What is the treatment and severity of chronic wrist pain?

Treatment and Severity of Chronic Wrist Pain

Chronic wrist pain requires diagnostic imaging followed by targeted treatment based on the underlying cause, with MRI being the recommended first-line advanced imaging when radiographs are normal or nonspecific. 1

Diagnostic Approach

• Radiographs are the most appropriate initial imaging study for evaluating chronic wrist pain, as they can establish specific diagnoses including arthritis, complications of injury, infection, bone tumors, impaction syndromes, and static wrist instability 2
• Standard radiographic examination should include posterior-anterior and lateral views in neutral position, supplemented by one or more oblique views 2
• When radiographs are normal or nonspecific, MRI is the recommended next study as it accurately depicts abnormalities of bones, bone marrow, articular cartilage, ligaments, TFCC, synovium, tendons, and neurovascular structures 1, 3
• A dedicated receiver coil or transmit-receive coil is necessary for high-resolution MRI of the wrist 3
• MRI performed with a 3.0 T magnet provides better signal-to-noise ratio and better contrast compared with 1.5 T or lower field strength systems 3

Differential Diagnosis Based on Location

• Radial-sided wrist pain: De Quervain tenosynovitis, scapholunate ligament tears 2, 3
• Ulnar-sided wrist pain: Distal radioulnar joint subluxation, triangular fibrocartilage complex (TFCC) tears 2, 3
• Central wrist pain: Ganglion cysts, Kienböck disease (avascular necrosis of the lunate) 2

Advanced Imaging Options

• MR arthrography (with contrast injection) has higher sensitivity than non-contrast-enhanced MRI for diagnosis of complete and incomplete scapholunate and lunotriquetral ligament tears 3, 1
• CT arthrography may be more sensitive for tears of the biomechanically important dorsal ligament fibers compared to conventional MRI 1
• Ultrasound is useful for examining extra-articular soft tissues, such as suspected ganglion cysts, and for diagnosing abnormalities of flexor and extensor tendons 2, 3
• CT is preferred for suspected distal radioulnar joint subluxation, where images of both wrists can be obtained in both supination and pronation 2, 3

Treatment Options

Pharmacological Management

• NSAIDs such as naproxen are effective for pain management in various wrist conditions 4
• Naproxen has been shown to be effective in controlling disease activity in conditions like rheumatoid arthritis, osteoarthritis, tendonitis and bursitis 4
• NSAIDs should be used at the lowest effective dose for the shortest duration possible due to potential side effects including gastrointestinal bleeding and cardiovascular risks 4
• For inflammatory arthritis, pharmacological treatment according to rheumatology guidelines is recommended 2

Non-Pharmacological Management

• Physical activity and exercise are recommended for both osteoarthritis and inflammatory arthritis 2
• Consider orthotics (splints, braces) if pain impedes functioning 2
• For specific conditions like ganglion cysts, follow-up with repeat MRI at least every 6 months until resolution is recommended for patients with persistent symptoms 5

Severity Assessment and Prognosis

• When diagnosis is delayed, some wrist pathologies can lead to relatively poor outcomes, such as scaphoid fracture nonunion resulting in diffuse wrist osteoarthritis 6
• Chronic wrist pain can be functionally limiting and is best managed with timely diagnosis and treatment 6
• The complex anatomy of the wrist leads to a broad differential diagnosis, making proper assessment crucial 6, 7
• A definite diagnosis can be established in approximately 70% of cases with careful history taking, thorough physical examination, and simple imaging techniques 8, 9

Common Pitfalls and Caveats

• Conventional arthrography alone is usually not appropriate and has largely been supplanted by CT arthrography, MRI, and MR arthrography 3
• Bone scintigraphy, while sensitive to bone abnormalities, suffers from a lack of specificity and cannot detect soft-tissue abnormalities 3
• NSAIDs should never be used right before or after coronary artery bypass graft surgery and should be used with caution in patients with cardiovascular disease, as they increase the chance of heart attack and stroke 4
• NSAIDs can cause ulcers and bleeding in the stomach and intestines at any time during treatment, with increased risk in older adults, those taking corticosteroids or anticoagulants, and those with longer duration of use 4