What are the treatment options for a teenager experiencing wrist pain?

Wrist Pain in a Teenager: Treatment Approach

For a teenager with wrist pain, begin with plain radiographs (PA, lateral, and oblique views) as the initial diagnostic step, followed by targeted treatment based on the specific diagnosis identified, with MRI reserved for cases where radiographs are normal or nonspecific. 1

Initial Diagnostic Workup

Radiographic Evaluation

• Obtain standard radiographs first including posterior-anterior, lateral (in neutral position), and oblique views 1
• The lateral view is particularly important for identifying malalignments and soft-tissue swelling 1
• Radiographs can establish specific diagnoses in many cases including fractures, arthritis, infection, bone tumors, impaction syndromes, and static wrist instability 1
• In adolescent athletes (especially gymnasts), consider stress views to evaluate for physeal stress injuries 2

Location-Based Differential Diagnosis

The anatomic location of pain guides the diagnostic approach:

Radial-sided pain:

• De Quervain tenosynovitis (stenosing tenosynovitis of first dorsal compartment) 1
• Scaphoid fracture or nonunion 3
• Scapholunate ligament injury 2

Ulnar-sided pain:

• Triangular fibrocartilage complex (TFCC) tears 2
• Distal radioulnar joint subluxation 1
• Ulnar impaction syndrome 2

Central/dorsal pain:

• Ganglion cysts 1, 4
• Kienböck disease (avascular necrosis of lunate) 1
• Scapholunate ligament tears 5

Advanced Imaging When Radiographs Are Normal

MRI Without Contrast

• MRI without IV contrast is the most appropriate next study when radiographs are normal or nonspecific 1, 5
• MRI accurately depicts bones, bone marrow, articular cartilage, ligaments, TFCC, synovium, tendons, and neurovascular structures 1
• For suspected occult fractures or stress fractures (common in adolescent gymnasts), MRI is highly sensitive and can identify physeal stress injuries 2
• MRI at 3.0 Tesla provides better signal-to-noise ratio than 1.5 Tesla systems 2

Alternative Imaging Modalities

• Ultrasound is appropriate for suspected ganglion cysts, tendon pathology (especially de Quervain tenosynovitis), or when guiding aspiration 1, 4
• CT without contrast may be preferred for suspected hook of hamate fractures or distal radioulnar joint subluxation (where bilateral imaging in supination and pronation is needed) 2, 1

When to Consider MR Arthrography

• Direct MR arthrography has higher sensitivity than non-contrast MRI for complete and incomplete ligament tears (scapholunate and lunotriquetral) 5
• Consider for persistent radial or ulnar-sided pain when standard MRI is inconclusive 2, 5
• However, this is rarely the initial advanced imaging choice in teenagers unless there is high clinical suspicion for intra-articular pathology 2

Treatment Based on Diagnosis

Conservative Management

• For osteoarthritis or overuse injuries: acetaminophen, NSAIDs, physical activity modification, and exercise 1
• Splinting/bracing is appropriate when pain impedes functioning 1
• For de Quervain tenosynovitis: thumb spica splinting and NSAIDs initially 3

Specific Conditions Requiring Specialist Referral

• Scaphoid fractures (even suspected): immediate immobilization and orthopedic referral to prevent nonunion 6, 3
• Kienböck disease: early referral to prevent progressive carpal collapse 6
• Ganglion cysts with severe pain: surgical excision is most effective (recurrence rate 7-39%) 4

When Inflammatory Arthritis Is Suspected

Although less common in teenagers, if there are systemic symptoms or multiple joint involvement:

• Obtain ESR, CRP, rheumatoid factor, and anti-citrullinated protein antibodies 1
• MRI with IV contrast can identify active synovitis and bone marrow edema (osteitis) 1
• Early rheumatology referral is critical as bone marrow edema predicts disease progression 1

Critical Pitfalls to Avoid

• Do not miss scaphoid fractures: Up to 30% are missed on initial radiographs; if clinical suspicion is high (tenderness in anatomic snuffbox), immobilize and obtain repeat radiographs in 10-14 days or proceed directly to MRI 3
• Do not delay imaging for suspected infection: if septic arthritis is suspected, perform joint aspiration immediately without waiting for advanced imaging 2
• Do not obtain MRI with IV contrast routinely: it adds little benefit for most wrist pain etiologies unless inflammatory arthritis is suspected 2
• Recognize physeal stress injuries in young athletes: these are MRI-sensitive but radiographically occult, particularly in gymnasts with chronic wrist pain 2