From the Guidelines
The workup for chronic left wrist pain should begin with a thorough history and physical examination, followed by initial imaging with plain radiographs (X-rays) in multiple views to evaluate for fractures, arthritis, or other bony abnormalities, as recommended by the most recent guidelines 1. The initial evaluation should focus on the onset, duration, and exacerbating factors of the pain.
- Key aspects of the history include:
- Trauma or injury
- Repetitive strain
- Systemic symptoms such as fever or weight loss
- Physical examination should assess:
- Range of motion
- Tenderness
- Swelling
- Neurological function
If X-rays are inconclusive, advanced imaging such as MRI is recommended to assess soft tissue structures including ligaments, tendons, and cartilage, as suggested by recent studies 1.
- MRI without IV contrast is usually appropriate as the next imaging study for chronic wrist pain following normal radiographs or radiographs remarkable for nonspecific arthritis.
- Ultrasound can be useful for dynamic assessment of tendon pathology. Laboratory tests including ESR, CRP, rheumatoid factor, and anti-CCP antibodies should be considered if inflammatory arthritis is suspected.
- Conservative management typically includes NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 2-3 weeks, along with wrist immobilization using a splint, particularly at night and during aggravating activities.
- Physical therapy focusing on strengthening and range of motion exercises is beneficial. For persistent pain, a corticosteroid injection (such as methylprednisolone 40mg with lidocaine) may provide relief.
- If conservative measures fail after 6-8 weeks, referral to a hand specialist is warranted to consider surgical options. The wrist contains multiple small bones, ligaments, and tendons that can be sources of chronic pain, making accurate diagnosis crucial for effective treatment, as emphasized by recent guidelines 1.
From the Research
Diagnostic Approach
The appropriate workup for chronic left wrist pain involves a thorough history and physical examination, as well as various imaging techniques 2, 3, 4. A systematic evaluation of the patient is necessary to determine the cause of the wrist pain and formulate an effective therapeutic plan 4.
Imaging Techniques
Imaging techniques such as standard radiography, computed tomography, magnetic resonance imaging, and radionuclide imaging may be essential in the evaluation of chronic wrist pain 2, 5, 6. However, the majority of additional imaging may be classified as unnecessary, with the exception of a few cases where CT scans or other imaging modalities may be highly valuable 5.
Clinical Assessment
Clinical assessment and X-rays are typically sufficient for a hand specialist to diagnose and manage chronic wrist pain, and few patients require additional imaging 5. A structured approach to diagnosis and management, including a thorough history, physical examination, and simple imaging techniques, can establish a diagnosis in a significant proportion of cases 6.
Key Considerations
- A thorough history and physical examination are key to diagnosing chronic wrist pain 2, 3, 4
- Imaging techniques should be used judiciously, with consideration of the potential benefits and limitations of each modality 2, 5, 6
- A systematic evaluation of the patient is necessary to determine the cause of the wrist pain and formulate an effective therapeutic plan 4
- Clinical assessment and X-rays are often sufficient for diagnosis and management, with additional imaging reserved for select cases 5