What are the management options for wrist pain?

Management Options for Wrist Pain

Radiography is the most appropriate initial imaging study for evaluating chronic wrist pain, followed by MRI or ultrasound depending on the suspected underlying cause. 1

Initial Diagnostic Approach

• Radiography (X-ray) should be the first imaging study for all patients with chronic wrist pain to evaluate bone architecture, alignment, joint spaces, and soft tissues 1
• If radiographs are normal or show nonspecific findings, the next imaging study depends on the suspected underlying cause 1

Advanced Imaging Options Based on Clinical Suspicion

For Nonspecific Wrist Pain

• MRI without IV contrast or MR arthrography is usually appropriate as the next imaging study when radiographs are normal or show nonspecific arthritis 1
• MRI accurately depicts abnormalities of bones, bone marrow, articular cartilage, ligaments, TFCC, synovium, tendons, and neurovascular structures 1

For Suspected Tendon Pathology

• Either ultrasound or MRI without IV contrast is usually appropriate when there is concern for tendon injury, tenosynovitis, or tendon pathology 1
• Ultrasound is particularly useful for examining extra-articular soft tissues and can be used for dynamic assessment 1

For Suspected Carpal Tunnel Syndrome

• Ultrasound or MRI without IV contrast may be appropriate when clinical concern exists for carpal tunnel syndrome 1, 2
• Ultrasound measurement of median nerve size is a validated technique in patients with clinical symptoms of carpal tunnel syndrome 1

For Suspected Scaphoid Fracture or Osteonecrosis

• MRI without IV contrast or CT without IV contrast is usually appropriate when there is concern for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis 1
• MRI is highly sensitive to changes in bone marrow composition and can identify radiographically occult fractures 1

Treatment Options

Conservative Management

• NSAIDs such as naproxen can be used for pain management, but should be used at the lowest effective dose for the shortest duration due to risks of gastrointestinal bleeding and cardiovascular events 3
• Immobilization with orthotic devices for acute injuries, particularly those involving ligaments 4
• Structured rehabilitation programs including:
  • Scapholunate-stabilizing muscle strengthening 4
  • Proprioception training 4
  • Progressive wrist exercises 4

Interventional Options

• Intra-articular corticosteroid injections for inflammatory conditions 5
• Ultrasound-guided therapeutic injections for specific conditions 1

Surgical Management

• Reserved for cases that fail conservative management 5
• Particularly important for certain conditions where delayed treatment can result in long-term deformity or disability, such as scaphoid nonunion and Kienböck's disease 6
• For carpal tunnel syndrome, surgical decompression is the most effective treatment for moderate to severe cases 2

Common Pitfalls and Caveats

• Relying solely on radiographs may miss soft tissue pathologies that require advanced imaging 1
• Delayed diagnosis of certain conditions like scaphoid nonunion and Kienböck's disease can lead to long-term deformity or disability 6
• NSAIDs should be used cautiously, especially in elderly patients or those with gastrointestinal, cardiovascular, or renal risk factors 3
• When using MRI for wrist imaging, a dedicated receiver coil or transmit-receive coil is necessary to provide adequate signal-to-noise ratio 1
• Ultrasound accuracy is highly operator-dependent and should be performed by experienced sonographers 1