What should I do with a complaint of neck pain, hand tremors, and wrist pain?

Evaluation and Management of Neck Pain, Hand Tremors, and Wrist Pain

Begin with plain radiographs of the wrist (3 views: posteroanterior, lateral, and oblique) to evaluate the wrist pain, while simultaneously pursuing a focused neurological evaluation to determine if the neck pain and hand tremors represent a cervical radiculopathy or separate neurological condition. 1

Initial Diagnostic Approach

For the Wrist Pain Component

• Obtain standard radiographs first including posteroanterior, lateral, and oblique views to assess for fractures, arthritis, alignment abnormalities, ulnar variance, joint spaces, and soft tissue swelling. 1
• Radiographs alone can establish a diagnosis or confirm clinical suspicion in many cases and may be the only imaging needed. 1
• Standard radiographic views allow assessment of static instability, chronic healed and nonunited fractures, soft tissue mineralization, and erosions. 1

For the Neck Pain and Hand Tremors

• The combination of neck pain with hand tremors raises concern for cervical radiculopathy or myelopathy, which requires a different diagnostic pathway than isolated wrist pain. 2
• Perform a detailed neurological examination focusing on:
  • Motor strength in upper extremity myotomes
  • Sensory distribution patterns
  • Deep tendon reflexes
  • Presence of upper motor neuron signs (if myelopathy suspected)
  • Characterization of tremor (resting vs. action vs. postural)

Critical pitfall: Do not assume all three symptoms are related to a single wrist pathology. The presence of tremors with neck pain suggests a neurological etiology that may be independent of or contributing to the wrist pain. 2

Algorithmic Decision Tree After Initial Radiographs

If Radiographs Show Specific Abnormalities:

• Fracture or arthritis identified: Treat accordingly based on findings. 1
• No further imaging may be needed unless clinical course doesn't improve with conservative measures. 2

If Radiographs Are Normal or Show Only Nonspecific Arthritis:

Next step depends on clinical suspicion:

• For suspected tendon pathology (tenosynovitis, tendinopathy, De Quervain's): Order either ultrasound OR MRI without IV contrast—these are equivalent alternatives. 1

  • Ultrasound advantages: Can assess tendons dynamically, evaluate for stenosing tenosynovitis, intersection syndrome, and pulley injuries. 1
  • MRI advantages: Better for assessing bone marrow edema and deeper structures. 1

• For suspected carpal tunnel syndrome (if numbness/tingling present): Order either ultrasound OR MRI without IV contrast. 1, 3

  • Ultrasound can measure median nerve cross-sectional area with validated diagnostic criteria. 3
  • However, carpal tunnel syndrome is primarily a clinical and electrodiagnostic diagnosis. 1

• For nonspecific chronic wrist pain: MRI without IV contrast is usually appropriate as the next study. 1, 4

  • MRI accurately depicts bones, bone marrow, articular cartilage, ligaments, TFCC, synovium, tendons, and neurovascular structures. 4

Addressing the Tremor Component

The hand tremor requires separate evaluation as it is not typically caused by wrist pathology:

• Consider cervical spine imaging (MRI cervical spine) if neurological examination suggests radiculopathy or myelopathy
• Tremor characterization may require neurological consultation if it represents:
  • Essential tremor
  • Parkinsonian tremor
  • Cerebellar pathology
  • Peripheral neuropathy

Conservative Management While Awaiting Advanced Imaging

• Ergonomic modifications and activity pacing should be offered to every patient with hand and wrist pain. 5
• Topical NSAIDs are first-line pharmacological treatment due to superior safety profile. 5
• Exercises to improve function and muscle strength should be considered for all patients. 5
• Orthoses (splints) should be considered for symptom relief, particularly if pain impedes functioning. 4, 5

Red Flags Requiring Urgent Evaluation

• Progressive neurological deficits (suggests myelopathy)
• Bilateral symptoms with gait disturbance (suggests cervical myelopathy)
• Fever with joint swelling (requires joint aspiration to rule out septic arthritis) 4
• Severe trauma history (may need immediate advanced imaging)

Key clinical pearl: A detailed history can lead to specific diagnosis in approximately 70% of patients with wrist pain, but the addition of neck pain and tremors significantly expands the differential diagnosis beyond local wrist pathology. 2