What is the initial evaluation and management for a patient presenting with wrist pain?

Initial Evaluation and Management of Wrist Pain

Begin with plain radiographs (posterior-anterior, lateral, and oblique views) as the first-line imaging study for any patient presenting with wrist pain, as this establishes a specific diagnosis in the majority of cases and guides all subsequent management decisions. 1, 2

Clinical History - Key Elements to Elicit

A detailed history alone leads to a specific diagnosis in approximately 70% of wrist pain cases 3:

• Mechanism of injury: Spontaneous onset, distant trauma history, or repetitive loading activities suggest carpal bone nonunion or avascular necrosis 3
• Pain location: Radial-sided (De Quervain tenosynovitis), ulnar-sided (distal radioulnar joint subluxation, TFCC injury), or central (ganglion cysts, Kienböck disease) 2
• Pain pattern: Worsening with movement suggests mechanical pathology; rest pain suggests inflammatory or infectious etiology 2
• Associated symptoms: Numbness suggests nerve compression (carpal tunnel syndrome); swelling suggests inflammatory arthritis or infection 2, 4

Physical Examination - Specific Maneuvers

Palpate systematically to localize tenderness to specific anatomic structures 3:

• Finkelstein's test: De Quervain tenosynovitis 3
• Scaphoid tubercle tenderness: Scaphoid fracture or nonunion 3
• Lunotriquetral shear test: TFCC or lunotriquetral ligament injury 3
• Watson's test (scaphoid shift): Scapholunate ligament instability 3
• Grind test: First carpometacarpal arthritis 3

Initial Imaging Algorithm

Standard Radiographs (Always First)

Obtain posterior-anterior and lateral views in neutral position, supplemented by oblique views 1, 2:

• Lateral view demonstrates malalignments and soft-tissue swelling 2
• Stress positions can elicit dynamic instability not visible on standard views 2
• Radiographs identify fractures, arthritis, bone tumors, impaction syndromes, and static wrist instability 2

When Radiographs Are Normal or Equivocal

MRI without IV contrast is the next appropriate study for persistent symptoms with unclear diagnosis 1, 2:

• MRI accurately depicts bones, bone marrow, articular cartilage, ligaments, TFCC, synovium, tendons, and neurovascular structures 2, 4
• For radial-sided pain: MRI without IV contrast 1
• For ulnar-sided pain: Either MRI without IV contrast or MR arthrogram 1
• For suspected occult fractures or stress fractures: Either MRI or CT without contrast 1

Location-Specific Advanced Imaging

Ultrasound is preferred for extra-articular pathology 2, 5:

• Ganglion cysts: Ultrasound confirms fluid-filled nature with accuracy similar to MRI 5
• Tendon pathology: Ultrasound effectively diagnoses flexor and extensor tendon abnormalities 2
• Carpal tunnel syndrome: Ultrasound measures median nerve cross-sectional area 2, 4

CT scanning is preferred for distal radioulnar joint subluxation, obtaining images of both wrists in supination and pronation 2

When to Suspect Inflammatory Arthritis

Order MRI with or without IV contrast if inflammatory arthritis is suspected and guidance for management is needed 1:

• MRI with contrast identifies active synovitis, inflammatory tenosynovitis, and bone marrow edema (osteitis) 2
• Bone marrow edema on MRI is the best predictor of future rheumatoid arthritis progression 2

Obtain laboratory testing when inflammatory conditions are suspected 2:

• ESR and CRP for diagnosis and prognosis of undifferentiated peripheral inflammatory arthritis 2
• Rheumatoid Factor (RF) and Anti-Citrullinated Protein Antibodies (ACPA) are predictive of rheumatoid arthritis 2
• ANA testing if connective tissue disease is suspected 2
• HLA-B27 for suspected spondyloarthropathies 2

When to Suspect Infection

Patients with suspected wrist infection should undergo joint aspiration immediately 1:

• Joint aspiration and synovial fluid analysis should be performed when joint effusion is present 2

Initial Management Based on Diagnosis

For osteoarthritis: Acetaminophen, NSAIDs, physical activity, and exercise; consider orthotics if pain impedes functioning 2

For inflammatory arthritis: Pharmacological treatment per rheumatology guidelines, physical activity, and exercise 2

For ganglion cysts with severe pain: Surgical excision is most effective for preventing recurrence (7-39% recurrence rate) 5

For suspected Kienböck disease without radiographic confirmation: MRI without IV contrast 1

For carpal tunnel syndrome: Clinical evaluation combined with electrophysiologic studies; imaging usually not needed, but ultrasound or MRI without contrast may be appropriate in selected circumstances 1, 4

Common Pitfalls to Avoid

• Do not skip radiographs: Even when clinical suspicion is high for soft tissue pathology, radiographs may reveal unexpected bony abnormalities 1, 2
• Do not use IV contrast routinely: It adds no benefit for most wrist pathology except suspected inflammatory arthritis 1
• Do not order bone scans, arthrography, or CT arthrography: These are not routinely used in modern wrist pain evaluation 1
• Refer to specialist if diagnosis remains unclear after appropriate imaging: Consider cineroentgenography, diagnostic arthrography, or arthroscopy 3, 6