Examine the hand with the palms down on a pillow, then turn them over, palpate the wrist and small joints, test active and passive movement, and finish with function and a nerve assessment. NICE Clinical Knowledge Summaries describe Phalen's, Tinel's and Durkan's tests for carpal tunnel syndrome, and warn against using any of them alone.

Key takeaways

  • NICE CKS places carpal tunnel symptoms in the median nerve distribution: thumb, index, middle and the radial half of the ring finger.
  • Phalen's test is positive if flexing the wrist for 60 seconds reproduces median nerve pain or paraesthesia.
  • Durkan's test applies direct pressure over the proximal edge of the transverse carpal ligament at the proximal wrist crease.
  • The 2024 AAOS guideline, quoted by NICE CKS, found strong evidence that Phalen's or Tinel's tests should not be used in isolation.
  • NICE NG38 recommends MRI as first-line imaging for a suspected scaphoid fracture after thorough clinical examination.

What is the examiner marking at the hand station?

The Intercollegiate blueprint marks a physical examination station out of 20 across four domains: clinical and technical skill carries 8 marks, and clinical knowledge and its application, communication and professionalism carry 4 marks each. The station also gets a separate global rating of pass, borderline or fail.

More than half the marks therefore sit outside your knowledge of the condition, so a silent but technically correct examination scores poorly. You are signalled at six minutes of the nine to present your findings, so the sequence has to finish inside six.

The examiner is marking a structured sequence that ends in function, because the hand station is about what the patient can do. Interpretation carries as many marks as technique.

Say what each finding would mean as you go, rather than saving everything for a summary you may not reach.

How should you start the hand and wrist examination?

Introduce yourself, gain consent, expose both arms to above the elbow and ask about pain or stiffness before you touch.

Rest the hands palms down on a pillow. NICE CKS asks you to examine the whole upper limb, including neck, shoulder, elbow and wrist, particularly when the presentation is atypical.

What am I looking for on inspection of the hands?

Look at the dorsum first, then the palms, then the elbows, comparing sides.

  • Skin and nails, for erythema, nail pitting, psoriatic plaques and scars
  • Muscle wasting, especially of the thenar eminence, which NICE CKS lists as a sign of prolonged or severe carpal tunnel syndrome
  • Joint swelling and deformity, including ulnar deviation, swan neck and boutonniere
  • Nodes, with Heberden's nodes at the distal interphalangeal joints and Bouchard's nodes at the proximal interphalangeal joints, as NICE CKS describes in hand osteoarthritis
  • Squaring at the base of the thumb, which NICE CKS attributes to subluxation and remodelling at the first carpometacarpal joint

What should you palpate at the wrist and hand?

Feel temperature with the back of your hand, then palpate systematically from the radius and ulna distally into the carpus and the small joints.

Palpate the anatomical snuffbox and the scaphoid tubercle. NICE CKS lists tenderness at both sites as the trigger for wrist imaging after injury.

Which movements should you test?

Test active then passive movement at the wrist, then the fingers and thumb, comparing sides.

  • Wrist flexion and extension, demonstrated with the prayer and reverse prayer positions
  • Radial and ulnar deviation
  • Finger flexion and extension, then abduction and adduction
  • Thumb abduction, opposition and extension, which NICE CKS links to median nerve function

Which special tests are worth performing?

Three provocation tests for carpal tunnel syndrome, described by NICE CKS, plus one each for ulnar nerve and thumb tendon pathology.

  • Phalen's test, positive if 60 seconds of wrist flexion causes pain or paraesthesia in the median distribution
  • Tinel's test, tapping lightly over the median nerve at the volar wrist, and more accurate with a tendon hammer per NICE CKS
  • Durkan's compression test, thumb pressure over the proximal edge of the transverse carpal ligament
  • Froment's sign, where the thumb flexes at the interphalangeal joint to grip paper because ulnar-innervated adductor pollicis is weak
  • The staged Finkelstein test for de Quervain's, which provokes pain at the tip of the radial styloid

How do you assess function and the nerves?

Function is the point of the hand. Test power grip, pinch grip and a practical task such as undoing a button or holding a pen.

Then test the three nerves: thumb abduction for the median nerve, finger abduction for the ulnar nerve, wrist and finger extension for the radial nerve, with sensation over the thenar pulp, the little finger and the dorsal first web space.

What are the most common mistakes at this station?

  • Never turning the hands over, so Dupuytren's disease and palmar wasting are missed
  • Treating a positive Phalen's or Tinel's test as diagnostic, which the 2024 AAOS guidance explicitly warns against
  • Performing Eichhoff's manoeuvre, thumb inside a clenched fist, and calling it Finkelstein's; it is more provocative and produces more false positives
  • Running out of time before the functional assessment, which is where the marks sit
  • Forgetting to compare the two hands, or to look at the elbows for nodules and plaques

How should you finish the hand and wrist examination?

Offer to examine the elbow and cervical spine, assess vascular status, and state your imaging plan.

NICE NG38 recommends considering MRI as first-line imaging for a suspected scaphoid fracture following thorough clinical examination, which is a strong line to deliver at this station.

The MRCS Part B Questions bank has a hand and wrist examination station at /Sample-Questions.