Hand & Wrist Examination
A 12-section hand and wrist examination covering look, feel, move, nerves, special tests and function, including comments on findings.
Musculoskeletal · Self-paced
12 sections · 63 actionable steps
Before you begin
Equipment
Pillow to rest the hands on
Cup for power grip
Coin, button and pen for function
Sheet of paper for Froment’s sign
Cotton wool or Neurotip
The aim
Describe the pattern of joint, tendon and nerve involvement, then say how it affects function.
Look, feel and move tell you what is wrong. Nerves, special tests and function show the cause and what it means for the patient.
How to use this guide
Read it through: Learn the sequence and the reason behind each step before you practise.
Practise in pairs: One examines, one reads the steps aloud and ticks each circle as it is completed.
Present aloud: Finish every attempt with a concise summary, as you would for an examiner.
The sequence
Talk
Introduce, consent, pain
Look
Dorsal and palmar surfaces
Feel
Temperature, joints, snuffbox
Move
Active, passive, power
Test
Nerves, special tests, function
Step 1. Introduction
Hand hygiene
Hand wash/rub
Introduce yourself
Introduce yourself to the patient
Explain the purpose
Explain the purpose of the examination
Obtain consent
Obtain consent
Ask about pain
Ask where it hurts before you touch anything, and agree that the patient will tell you if anything is painful
Position and exposure
Sit the patient facing you with both arms exposed above the elbows. Rest the hands on a pillow
Dominance and occupation
Ask which hand is dominant and what the patient does for work and hobbies
Set up first
Rest both hands on a pillow, palms down. Ask about dominance and occupation early; they shape your summary.
Step 2. General Inspection
Surroundings
Splints, walking aids, adapted cutlery or medications around the patient
Posture and comfort
How the patient holds the arms; guarding of a painful limb
Other joints and skin
Psoriatic plaques, a rash, or swelling of other joints
Elbows
Rheumatoid nodules or psoriatic plaques over the extensor surfaces
Look beyond the hands
Rheumatoid nodules or psoriatic plaques at the elbows often give away the diagnosis.
Step 3. Look: the Dorsal Surface
Skin
Scars, erythema, thin skin and bruising from steroids
Nails
Pitting, onycholysis, clubbing and nail-fold infarcts
Joint swelling
Soft swelling of the MCP and PIP joints, or bony swelling of the DIP and PIP joints
Deformities
Ulnar deviation, swan neck, boutonnière and Z-thumb deformities, and squaring of the thumb base
Muscle wasting
Guttering between the metacarpals and wasting of the first dorsal interosseous
Inflammatory or degenerative?
Rheumatoid: symmetrical MCP and PIP swelling, sparing the DIPs.
Osteoarthritis: Heberden’s (DIP) and Bouchard’s (PIP) nodes, squared thumb base.
Name the deformity
Swan neck: PIP hyperextended, DIP flexed.
Boutonnière: PIP flexed, DIP hyperextended.
Step 4. Look: the Palmar Surface
Turn the hands over
Ask the patient to turn their hands palms up
Palmar erythema
Reddening of the thenar and hypothenar eminences
Thenar and hypothenar wasting
Thenar wasting in median nerve lesions; hypothenar wasting in ulnar nerve lesions
Dupuytren’s contracture
Thickened cords and nodules, usually towards the ring and little fingers
Scars and swellings
Carpal tunnel release scars, ganglia over the wrist
Dupuytren’s contracture
Painless palmar fibrosis, linked with family history, alcohol, diabetes and epilepsy medication.
Step 5. Feel
Temperature
Back of your hand over the forearm, wrist and MCP joints of both hands. Compare sides
Radial and ulnar pulses
Check both at the wrist
Palmar thickening
Feel for Dupuytren’s cords and nodules in the palm
Muscle bulk
Feel the thenar and hypothenar eminences
MCP squeeze
Gently squeeze across the MCP joints while watching the patient’s face for pain
Bimanual joint palpation
Each MCP, PIP and DIP joint and the wrist. Is swelling soft and boggy (synovitis) or hard (bony)?
Anatomical snuffbox
Tenderness suggests a scaphoid fracture
Tendon sheaths
Palpate the flexor sheaths for thickening, crepitus or a triggering nodule
Watch the face
Ask about pain before you touch, and keep watching the patient’s face as you palpate.
The snuffbox
Snuffbox tenderness after a fall on an outstretched hand is a scaphoid fracture until proven otherwise.
Step 6. Move: Active
Wrist extension
Prayer sign: palms together, elbows raised
Wrist flexion
Reverse prayer sign: backs of the hands together
Make a fist
Can all fingertips reach the palm?
Spread the fingers
Then bring them back together
Thumb opposition
Touch the tip of the thumb to each fingertip in turn
Pronation and supination
Elbows tucked into the sides at 90°, turn the palms down and up
Quick screen
The prayer and reverse prayer signs test both wrists at once. Normal extension is about 70° and flexion about 80°.
Step 7. Move: Passive
Wrist flexion and extension
Support the forearm; note range, pain and crepitus
Radial and ulnar deviation
Move the wrist from side to side
Finger joints
Move the MCP, PIP and DIP joints through their range. Can deformities be corrected passively?
Thumb
Flexion, extension, abduction and adduction
Step 8. Power
Wrist extension
“Cock your wrists back and stop me pushing them down.” Radial nerve, C6–C7
Finger extension
“Straighten your fingers and stop me pushing them down.” Posterior interosseous nerve
Finger abduction
“Spread your fingers and stop me pushing them together.” Ulnar nerve, T1
Thumb abduction
“Point your thumb to the ceiling and stop me pushing it down.” Median nerve
Froment’s sign
Grip a sheet of paper between the thumb and index finger. Thumb IP flexion suggests ulnar nerve weakness
Grip strength
Ask the patient to squeeze two of your fingers
One movement per nerve
Radial: wrist extension. Ulnar: finger abduction. Median: thumb abduction (the LOAF muscles).
Step 9. Sensation
Median nerve
Light touch over the pad of the index finger
Ulnar nerve
Light touch over the pad of the little finger
Radial nerve
Light touch over the dorsal first web space
Compare sides
Test with the patient’s eyes closed and compare with the other hand
Autonomous zones
Each test site is supplied by one nerve only, so loss there localises the lesion.
Step 10. Special Tests
Tinel’s test
Tap over the carpal tunnel. Tingling in the median nerve distribution suggests carpal tunnel syndrome
Phalen’s test
Hold the wrists fully flexed, backs of the hands together, for 60 seconds. Reproduced symptoms suggest carpal tunnel syndrome
Finkelstein’s test
Thumb in the palm, fingers closed over it, then gently ulnar deviate. Pain over the radial styloid suggests de Quervain’s tenosynovitis
Flexor digitorum profundus
Hold the PIP joint straight and ask the patient to bend the fingertip
Flexor digitorum superficialis
Hold the other fingers straight and ask the patient to bend the finger being tested
Scaphoid compression
Axial pressure along the thumb. Pain at the wrist suggests a scaphoid fracture
Carpal tunnel tests
Phalen’s test is more sensitive than Tinel’s, but neither rules carpal tunnel syndrome in or out on its own.
Source terminology — tutor review
The PDF labels the thumb-in-palm manoeuvre Finkelstein’s test. Some curricula distinguish this from Eichhoff’s manoeuvre; the source wording is retained. Confirm the required name and technique with your tutor before practice.
Step 11. Function
Power grip
Hold a cup or grip your fingers
Pincer grip
Pick up a coin from a flat surface
Fine movements
Undo and do up a button
Writing
Write a short sentence with a pen
Function matters
Ask what the patient cannot do: cooking, dressing, writing or work. This drives management.
Step 12. Conclusion
Thank the patient
Thank the patient and help them to cover up
Hand hygiene
Hand wash/rub
Summarise
Pattern of joint involvement, deformities, nerve findings and functional impact
Suggest further assessment
Examine the elbow and cervical spine, a full upper limb neurological examination and X-rays of both hands and wrists
Finish strongly
Give the pattern, the likely diagnosis and the functional impact, then offer elbow, neck and X-ray assessment.
Run it from memory
Cover the steps and recite the sequence.
- Step 1. Introduction
- Step 2. General Inspection
- Step 3. Look: the Dorsal Surface
- Step 4. Look: the Palmar Surface
- Step 5. Feel
- Step 6. Move: Active
- Step 7. Move: Passive
- Step 8. Power
- Step 9. Sensation
- Step 10. Special Tests
- Step 11. Function
- Step 12. Conclusion
What your findings mean
Patterns of arthritis
Look at which joints are involved and how
| Feature | Rheumatoid arthritis | Osteoarthritis | Psoriatic arthritis |
|---|---|---|---|
| Joints | MCP, PIP and wrist; symmetrical; spares DIPs | DIP, PIP and thumb base | DIP joints, often asymmetrical |
| Swelling | Soft, boggy synovitis | Hard, bony nodes | Dactylitis (sausage digits) |
| Deformities | Ulnar deviation, swan neck, boutonnière, Z-thumb | Heberden’s and Bouchard’s nodes, squared thumb base | Arthritis mutilans, telescoping digits |
| Other signs | Rheumatoid nodules, vasculitis, carpal tunnel | Usually none | Nail pitting, onycholysis, plaques |
Nerve lesions in the hand
| Nerve | Motor signs | Sensory loss | Common cause |
|---|---|---|---|
| Median | Thenar wasting, weak thumb abduction | Lateral 3½ digits, palmar side | Carpal tunnel syndrome |
| Ulnar | Hypothenar and interossei wasting, clawing, Froment’s sign | Medial 1½ digits | Compression at the elbow |
| Radial | Wrist and finger drop | Dorsal first web space | Humeral shaft fracture |
Soft-tissue conditions
| Condition | Findings |
|---|---|
| Trigger finger | Finger locks in flexion; tender nodule over the A1 pulley |
| De Quervain’s tenosynovitis | Radial wrist pain; positive Finkelstein’s test |
| Ganglion | Smooth, firm swelling over the wrist that may transilluminate |
| Mallet finger | DIP droops and cannot be actively extended |
Act on these findings
Snuffbox tenderness after a fall — treat as a scaphoid fracture
Hot, red, swollen joint — consider septic arthritis
Acute median nerve symptoms after wrist trauma — urgent orthopaedic review
Wound over an MCP joint after a punch — fight bite; urgent washout
Presenting your findings
Model presentation
“I examined the hands of Mrs Smith, a 62-year-old right-handed retired teacher. There were rheumatoid nodules at both elbows. There was symmetrical soft swelling of the MCP and PIP joints with sparing of the DIPs, ulnar deviation at the MCPs and swan neck deformities of the right index and middle fingers.
The swollen joints were warm and tender, and wrist movements were reduced and painful. Grip strength was reduced, but sensation was normal and Tinel’s and Phalen’s tests were negative. She had difficulty with buttons and pincer grip. These findings are consistent with active rheumatoid arthritis with significant functional impairment.”
Structure
| Stage | Include |
|---|---|
| Who | Name, age, dominance, job |
| Look | Pattern and deformities |
| Feel | Warmth, synovitis, tenderness |
| Move | Range, power, nerves |
| Function | Impact and diagnosis |
Common pitfalls
Not asking about pain before palpating
Inspecting the dorsal surface only
Forgetting to look at the elbows
Not watching the face during palpation
Testing power without isolating each nerve
Skipping the functional assessment
To complete the examination
Elbow and cervical spine examination
Full upper limb neurological examination
X-rays of both hands and wrists
Bloods: RF, anti-CCP, ESR and CRP, urate
Nerve conduction studies if a nerve lesion is suspected
Sources
Checklist and learning content: supplied Hand and Wrist Examination Guide PDF, in the med study partner examination checklist format.
Further reading: Talley NJ, O’Connor S. Clinical Examination: A Systematic Guide to Physical Diagnosis. Elsevier. Apley and Solomon’s System of Orthopaedics and Trauma. CRC Press.
Always follow your own medical school’s marking criteria and local clinical policies. Made for learning, not for clinical decision-making.
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