Treatment for Wrist Tenderness in a Young Adult
Begin with plain radiographs of the wrist as the initial diagnostic step, followed by conservative management with NSAIDs and activity modification if imaging is negative or shows only minor findings. 1
Initial Diagnostic Approach
Obtain plain radiographs first in all patients presenting with wrist tenderness, regardless of suspected diagnosis. 1 This is the standard of care recommended by the American College of Radiology for both acute trauma and chronic wrist pain scenarios.
- If radiographs are negative or equivocal and symptoms persist, proceed to advanced imaging with MRI without IV contrast, which can be obtained at 10-14 days after initial presentation. 1
- For dorsal wrist tenderness specifically, MRI is the preferred next study as it accurately depicts abnormalities of bones, bone marrow, articular cartilage, ligaments, tendons, and neurovascular structures. 2
Conservative Treatment Protocol
First-Line Pharmacologic Management
Topical NSAIDs are preferred over oral NSAIDs for localized wrist pain, particularly when only a few joints are affected and pain is mild to moderate. 1
- Topical NSAIDs provide equivalent pain relief to oral NSAIDs (effect size = -0.05,95% CI -0.27 to 0.17) but with significantly fewer gastrointestinal side effects (RR = 0.81,95% CI 0.43 to 1.56). 1
- If oral NSAIDs are needed, ibuprofen 400 mg every 4-6 hours is appropriate for mild to moderate pain, with a maximum daily dose of 3200 mg. 3
- Use the lowest effective dose for the shortest duration, and administer with meals or milk if gastrointestinal complaints occur. 3
Immobilization and Splinting
Wrist splinting may be appropriate for certain conditions causing wrist tenderness, though evidence is limited. 1, 4
- For thumb base involvement with wrist tenderness, full splints covering both the thumb base and wrist provide more pain relief than half splints (effect size = 0.64,95% CI 0.02 to 1.26). 1
- Avoid prolonged immobilization as it can lead to muscle deconditioning and potentially worsen symptoms. 5
Activity Modification
Rest from aggravating activities is essential, particularly if the tenderness is related to overuse or repetitive loading. 6, 7
- Intersection syndrome (tendinitis in the first and second dorsal compartments) responds to rest, ice, NSAIDs, and wrist splinting. 7
- Stenosing tenosynovitis of the flexor carpi radialis tendon, which causes radial-sided wrist tenderness, typically improves with conservative management before considering operative decompression. 8
When to Escalate Care
If symptoms persist despite 4-6 weeks of conservative management, consider:
- Advanced imaging with MR arthrography or CT arthrography, which have higher sensitivity than non-contrast MRI for ligament tears and cartilage defects. 1, 2
- Ultrasound evaluation can assess tendons, vascular structures, and measure median nerve size if carpal tunnel syndrome is suspected. 5, 2
- Referral to orthopedic specialist if all imaging is negative and clinically significant pain continues, as diagnostic arthrography or arthroscopy may be needed. 6
Critical Differential Diagnoses to Consider
In a young adult with wrist tenderness, consider:
- Avascular necrosis of the lunate (Kienböck's disease) if there is dorsal lunate tenderness and limited wrist motion, particularly after weight-bearing activities. 9
- Carpal bone nonunion or avascular necrosis if there is spontaneous onset or vague history of trauma with repetitive loading activities. 6
- Intersection syndrome if tenderness and crepitation occur several centimeters proximal to Lister's tubercle, especially in athletes involved in rowing, racket sports, or weight lifting. 7