In an adult with acute dorsal wrist pain, swelling and clicking, and no fracture or neurologic deficit, how should I perform and interpret a Tinel sign to evaluate for median or ulnar nerve involvement?

Tinel Sign for Median and Ulnar Nerve Evaluation in Acute Dorsal Wrist Trauma

In an adult with acute dorsal wrist pain, swelling, and clicking without fracture or neurologic deficit, perform Tinel sign by gently tapping over the median nerve at the carpal tunnel (volar wrist) and ulnar nerve at Guyon's canal (ulnar volar wrist) using controlled fingertip percussion—a positive test produces tingling or paresthesias in the nerve distribution, suggesting nerve irritation or compression, though this finding has limited diagnostic value in acute trauma without pre-existing neurologic symptoms.

How to Perform Tinel Sign Correctly

Technique and Force Control

• Use gentle fingertip tapping over the nerve site with controlled, standardized force to avoid false-positive results 1
• Overzealous tapping can produce a false-positive "percussion test" rather than a true Tinel sign, so adhere to threshold force limits 1
• The test should be performed with the patient's hand positioned comfortably, typically on the examining table 2

Anatomical Locations for Wrist Evaluation

• For median nerve: Tap over the volar aspect of the wrist at the carpal tunnel (between the flexor tendons) 2
• For ulnar nerve: Tap over the ulnar volar wrist at Guyon's canal 3
• Note that your patient has dorsal wrist pain, so median nerve compression at the carpal tunnel or ulnar nerve involvement would be unusual anatomically unless there is associated volar pathology

Interpretation of Results

Positive Tinel Sign

• A positive test produces tingling or paresthesias radiating into the distribution of the tapped nerve 4, 3
• For median nerve: tingling in thumb, index, middle, and radial half of ring finger
• For ulnar nerve: tingling in little finger and ulnar half of ring finger

Clinical Significance in Your Scenario

• Tinel sign is primarily used for diagnosing compression neuropathies (carpal tunnel syndrome, cubital tunnel syndrome) and evaluating regenerating nerves after injury 3, 5
• In acute trauma without pre-existing neurologic deficits, a positive Tinel sign would be unusual and might suggest:
  • Acute nerve contusion or stretch injury
  • Developing compartment syndrome (though this would present with other signs)
  • Pre-existing subclinical nerve compression unmasked by trauma

Diagnostic Accuracy Considerations

• The frequency of Tinel sign varies widely in literature, and its clinical value has remained controversial since introduction 4, 5
• In carpal tunnel syndrome studies, Tinel sign shows significant correlation with motor and sensory conduction velocity abnormalities (p < 0.05), with increased frequency when distal latencies exceed 4.5 ms 5
• Important caveat: Tinel sign only indicates nerve irritation or regeneration progress—it does not predict complete functional recovery 4

Clinical Algorithm for Your Patient

Step 1: Initial Assessment

• Given dorsal wrist pain with swelling and clicking, the primary concern is ligamentous injury (scapholunate or lunotriquetral ligament) or tendon pathology, not nerve compression 2
• Perform Tinel sign at both median and ulnar nerve locations as part of comprehensive neurovascular examination 2

Step 2: If Tinel Sign is Negative (Expected Finding)

• This is the expected result in acute dorsal wrist trauma without neurologic deficit
• Proceed with evaluation for ligamentous injury using appropriate imaging (MRI or ultrasound for soft tissue evaluation) 2, 6

Step 3: If Tinel Sign is Unexpectedly Positive

• Document the specific nerve distribution of paresthesias
• Consider that this may represent:
  • Incidental finding of pre-existing nerve compression
  • Acute nerve contusion from trauma mechanism
  • Need for more comprehensive neurovascular assessment
• Do not delay appropriate imaging for the primary complaint (dorsal wrist pain with clicking) 2, 7

Common Pitfalls to Avoid

• Do not use excessive force when tapping, as this produces false-positive percussion tests rather than true Tinel sign 1
• Do not interpret Tinel sign as predicting complete nerve recovery—it only signals nerve irritation or regeneration progress 4
• Do not focus solely on nerve testing when the clinical presentation (dorsal wrist pain, swelling, clicking) suggests ligamentous or tendon pathology as the primary problem 2
• Do not skip appropriate imaging based on negative Tinel sign—your patient needs evaluation for soft tissue injury given the clinical presentation 6, 7

Next Steps for This Patient

• Obtain three-view wrist radiographs (PA, lateral, 45° semipronated oblique) if not already done 7
• If radiographs negative and symptoms persist, proceed to MRI without IV contrast or high-frequency ultrasound to evaluate for ligamentous tears, tendon injuries, or occult fractures 2, 6
• The "clicking" suggests possible ligamentous instability or tendon subluxation, which requires soft tissue imaging for definitive diagnosis 2