Mateusz Gładysz FESSH prep

FESSH prep Physical examination Thumb carpometacarpal provocative tests, de Quervain tests and the clinical signs of scaphoid fracture

Examination of the thumb base and radial wrist

Last reviewed v1.0

FESSH-037Physical examination●○○ basic

Regarding clinical examination of the thumb base and the radial side of the wrist:

  1. 1.The carpometacarpal grind test for thumb basal joint osteoarthritis has low sensitivity (roughly 30–65 per cent across studies) but high specificity (roughly 80–100 per cent), so a negative grind test does not exclude radiographic trapeziometacarpal arthritis.

  2. 2.In Gelberman's prospective evaluation of 129 patients, the thumb metacarpal adduction and extension provocative tests were less sensitive than the grind test for trapeziometacarpal arthritis.

  3. 3.The wrist hyperflexion and abduction of the thumb (WHAT) test has a sensitivity of about 0.99 but a specificity of only about 0.29 for de Quervain tenosynovitis against ultrasound, and it also detects instability of the first-compartment tendons after surgical release.

  4. 4.Anatomical snuffbox tenderness in the first 24 hours after a fall is highly specific for scaphoid fracture.

  5. 5.In patients with a clinically suspected scaphoid fracture and normal initial radiographs, about 9 per cent have an occult fracture, and no single clinical feature satisfactorily excludes it.

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Question ID
FESSH-037
First published
Last reviewed
Version
v1.0
Answer key and explanations — open after answering

  1. 1. The carpometacarpal grind test for thumb basal joint osteoarthritis has low sensitivity (roughly 30–65 per cent across studies) but high specificity (roughly 80–100 per cent), so a negative grind test does not exclude radiographic trapeziometacarpal arthritis.

    True

    In Gelberman's prospective evaluation of 129 patients the grind test had a sensitivity of 0.44 and a specificity of 0.92 with poor interrater reliability (kappa 0.31). Merritt found sensitivity 42–53% and specificity 80–93% depending on the tester, Choa 30% and 96.7%, and Sela 64% and 100%; Model concluded that the often-quoted grind test is of limited diagnostic value. A positive test (pain, crepitus or both on axial compression and rotation of the metacarpal) supports the diagnosis, but a negative test leaves it open.

    • Gelberman RH, Boone S, Osei DA, Cherney S, Calfee RP. Trapeziometacarpal Arthritis: A Prospective Clinical Evaluation of the Thumb Adduction and Extension Provocative Tests. J Hand Surg Am. 2015;40(7):1285-91. PMID 25986651
    • Merritt MM, Roddey TS, Costello C, Olson S. Diagnostic value of clinical grind test for carpometacarpal osteoarthritis of the thumb. J Hand Ther. 2010;23(3):261-7; quiz 268. PMID 20452743
    • Choa RM, Parvizi N, Giele HP. A prospective case-control study to compare the sensitivity and specificity of the grind and traction-shift (subluxation-relocation) clinical tests in osteoarthritis of the thumb carpometacarpal joint. J Hand Surg Eur Vol. 2013;39(3):282-5. PMID 24127463
    • Sela Y, Seftchick J, Wang WL, Baratz ME. The diagnostic clinical value of thumb metacarpal grind, pressure-shear, flexion, and extension tests for carpometacarpal osteoarthritis. J Hand Ther. 2017;32(1):35-40. PMID 29150383
    • Model Z, Liu AY, Kang L, Wolfe SW, Burket JC, Lee SK. Evaluation of Physical Examination Tests for Thumb Basal Joint Osteoarthritis. Hand (N Y). 2016;11(1):108-12. PMID 27418899

  2. 2. In Gelberman's prospective evaluation of 129 patients, the thumb metacarpal adduction and extension provocative tests were less sensitive than the grind test for trapeziometacarpal arthritis.

    False

    The reverse was found. In that study the adduction manoeuvre had a sensitivity of 0.94 and a specificity of 0.93, and the extension manoeuvre 0.94 and 0.95, with excellent interrater reliability (kappa 0.79 and 0.84), against a grind-test sensitivity of 0.44. Point tenderness over the joint was also sensitive (0.94) but less specific (0.81). Test performance varies between series and examiners: Sela reported sensitivities of 64% for the grind test, 99% for the pressure-shear test and only 36% and 46% for thumb flexion and extension tests, all with specificities of 95–100%. The adduction and extension tests reproduce pain by loading the joint at the extremes of its arc rather than by grinding.

    • Gelberman RH, Boone S, Osei DA, Cherney S, Calfee RP. Trapeziometacarpal Arthritis: A Prospective Clinical Evaluation of the Thumb Adduction and Extension Provocative Tests. J Hand Surg Am. 2015;40(7):1285-91. PMID 25986651
    • Sela Y, Seftchick J, Wang WL, Baratz ME. The diagnostic clinical value of thumb metacarpal grind, pressure-shear, flexion, and extension tests for carpometacarpal osteoarthritis. J Hand Ther. 2017;32(1):35-40. PMID 29150383

  3. 3. The wrist hyperflexion and abduction of the thumb (WHAT) test has a sensitivity of about 0.99 but a specificity of only about 0.29 for de Quervain tenosynovitis against ultrasound, and it also detects instability of the first-compartment tendons after surgical release.

    True

    Goubau and colleagues tested 100 patients against an ultrasound reference: the WHAT test (full wrist flexion with resisted thumb abduction) had a sensitivity of 0.99, a specificity of 0.29, a positive predictive value of 0.95 and a negative predictive value of 0.67, each better than Eichhoff's manoeuvre in the same cohort. Its specificity remains low in absolute terms, so it is a rule-out rather than a rule-in test. Renson's series confirmed that the WHAT test is effective in diagnosing symptomatic instability of the extensor pollicis brevis and abductor pollicis longus after simple release of the first compartment.

    • Goubau JF, Goubau L, Van Tongel A, Van Hoonacker P, Kerckhove D, Berghs B. The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff's Test. J Hand Surg Eur Vol. 2013;39(3):286-92. PMID 23340762
    • Renson D, Mermuys K, Vanmierlo B, Bonte F, Van Hoonacker P, Kerckhove D, et al.. Pulley Reconstruction for Symptomatic Instability of the Tendons of the First Extensor Compartment Following de Quervain's Release. J Wrist Surg. 2017;7(1):31-37. PMID 29383273

  4. 4. Anatomical snuffbox tenderness in the first 24 hours after a fall is highly specific for scaphoid fracture.

    False

    In Parvizi's prospective study of 215 consecutive patients, anatomical snuffbox tenderness, scaphoid tubercle tenderness and pain on longitudinal thumb compression were each 100% sensitive at the initial examination, but their specificities were only 9%, 30% and 48% respectively. Combining the three signs within the first 24 hours kept sensitivity at 100% and improved specificity to 74%. Mallee's meta-analysis found snuffbox tenderness to be the most sensitive clinical test, with specificity ranging from 0.03 to 0.98 across studies, and warned that its low specificity leads to considerable overtreatment.

    • Parvizi J, Wayman J, Kelly P, Moran CG. Combining the clinical signs improves diagnosis of scaphoid fractures. A prospective study with follow-up. J Hand Surg Br. 1998;23(3):324-7. PMID 9665518
    • Mallee WH, Henny EP, van Dijk CN, Kamminga SP, van Enst WA, Kloen P. Clinical diagnostic evaluation for scaphoid fractures: a systematic review and meta-analysis. J Hand Surg Am. 2014;39(9):1683-1691.e2. PMID 25091335

  5. 5. In patients with a clinically suspected scaphoid fracture and normal initial radiographs, about 9 per cent have an occult fracture, and no single clinical feature satisfactorily excludes it.

    True

    Coventry's 2023 systematic review of eight diagnostic-accuracy studies (1,685 wrists with normal initial radiographs) found a 9.0% prevalence of scaphoid fracture. Absence of anatomical snuffbox tenderness significantly reduced the likelihood of an occult fracture (sensitivity 92.1%, specificity 48.4%, negative likelihood ratio 0.2), but no single feature was sufficient to rule one out. This is the rationale for immobilising the clinically suspected scaphoid and arranging repeat radiographs, MRI or CT rather than relying on the initial examination alone.

    • Coventry L, Oldrini I, Dean B, Novak A, Duckworth A, Metcalfe D. Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies. Emerg Med J. 2023;40(8):576-582. PMID 37169546
    • Mallee WH, Henny EP, van Dijk CN, Kamminga SP, van Enst WA, Kloen P. Clinical diagnostic evaluation for scaphoid fractures: a systematic review and meta-analysis. J Hand Surg Am. 2014;39(9):1683-1691.e2. PMID 25091335