Provocative tests of the wrist

1. In the Watson scaphoid shift test the examiner's thumb presses on the palmar tubercle of the scaphoid while the wrist is moved from ulnar to radial deviation; a positive test is a painful dorsal subluxation of the scaphoid over the dorsal rim of the radius, often with a clunk as thumb pressure is released.

True

Watson, Ashmead and Makhlouf described the scaphoid shift in 1988 as a manoeuvre for scaphoid and periscaphoid pathology. Sustained thumb pressure on the tubercle blocks the scaphoid's normal flexion as the wrist moves from ulnar deviation and slight extension into radial deviation and slight flexion; when the scapholunate restraints are incompetent the proximal pole subluxes dorsally over the dorsal rim of the radius, and releasing the thumb lets it reduce with a painful clunk. Comparison with the contralateral wrist is part of the test, and pain, not mobility alone, is the discriminating finding.

• Watson HK, Ashmead D, Makhlouf MV. Examination of the scaphoid. J Hand Surg Am. 1988;13(5):657-60. PMID 3241033
• Lane LB. The scaphoid shift test. J Hand Surg Am. 1993;18(2):366-8. PMID 8463609
• Schmauss D, Pöhlmann S, Weinzierl A, Schmauss V, Moog P, Germann G, et al.. Relevance of the Scaphoid Shift Test for the Investigation of Scapholunate Ligament Injuries. J Clin Med. 2022;11(21):6322. PMID 36362552

2. A positive scaphoid shift test is found in fewer than 5% of uninjured wrists.

False

Easterling and Wolfe found a positive but painless scaphoid shift in 32% of 100 uninjured patients, and Wolfe, Gupta and Crisco recorded positive findings in 36% of normal individuals examined under fluoroscopy. Positive shifts in normal wrists correlate with generalised ligamentous laxity rather than with radiographic malalignment, and 14% were unilateral, so neither hypermobility nor asymmetry alone is diagnostic. In arthroscopy-verified series the test's sensitivity for scapholunate ligament injury is only around 50–70%.

• Easterling KJ, Wolfe SW. Scaphoid shift in the uninjured wrist. J Hand Surg Am. 1994;19(4):604-6. PMID 7963316
• Wolfe SW, Gupta A, Crisco JJ. Kinematics of the scaphoid shift test. J Hand Surg Am. 1997;22(5):801-6. PMID 9330136

3. The ulnar fovea sign is elicited by pressing the examiner's thumb into the soft spot between the ulnar styloid and the flexor carpi ulnaris tendon, and in the original series it had a sensitivity of 95.2% and a specificity of 86.5% for foveal disruption of the distal radioulnar ligaments and/or ulnotriquetral ligament injury.

True

Tay, Tomita and Berger defined a positive sign as exquisite tenderness that replicates the patient's pain, compared with the contralateral side, in the interval between the ulnar styloid and the flexor carpi ulnaris tendon. In 272 consecutive arthroscopy patients the sign was positive in 156, with 90 foveal disruptions and 68 ulnotriquetral ligament injuries found. The sign does not distinguish the two conditions: ulnotriquetral split tears are typically associated with a stable distal radioulnar joint and foveal disruptions with an unstable one. A later series found an arthroscopic foveal tear in only 21 of 73 fovea-positive wrists, so the sign is sensitive rather than specific for foveal detachment.

• Tay SC, Tomita K, Berger RA. The "ulnar fovea sign" for defining ulnar wrist pain: an analysis of sensitivity and specificity. J Hand Surg Am. 2007;32(4):438-44. PMID 17398352
• Choudhury MM, Ling AAA, Yap RTJ. Is the ulnar fovea sign positive only in foveal tears of the triangular fibrocartilage complex?. J Hand Surg Eur Vol. 2024;50(5):661-662. PMID 39315552

4. Finkelstein's original test for de Quervain tenosynovitis consists of the patient clenching the thumb inside the fist while the examiner ulnarly deviates the wrist.

False

The clenched-thumb-and-ulnar-deviation manoeuvre is Eichhoff's test, which most textbooks and clinicians wrongly label as Finkelstein's. Finkelstein's 1930 description elicits pain by the examiner grasping the thumb and applying traction into ulnar deviation and flexion. Elliott traced the descriptive error through three decades of English-language literature and warned that it produces false positives; in 72 asymptomatic wrists, Eichhoff's manoeuvre produced false-positive pain whereas the correctly performed Finkelstein test did not, and it caused less discomfort.

• Wu F, Rajpura A, Sandher D. Finkelstein's Test Is Superior to Eichhoff's Test in the Investigation of de Quervain's Disease. J Hand Microsurg. 2018;10(2):116-118. PMID 30154628
• Elliott BG. Finkelstein's test: a descriptive error that can produce a false positive. J Hand Surg Br. 1992;17(4):481-2. PMID 1402284

5. The lunotriquetral ballottement test, attributed to Reagan, is performed by stabilising the lunate and displacing the triquetrum dorsally and palmarly; pain, crepitus or laxity suggests lunotriquetral ligament injury.

True

Reagan, Linscheid and Dobyns described lunotriquetral sprains in 1984 as typically following hyperextension and twisting of the wrist, with point tenderness, laxity and often a snap over the lunotriquetral joint; their dorsopalmar manipulation of the triquetrum on the lunate demonstrating crepitus and laxity is the ballottement (shuck) test. Kleinman's shear test is the other eponymous lunotriquetral manoeuvre. Against arthroscopy the ballottement test has modest accuracy, so a positive result supports rather than confirms the diagnosis.

• Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetral sprains. J Hand Surg Am. 1984;9(4):502-14. PMID 6747234
• Weiss LE, Taras JS, Sweet S, Osterman AL. Lunotriquetral injuries in the athlete. Hand Clin. 2000;16(3):433-8. PMID 10955216