What are the diagnostic tests and management options for chronic wrist pain that worsens with movement?

Diagnostic Approach for Chronic Wrist Pain with Movement Exacerbation

Radiographs are the most appropriate initial imaging study for evaluating chronic wrist pain that worsens with movement, as they can establish specific diagnoses in many cases including arthritis, complications of injury, infection, bone tumors, impaction syndromes, and static wrist instability. 1

Initial Imaging Evaluation

• Standard radiographic examination should include posterior-anterior and lateral views in neutral position and rotation, supplemented by one or more oblique views 1
• Lateral view is particularly important for demonstrating malalignments and soft-tissue swelling 1
• Stress positions and maneuvers can be performed during radiography to elicit dynamic instability not visible on standard radiographs 1

Differential Diagnosis Based on Location

Radial-Sided Wrist Pain

• Scaphoid fracture nonunion 2
• Thumb carpometacarpal joint osteoarthritis 2
• Scapholunate ligament instability 2
• De Quervain tenosynovitis (extra-articular) 1, 2

Ulnar-Sided Wrist Pain

• Triangular fibrocartilage complex (TFCC) injuries 2
• Extensor carpi ulnaris tendinopathy 2
• Distal radioulnar joint subluxation 1

Central Wrist Pain

• Carpal tunnel syndrome 2
• Ganglion cysts 1, 2
• Kienböck disease (avascular necrosis of the lunate) 1

Advanced Imaging Selection

MRI Without IV Contrast

• Usually appropriate as next study when radiographs are normal or nonspecific and soft tissue pathology is suspected 1
• Accurately depicts abnormalities of bones, bone marrow, articular cartilage, ligaments, TFCC, synovium, tendons, and neurovascular structures 1
• Requires dedicated receiver coil or transmit-receive coil for high-resolution imaging 1

MRI With IV Contrast

• Particularly useful when inflammatory arthritis is suspected 1
• Helps identify active synovitis, inflammatory tenosynovitis, and bone marrow edema (osteitis) 1
• Bone marrow edema on MRI in early rheumatoid arthritis is the best predictor of future disease progression 1

CT Scanning

• Preferred for suspected distal radioulnar joint subluxation, where images of both wrists can be obtained in both supination and pronation 1
• Provides high-resolution images of both wrists simultaneously with shorter acquisition times than MRI 1
• Less sensitive to soft-tissue abnormalities compared to MRI 1

Ultrasound

• Useful for examining extra-articular soft tissues, such as suspected ganglion cysts 1
• Effective for diagnosing abnormalities of flexor and extensor tendons and tendon sheaths 1
• Can identify erosions and active synovitis (with power Doppler) in rheumatoid arthritis 1
• Validated technique for measuring median nerve size in carpal tunnel syndrome 1

Laboratory Testing When Inflammatory Conditions Suspected

• Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) should be obtained for diagnosis and prognosis of undifferentiated peripheral inflammatory arthritis 3
• Rheumatoid Factor (RF) and Anti-Citrullinated Protein Antibodies (ACPA) testing is indicated as these are predictive of rheumatoid arthritis diagnosis 3
• Antinuclear antibody (ANA) testing should be considered if connective tissue disease is suspected 3
• HLA-B27 testing may be helpful when spondyloarthropathies are suspected 3
• Joint aspiration and synovial fluid analysis should be performed when there is joint effusion 3

Common Pitfalls to Avoid

• Overreliance on advanced imaging before specialist consultation - studies show 73% of pre-consultation advanced imaging (77% of MRIs and 100% of ultrasounds) may be unnecessary 4
• Clinical assessment and radiographs are typically sufficient for a hand specialist to diagnose and manage chronic wrist pain 4
• Overreliance on negative RF or ACPA results, as these can be negative in early rheumatoid arthritis 3
• Neglecting to repeat laboratory tests when clinically indicated, as serological markers may evolve over time 3
• Failing to consider both intra-articular and extra-articular causes of wrist pain 5

Management Approach

• For osteoarthritis: acetaminophen, nonsteroidal anti-inflammatory drugs, physical activity, and exercise 6
• For inflammatory arthritis: pharmacological treatment according to rheumatology guidelines, physical activity, and exercise 6
• Consider orthotics (splints, braces) if pain impedes functioning 6
• Timely diagnosis and treatment are essential as delayed diagnosis of some wrist pathologies (e.g., scaphoid fracture nonunion) can lead to poor outcomes 2