What is the next best step in managing a patient with RA and persistent right wrist pain unresponsive to conservative measures?

Management of Persistent Wrist Pain in a Patient with Rheumatoid Arthritis

For a patient with RA and persistent right wrist pain that is worse after working as a waitress, who has failed activity modification, thumb spica splint, and glucocorticoid injection, and presents with marked pain on the radial aspect of the wrist when the thumb is fully flexed, the next best step is to obtain an MRI of the wrist without IV contrast.

Diagnostic Considerations

The clinical presentation suggests De Quervain's tenosynovitis or other inflammatory tendon pathology that has been resistant to first-line treatments. The key findings supporting this include:

• Pain localized to the radial aspect of the wrist
• Pain exacerbated when the thumb is fully flexed (positive Finkelstein's test)
• Occupational risk factor (waitressing involves repetitive wrist movements)
• Underlying RA, which increases risk of tenosynovitis
• Failed response to conservative measures

Imaging Selection Rationale

According to the ACR Appropriateness Criteria for chronic wrist pain:

1. When radiographs are normal or nonspecific and there is concern for tendon injury, tenosynovitis, or tendon pathology, MRI without IV contrast or ultrasound are both usually appropriate next imaging studies 1.

2. For patients with suspected inflammatory arthritis, MRI is the recommended next study after routine radiographs 1.

3. The contrast resolution of MRI makes it ideal to assess soft tissue abnormalities in the hand and wrist, including tendinopathy, tendon tear, and tenosynovitis 1.

Management Algorithm

1. Imaging:

   • Obtain MRI of the wrist without IV contrast to evaluate for:
     • Extent of tenosynovitis
     • Tendon damage or tears
     • Degree of synovitis in the wrist joints
     • Presence of erosions not visible on plain radiographs

2. Based on MRI findings:

   • If significant tenosynovitis: Consider surgical release (particularly for De Quervain's tenosynovitis resistant to conservative treatment)
   • If significant active RA synovitis: Optimize DMARD therapy

3. DMARD Optimization:

   • Review current RA medication regimen
   • If not on optimal therapy, adjust according to EULAR recommendations:
     • Methotrexate should be part of the first treatment strategy 1
     • If treatment target is not achieved with the first DMARD strategy, consider adding a biologic DMARD 1
     • For difficult-to-treat RA, assess for comorbidities that may mimic or exacerbate symptoms 1

4. Non-pharmacological Interventions:

   • Occupational therapy referral for:
     • Joint protection techniques 1
     • Assistive devices specific to waitressing tasks 1
     • Proper splinting (consider custom-made rather than off-the-shelf) 1

Evidence-Based Considerations

The EULAR recommendations for hand osteoarthritis (which can be applied to mechanical wrist pain components) suggest that when splinting and injections have failed, surgical options should be considered for patients with severe thumb base pain when conservative treatments have failed 1.

For patients with RA and persistent localized symptoms despite systemic treatment, the ACR guideline recommends:

• Use of splinting, orthoses, and/or compression for hand/wrist involvement 1
• Referral to occupational therapy or physical therapy 1

Common Pitfalls to Avoid

1. Misattributing all symptoms to RA: The patient's symptoms may represent a separate mechanical issue (like De Quervain's tenosynovitis) that requires specific treatment beyond RA management.

2. Continuing ineffective treatments: The patient has already failed three conservative approaches (activity modification, splinting, and injection), making it important to progress to more definitive diagnosis and treatment.

3. Overlooking occupational factors: The patient's work as a waitress involves repetitive wrist movements that may be contributing to the condition and require specific ergonomic interventions.

4. Focusing only on pharmacological management: While DMARD optimization is important, addressing biomechanical factors through proper splinting, ergonomic modifications, and potentially surgical intervention may be necessary for symptom relief.

By obtaining an MRI to clarify the diagnosis and extent of pathology, you can determine whether surgical intervention is needed or if further optimization of medical therapy and occupational modifications would be more appropriate.