What are the management options for wrist pain?

Management of Wrist Pain

Begin with plain radiographs (posterior-anterior, lateral, and oblique views) as the first-line imaging for all patients with wrist pain, then proceed to MRI without contrast if radiographs are normal or nonspecific. 1, 2

Initial Diagnostic Imaging Algorithm

• Obtain standard radiographs first to evaluate bone architecture, alignment, joint spaces, and soft tissues in all patients presenting with wrist pain 1, 2
• Radiographs should include posterior-anterior and lateral views in neutral position, plus oblique views 2
• If radiographs are normal or show nonspecific findings, proceed to advanced imaging based on clinical suspicion 1

Advanced Imaging Based on Clinical Presentation

Nonspecific or Chronic Wrist Pain

• Order MRI without IV contrast when radiographs are normal or show only nonspecific arthritis 1, 2
• MRI accurately depicts abnormalities of bones, bone marrow, articular cartilage, ligaments, TFCC, synovium, tendons, and neurovascular structures 1, 2
• Use a dedicated receiver coil or transmit-receive coil for adequate signal-to-noise ratio 1

Suspected Tendon Pathology

• Use either ultrasound or MRI without IV contrast for suspected tendon injury, tenosynovitis, or tendinopathy 1, 2
• Ultrasound is particularly useful for examining extra-articular soft tissues and allows dynamic assessment 1
• Ultrasound accuracy is highly operator-dependent and requires experienced sonographers 1

Suspected Carpal Tunnel Syndrome

• Order ultrasound or MRI without IV contrast when clinical concern exists for median nerve compression 1, 2
• Ultrasound measurement of median nerve size is a validated diagnostic technique 1
• Surgical decompression is the most effective treatment for moderate to severe carpal tunnel syndrome 1

Radial-Sided Wrist Pain

• MRI without contrast is usually appropriate, though direct MR arthrography has higher sensitivity for complete and incomplete ligament tears 2

Ulnar-Sided Wrist Pain

• MRI is highly accurate for central disc tears 2
• MR arthrography or CT arthrography may be needed for peripheral TFCC tears 2

Suspected Scaphoid Fracture or Osteonecrosis

• Order MRI without IV contrast or CT without IV contrast when concerned for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis 1, 2
• MRI is highly sensitive to changes in bone marrow composition and can identify radiographically occult fractures 1, 2

Suspected Inflammatory Arthritis

• Look for morning stiffness and joint swelling as key clinical indicators 2
• Order MRI with IV contrast when inflammatory arthritis is suspected, as enhancing bone marrow edema is the best predictor of disease progression in early rheumatoid arthritis 2
• Ultrasound with power Doppler can identify active synovitis and predict erosion progression 2

Management of Specific Conditions

Ganglion Cysts

• Use ultrasound as the initial imaging modality to confirm the fluid-filled nature of the cyst 3
• MRI is appropriate for suspected occult ganglion cysts or when there's concern about solid tumors 3
• Surgical excision is the most effective treatment for preventing recurrence, with recurrence rates of 7-39% 3
• For patients with persistent symptoms managed conservatively, repeat MRI at least every 6 months until resolution 3

Dorsal Central Wrist Pain (Peri-Scapholunate Ligament Injury)

• A structured 16-week home-based rehabilitation program including immobilization and rehabilitation exercises can significantly reduce pain and improve function 4
• Conservative management includes education, immobilization with orthotic devices, scapholunate-stabilizing muscle strengthening, and proprioception training 4

Arthritic Conditions

• Conservative care consists of rest, splinting, anti-inflammatory drugs, intra-articular corticosteroid injection, and rehabilitation therapy 5
• Surgical procedures are reserved for persistent cases of pain or instability that do not respond to conservative treatment 5

Critical Pitfalls to Avoid

• Do not rely solely on radiographs, as they may miss soft tissue pathologies requiring advanced imaging 1
• Delayed diagnosis of scaphoid nonunion and Kienböck's disease can result in long-term deformity or disability 6
• Ensure ultrasound is performed by experienced operators to avoid false-negative results 1
• Consider ultrasound-guided therapeutic injections for specific conditions 1