A patient who fell on their hands 1.5 months ago has normal wrist range of motion but experiences mild‑to‑moderate lateral wrist pain with heavy lifting or push‑ups. What evaluation and management steps are recommended?

Evaluation and Management of Lateral Wrist Pain After Fall

Start with plain radiographs (posteroanterior, lateral, and specialized views including posteroanterior in ulnar deviation and pronated oblique) to rule out occult fracture or nonunion, particularly of the scaphoid or other carpal bones, which can present with preserved range of motion but pain on loading activities 1.5 months post-injury 1.

Initial Clinical Assessment

Your examination should focus on:

• Localized palpation at the point of greatest pain on the lateral (radial) wrist—this has 94.3% sensitivity for identifying pathology 2, 3
• Pain with grip and supination testing—positive predictive values of 89.3% and 96% respectively for fracture 3
• Active and passive range of motion testing—pain during these maneuvers has the highest negative predictive values (90.9% and 89.5%) for ruling out fracture 3
• Assess for swelling and compare bilaterally—edema has a 95.2% positive predictive value for fracture 3
• Perform Finkelstein's test to evaluate for de Quervain tenosynovitis (common cause of radial-sided pain with loading activities) 4

Imaging Algorithm

Plain radiographs are the appropriate initial imaging study 1. The ACR Appropriateness Criteria explicitly designate radiography as the first-line modality for chronic hand and wrist pain.

Critical Pitfall

Conventional radiography alone misses up to 30% of scaphoid fractures 4. Given your patient's mechanism (fall on outstretched hand) and timing (6 weeks post-injury), an occult or nonunited scaphoid fracture remains a significant concern despite preserved range of motion.

If Initial Radiographs Are Negative

When clinical suspicion remains high (pain with loading, specific anatomic tenderness) but radiographs are normal:

• MRI without contrast is the next appropriate study to evaluate for:
  • Occult or healing fractures
  • Scaphoid nonunion
  • Avascular necrosis (particularly scaphoid or lunate)
  • Ligamentous injury
  • Tendinopathy (extensor carpi ulnaris, abductor pollicis longus/extensor pollicis brevis in de Quervain's) 1, 5

Management Based on Findings

If scaphoid fracture or nonunion is identified: Immediate orthopedic referral is warranted, as nonunion can lead to avascular necrosis and long-term disability affecting quality of life 4, 6.

If de Quervain tenosynovitis is confirmed: Initial conservative management with thumb spica splinting and activity modification, with consideration for corticosteroid injection if symptoms persist.

If ligamentous injury is identified: Referral to hand specialist for potential surgical intervention, as chronic instability significantly impacts functional outcomes.

Why This Approach Matters

Patients with spontaneous onset of pain or vague trauma history who perform repetitive loading activities are at risk for carpal bone nonunion or avascular necrosis 6. The 6-week timeframe places your patient in a critical window where an initially occult fracture may have failed to unite, and early intervention can prevent progression to avascular necrosis—a condition that severely impacts long-term wrist function and quality of life.

The preserved range of motion is reassuring but does not exclude significant pathology; pain specifically with loading activities (pushups, heavy lifting) suggests either incomplete fracture healing, ligamentous injury, or tendinopathy requiring definitive diagnosis 4, 3.