What are the steps for a right wrist exam and initial management?

Right Wrist Examination and Initial Management

The right wrist examination should begin with radiographs as the standard initial imaging study, followed by a systematic physical examination including inspection, palpation, range of motion testing, and special provocative tests to identify the specific cause of wrist pain. 1, 2

Physical Examination Components

Inspection

• Observe for swelling, erythema, deformity, muscle atrophy, and skin changes
• Compare symmetry with the contralateral wrist
• Note any visible masses or abnormal alignment

Palpation

• Systematically palpate bony landmarks:
  • Distal radius and ulna
  • Scaphoid (anatomical snuffbox)
  • Lunate
  • Triquetrum
  • Pisiform
  • Trapezium, trapezoid, capitate, and hamate
  • Metacarpal bases
• Palpate soft tissue structures:
  • Extensor and flexor tendons
  • Triangular fibrocartilage complex (TFCC)
  • Distal radioulnar joint (DRUJ)
  • Carpal tunnel

Range of Motion Testing

• Active and passive motion in:
  • Flexion and extension
  • Radial and ulnar deviation
  • Pronation and supination
• Compare with contralateral side
• Note any pain, crepitus, or limitations

Special Tests

• Scaphoid pathology: Watson's test (scaphoid shift test)
• TFCC tears: Ulnar fovea sign, piano key test
• Carpal instability: Lunotriquetral shear test, midcarpal shift test
• De Quervain's tenosynovitis: Finkelstein's test
• Carpal tunnel syndrome: Tinel's sign, Phalen's test
• Distal radioulnar joint instability: Piano key test, supination lift test

Initial Imaging

• Standard radiographic examination should include:
  • Posterior-anterior view (neutral position)
  • Lateral view
  • Oblique view 1
  • Consider additional scaphoid view (PA in ulnar deviation) if scaphoid pathology suspected 2

Initial Management Algorithm

1. For suspected fracture with normal radiographs:

   • Immobilize in a splint or cast for 10-14 days
   • If symptoms persist, obtain MRI without contrast (preferred) or CT without contrast 2
   • For suspected scaphoid fracture, use thumb spica cast and follow-up radiographs at 2 weeks 2

2. For suspected ligamentous injury or TFCC tear:

   • Initial conservative management with immobilization and NSAIDs
   • If symptoms persist >2 months, obtain MRI without contrast 1, 2

3. For suspected carpal tunnel syndrome:

   • Wrist splinting in neutral position
   • Consider NSAIDs for inflammation
   • If symptoms persist, obtain electrodiagnostic testing before considering steroid injection or surgery 3, 4

4. For suspected tendinopathy (e.g., De Quervain's):

   • Rest, ice, NSAIDs
   • Splinting
   • If symptoms persist, consider steroid injection 4

5. For persistent unexplained pain despite conservative treatment:

   • MRI without contrast is the preferred next study 1, 2
   • Consider CT without contrast for detailed evaluation of bony architecture 2

Common Pitfalls and Caveats

• Scaphoid fractures may be radiographically occult initially; maintain high suspicion with anatomical snuffbox tenderness 1, 4
• Avoid unnecessary repeat imaging if it will not change management 2
• A detailed history alone may lead to a specific diagnosis in approximately 70% of patients with wrist pain 5
• Ulnar-sided wrist pain is often more complex and may require specialized views or advanced imaging 1
• Consider systemic causes of wrist pain (inflammatory arthritis) when bilateral or multiple joint involvement 1

Remember that persistent symptoms despite appropriate initial management warrant further investigation with advanced imaging or specialist referral, particularly when the diagnosis remains unclear or when symptoms fail to improve with conservative measures 5, 6.