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Wrist and hand red flags

What you cannot afford to miss in wrist and hand pain, before any special test.

Most wrist and hand pain is musculoskeletal. These are the conditions that are not, or that need referral before treatment, with the features that point to each. Every row carries its source, listed at the foot of the page.

Use with your local protocols. Referral pathways, and how urgently to act, differ between health services and countries: where your local protocol or current guideline differs, follow it. Never delay emergency care to check a protocol.

Can’t missWhat points to it
Scaphoid fracture1,2Tenderness in the anatomical snuffbox or over the scaphoid tubercle after a fall on the outstretched hand. The initial X-ray can be normal (in up to 1 in 4). The wrist should be immobilised in a splint or cast and follow-up imaging arranged, even when the initial film is normal.
Perilunate or lunate dislocation3High-energy wrist trauma with deformity, persistent pain, or new numbness or weakness in the hand. The injury is easily missed on a cursory reading of the X-ray, and a report of 'no fracture seen' does not complete the assessment. Send the patient to an emergency department now; new numbness or weakness in the hand makes this more urgent still.
Acute carpal tunnel syndrome after a fracture4Worsening pain, numbness or weakness in the median distribution after a wrist fracture or marked swelling. Unlike chronic carpal tunnel syndrome, this is an emergency that may require urgent decompression. Same-day referral is required.
Compartment syndrome of the forearm or hand5,6Pain out of proportion to the injury, aggravated by passive finger stretch, in a tense, swollen forearm or hand. When the small intrinsic compartments of the hand are involved, the fingers may rest with the knuckles extended and the finger joints flexed. A palpable pulse does not exclude the diagnosis. Send the patient to an emergency department now.
Septic wrist or flexor sheath infection7,8,9A hot, swollen, very painful wrist with restricted movement. Fever is often absent, so its absence does not exclude infection. A finger held in slight flexion, swollen along its whole length, tender along the flexor sheath and painful on passive extension indicates a surgical emergency: send the patient to an emergency department now. A suspected septic wrist needs same-day medical assessment.
Bite wounds and high-pressure injection injuries10,11,12A small laceration over a knuckle after the fist has struck another person's teeth (the mechanism should be asked about directly, as these wounds are often underestimated), any animal bite to the hand, or a high-pressure injection injury, however small and painless the entry wound. Bites need same-day surgical assessment rather than wound care alone; a high-pressure injection injury is a surgical emergency: send the patient to an emergency department now.
Tendon injuries requiring timely treatment13,14Loss of active flexion at a finger joint after a laceration on the palmar side of a finger, or sudden loss of fingertip flexion after a grabbing injury ('jersey finger'), requires hand surgery review within 24 hours. A mallet or boutonnière deformity that has not been splinted should not wait for a routine appointment.
Inflammatory arthritis15Symmetrical swelling and stiffness of the small joints with morning stiffness lasting more than an hour (rheumatoid pattern, with the fingertip joints usually spared), or fingertip-joint involvement with nail pitting or a sausage digit (psoriatic pattern). Referral for medical assessment and blood tests is indicated.
Tumour16,17Most lumps at the wrist are ganglia, but a mass that is enlarging, deep, firm, painful or larger than a golf ball (about 5 cm) requires imaging rather than reassurance. A personal history of cancer, unexplained weight loss or constant night pain raises the possibility of metastatic disease and warrants referral for prompt medical assessment.
Complex regional pain syndrome18Pain out of proportion to the injury, with asymmetry of temperature, colour, sweating or swelling that is not settling in the weeks after a fracture or operation. The condition responds far better to treatment when identified early, so the patient should be referred early rather than continuing through the pain.

A red flag raises suspicion; it does not make the diagnosis, and its absence does not rule the condition out. The table is not a complete list of every serious condition, and it is not a clinical protocol. When a red flag is present, act on the referral advice in the row, in line with your local protocols. This page is for registered health practitioners and students and is not clinical advice for patients; see the terms of use.

Last checked against the cited sources: 15 October 2026.

Then the tests: Wrist and hand special tests, with sensitivity, specificity and likelihood ratios.

Get the book for how to do and read each wrist and hand test with published figures, and which carpal tunnel test to trust

This table opens the chapter ‘The wrist and hand’ in Rule It In, Rule It Out. The book then works through the questions that matter in this region, with the published figures for each test and how to read them.

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Sources

  1. Hayat Z, Varacallo M. Scaphoid Wrist Fracture. StatPearls Publishing; updated August 4, 2023. Link
  2. 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. Link
  3. Frane N, Goldenberg WM. Perilunate Dislocation. StatPearls Publishing; updated 2023. Link
  4. Gillig JD, White SD, Rachel JN. Acute carpal tunnel syndrome: a review of current literature. Orthop Clin North Am. 2016;47(3):599–607. Link
  5. Chandraprakasam T, Ashok Kumar R. Acute compartment syndrome of forearm and hand. Indian J Plast Surg. 2011;44(2):212–218. Link
  6. Stavrakakis IM, Magarakis GE, Tosounidis TH. Hand compartment syndrome. In: Mirza SB, Elawady K, eds. A Comprehensive Review of Compartment Syndrome. London: IntechOpen; 2021. Link
  7. Earwood JS, Walker TR, Sue GJC. Septic arthritis: diagnosis and treatment. Am Fam Physician. 2021;104(6):589–597. Link
  8. Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478–1488. Link
  9. Hermena S, Tiwari V. Pyogenic Flexor Tenosynovitis. StatPearls Publishing; updated January 8, 2024. Link
  10. Malahias M, Jordan D, Hughes O, Khan WS, Hindocha S. Bite injuries to the hand: microbiology, virology and management. Open Orthop J. 2014;8:157–161. Link
  11. Raval P, Khan W, Haddad B, Mahapatra AN. Bite injuries to the hand - review of the literature. Open Orthop J. 2014;8:204–208. Link
  12. Pertea M, Luca S, Benamor M, et al. High-pressure injection injury of the hand: a rare but true surgical emergency. J Clin Med. 2025;14(1):72. Link
  13. British Society for Surgery of the Hand. Flexor Tendon Trauma Standards. Link
  14. Beutel BG, Binstead JT, Tafti D. Boutonniere Deformity. StatPearls Publishing; updated March 6, 2026. Link
  15. Mohammed RH, Bhutta BS. Hand and Wrist Rheumatoid Arthritis. StatPearls Publishing. Link
  16. Nandra R, Forsberg J, Grimer R. If your lump is bigger than a golf ball and growing, think Sarcoma. Eur J Surg Oncol. 2015;41(10):1400–1405. Link
  17. Coleman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res. 2006;12(20):6243s–6249s. Link
  18. Harden RN, Oaklander AL, Burton AW, et al. Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 4th Edition. Pain Med. 2013;14(2):180–229. Link

Red flags for other regions: Neck · Shoulder · Elbow · Thoracic spine and chest wall · Low back and pelvis · Hip and groin · Knee · Ankle and foot

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