What is the management for a wrist bulge?

Management of Wrist Bulging

For wrist bulging, the recommended initial management is radiographic evaluation followed by appropriate treatment based on the underlying cause, with splinting being particularly effective for thumb base osteoarthritis. 1

Initial Evaluation

• Radiographs are the most appropriate first-line imaging study for any chronic wrist pain or bulging, as they can identify arthritis, fractures, bone tumors, and alignment abnormalities 1
• If radiographs are normal or inconclusive but symptoms persist, MRI without IV contrast is the next recommended imaging study to evaluate soft tissue abnormalities 1
• For suspected ganglion cysts (a common cause of wrist bulging), ultrasound is an appropriate alternative to MRI, with similar diagnostic accuracy 1

Management Based on Specific Diagnoses

For Osteoarthritis-Related Wrist Bulging:

1. Splinting/Orthoses

   • Splints are strongly recommended for thumb base osteoarthritis 1
   • Full splints covering both thumb base and wrist provide more pain relief than half splints (covering only thumb base) 1
   • Long-term use of orthoses is advocated for symptom relief 1

2. Topical Treatments

   • Topical NSAIDs are preferred as first-line pharmacological treatment due to safety considerations 1
   • Topical NSAIDs provide effective pain relief (ES = 0.77,95% CI 0.32 to 1.22) with fewer gastrointestinal side effects than oral NSAIDs 1
   • Topical capsaicin is also effective for hand osteoarthritis 1

3. Oral Medications

   • Oral NSAIDs should be considered for limited duration when topical treatments are insufficient 1
   • Chondroitin sulfate may be used for pain relief and improved functioning 1

For Inflammatory Conditions (e.g., Tenosynovitis with Rice Bodies):

• Synovectomy may be required for extensive tenosynovitis with rice bodies 2
• MRI can help identify rice bodies, which appear as inclusions within synovial tissue 2
• Surgical intervention can provide significant relief and functional improvement in cases of extensive synovitis 2

For Ganglion Cysts:

• Ultrasound or MRI without IV contrast can confirm diagnosis 1
• Aspiration may provide temporary relief 1
• Surgical excision is indicated for persistent symptomatic ganglion cysts 1

Physical Therapy Approaches

• Education and training in ergonomic principles should be offered to all patients 1
• Exercises to improve function and muscle strength should be considered for all patients 1
• Active finger motion exercises are recommended to prevent stiffness, particularly after immobilization 1

Emerging Therapies

• Sustained Acoustic Medicine (SAM) has shown promise as an add-on therapy for musculoskeletal injuries, with reported pain reduction and improved function 3
• Local application of heat may provide symptomatic relief, though direct research evidence for hand conditions is limited 1

Important Considerations and Pitfalls

• Avoid prolonged immobilization when possible, as it can lead to stiffness and reduced function 1
• When external fixation is used, limiting the duration of fixation is important to prevent complications 1
• Intra-articular glucocorticoid injections should generally not be used in hand osteoarthritis but may be considered for painful interphalangeal joints in specific cases 1
• Conventional or biological disease-modifying antirheumatic drugs are not recommended for hand osteoarthritis 1

Surgical Options

• Surgery should be considered when other treatment modalities have not been sufficiently effective in relieving pain 1
• For thumb base osteoarthritis, trapeziectomy should be considered 1
• For interphalangeal joint osteoarthritis, arthrodesis or arthroplasty may be appropriate 1

Remember that proper diagnosis of the underlying cause of wrist bulging is essential for determining the most appropriate treatment approach.