What are the differential diagnoses and management options for a patient presenting with wrist pain?

Differential Diagnoses for Wrist Pain

Begin with standard 4-view radiographs (PA, lateral, oblique, and scaphoid views) as the initial diagnostic study, which establishes specific diagnoses in the majority of cases and guides all subsequent management decisions. 1, 2

Diagnostic Algorithm by Pain Location

Radial-Sided Wrist Pain

• De Quervain tenosynovitis (extra-articular): Diagnosed with Finkelstein's test positivity and negative grind test 1, 3
• Scaphoid fracture: Most commonly fractured carpal bone after fall on outstretched hand; conventional radiographs miss up to 30% of cases 3
• Scaphotrapezial-trapezoid (STT) arthritis: Evaluate with grind test during physical examination 1, 4

Ulnar-Sided Wrist Pain

• Distal radioulnar joint (DRUJ) subluxation: Requires CT scanning of both wrists in supination and pronation for definitive diagnosis 1
• Ulnar neuropathy: Presents with sensory changes in fourth and fifth digits; common in activities involving repetitive wrist extension (cycling, karate, baseball catching) 3
• Triangular fibrocartilage complex (TFCC) injury: Best visualized on MRI without contrast 1

Central Wrist Pain

• Ganglion cysts: Diagnosed effectively with ultrasound examination 1
• Kienböck disease (avascular necrosis of lunate): Identified on radiographs or MRI 1
• Carpal instability: Requires stress views and dynamic maneuvers during radiography 1, 2

Inflammatory/Systemic Causes

• Rheumatoid arthritis: Order RF, ACPA, ESR, and CRP; MRI with contrast shows bone marrow edema (best predictor of disease progression) 1
• Other inflammatory arthropathies: Consider ANA testing for connective tissue disease, HLA-B27 for spondyloarthropathies 1
• Septic arthritis: Perform joint aspiration and synovial fluid analysis when effusion present 1

Imaging Strategy

Initial Study (Always Start Here)

• 4-view radiographic series: PA, lateral, 45° semipronated oblique, and scaphoid view 2
• Lateral view demonstrates malalignments and soft-tissue swelling 1, 2
• Stress positions can elicit dynamic instability not visible on standard views 1

When Radiographs Are Normal or Nonspecific

For suspected soft tissue pathology:

• MRI without IV contrast is the next appropriate study, accurately depicting bones, bone marrow, articular cartilage, ligaments, TFCC, synovium, tendons, and neurovascular structures 1

For suspected inflammatory conditions:

• MRI with IV contrast identifies active synovitis, inflammatory tenosynovitis, and bone marrow edema (osteitis) 1
• Ultrasound with power Doppler can identify erosions and active synovitis in rheumatoid arthritis 1

For suspected scaphoid fracture with negative initial radiographs:

• Place patient in short arm cast and repeat radiographs in 10-14 days, OR proceed directly to MRI without contrast 2, 3
• Bone scan is an alternative if MRI unavailable 3

For suspected DRUJ subluxation:

• CT scanning of both wrists in supination and pronation 1

For suspected extra-articular soft tissue pathology:

• Ultrasound examines ganglion cysts, flexor/extensor tendons, tendon sheaths, and can measure median nerve size in carpal tunnel syndrome 1

Management Based on Diagnosis

Osteoarthritis

• Acetaminophen and NSAIDs as first-line pharmacological treatment 1
• Physical activity and exercise 1
• Orthotics (splints, braces) if pain impedes functioning 1

Inflammatory Arthritis

• Pharmacological treatment per rheumatology guidelines 1
• Physical activity and exercise 1
• Consider orthotics if pain impedes functioning 1

De Quervain Tenosynovitis

• NSAIDs, splinting, and activity modification 3
• Corticosteroid injection if conservative measures fail 3

Scaphoid Fracture

• Immobilization in short arm cast; missed fractures lead to nonunion, avascular necrosis, and post-traumatic arthritis 2

Critical Pitfalls to Avoid

• Never rely on only 2 radiographic views—this is inadequate for detecting wrist fractures, particularly scaphoid injuries 2
• Do not dismiss persistent radial pain with normal radiographs—up to 30% of scaphoid fractures are missed on initial imaging 3
• Always obtain laboratory studies when inflammatory arthritis suspected—ESR, CRP, RF, and ACPA guide diagnosis and prognosis 1
• Perform joint aspiration when effusion present—septic arthritis must be ruled out 1
• Consider referral for arthroscopy or diagnostic arthrography when all imaging is negative but clinically significant pain persists 5, 6