What is the best initial workup and management for unilateral wrist pain in an 18-year-old?

Initial Workup and Management for Unilateral Wrist Pain in an 18-Year-Old

Radiographs are the most appropriate initial imaging study for unilateral wrist pain in an 18-year-old, followed by targeted management based on clinical findings and radiographic results. 1

Initial Diagnostic Approach

First-Line Imaging

• Standard radiographs (3-view examination) should be obtained first:
  • Posterior-anterior view
  • Lateral view
  • Oblique view
  • Consider adding a fourth projection (semisupinated oblique) for better visualization of distal radius 2

Clinical Evaluation (Concurrent with Imaging)

• Localize pain through palpation of specific anatomic structures:

  • Radial-sided pain: Consider scaphoid injury, De Quervain's tenosynovitis
  • Ulnar-sided pain: Consider TFCC tears, ulnar impaction syndrome
  • Dorsal pain: Consider extensor tendon pathology, ganglion cysts
  • Volar pain: Consider carpal tunnel syndrome, flexor tendinopathy 3

• Perform targeted special tests based on suspected pathology:

  • Finkelstein's test for De Quervain's tenosynovitis
  • Scaphoid compression test (pain with axial loading of thumb)
  • Watson's test for scaphoid instability
  • TFCC load test (pain with ulnar deviation and axial loading)
  • Lunotriquetral shear test for lunotriquetral instability 3, 4

Management Algorithm Based on Initial Findings

If Radiographs Show Fracture:

1. Scaphoid fracture:

   • Immobilize in short arm thumb spica cast
   • Follow-up radiographs at 2 weeks
   • If displacement >1mm or unstable pattern: Consider surgical fixation 1, 2

2. Distal radius fracture:

   • Non-displaced: Cast immobilization for 4-6 weeks
   • Displaced: Consider reduction and surgical fixation if:
     • Coronally oriented fracture line
     • Die-punch depression
     • More than three articular fragments 2

If Radiographs Are Normal or Nonspecific:

1. With clinical suspicion of occult fracture:

   • Immobilize in splint or cast for 10-14 days
   • If symptoms persist, obtain MRI without contrast (preferred) or CT without contrast 1, 2

2. With clinical findings suggestive of soft tissue injury:

   • Initial conservative management with:
     • Rest, ice, compression, elevation
     • NSAIDs for pain and inflammation
     • Activity modification
     • Wrist splint for 2-4 weeks 2

3. With clinical suspicion of inflammatory condition:

   • Consider MRI without contrast if symptoms persist beyond 2-4 weeks of conservative treatment 1, 2

Advanced Imaging Indications (If Initial Management Fails)

• MRI without contrast is the preferred next study for:

  • Persistent symptoms >2 months despite conservative treatment
  • Suspected ligamentous injury or TFCC tear
  • Suspected occult fracture with negative follow-up radiographs
  • Suspected avascular necrosis (e.g., Kienböck's disease) 1, 2

• CT without contrast is preferred for:

  • Detailed evaluation of bony architecture
  • Suspected occult fracture when MRI is contraindicated
  • Evaluation of fracture healing or malunion 1

• Ultrasound may be useful for:

  • Suspected ganglion cyst
  • Tendon pathology (e.g., De Quervain's tenosynovitis)
  • Guiding therapeutic injections 1, 2

Common Pitfalls to Avoid

• Assuming negative radiographs rule out significant pathology - up to 70% of scaphoid fractures may be radiographically occult initially 2

• Prolonged conservative management without definitive diagnosis - can lead to delayed treatment and chronic pain 2

• Failure to consider age-appropriate diagnoses - in an 18-year-old, consider sports injuries, overuse syndromes, and growth plate injuries rather than degenerative conditions 5

• Relying solely on imaging without correlation to clinical findings - a detailed history and physical examination can lead to a specific diagnosis in approximately 70% of patients with wrist pain 3

By following this systematic approach to the evaluation and management of unilateral wrist pain in an 18-year-old, clinicians can efficiently diagnose and treat the underlying condition while avoiding unnecessary testing or treatment delays.