Textbook of Urgent Care Medicine, Chapter 34, Hand and Wrist Pain and Injury

Published on November 5, 2026

Original authors: Ashley Simela and Scott M. Zimmer

Originally published in 2014. Substantially updated and clinically reviewed in 2026.

INTRODUCTION

Hand and wrist injuries are extremely common presentations in the urgent care setting. Unfortunately, they are also notoriously mishandled. Patients and clinicians alike underestimate the significance of hand injuries in particular, and the potential for lifelong complications is not to be underestimated. Having a clear understanding of the functional anatomy along with the motor and sensory distributions and injury implications is paramount to proper diagnosis and treatment.

PRESENTATION

Presentation depends on mechanism of injury. The differential diagnosis is determined initially by the presence or absence of trauma. Stability and urgency are then assessed so that proper disposition and follow-up are ensured. Crush injuries, injection injuries, and open injuries deserve special attention.

TRIAGE PEARLS

Neurovascular status and immobilization are the hallmarks of initial triage for upper extremity injuries.
Hypotension, tachycardia, or both can herald impending shock. Patients with these symptoms should be seen by the provider immediately.
Absent or weak pulses distal to the injury require immediate evaluation.
Temporary splinting can reduce pain significantly.
Pain assessment and treatment are important at triage.
Immediate emergency department transfer is warranted for an ischemic digit or hand, an open dislocation, suspected compartment syndrome, high-pressure injection injury, rapidly progressive deep-space infection, or a major injury with an altered neurologic or vascular examination. Do not delay transfer for routine tests or imaging. [3,10]

HISTORY PEARLS

Acute, subacute, or chronic
Mechanism of injury
Differential diagnosis and testing are dictated by the mechanism of injury (MOI).
Children may have difficulty explaining the MOI.
Some important MOIs include the following: fall on an outstretched hand (distal radius or scaphoid fracture); direct blow to the hand (metacarpal fracture); crush injury (nail-bed or tuft injury); hyperflexion or hyperextension (tendon or ligament injury); grabbing (mallet finger); and repetitive use (de Quervain tenosynovitis).
Ask about penetrating trauma, industrial paint or grease guns, bites, punctures, contamination, diabetes, immunosuppression, hand dominance, occupation, and pre-injury function. A high-pressure injection wound may appear innocuous at first. [10]
The presence of numbness, swelling, or coldness can indicate neurovascular compromise or injury, or compartment syndrome.
Paresthesias and weakness can indicate nerve entrapment or injury consistent with distribution.
The impact on activities of daily living can give the clinician important insight into the nature and degree of injury or other pathology.

PHYSICAL EXAM PEARLS

Ideally the patient should be seated facing opposite the examiner.
The hand should be specifically inspected for discoloration, deformity, muscular atrophy, swelling, and any previous scars.
Careful inspection of the contralateral hand is also important for comparison.
Palpation of the affected area can identify areas of tenderness, masses, joint effusion, or crepitus.
Range of motion, both passive and active flexion, should be assessed when it will not worsen an unstable injury.
Document finger cascade, the ability to make a fist, rotational alignment, individual tendon function, two-point discrimination when appropriate, and neurovascular status before and after splinting or reduction. Avoid forcing motion in a suspected unstable fracture or tendon injury. [3]

Neurologic Assessment

Evaluation of the peripheral nerves should focus on sensory and motor function.
Radial nerve sensation: dorsal thumb-index web space. Median nerve sensation: palmar index fingertip. Ulnar nerve sensation: palmar aspect of the small finger.
Each individual digital nerve should be assessed independently by testing the radial and ulnar sides of each fingertip on the palmar aspect.
Radial motor function: thumb and wrist extension. Median/anterior interosseous function: thumb interphalangeal and index distal interphalangeal flexion (the “OK” sign). Ulnar motor function: finger abduction and adduction. Record pre- and postprocedure findings. [3]

Vascular Assessment

Grayish or white discoloration of the skin may indicate arterial interruption.
Venous blockage may yield a purple discoloration.
Capillary refill is a quick way to assess circulation. Pressing down on the fingertip or nail bed produces a focal area of white discoloration that should return to a pink color within 2 seconds of release.
Palpate radial and ulnar pulses and compare temperature, color, capillary refill, and pulse oximetry waveform if available. Normal pulses alone do not exclude digital arterial injury. The Allen test is an adjunct when it can be performed reliably, not proof that an injured artery is safe to ignore. [3]

Specific Neuromuscular Assessment

Flexor digitorum profundus muscle: stabilize the proximal interphalangeal (PIP) joint and ask the patient to flex the distal interphalangeal (DIP) joint.
Flexor digitorum superficialis muscle: with the other fingers held in extension, ask the patient to flex the PIP joint against resistance.
Extensor pollicis longus: lay the hand flat on a table and raise only the thumb.
Interossei and lumbricals: assess finger abduction, adduction, and intrinsic hand function.
Carefully test each tendon before anesthetic infiltration whenever possible. Partial tendon injury may retain active motion; pain or weakness with resisted motion and catching should raise suspicion despite a small laceration. [3]

TESTING PEARLS

Radiographs should be ordered if there is a concern for fracture.
Plain films are the mainstay of the urgent care evaluation of hand and wrist injuries.
Obtain at least appropriate anteroposterior, lateral, and oblique views directed at the injured site. A true lateral view is particularly important for joint alignment and fracture-dislocations. Radiographs do not exclude tendon, nerve, or ligament injury. [1]
When initial radiographs are negative or equivocal but clinical suspicion for a fracture remains, appropriate next steps include immobilization and specialist-directed MRI, CT, or repeat radiographs in 10–14 days. Suspected scaphoid fracture benefits from an expedited definitive imaging pathway. [1,8]
Electrodiagnostic testing is not typically performed in urgent care. For carpal tunnel syndrome, a structured clinical assessment such as the CTS-6 can support diagnosis without routinely obtaining electromyography or nerve-conduction studies. [2]

Table 1. Urgent care examination and initial testing

Finding or concern	Urgent care action
Focal bony tenderness or deformity	Obtain site-specific radiographs; immobilize before transfer when unstable.
Anatomic snuffbox/scaphoid tubercle tenderness	Immobilize and arrange early MRI/CT or specialist assessment even if initial films are normal.
Loss of active DIP/PIP motion or painful weakness	Assess each flexor/extensor tendon; splint and refer promptly for suspected tear.
Altered perfusion, progressive numbness or severe pain	Check neurovascular status and transfer emergently.
Puncture, bite, injection or infected flexor sheath	Assess wound and deep-structure involvement; escalate when joint/tendon/deep infection is possible.

DIAGNOSIS PEARLS

Nail Bed and Fingertip Injuries

Fingertip injuries are among the most common hand injuries.
Typical mechanisms are crush injuries in a car door and work-related machine or tool injuries.
Particular attention must be given to preserving the integrity of the nail bed and matrix as well as sensation to the finger pulp.
Assess nail plate position and integrity, subungual hematoma, nail-fold disruption, distal sensation, and possible distal phalanx fracture. Obtain radiographs for major crush injuries or suspected fracture. [4,5]
An intact, adherent nail with a painful uncomplicated subungual hematoma can generally be treated by trephination; routine nail removal is unnecessary. A disrupted nail plate or significant nail-bed laceration may require repair or hand-surgery referral. A clean uncomplicated repair does not automatically require oral antibiotics. [4,5]

Bite Wounds

In general, human bites occur on a clenched fist after a fight.
Animal bites commonly occur on the fingers of the dominant hand. Dog bites are the most common, followed by cat bites.
The digit should be examined in both flexion and extension.
The depth and age of the wound should be determined.
Sensation and tendon function should be assessed.
For any dorsal metacarpophalangeal laceration following a fight, presume possible joint or extensor-tendon penetration until definitively evaluated. Examine in the clenched-fist position as tolerated, obtain radiographs for suspected retained tooth or fracture, irrigate, cover, and arrange urgent hand-surgery/ED evaluation. [3,6]
For animal bites, assess joint or tendon involvement, rabies exposure, tetanus status, and indications for antimicrobial prophylaxis. Routine wound cultures are not useful in an uninfected bite; culture exudate if infection is present. [6,7]

Carpal Tunnel Syndrome

Carpal tunnel syndrome is the most common compression syndrome at the wrist.
Patients report numbness along the median nerve distribution, including the thumb, index, long finger, and half of the ring finger.
Clumsiness and grip weakness are also common.
The hand should be inspected for signs of atrophy or atrophy seen in a late stage over the thenar eminence.
Phalen and Tinel maneuvers are supportive, but no single provocative test establishes the diagnosis. The CTS-6 combines symptoms and examination findings. MRI is not routinely indicated; electrodiagnostic testing can be reserved for selected uncertain cases or specialist planning. [2]

De Quervain Tenosynovitis

Symptoms include inflammation, irritation, and swelling of the sheath that surrounds the abductor pollicis longus and the extensor pollicis brevis.
Typically patients report pain with active thumb abduction and extension against resistance.
Examination reveals swelling and tenderness over the first dorsal compartment.
Finkelstein or related thumb-provocation maneuvers may reproduce pain, but avoid unnecessary force. This is primarily a clinical diagnosis; radiographs are useful when bony pathology is suspected. [11]

Fingertip Infections

Infections of the fingertip typically occur in two locations: the pulp (felon) of the finger and the tissue surrounding the fingernail (paronychia).
The presence of a fluid-filled vesicle may indicate herpetic whitlow.
Distinguish early cellulitis from fluctuance indicating an abscess. Acute paronychia with a drainable abscess and felon with pulp-space abscess may require drainage; herpetic whitlow must not be incised. Redness, marked pain, impaired motion, and systemic illness raise concern for deeper infection. [3]

Flexor Tendon Injuries

Lacerations of the palmar surface of the hand may result in injury to the flexor tendons.
Each finger is supplied with two flexor tendons, the flexor digitorum profundus and the flexor digitorum superficialis.
Partial ruptures can be easily missed, and careful testing of each tendon is important.
Suspected tendon laceration requires wound protection, a carefully positioned splint, and prompt hand-surgery consultation, preferably within 24 hours for complete loss of function or an open deep injury. Avoid blind exploration and do not defer potentially repairable injuries to routine one-week review. [3]

Flexor Tendon Sheath Infections (Flexor Tenosynovitis)

Signs of flexor tenosynovitis (Kanavel signs) include fusiform swelling of the digit, tenderness along the tendon sheath, increased pain on passive extension, and flexed position of the finger at rest.
Not all four signs are present early; absence of fever or a normal white blood cell count does not exclude pyogenic flexor tenosynovitis. If suspected, arrange same-day emergency hand-surgery/ED evaluation. Antibiotics alone with delayed follow-up are not an adequate urgent care disposition. [3,12]

Fractures of the Metacarpals and Phalanges

Metacarpal and phalangeal fractures are common injuries in adults.
The finger should be examined in flexion and extension to detect rotational alignment.
Ligamentous stability and tendon integrity should be assessed.
Radiographs should include views sufficient to assess angulation, shortening, intra-articular extension, and rotation. Rotational deformity is unacceptable even when radiographic displacement is modest. Open, unstable, displaced intra-articular, or markedly rotated fractures require prompt hand referral. [3]

Proximal and Middle Phalangeal Fractures

There may be rotational malalignment even in minimally displaced fractures.
It is imperative to obtain a perfect lateral x-ray of the injured joint.

Figure 1. Comminuted middle phalangeal fracture. Original image courtesy of Scott M. Zimmer, MD.

Boxer’s Fracture

A boxer’s fracture is a fracture of the distal metaphysis of the fifth metacarpal that results from a closed fist striking an object.
Assessment of the overlying skin is essential because a fracture after punching a person may also represent a human bite. Splint stable closed fractures with acceptable alignment and arrange hand follow-up; the tolerable neck angulation varies by digit, function, and specialist protocol. Rotation warrants urgent referral. [3,6]

Mallet Finger

Mallet finger is a deformity caused by rupture, laceration, or avulsion of the insertion of the extensor tendon at the base of the distal phalanx.
Patients often report pain and an inability to actively extend the DIP joint.
A lateral radiograph will reveal a small bony avulsion in some instances (bony mallet), whereas findings for most x-rays are negative.

For a closed, stable mallet injury, continuously immobilize the DIP joint in full extension or slight hyperextension for 6–8 weeks while leaving the PIP free. If the DIP flexes during cleaning, the treatment clock may need to restart. Large articular avulsion, volar subluxation, open injury, or inability to maintain alignment requires hand-surgery assessment. [3,9]

Fracture at the Base of the Thumb

A Bennett fracture is an oblique fracture of the base of the thumb where it enters the carpometacarpal joint.
A Rolando fracture is a Y-shaped intra-articular fracture at the base of the thumb.
Both are potentially unstable intra-articular injuries. Place in a thumb-spica splint, assess rotation and sensation, and arrange urgent hand-surgery review; do not attempt definitive treatment on radiographic angulation alone. [3]

Gamekeeper’s Thumb

Gamekeeper’s thumb is an injury to the ulnar collateral ligament at the metacarpophalangeal joint of the thumb.
Tenderness at the base of the thumb is a key sign, but it is difficult to assess instability acutely.
A complete tear or Stener lesion can require repair. Obtain radiographs for avulsion and immobilize in a thumb spica; avoid repeated forceful valgus stress and arrange early hand-surgery consultation when instability is suspected. [3]

Carpal Fractures and Scaphoid Injury

Scaphoid fractures are common after a fall on an outstretched hand, with tenderness at the anatomic snuffbox or scaphoid tubercle. Plain films may be negative despite fracture. [1,8]

Figure 3. Scaphoid wrist fracture. Original image courtesy of Scott M. Zimmer, MD.

Immobilize suspected injuries despite negative initial radiographs and arrange early MRI or CT through a specialist pathway. Repeat films at 10–14 days remain an alternative when advanced imaging is not promptly available, but routine delay without a plan risks missed fracture. [1,8]
Hook-of-hamate, triquetral, and other carpal fractures may require dedicated radiographs or CT when the mechanism and examination warrant it. Evaluate for associated nerve symptoms. [1]

Fracture of the Distal Radius

Fractures of the distal radius are among the most common fracture types in adults.
A Colles fracture results in a dorsally displaced fracture fragment, whereas a Smith fracture results in the fragment being tilted downward.
Patients usually report pain, tenderness, and swelling with deformity of the wrist after falling on an outstretched hand.
The presence of swelling deformity and any open wounds should be assessed.
Sensation in the hand should be tested.
Circulation to the fingertips must be checked.
Obtain wrist-centered anteroposterior and lateral radiographs. An unstable appearance, marked deformity, open injury, acute median nerve symptoms, or vascular compromise requires urgent evaluation. Splint with adequate swelling room. [1,9]
For adults younger than 65 years, AAOS/ASSH guidance supports consideration of fixation for post-reduction shortening >3 mm, dorsal tilt >10°, or intra-articular displacement/step-off >2 mm; these are specialist decision aids rather than urgent care reduction targets. In older adults, the absence of long-term functional benefit from routine fixation supports individualized decisions. [9]

High-Pressure Injection Injuries

These are devastating.
Generally goes from the finger into the deep spaces of the hand.
Can rapidly progress.
Possibly innocuous-looking wound at first.
Represents a surgical emergency, just as an open fracture does.
Immediately arrange EMS/ED transfer for hand-surgery evaluation. Do not incise the wound, attempt to express the material, or await worsening swelling. Document injected substance, estimated pressure, entry site, time, pain, sensation, and perfusion. Give appropriate analgesia, tetanus prophylaxis when indicated, and keep the patient NPO pending emergency assessment. [10]

Carpal and Radiocarpal Dislocation

Usually a result of high-energy injuries.
Potential for associated compartment syndrome and median nerve symptoms.
Evaluate carpal alignment on true lateral radiographs. Suspected perilunate/lunate, radiocarpal, or complex carpometacarpal dislocation requires immediate ED/hand-surgery evaluation and appropriate immobilization, even if the initial films are subtle. [1,3]

Figure 4. Dorsal radiocarpal dislocation. Original image courtesy of Scott M. Zimmer, MD.

Phalangeal and Carpometacarpal Dislocations

Simple, closed interphalangeal dislocations may be reduced by a suitably trained clinician after evaluation for fracture, tendon injury, and neurovascular compromise; obtain post-reduction films and reassess stability and function. Open, irreducible, unstable, or fracture-dislocations require specialist care. [3,5]
Avoid forceful traction on complex metacarpophalangeal dislocations because volar plate entrapment can prevent closed reduction and worsen injury. [3]

Figure 5. Dorsal dislocation of the fourth and fifth carpometacarpal joints. Original image courtesy of Scott M. Zimmer, MD.