What are the treatment and management options for right wrist pain?

Treatment and Management of Right Wrist Pain

Begin with topical NSAIDs or capsaicin combined with appropriate splinting, followed by oral NSAIDs if topical agents are insufficient, while immediately initiating active finger range of motion exercises to prevent devastating finger stiffness. 1

Initial Diagnostic Workup

• Obtain standard wrist radiographs (posterior-anterior and lateral views) as the first imaging study for any patient with wrist pain. 2, 3 The lateral view is particularly important for demonstrating malalignments and soft-tissue swelling. 3

• If radiographs are negative but symptoms persist beyond 2 weeks, proceed to MRI without IV contrast to evaluate for ligament injuries, TFCC tears, tendon pathology, or occult fractures. 2, 4

• For suspected tendon injury or tenosynovitis, ultrasound or MRI without IV contrast are equivalent alternatives for next-step imaging. 2

Pharmacological Management

First-Line Topical Therapy

• Topical NSAIDs are highly effective for wrist/hand pain with an effect size of 0.77 (95% CI 0.32 to 1.22), equivalent to oral NSAIDs but with significantly better gastrointestinal safety (no more GI side effects than placebo, RR = 0.81). 1

• Topical capsaicin achieves clinical improvement with an NNT of 3 (95% CI 2 to 5) within 4 weeks, though minor local skin reactions may occur. 1

Second-Line Oral Therapy

• If topical agents are insufficient, use oral NSAIDs at 400 mg ibuprofen every 4-6 hours as necessary for pain relief. 5 In controlled trials, doses greater than 400 mg were no more effective than the 400 mg dose. 5

• For chronic inflammatory conditions like rheumatoid arthritis or osteoarthritis, ibuprofen 1200-3200 mg daily (400-800 mg three to four times daily) may be used, with the dose tailored to individual response. 5 Use the lowest effective dose for the shortest duration. 5

• Acetaminophen is recommended as part of the treatment regimen for osteoarthritis-related wrist pain. 1

Splinting and Immobilization Strategy

Critical Splinting Principles

• Never immobilize fingers along with the wrist—maintain full finger range of motion from the first encounter to prevent devastating finger stiffness. 1, 4 Finger stiffness is one of the most functionally disabling complications and extremely difficult to treat once established. 1

• Use splints when pain impedes functioning, but avoid prolonged immobilization to prevent stiffness. 1

Splint Selection Based on Pathology

• For thumb base osteoarthritis, full splints (covering both thumb and wrist) provide superior pain relief compared to half splints (ES = 0.64,95% CI 0.02 to 1.26), with NNT of 4 for improving daily activities. 1

• For suspected ulnar-sided injuries (TFCC tears, ECU tendon pathology), use ulnar gutter splints or wrist splints including the ulnar aspect. 1, 4

Immediate Mobilization Protocol

• Immediately initiate active finger range of motion exercises even while splinted, as this is extremely cost-effective and does not adversely affect an adequately stabilized injury. 1, 4

Exercise and Physical Therapy

• General exercise shows positive to mixed effects for hand/wrist osteoarthritis (GRADE quality: ⊕⊕). 1

• Strength and resistance training demonstrates positive to mixed effects for hand/wrist conditions (GRADE quality: ⊕⊕). 1

• Tai chi, yoga, and qigong show positive effects for hand/wrist osteoarthritis, though evidence quality is very low (GRADE quality: ⊕). 1

• For non-specific chronic wrist pain, grip-strengthening exercises combined with wrist stability training performed for 20 minutes twice weekly for 4 weeks significantly improve pain, function, grip strength, and muscle strength. 6

Pattern Recognition and Specific Management

Inflammatory Arthritis Pattern

• If morning stiffness >30 minutes, symmetric joint involvement, and systemic symptoms are present, proceed directly to MRI without and with IV contrast if guidance for management or prognostication is needed. 3 The addition of postcontrast imaging distinguishes synovitis from joint effusion and aids in detection of tenosynovitis. 3

Suspected Wrist Sprain with Ulnar-Sided Pain

• Ulnar-sided pain below the styloid with a "pop" sensation during lifting suggests possible TFCC injury, ulnar styloid fracture, or ECU tendon pathology rather than a simple "sprain." 4 Do not assume "wrist sprain" without imaging. 1

• Obtain standard wrist radiographs (PA, lateral, and oblique views) to rule out fracture. 4

• If radiographs are negative and symptoms persist beyond 2 weeks, MRI without IV contrast is usually appropriate to evaluate for TFCC tears, ligament injuries, and occult fractures. 4

Carpal Tunnel Syndrome

• For suspected carpal tunnel syndrome with normal or indeterminate radiographs, ultrasound or MRI without IV contrast may be appropriate as equivalent alternatives. 2

• Conservative therapy includes wrist splints, steroid injection, NSAIDs, and pyridoxine, followed by reexamination in three weeks. 7

Multidisciplinary Referral Indications

• Refer for multidisciplinary treatment if more than one treatment modality is indicated or if monotherapy has failed. 3

• Specific scenarios requiring multidisciplinary approach include psychological distress combined with sedentary lifestyle, chronic pain with sleep disturbance, and obesity contributing to pain and disability. 3

Critical Pitfalls to Avoid

• Never assume "wrist sprain" without imaging—ulnar-sided pain with a "pop" during lifting suggests TFCC injury, ulnar styloid fracture, or ECU pathology requiring specific management. 1

• Avoid prolonged immobilization—early controlled motion prevents stiffness while promoting healing. 1, 4

• Do not immobilize fingers along with the wrist—maintain full finger range of motion from the first encounter to prevent devastating finger stiffness. 1, 4

• Do not rely on conventional radiography alone for suspected scaphoid fractures, as it can miss up to 30% of cases. 8 Use specialized views and repeat radiography in 10-14 days, or proceed to bone scan or MRI if clinical suspicion remains high. 8