What is the best approach to manage bilateral wrist pain in a middle-aged female?

Management of Bilateral Wrist Pain in a Middle-Aged Female

Begin with standard radiographs (posterior-anterior and lateral views) as the essential first imaging study, followed by a structured clinical assessment to determine if this represents inflammatory arthritis, overuse syndrome, or structural pathology. 1

Initial Diagnostic Approach

Mandatory First Step: Radiography

• Obtain standard wrist radiographs (posterior-anterior and lateral views in neutral position) as the best initial imaging examination for any patient with chronic wrist pain 1
• The lateral view is particularly important for demonstrating malalignments and soft-tissue swelling 1
• Radiographs may establish specific diagnoses including arthritis, impaction syndromes, or static wrist instability 1

Clinical Assessment Focus

The bilateral nature of symptoms in a middle-aged female raises specific diagnostic considerations:

Key features to identify:

• Inflammatory arthritis pattern: Morning stiffness >30 minutes, symmetric joint involvement, systemic symptoms suggest rheumatoid arthritis or seronegative spondyloarthropathy 1
• Overuse/mechanical pattern: Pain with specific activities, asymmetric symptoms despite bilateral involvement, no morning stiffness 1, 2
• Nerve entrapment: Sensory changes, nocturnal symptoms suggest carpal tunnel syndrome 1, 2

Management Algorithm Based on Clinical Presentation

If Inflammatory Arthritis is Suspected

Proceed directly to MRI without and with IV contrast if guidance for management or prognostication is needed 1

• The addition of postcontrast imaging distinguishes synovitis from joint effusion and ganglion cysts 1
• Postcontrast MRI aids in detection of tenosynovitis, which is critical for inflammatory arthritis diagnosis 1
• This imaging should be obtained before initiating disease-modifying therapy to establish baseline disease activity 1

Initiate comprehensive non-pharmacologic management immediately:

• Provide patient education materials about staying active and joint protection principles 1
• Offer psychoeducation by the health professional regarding pain mechanisms 1
• Refer to occupational therapy for splints, braces, or ergonomic adaptations if pain during activities of daily living impedes functioning 1
• Consider referral to physiotherapist for individually tailored graded physical exercise or strength training if the patient cannot initiate physical activity independently 1

If Mechanical/Overuse Pattern is Identified

For normal or nonspecific radiographs with persistent symptoms, obtain MRI without IV contrast 1, 3

• MRI without IV contrast is sufficient for assessing ligament tears, tendinopathy, tenosynovitis, and occult fractures 1, 3
• At 3.0T, MRI demonstrates sensitivity of 70-87% and specificity of 90-97% for scapholunate tears 1
• MRI is particularly useful for diagnosing tendon abnormalities including tendinopathy, tenosynovitis, and intersection syndromes 1

Conservative management should be initiated concurrently:

• Prescribe wrist splints for symptom relief during activities, fitted by occupational therapist 1
• Provide education about appropriate joint use and ergonomic principles 1
• Initiate graded physical exercise program through physiotherapy referral 1
• Address any psychosocial factors (fear of movement, catastrophizing) that may underlie sedentary lifestyle with cognitive-behavioral therapy if needed 1

If Carpal Tunnel Syndrome is Suspected

Diagnosis is primarily clinical combined with electrophysiologic studies; imaging is usually not needed 1

• In selected circumstances where diagnosis remains uncertain, either wrist ultrasound or MRI without contrast may be appropriate 1
• Ultrasound can assess for median nerve entrapment and is reasonable for nerve evaluation per American College of Rheumatology 1

Management approach:

• Initiate nighttime wrist splinting in neutral position 1
• Provide ergonomic workplace modifications through occupational therapy 1
• Consider corticosteroid injection if conservative measures fail 1

Advanced Imaging Considerations

When to Escalate to MR Arthrography

If MRI without contrast is non-diagnostic but clinical suspicion remains high for ligament pathology, proceed to direct MR arthrography 1, 3

• Direct MR arthrography has higher sensitivity than non-contrast MRI (even at 3.0T) for complete and incomplete scapholunate and lunotriquetral ligament tears 1, 3
• MR arthrography allows more accurate determination of which specific ligament segments are torn, which has important biomechanical implications 1
• CT arthrography may be more sensitive for tears of biomechanically important dorsal ligament fibers 3

Role of Ultrasound

Ultrasound may be appropriate as an alternative to MRI in specific circumstances 1

• US can identify synovitis, joint effusion, tenosynovitis, tendinopathy, and tendon injury 1
• In one study, US was contributory to clinical assessment in 76% of patients referred from hand surgeons 1
• US is particularly useful for guiding therapeutic injections if needed 4
• Important caveat: An interdisciplinary consensus recommended against including US in standard evaluation of scapholunate instability 1

Multidisciplinary Treatment Indications

Refer for multidisciplinary treatment if more than one treatment modality is indicated or if monotherapy has failed 1

Specific scenarios requiring multidisciplinary approach:

• Psychological distress combined with sedentary lifestyle 1
• Chronic pain with sleep disturbance requiring both pain management and sleep interventions 1
• Obesity contributing to pain and disability, requiring dietitian, psychologist, or community lifestyle services 1

Additional Management Considerations

Sleep Disturbance

• If sleep disturbance is reported, inquire about causes (pain, persistent worrying, poor sleep habits) 1
• Offer basic education about good sleep hygiene practices 1
• If sleep remains severely disturbed, refer to specialized sleep clinic 1

Weight Management

• If the patient is obese, explain that obesity can contribute to pain and disability 1
• Discuss accessible weight management options or refer to specialized support 1

Pharmacological Management

• Ask about existing use of prescribed and over-the-counter pain relief to ensure safe dosing 1
• Follow recent pharmacological recommendations for inflammatory arthritis or osteoarthritis as appropriate 1

Common Pitfalls to Avoid

• Do not continue splint use beyond necessary time, as this can lead to stiffness and delayed recovery 4
• Do not obtain bone scan as initial advanced imaging; it lacks specificity and cannot detect soft-tissue abnormalities responsible for most chronic wrist pain 1
• Do not perform conventional arthrography alone; it has been largely supplanted by CT arthrography, MRI, and MR arthrography which provide superior anatomic detail 1
• Do not delay specialist referral if symptoms persist despite conservative management for 6-8 weeks, as conditions like scaphoid nonunion and Kienböck's disease can result in long-term disability with delayed treatment 5