What is the next best step for a patient with a Fall On Outstretched Hand (FOOSH) injury resulting in ulnar-sided wrist pain, particularly at the base of the 5th metacarpal bone dorsally, with limited wrist range of motion (ROM) and a normal X-ray?

From the Guidelines

The next best step for a patient with ulnar-sided wrist pain following a FOOSH injury, particularly at the base of the 5th metacarpal dorsally with limited wrist range of motion and negative X-rays, would be to obtain an MRI of the wrist. This recommendation is based on the clinical presentation which strongly suggests a possible hamate fracture or triangular fibrocartilage complex (TFCC) injury, which are often missed on plain radiographs 1. The American College of Radiology (ACR) Appropriateness Criteria for chronic wrist pain recommends that when radiographs are normal or equivocal in a patient with ulnar-sided pain, either MRI without IV contrast or an MR arthrogram of the wrist is usually appropriate 1.

While waiting for the MRI, the patient should be placed in a removable wrist splint, advised to rest the wrist, apply ice for 15-20 minutes several times daily, take NSAIDs such as ibuprofen 400-600mg three times daily with food for pain and inflammation (if not contraindicated), and elevate the wrist when possible. The MRI is crucial because these ulnar-sided wrist injuries can lead to chronic instability and pain if not properly diagnosed and treated. Early diagnosis allows for appropriate management, which may include continued immobilization for certain injuries or surgical intervention for others, particularly if there is significant ligamentous disruption or an occult fracture affecting wrist stability.

Key points to consider in the management of this patient include:

• The importance of advanced imaging such as MRI for diagnosing occult fractures or soft tissue injuries not visible on plain radiographs 1.
• The role of MRI in identifying changes in bone marrow composition, thus facilitating the diagnosis of radiographically occult acute fractures throughout the skeleton, including in the wrist 1.
• The potential for CT without IV contrast as an alternative to MRI for identifying radiographically occult fractures and stress fractures, although MRI's sensitivity for bone bruises and soft-tissue injuries is greater than CT 1.

From the Research

Next Best Step for FOOSH Resulting in Ulnar Sided Wrist Pain

The patient presents with ulnar sided wrist pain, particularly at the base of the 5th metacarpal dorsally, with limited wrist ROM and nil acute findings on X-ray. The next best step would be to:

• Perform a thorough physical examination, including provocative maneuvers such as the ulnocarpal stress test, ulnar foveal sign, and pisotriquetral shear test, to help determine the cause of the pain 2, 3
• Consider diagnostic imaging, such as MRI or CT, to rule out soft tissue or bony injuries, particularly if the physical examination is inconclusive 4, 3
• Use diagnostic arthroscopy as a reference standard to confirm the diagnosis, if necessary 5
• Evaluate the patient's symptoms and history to determine if they are at risk for ulnar nerve entrapment or other conditions that may be contributing to their pain 4

Possible Diagnoses to Consider

• Triangular fibrocartilage complex (TFCC) injuries
• Ulnocarpal abutment syndrome (UCAS)
• Pisotriquetral arthritis (PTA)
• Triquetral fracture or non-union
• Distal radioulnar joint arthritis (DRUJ OA)
• Extensor carpi ulnaris (ECU) pathology
• Ulnar nerve entrapment

Diagnostic Tests to Consider

• Ulnocarpal tenderness test
• Lunotriquetral ligament laxity test
• Bone scan
• Radiocarpal arthrogram
• Midcarpal arthrogram
• MRI or CT scan
• Diagnostic arthroscopy 2, 3, 5