Management of Wrist Pain with Lateral Deviation
Start with plain radiographs (PA, lateral, and oblique views) as your initial imaging study, then proceed with a systematic anatomic examination focusing on the ulnar side of the wrist where lateral deviation pain typically originates 1.
Initial Diagnostic Approach
Imaging Strategy
Begin with standard three-view wrist radiographs—this is the only appropriate first imaging study and may be sufficient to establish your diagnosis 1. The radiographs assess:
- Ulnar variance and alignment
- Joint spaces and impaction syndromes
- Static instability patterns
- Soft tissue swelling and mineralization
Do not order MRI, CT, bone scan, or any arthrography as your initial imaging—there is no evidence supporting these as first-line studies 1.
Physical Examination Focus
Pain with lateral deviation (ulnar deviation) points to specific anatomic structures on the ulnar side of the wrist. Your examination should systematically evaluate:
Key provocative maneuvers:
- Triquetrohamate (TH) joint palpation with passive dorsiflexion and ulnar deviation - THIS (triquetrohamate impaction syndrome) is frequently missed and accounts for ulnar-sided pain, especially in athletes performing two-handed sports 2
- Piano key test - for distal radioulnar joint (DRUJ) instability 3
- Ulnar impaction test - ulnocarpal abutment
- Shuck test - TFCC integrity
- Foveal stress test - TFCC foveal attachment
- ECU synergy test - extensor carpi ulnaris pathology 3
Common Diagnostic Pitfalls
Critical warning: TFCC injury and ECU tendinopathy account for over 50% of misdiagnoses in ulnar-sided wrist pain 2. The delay in correct diagnosis averages more than 7 months 2. Don't reflexively diagnose TFCC tears—be systematic.
Use the "storey concept" for anatomic localization (using the ulnar styloid as your reference point) 4:
- Lower storey: DRUJ pathology
- Intermediate storey: Radiocarpal joint (TFCC, ulnar impaction)
- Upper storey: Midcarpal and carpometacarpal joints (TH impaction, lunotriquetral instability)
Next Steps After Normal or Nonspecific Radiographs
If radiographs are normal or show only nonspecific arthritis and pain persists:
Consider diagnostic injection under fluoroscopy: Instill lidocaine into the suspected joint (e.g., TH joint with wrist in radial deviation) to confirm the pain source 2.
Advanced imaging options (order through hand surgery consultation):
- Ultrasound is useful for superficial structures (tendons, ligaments) and allows dynamic examination 1
- MRI without contrast for soft tissue evaluation
- CT arthrography has 92-94% sensitivity for TFCC tears and 80-100% for intrinsic ligament tears, particularly useful for scapholunate instability 1
Treatment Algorithm
Conservative Management (First-line)
- Wrist splinting in neutral position
- Activity modification (especially two-handed sports)
- NSAIDs
- Physical therapy focusing on strengthening
Success rate: Approximately 50% of patients respond to conservative treatment 2.
Surgical Intervention
Reserved for failed conservative management (typically after 3-6 months). Surgical options depend on specific diagnosis but achieve approximately 80% return to full activities without limitation 2.
Sport-Specific Considerations
Two-handed sports (golf, baseball) are responsible for >60% of TH impaction cases, and these uniquely involve the lead (nondominant) hand with pain at impact 2. If your patient fits this profile, TH impaction should be high on your differential even with normal radiographs.