degrees, locate the lateral aspect of the elbow. The lateral epicondyle is the bony prominence on the outer (lateral) side of the distal humerus, approximately 1–2 cm proximal to the radial head. It is easily palpable through the skin.
• What it feels like: A broad, rounded bony prominence. It is less prominent than the medial epicondyle — the lateral epicondyle is wider and flatter, giving a more gradual contour to the lateral elbow.
• Client position: Seated with the elbow flexed to 90 degrees, forearm in neutral (thumb up).
• Confirmation: Place your finger on the lateral epicondyle and ask the client to extend the wrist against resistance. The common extensor tendon originates here — you should feel the tendon tighten directly distal to the epicondyle. The epicondyle itself does not move; it is part of the humerus.
• Common errors: Confusing the lateral epicondyle with the radial head, which is immediately distal to it. The radial head rotates with forearm pronation/supination — the epicondyle does not. If the structure under your finger moves when the client pronates and supinates, you are on the radial head, not the epicondyle.
• Clinical significance: Origin of the common extensor tendon (ECRB, EDC, ECU, EDM) — tenderness here is the hallmark of lateral epicondylitis (tennis elbow). Pain with resisted wrist extension and resisted middle finger extension (ECRB-specific) localizes the pathology. The most common overuse injury of the elbow.

Medial Epicondyle of the Humerus

• How to find it: With the elbow flexed to 90 degrees, palpate the medial (inner) aspect of the elbow. The medial epicondyle is the prominent bony point on the inner side of the distal humerus. It is more prominent and sharper than the lateral epicondyle — it projects more distinctly from the humeral shaft.
• What it feels like: A sharp, well-defined bony projection, clearly palpable and often visible. It is approximately the size of a fingertip and projects medially from the distal humerus.
• Client position: Seated with the elbow flexed to 90 degrees, forearm supinated.
• Confirmation: Place your finger on the medial epicondyle and ask the client to flex the wrist against resistance. The common flexor tendon originates here — you should feel the tendon tighten just distal to the epicondyle. The epicondyle does not move.
• Common errors: Pressing too firmly on the posterior surface of the medial epicondyle, where the ulnar nerve runs in the cubital tunnel (the groove between the medial epicondyle and the olecranon). Pressing on the nerve produces electric-shock tingling into the ring and little fingers — this is the "funny bone" sensation. Stay on the medial surface of the epicondyle, not the posterior groove.
• Clinical significance: Origin of the common flexor tendon (pronator teres, FCR, palmaris longus, FCU, FDS) — tenderness is the hallmark of medial epicondylitis (golfer's elbow). The ulnar nerve passes in the cubital tunnel directly posterior to the medial epicondyle — see Nerve Passages. The ulnar collateral ligament (UCL) attaches here — valgus stress at the elbow loads this ligament.

Olecranon

• How to find it: With the elbow flexed to 90 degrees, the olecranon is the most posterior and proximal bony prominence of the elbow — the "point" of the elbow. It is the proximal end of the ulna.
• What it feels like: A large, broad, rounded bony projection. It forms the entire posterior prominence of the elbow. The triceps tendon inserts on its superior surface; the olecranon bursa covers its posterior surface.
• Client position: Seated with the elbow flexed to 90 degrees.
• Confirmation: With the elbow flexed to 90 degrees, the olecranon and the two epicondyles form an equilateral triangle (viewed from behind). With the elbow extended, these three points should form a straight line. This triangle/line relationship is a clinical test for elbow fracture or dislocation — disruption of this relationship suggests bony displacement.
• Common errors: Confusing the olecranon with the medial epicondyle. The olecranon is the most posterior point; the medial epicondyle is more medial and slightly proximal. In the flexed elbow, the olecranon is the point that protrudes farthest posteriorly.
• Clinical significance: The olecranon bursa overlies the posterior surface — bursitis produces a visible and palpable fluid-filled swelling over the elbow tip. Olecranon fractures occur from falls onto the elbow tip. The triangle relationship (olecranon + two epicondyles) is assessed after elbow trauma to screen for fracture or dislocation.

Radial Head

• How to find it: Locate the lateral epicondyle. Drop your finger approximately 1–2 cm distally and slightly anteriorly. The radial head is the first bony prominence you encounter distal to the lateral epicondyle. It is in the soft tissue depression just below the epicondyle.
• What it feels like: A smooth, disc-shaped bony prominence approximately 1.5–2 cm in diameter. It is smaller and more subtle than the epicondyle above it.
• Client position: Seated with the elbow flexed to 90 degrees, forearm in neutral.
• Confirmation: The definitive confirmation is rotation. Keep your fingertip on the radial head and ask the client to slowly pronate and supinate the forearm. The radial head spins under your finger — it rotates like a wheel. No other structure at the lateral elbow rotates with forearm pronation/supination. This is one of the most satisfying palpation confirmations in the body.
• Common errors: Palpating the lateral epicondyle instead (which does not rotate) or the capitulum of the humerus (which is proximal to the radial head and does not rotate). If the structure does not spin with pronation/supination, you are not on the radial head.
• Clinical significance: Radial head fractures are common after falls onto an outstretched hand (FOOSH injuries). Tenderness at the radial head combined with painful pronation/supination after a fall is highly suggestive. The annular ligament wraps around the radial head — subluxation (nursemaid's elbow) occurs when the radial head slips partially out of the annular ligament, typically in children.

Radial Styloid

• How to find it: With the forearm in neutral (thumb up), slide your finger distally along the lateral (radial) side of the forearm. The radial styloid is the bony prominence at the very distal end of the radius, on the lateral side of the wrist. It is the farthest distal point on the radial side of the forearm.
• What it feels like: A broad, rounded bony projection. It extends approximately 1 cm more distally than the ulnar styloid — the radius is longer than the ulna distally. The anatomical snuffbox is immediately distal to it.
• Client position: Seated with the forearm in neutral, wrist in neutral.
• Confirmation: The radial styloid is the lateral boundary of the wrist. It does not move with wrist motion (it is the end of the radius). The tendons of the APL and EPB cross over it — they may be palpable as cords during thumb extension and abduction.
• Common errors: Confusing the radial styloid with the scaphoid tubercle (which is more distal and palmar) or the base of the first metacarpal (which is even more distal).
• Clinical significance: The brachioradialis inserts here. The first dorsal compartment tendons (APL, EPB) cross directly over the styloid — tenderness and swelling here with positive Finkelstein's test indicates de Quervain's tenosynovitis. Distal radius fractures (Colles' fracture) often involve the styloid.

Ulnar Styloid

• How to find it: With the forearm in neutral, slide your finger distally along the medial (ulnar) side of the posterior forearm. The ulnar styloid is the small bony projection at the very distal end of the ulna, on the medial-posterior side of the wrist. It is less prominent than the radial styloid and sits approximately 1 cm more proximal (the ulna is shorter than the radius distally).
• What it feels like: A small, pointed bony projection, approximately half the size of the radial styloid. It may be partially obscured by the ECU tendon that runs adjacent to it.
• Client position: Seated with the forearm pronated (palm down) — this brings the ulnar styloid to a more dorsal and accessible position.
• Confirmation: The ulnar styloid does not move with wrist flexion/extension but does become more or less prominent with pronation/supination (because the radius rotates around the ulna). In pronation, the styloid is more dorsal; in supination, it is more medial.
• Common errors: Confusing the ulnar styloid with the head of the ulna (which is the larger, rounded prominence just proximal to the styloid). The head is broader; the styloid is the small point projecting from the distal end of the head.
• Clinical significance: Ulnar styloid fractures frequently accompany distal radius fractures. Tenderness at the ulnar styloid after a FOOSH injury should raise suspicion. The TFCC (triangular fibrocartilage complex) attaches at the base of the ulnar styloid — TFCC tears produce ulnar-sided wrist pain and tenderness at or near the styloid.

Anatomical Snuffbox

• How to find it: Ask the client to extend and abduct the thumb (hitchhiker position). Two prominent tendons become visible on the radial side of the wrist: the EPL tendon (dorsal boundary) and the APL/EPB tendons (palmar boundary). The anatomical snuffbox is the triangular depression between these two tendon groups, just distal to the radial styloid.
• What it feels like: A soft, triangular depression bounded by taut tendons on either side. The floor of the snuffbox contains the scaphoid bone — press into the depression and you are directly on the scaphoid waist.
• Client position: Seated. The thumb must be actively extended and abducted to make the tendons prominent.
• Confirmation: The depression is only clearly visible and palpable when the thumb is actively extended. When the thumb relaxes, the snuffbox flattens. The radial artery pulse can be felt in the snuffbox (the radial artery crosses its floor).
• Common errors: Not having the client actively extend the thumb — without active extension, the bounding tendons are not taut and the snuffbox is not identifiable. Also, confusing the snuffbox with the first dorsal compartment (which is more proximal, over the radial styloid).
• Clinical significance: The scaphoid bone forms the floor — tenderness in the anatomical snuffbox after a FOOSH injury is the hallmark screen for scaphoid fracture. Scaphoid fractures are notorious for negative initial X-rays (the fracture line may not be visible for 10–14 days). If snuffbox tenderness is present after a fall, treat as a fracture until proven otherwise and refer for repeat imaging.

Scaphoid

• How to find it: Locate the anatomical snuffbox (as described above). Press into the floor of the snuffbox — you are on the scaphoid waist. Alternatively, from the palmar side, locate the distal wrist crease on the radial side. The scaphoid tubercle is palpable as a small bony bump at the base of the thenar eminence, just distal to the radial styloid.
• What it feels like: Dorsally (in the snuffbox): a firm bony floor within the soft tissue depression. Palmarly (scaphoid tubercle): a small, rounded bony point at the proximal base of the thenar eminence.
• Client position: Seated, wrist in slight extension with the thumb extended for dorsal palpation. Wrist in neutral with slight radial deviation for palmar tubercle palpation.
• Confirmation: Palpate the snuffbox floor while the client ulnar deviates the wrist — the scaphoid becomes more prominent as it extends. Radial deviation makes it less prominent.
• Common errors: Confusing the scaphoid tubercle with the trapezium (which is more distal — at the base of the first metacarpal) or the radial styloid (which is more proximal).
• Clinical significance: Most commonly fractured carpal bone (70% of all carpal fractures). The scaphoid has a retrograde blood supply — fractures through the waist risk avascular necrosis of the proximal pole. Snuffbox tenderness after a FOOSH injury warrants immobilization and medical referral regardless of initial X-ray findings.

Pisiform

• How to find it: With the client's palm facing up (supinated), locate the ulnar (medial) side of the wrist. The pisiform is the small, round bony prominence on the palmar surface of the wrist, at the base of the hypothenar eminence. It sits directly on the anterior surface of the triquetrum.
• What it feels like: A small, round, pea-shaped bone (pisiform literally means "pea-shaped") approximately 1 cm in diameter. It is subcutaneous on its palmar surface and very easy to palpate. You can grasp it between your thumb and finger and rock it slightly side to side — it is the most mobile carpal bone.
• Client position: Seated with the forearm supinated, wrist relaxed.
• Confirmation: The pisiform is the only carpal bone you can grasp and move independently. Gently rock it mediolaterally — the slight mobility confirms you are on the pisiform and not on the hook of hamate (which is more lateral and immobile) or the ulnar styloid (which is more proximal and dorsal).
• Common errors: Confusing the pisiform with the hook of hamate (which is approximately 1–2 cm distal and lateral — see below). The pisiform is more proximal and more medial.
• Clinical significance: The FCU inserts on the pisiform. The pisiform and the hook of hamate form the ulnar boundary of Guyon's canal (the ulnar tunnel) — the ulnar nerve and artery pass through this canal. Compression here produces ulnar tunnel syndrome (Guyon's canal syndrome). Tenderness at the pisiform may indicate FCU tendinopathy or pisotriquetral joint irritation.

Hook of Hamate

• How to find it: From the pisiform, move approximately 1.5–2 cm distally and slightly laterally (toward the palm). The hook of hamate is a small, curved bony projection on the palmar surface of the hamate. Alternatively, place your thumb's IP joint on the pisiform with the thumb pointing toward the web space between the index and middle fingers — the tip of your thumb lands approximately on the hook of hamate.
• What it feels like: A small, hook-shaped bony prominence deep in the hypothenar eminence. It is smaller and deeper than the pisiform — it requires firmer pressure through the hypothenar muscles to palpate. It may feel like a small, hard point under your fingertip.
• Client position: Seated with the forearm supinated, wrist slightly extended to tighten the palmar tissues.
• Confirmation: Press firmly on the hook and ask the client to flex the ring and little fingers against resistance — the flexor tendons to these digits pass adjacent to the hook, and the hypothenar muscles tighten around it. Tenderness on direct palpation that is sharply localized to a point suggests the hook.
• Common errors: Not pressing firmly enough — the hook is deep to the hypothenar muscles. Also, confusing it with the pisiform (which is more proximal and medial) or a flexor tendon.
• Clinical significance: The hook of hamate and the pisiform form the ulnar border of the carpal tunnel and the boundaries of Guyon's canal. Hook of hamate fractures occur from direct blows (gripping sports — golf club, baseball bat, hockey stick striking the palm). Tenderness at the hook after a grip-loading injury warrants imaging. The ulnar nerve's deep motor branch wraps around the hook — fractures can damage this branch, producing weakness of the interossei without sensory loss.

Metacarpal Heads — "The Knuckles"

• How to find it: Ask the client to make a fist. The metacarpal heads become prominently visible on the dorsal surface of the hand as the knuckles. The 3rd metacarpal head (middle finger knuckle) is the most prominent. With the hand open, the metacarpal heads are palpable at the distal palm approximately 1–2 cm proximal to the MCP joint crease.
• What it feels like: Rounded, smooth bony prominences in a row across the dorsal hand. Each head is approximately 1 cm in diameter. The 2nd and 3rd heads are the most prominent; the 5th is the smallest.
• Client position: Seated. Fist clenched for visualization; hand open and relaxed for palpation.
• Confirmation: The metacarpal heads are the MCP joints — flexion and extension of the fingers occurs at these points. If you place your finger on a knuckle and ask the client to flex and extend the MCP joint, the proximal phalanx moves on the metacarpal head.
• Common errors: Confusing the metacarpal heads with the PIP joints (which are more distal and are the second row of prominent joints in the fingers). The MCP joints (knuckles) are at the junction of the palm and fingers.
• Clinical significance: Metacarpal head fractures (boxer's fracture — typically the 5th metacarpal neck) present with loss of the normal knuckle prominence and point tenderness. MCP joint swelling at multiple metacarpal heads is a characteristic early finding in rheumatoid arthritis (symmetric MCP involvement).