What is the initial outpatient management for a 26-year-old female presenting with left wrist pain?

Initial Outpatient Management of Left Wrist Pain in a 26-Year-Old Female

Begin with plain radiographs (posterior-anterior and lateral views) as the first-line imaging study, followed by a focused history and physical examination to guide further management. 1, 2

History Taking: Key Elements to Elicit

Onset and Mechanism

• Acute traumatic onset: Inquire about falls onto an outstretched hand, which commonly causes scaphoid fractures (the most frequently fractured carpal bone) 3
• Spontaneous or gradual onset: Consider carpal bone nonunion, avascular necrosis, or overuse tendinopathy 4, 3
• Repetitive loading activities: Ask about occupational or recreational activities involving repetitive wrist extension (cycling, typing, racquet sports) that may cause tendinopathy or nerve entrapment 4, 3

Pain Localization

• Radial-sided pain: Suggests scaphoid pathology, scapholunate ligament injury, or de Quervain tenosynovitis 1, 3
• Ulnar-sided pain: Consider TFCC tears, lunotriquetral ligament injury, or ulnar nerve entrapment 1, 3
• Dorsal wrist pain: May indicate ganglion cysts, ligament tears, or carpal instability 5

Associated Symptoms

• Numbness or paresthesias: Determine distribution (median nerve for carpal tunnel syndrome affecting thumb/index/middle fingers; ulnar nerve for fourth and fifth digits) 6, 3
• Weakness or grip difficulty: Suggests nerve compression or severe tendon pathology 7
• Morning stiffness and joint swelling: Raises concern for inflammatory arthritis 1

Functional Impact

• Document specific activities that provoke or relieve pain 4
• Assess impact on activities of daily living and work 4

Physical Examination: Systematic Approach

Inspection and Palpation

• Localize tenderness to specific anatomic structures through systematic palpation of the radial styloid, scaphoid (anatomic snuffbox), lunate, ulnar styloid, and TFCC 4, 3
• Assess for swelling, deformity, or visible masses 4

Special Tests

• Finkelstein test: For de Quervain tenosynovitis (radial-sided pain) 3
• Scaphoid compression test (grind test): For scaphoid pathology 4, 3
• Watson's test: For scapholunate instability 4
• Lunotriquetral shear test: For lunotriquetral ligament injury 4
• Phalen's and Tinel's tests: For carpal tunnel syndrome 7

Initial Imaging

Obtain standard radiographs (posterior-anterior and lateral views in neutral position, plus oblique views) as the first imaging study for all patients with wrist pain. 1, 2, 6

Radiographic Assessment

• Evaluate bone architecture, alignment, joint spaces, and soft tissues 2
• For suspected scaphoid fractures, add specialized views (posteroanterior in ulnar deviation, pronated oblique) as conventional radiography misses up to 30% of scaphoid fractures 3

Initial Conservative Management

Immobilization

• Apply wrist splint for suspected fractures, tendinopathy, or carpal tunnel syndrome pending definitive diagnosis 7
• For suspected scaphoid fracture with negative initial radiographs, immobilize and repeat radiographs in 10-14 days 3

Pharmacologic Management

Prescribe ibuprofen 400 mg every 4-6 hours as needed for pain relief (maximum 3200 mg daily), taken with meals or milk to minimize gastrointestinal complaints. 8

Activity Modification

• Advise avoidance of provocative activities and repetitive loading 4, 3

Advanced Imaging: When Radiographs Are Normal or Nonspecific

For Nonspecific or Persistent Pain

Order MRI without IV contrast as the next imaging study when radiographs are normal or show nonspecific findings. 1, 2

• MRI accurately depicts abnormalities of bones, bone marrow, cartilage, ligaments, TFCC, synovium, tendons, and neurovascular structures 5, 2

For Suspected Tendon Pathology

• Either ultrasound or MRI is appropriate for evaluating tendinopathy or tenosynovitis 2
• Ultrasound allows dynamic assessment and is useful for guiding therapeutic injections 1, 2

For Suspected Carpal Tunnel Syndrome

• Ultrasound or MRI can confirm median nerve compression when clinical diagnosis is uncertain 2, 6
• Ultrasound measurement of median nerve cross-sectional area is validated for diagnosis 6

For Suspected Scaphoid Fracture with Negative Radiographs

• MRI or bone scan can identify radiographically occult fractures 2, 3

For Radial-Sided Pain (Suspected Scapholunate Ligament Injury)

MRI without contrast is usually appropriate, though direct MR arthrography has higher sensitivity for complete and incomplete ligament tears. 1, 5

For Ulnar-Sided Pain (Suspected TFCC Tear)

• MRI is highly accurate for central disc tears 1
• MR arthrography or CT arthrography may be needed for peripheral TFCC tears 1

For Suspected Inflammatory Arthritis

Order MRI with IV contrast if inflammatory arthritis is suspected, as enhancing bone marrow edema (osteitis) is the best predictor of disease progression in early rheumatoid arthritis. 1

• Ultrasound with power Doppler can identify active synovitis and predict erosion progression 1

Common Pitfalls to Avoid

• Do not rely solely on initial radiographs for suspected scaphoid fractures—immobilize and obtain repeat imaging or advanced imaging if clinical suspicion remains high 3
• Do not order MRI as first-line imaging—radiographs must be obtained first to evaluate bone architecture and alignment 1, 2
• Do not delay referral for persistent symptoms—if conservative management fails after 3 weeks or diagnosis remains unclear despite appropriate imaging, refer to hand surgery or rheumatology 7, 9
• Ensure ultrasound is performed by experienced operators, as accuracy is highly operator-dependent 2