What is the initial management for ulnar sided wrist pain?

Initial Management of Ulnar-Sided Wrist Pain

Start with conservative treatment including NSAIDs, activity modification, and wrist splinting in neutral position for 4 weeks, combined with immediate three-view wrist radiographs to exclude fractures. 1

Immediate First Steps

Imaging

• Obtain posteroanterior, lateral, and oblique wrist radiographs immediately in neutral position and rotation to exclude fractures, assess ulnar variance, and identify arthritis or static instability 2, 1
• The lateral view is critical for identifying malalignments and soft-tissue swelling indicating acute injury 1
• Radiographs alone may establish the diagnosis in many cases without need for advanced imaging 1

Conservative Treatment Protocol

• Immobilize the wrist in neutral wrist and forearm position for 4 weeks 2
• Prescribe NSAIDs for pain control 1
• Implement activity modification to avoid aggravating movements 1
• At 4 weeks, begin gentle active motion exercises 2
• At 8-12 weeks, progress to strengthening exercises 2

When Conservative Treatment Fails

Advanced Imaging Indications

• If pain persists beyond 6-8 weeks despite conservative treatment and radiographs are normal or nonspecific, obtain MRI without IV contrast 1
• MRI is highly accurate for TFCC tears, ligament injuries, occult fractures, and bone marrow edema 1
• For central TFCC disc lesions, use high-resolution fast spin-echo or 3D gradient-recalled sequences, with 3.0T MRI potentially more accurate than 1.5T 2

Physical Therapy

• Initiate physical therapy for range of motion once acute pain subsides 1
• This should be coordinated with the immobilization timeline above 2

Important Clinical Pitfalls

• Positive ulnar variance after trauma may represent acute soft tissue injury rather than chronic ulnar impaction syndrome, so avoid rushing to surgical intervention 1
• Standard MRI has only fair sensitivity for peripheral TFCC attachments and ulnar disc attachments, so if clinical suspicion remains high despite negative MRI, consider MR arthrography 2
• The differential diagnosis is broad (TFCC tears, lunotriquetral ligament injuries, ulnar impaction syndrome, extensor carpi ulnaris disorders, pisotriquetral joint pathology), making systematic evaluation essential 3, 4