What are the differential diagnoses for acute wrist swelling and tenderness at the radial aspect with dorsal hand involvement, pain on movement, and no erythema?

Differential Diagnoses for Acute Radial-Sided Wrist Pain with Dorsal Hand Involvement

The most likely diagnoses for acute swelling and tenderness at the radial aspect of the wrist with dorsal hand involvement, pain on movement, and absence of erythema are: occult distal radius fracture, scaphoid fracture, scapholunate ligament injury, de Quervain tenosynovitis, dorsal wrist impingement, or dorsal wrist ganglion cyst.

Primary Osseous Considerations

Occult Fractures

• Distal radius fractures are extremely common and can be radiographically occult in up to 30% of cases initially 1
• Scaphoid fractures are the most commonly fractured carpal bone and conventional radiography alone can miss up to 30% of these fractures 2
• The radial styloid location with dorsal hand involvement strongly suggests involvement of the distal radius or scaphoid 1

Initial Imaging Approach

• Three-view radiography of the wrist (posteroanterior, lateral, and 45-degree semipronated oblique) is always indicated as initial imaging 1
• For suspected scaphoid fractures, specialized views including posteroanterior in ulnar deviation and pronated oblique improve sensitivity 2
• If initial radiographs are negative but clinical suspicion remains high, repeat radiography at 10-14 days can improve diagnostic yield 1, 2

Ligamentous Injuries

Scapholunate Ligament Pathology

• Scapholunate ligament tears commonly present with radial-sided wrist pain and dorsal swelling, particularly affecting the dorsal fibers 1
• The absence of erythema does not exclude ligamentous injury, as these injuries typically present without inflammatory signs 1
• MRI is accurate for diagnosing scapholunate ligament tears when radiographs are normal or nonspecific 1

Advanced Imaging for Ligament Assessment

• Direct MR arthrography has higher sensitivity than non-contrast MRI for complete and incomplete scapholunate ligament tears 1, 3
• CT arthrography may be more sensitive for tears of the biomechanically important dorsal ligament fibers compared to conventional MRI 1, 3

Tendinous Pathology

De Quervain Tenosynovitis

• De Quervain disease (stenosing tenosynovitis of the first dorsal compartment) is a common cause of radial-sided wrist pain with dorsal involvement 4, 5
• This condition affects the abductor pollicis longus and extensor pollicis brevis tendons and is more common in women 4
• Diagnosis is clinical, based on pain over the radial styloid with a positive Finkelstein test 2, 4, 5
• Ultrasound is useful for diagnosis and treatment planning, especially to identify an intercompartmental septum that may affect surgical management 1, 5

Other Tendon Considerations

• Extensor tendon tenosynovitis can present with dorsal wrist swelling and pain on movement 6
• In the absence of erythema and with acute onset, infectious tenosynovitis (including disseminated gonococcal infection) is less likely but should be considered if risk factors are present 6

Dorsal Wrist Impingement

• Dorsal wrist impingement occurs when the dorsal wrist capsule becomes trapped between the extensor carpi radialis brevis and the dorsal ridge of the scaphoid 7
• The diagnosis is purely clinical and depends on accurate localization by history and examination 7
• This condition presents with dorsal wrist pain exacerbated by wrist extension 7

Soft Tissue Masses

Ganglion Cysts

• Dorsal wrist ganglion cysts commonly arise from the scapholunate ligament and present with radial-sided dorsal swelling 1
• MRI and ultrasound can identify ganglion cysts as extra-articular findings that cause radial-sided pain 1

Diagnostic Algorithm

Step 1: Initial Assessment

• Obtain three-view wrist radiographs immediately 1
• Perform Finkelstein test to evaluate for de Quervain tenosynovitis 2, 4
• Assess for scaphoid tenderness in the anatomic snuffbox 2

Step 2: If Radiographs Are Negative

• For suspected occult fracture: consider CT without IV contrast to exclude or confirm wrist fractures 1
• For suspected ligamentous injury or soft tissue pathology: MRI without IV contrast is the next appropriate study 1, 3
• For suspected de Quervain tenosynovitis: ultrasound may be appropriate to guide diagnosis and treatment planning 1, 5

Step 3: Advanced Imaging Considerations

• If MRI is equivocal and ligamentous injury is strongly suspected, direct MR arthrography or CT arthrography provides higher sensitivity for scapholunate ligament tears 1, 3
• MR arthrography allows more accurate determination of which specific segments of the scapholunate ligament are torn, which has important biomechanical implications for wrist stability 1

Critical Pitfalls to Avoid

• Do not rely on two-view radiography alone, as it is inadequate for detecting wrist fractures 1
• Do not dismiss the possibility of occult fracture based on initial negative radiographs alone 1, 2
• Delayed diagnosis of scaphoid fractures is common and can lead to avascular necrosis and long-term complications 2
• In de Quervain tenosynovitis, failure to identify an intercompartmental septum preoperatively may lead to surgical failure 1, 5
• The absence of erythema does not exclude infection, particularly in immunocompromised patients or those with risk factors for disseminated gonococcal infection 6

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