What is the cause and treatment for wrist pain with external rotation along the ulnar aspect and swelling to the mid forearm?

Ulnar-Sided Wrist Pain with External Rotation and Swelling to Mid-Forearm

This presentation most likely represents a triangular fibrocartilage complex (TFCC) tear, ulnocarpal impaction syndrome, or extensor carpi ulnaris (ECU) tendonitis, and you should immediately obtain three-view wrist radiographs (posteroanterior, lateral, and oblique in neutral position) to assess for fractures, ulnar variance, and soft-tissue swelling. 1, 2

Initial Diagnostic Approach

Immediate Imaging

• Obtain standard three-view wrist radiographs as the essential first step (posteroanterior, lateral, and oblique views performed in neutral position and rotation). 1, 2
• The lateral view is critical for demonstrating malalignments and soft-tissue swelling, which your patient clearly has extending to the mid-forearm. 1, 3
• Radiographs will accurately measure ulnar variance, which is essential for diagnosing ulnocarpal impaction syndrome. 1, 3

Key Clinical Clues from Your Presentation

• Pain with external rotation (forearm supination) during grip is highly characteristic of TFCC tears and ulnocarpal impaction syndrome. 4, 5, 6
• Swelling extending to the mid-forearm suggests significant soft-tissue involvement, potentially ECU tendonitis or bursitis of the ulnar recess. 7, 8
• The ulnar-sided location points to the "black box" of the wrist—TFCC injuries, lunotriquetral ligament tears, or ulnar impaction syndrome. 5, 6

Advanced Imaging Algorithm (If Radiographs Are Normal or Nonspecific)

When to Proceed to MRI

• If radiographs show positive ulnar variance or are normal but pain persists beyond 4-6 weeks of conservative treatment, obtain MRI without IV contrast as the next study. 1, 2, 3
• MRI is highly accurate for central TFCC disc lesions using high-resolution sequences, particularly at 3.0T. 2
• MRI will also identify ECU tendonitis, bone marrow edema in the lunate (suggesting ulnocarpal impaction), and extra-articular pathology. 3, 7

When to Consider MR Arthrography

• If standard MRI is equivocal or you suspect peripheral TFCC tears (Palmer 1B) or lunotriquetral ligament injury, MR arthrography has significantly higher sensitivity than non-contrast MRI. 2, 9
• Standard MRI has only fair sensitivity for peripheral TFCC attachments and ulnar disc attachments. 2
• CT arthrography is an alternative with nearly 100% sensitivity and specificity for both TFCC and intrinsic ligament lesions. 2

Initial Conservative Management

Immediate Treatment (First 4 Weeks)

• Immobilize the wrist in neutral wrist and forearm position for 4 weeks. 2
• Prescribe NSAIDs and recommend activity modification, avoiding rotational loading and gripping activities. 3
• Consider wrist splinting to maintain neutral position. 3

Progressive Rehabilitation

• Begin gentle active motion at 4 weeks. 2
• Initiate strengthening exercises at 8-12 weeks. 2
• Physical therapy for range of motion once acute pain subsides. 3

Surgical Considerations (If Conservative Management Fails)

For Peripheral TFCC Tears

• Arthroscopic foveal repair with suture anchor for Palmer 1B tears with foveal detachment restores anatomic attachment critical for distal radioulnar joint (DRUJ) stability. 2

For Ulnocarpal Impaction Syndrome

• If positive ulnar variance is confirmed and conservative treatment fails, operative treatment aims to reduce load on the lunate through either open ulnar shortening osteotomy or arthroscopic wafer procedure. 4

Critical Pitfalls to Avoid

• Do not dismiss the possibility of occult fracture based on initial negative radiographs alone—repeat radiographs at 10-14 days can improve diagnostic yield. 9
• Do not rely on two-view radiography; three views are mandatory for adequate assessment. 9
• Recognize that bursitis of the ulnar recess can mimic TFCC pathology—it presents with local swelling and pain with forearm rotation during grip, but responds well to corticosteroid injection in non-traumatic cases. 8
• In cases with previous trauma or surgery, conservative management (including injections) is less likely to succeed. 8