Wrist & Hand — Fast Exam

Tap a diagnosis. Tests first, interpretation underneath.

30-second screen

Run this before any special testWas there a fall → which side of the wrist → tendon → nerve

Any fall on an outstretched hand? Then the scaphoid is a fracture until excluded. Tenderness in the anatomical snuffbox is not enough to exclude it, and a normal day-one radiograph does not either.
Which side of the wrist hurts? Radial → De Quervain's, scaphoid, thumb base. Ulnar → TFCC, ulnar nerve, pisotriquetral. Central/dorsal → scapholunate, Kienböck's. Palmar and diffuse with night symptoms → carpal tunnel.
Resisted testing in the planes that hurt — wrist extension and flexion, radial and ulnar deviation, thumb extension and abduction, finger flexion.
Nerve screen — median (thumb, index, middle), ulnar (little finger, intrinsic hand), and both hands compared. Two-point discrimination and thenar or hypothenar bulk.
Look at the hand shape. Thenar wasting, a dropped ring finger, a boutonnière, a mallet, a retracted flexor tendon. The diagnosis is often visible before you test anything.
Functional grip. Ask them to lift a chair by its back, open a jar, and pinch a key. Function tells you more than any single provocative manoeuvre.

The honest caveat: the wrist has the weakest special-test evidence of any region on this site, and the scaphoid is the one injury where a clinical miss causes real harm — avascular necrosis. Everything else here is a clinical diagnosis supported by a test, not made by one.

Tendon

De Quervain's tenosynovitisRadial wrist pain, worse gripping and thumb abduction

Hallmark

Pain over the radial styloid, worse with gripping, lifting, wringing, and thumb abduction. Common after new repetitive loading and in the postpartum period. Focal tenderness and sometimes thickening over the first dorsal compartment.

Tests

Finkelstein — thumb across the palm, then passively deviate the wrist ulnarward. Positive: sharp pain over the radial styloid. sensitive but poorly specific — it hurts plenty of normal wrists
Eichhoff — variant: the examiner holds the thumb abducted while deviating the wrist. Positive: same pain, reported as more specific than Finkelstein because the thumb is not flexed into the palm.
Focal tenderness over the first dorsal compartment — Positive: direct reproduction at the radial styloid. The most useful finding, and it localises better than either manoeuvre.

Next: clinical diagnosis. Distinguish from thumb base (CMC) osteoarthritis and from a scaphoid problem — palpate the joint and the snuffbox, and note that De Quervain's hurts over the styloid. Ultrasound-guided injection is effective; splinting and load modification first.

Extensor and flexor tendon injuriesA finger that will not straighten or will not bend

Hallmark

A laceration or forced movement, then a finger that has lost active motion. The joint involved tells you which structure is gone.

Tests — all are active motion, not provocative manoeuvres

Mallet finger — distal interphalangeal joint. Positive: the fingertip drops and cannot be actively straightened, but it extends passively. Distinguish from a bony avulsion — radiograph.
Boutonnière — central slip. Positive: proximal interphalangeal joint flexed and the distal joint extended, with an inability to actively extend the proximal joint. The Elson test helps.
Jersey finger — flexor digitorum profundus avulsion. Positive: the finger cannot flex at the distal joint while the other fingers are held extended. A rugby or football grab injury, and surgical.
Flexor tendon laceration — test each joint separately. Positive: loss of active flexion at one joint but not others localises the level.

Next: any penetrating wound near the palm or finger plus lost active motion is a tendon injury until proven otherwise. Do not assume a nerve injury just because it is numb — a laceration usually takes both.

Trigger fingerA clicking, then a catching finger — often a palpable nodule

Tests

Palpate the A1 pulley at the metacarpal head — Positive: a tender nodule and often a palpable click as the finger flexes and extends.
Ask them to make a fist and open it — Positive: the finger catches or locks, and they may need the other hand to release it.

Next: no special test needed. Worse in diabetes and with hypothyroidism — worth checking if a patient has multiple or recurrent triggers.

Ligament

Thumb UCL injury (skier's / gamekeeper's thumb)Fall on an abducted thumb — radiograph before you stress it

Hallmark

Acute valgus force on the thumb — a fall while skiing, holding a stick, or on the outstretched hand. Pain, swelling and tenderness at the ulnar aspect of the thumb metacarpophalangeal joint.

Tests

X-ray first, always — exclude an avulsion fracture or a fracture at the base of the proximal phalanx before applying stress.
Valgus stress at 30° of metacarpophalangeal flexion — the accessory ligament. Positive: opening of more than about 15° compared with the other thumb, or a soft endpoint. >15° difference suggests complete rupture
Valgus stress in extension — the proper ligament. Positive: instability in both flexion and extension raises the suspicion of a Stener lesion — the ligament displaced outside the adductor aponeurosis, which will not heal without surgery.
Palpable mass proximal to the joint — Positive: reported as highly sensitive but poorly specific for a complete tear.

Next: partial tears do well in a thumb spica for weeks. Complete tears and suspected Stener lesions go to a hand surgeon — and a Stener lesion that is not recognised early loses the chance of a good result. Compare both thumbs, use local anaesthetic if pain limits the test, and consider stress radiographs.

Scapholunate ligament injuryDorsal radial wrist pain with a clunk — and the test is unreliable

Hallmark

Dorsal wrist pain, worse on loading and on pushing up. Often after a fall. A visible gap on a clenched-fist radiograph is a late sign.

Tests

Scaphoid shift (Watson) — press on the scaphoid tubercle volarly while deviating the wrist from ulnar to radial. Positive: a painful clunk as the scaphoid shifts and reduces over the dorsal rim. whole cohort Sn 0.50; in suspected cases Sn 0.61 / Sp 0.62; other series Sn 47.6% / Sp 66.7%weak — do not use it to rule in or out
Scapholunate ballottement and the clenched-fist view — Positive: pain and a widened scapholunate interval on the radiograph.

Next: clinical examination is poor here. If the story fits and the pain persists, image properly — a normal resting radiograph does not exclude it. Do not let a negative Watson test close the question.

TFCC injuryUlnar wrist pain — the fovea sign is the good test here

Hallmark

Ulnar-sided wrist pain, worse on rotation and on loading — opening a jar, turning a key, pushing up. Often after a fall or a rotation injury.

Tests

Ulnar fovea sign — press your thumb into the soft spot between the ulnar styloid and the flexor carpi ulnaris tendon. Positive: pain or tenderness in that hollow → foveal disruption or ulnotriquetral ligament injury. Sn 95.2% / Sp 86.5% (Tay et al.) The best performing test on this page.
Ulnar grind / TFCC compression — load the wrist in ulnar deviation and rotate. Positive: ulnar pain with a click.
Piano key sign — the distal radioulnar joint. Positive: the ulnar head springs back when depressed → DRUJ instability.
Linscheid squeeze — squeeze the ulnar wrist between thumb and fingers. Positive: focal ulnar pain.

Next: the fovea sign is genuinely useful — a positive with the right history goes straight to imaging. MRI or arthroscopy for confirmation; the tear itself may not be the whole pain generator, since TFCC changes are common in asymptomatic wrists.

Nerve

Carpal tunnel syndromeNight-time numbness in thumb, index and middle — the patient shakes the hand

Hallmark

Nocturnal numbness and tingling in the median distribution, waking them, relieved by shaking the hand (the flick sign). Later: dropping things, thenar wasting, and reduced pinch. Sensation and pain can be normal by day, which is why the history carries the diagnosis.

Tests

Phalen — hold both wrists in full flexion for 60 seconds. Positive: tingling in the median distribution.
Durkan (carpal compression) — press directly over the carpal tunnel for 30 seconds. Positive: provoked symptoms. Generally the better performer of the two.
Tinel at the carpal tunnel — Positive: tingling into the median distribution.weak; frequently positive in normal hands
Thenar bulk, two-point discrimination, and pinch strength — Positive: atrophy or sensory loss → established compression, not early disease. This changes urgency.
Screen the neck, elbow and forearm — median symptoms can come from a C6–C7 root or a proximal compression. Do not inject a wrist before you have screened above it.

Next: diagnosis is clinical and confirmed with nerve conduction studies when the answer matters — before surgery, or when there is motor loss. Night splints and corticosteroid injection work early; thenar wasting is the point of no return.

Ulnar nerve at the handLittle finger numbness with a weak pinch

Tests

Froment sign — pinch paper between thumb and index while the examiner pulls it away. Positive: the thumb interphalangeal joint flexes to compensate for a weak adductor pollicis.
Jeanne sign — Positive: hyperextension at the thumb metacarpophalangeal joint during a key pinch, from adductor pollicis weakness.
Crossed fingers, abductor digiti minimi bulk, and two-point discrimination — Positive: any motor loss or hypothenar wasting → significant compression.

Next: always check the elbow (cubital tunnel) and the neck. Hand-level ulnar compression — Guyon's canal — is much less common than compression at the elbow, and treating the wrong level wastes months.

Other

Scaphoid and other carpal fracturesSnuffbox tenderness is not enough — and day-one films miss them

Hallmark

A fall on the outstretched hand with radial wrist pain. The scaphoid has a tenuous blood supply and an unrecognised fracture risks non-union and avascular necrosis.

Tests

Anatomic snuffbox and scaphoid tubercle tenderness — Positive: focal tenderness. sensitive but not specific — tenderness alone cannot exclude a fracture, and its absence does not reliably exclude one either
Axial loading of the thumb — Positive: pain in the scaphoid.
Radiograph, then repeat or image again — Positive: a scaphoid view. A negative day-one film is not the end of the question.

Next: if clinical suspicion is real and the radiograph is normal, immobilise and repeat imaging, or go straight to CT or MRI. This is the single place in the wrist where being wrong does lasting harm. Do not reassure on a normal radiograph alone.

Thumb base (CMC) osteoarthritisGrinding pain at the base of the thumb

Tests

Grind test — axial load applied along the thumb metacarpal while rotating. Positive: pain and crepitus at the trapeziometacarpal joint.
Palpation of the CMC joint line — Positive: focal tenderness at the base of the thumb, not at the radial styloid — which is how you separate it from De Quervain's.
Key pinch strength — Positive: painful, weak pinch. The main functional complaint and the best outcome measure.

Next: radiograph. Usually 50-plus years and female-predominant. Thumb-baseOA and De Quervain's are the two commonest radial-sided diagnoses and are frequently confused — the location of maximal tenderness separates them.

Choosing the imagingScaphoid is the exception to every rule — image it properly

Radiograph first — always, and with a specific scaphoid view when indicated. Add a clenched-fist or loaded view for suspected scapholunate instability.
CT — the best test for a suspected scaphoid fracture with a normal radiograph, and for fracture union. Do not wait weeks to find out.
MRI — occult fracture, TFCC and ligament injury, and Kienböck's. Very high sensitivity for a scaphoid fracture.
Ultrasound — tendons, ganglia, and guided injection. Poor for bone and for the triangular fibrocartilage.
Nerve conduction studies — carpal tunnel and ulnar neuropathy when the answer changes management or before surgery.

Worth remembering: a normal radiograph does not exclude a scaphoid fracture, and tendon and nerve lacerations are clinical diagnoses that no scan will make for you.

Red flags — before you test

Re-route before you testSix findings that take precedence over any special test

Stop and re-route

Fall on the outstretched hand with radial wrist pain, even with a normal radiograph → treat as a scaphoid fracture until excluded. Immobilise and re-image. This is the most important line on the page.
Penetrating injury with loss of active finger movement → tendon laceration. Surgical, and best assessed before the wound is closed.
Hot, swollen, exquisitely tender joint, or a human bite over a knuckle → septic arthritis or septic tenosynovitis. Urgent. Bites over the MCP joint are notoriously worse than they look.
Pain out of proportion, tense swelling, extreme pain on passive stretch of the fingers → compartment syndrome. Emergency.
Sudden inability to extend a finger after a distal radius fracture, with severe pain → extensor pollicis longus rupture. A known late complication.
Night pain, unexplained weight loss, or a history of cancer, or a destructive lesion on radiograph → malignancy. Urgent referral.

Built for Ruby — PRM & sports medicine wrist and hand reference.
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Sources. [1] Scaphoid shift (Watson) test — PMC9656589: Sn 0.50 overall, 0.61 with Sp 0.62 in suspected scapholunate injury; Ruston et al. Sn 47.6% / Sp 66.7%; LoStyo et al. Sn 69% / Sp 66%. [2] Ulnar fovea sign — Tay SC, Tomita K, Berger RA. J Hand Surg Am 2007;32:438–444: Sn 95.2% / Sp 86.5%. [3] Thumb UCL / gamekeeper's and skier's thumb — valgus stress at 30° with >15° difference indicating complete rupture; instability in both flexion and extension raising suspicion of a Stener lesion; radiograph before stress testing. Heyman et al. reported high sensitivity and low specificity for a palpable mass. [4] Snuffbox tenderness for scaphoid fracture — described as sensitive but not specific; a normal day-one radiograph does not exclude the fracture. CT or MRI where suspicion persists. [5] Tests without figures are described from standard technique. Where the literature does not provide robust accuracy data — including Finkelstein, Phalen, Durkan and Tinel — none is quoted rather than inventing one. Finkelstein in particular is widely reported as sensitive and poorly specific.

Diagnostic accuracy figures are pooled from the cited literature and vary widely between studies and populations. Interpret alongside history and pre-test probability. Not a decision-support system, and not a substitute for your own clinical judgement or local protocols.