What is the initial management and likely diagnosis for a patient presenting with wrist pain for one month in an urgent care setting?

Wrist Pain for One Month in Urgent Care: Diagnosis and Management

For a patient presenting with one-month duration of wrist pain in urgent care, obtain standard wrist radiographs (PA, lateral, and oblique views) as the initial diagnostic step, as this establishes specific diagnoses in most cases and guides all subsequent management decisions. 1, 2

Initial Diagnostic Approach

Immediate Imaging

• Order a minimum 3-view radiographic series (posteroanterior, lateral, and oblique views) as your first test 1, 2, 3
• Adding a fourth scaphoid view increases diagnostic yield for both distal radius fractures and scaphoid injuries 3
• The lateral view is particularly important for demonstrating malalignments and soft-tissue swelling 2, 3
• Radiographs can identify fractures, arthritis, bone tumors, impaction syndromes, static wrist instability, and complications of prior injury 1, 2

Clinical History Elements to Elicit

• Approximately 70% of wrist pain diagnoses can be made from history alone 4
• Ask specifically about: spontaneous onset versus trauma history, repetitive loading activities (suggests carpal bone nonunion or avascular necrosis), and location of pain (radial-sided, ulnar-sided, or central) 2, 4
• Document any numbness or tingling (suggests carpal tunnel syndrome or nerve compression) 5, 6

Physical Examination Localization

• Palpate systematically to localize tenderness to specific anatomic structures 4
• Perform provocative tests: Finkelstein's test (De Quervain tenosynovitis), grind test, lunotriquetral shear test, supination lift test, and Watson's test 4

Most Likely Diagnoses by Location

Radial-Sided Pain

• De Quervain tenosynovitis (extra-articular tendon inflammation) 2
• Scaphoid fracture complications (nonunion, malunion, osteonecrosis) 1

Ulnar-Sided Pain

• Distal radioulnar joint subluxation 2
• Triangular fibrocartilage complex (TFCC) injury 2

Central Wrist Pain

• Ganglion cysts (most common mass lesion) 2
• Kienböck disease (avascular necrosis of the lunate) 2, 7
• Carpal tunnel syndrome (if numbness present in median nerve distribution) 5, 6

Diffuse Pain

• Inflammatory arthritis (rheumatoid arthritis, other connective tissue diseases) 2
• Post-traumatic arthritis or wrist osteoarthritis 1

Management Algorithm Based on Initial Radiographs

If Radiographs Show Specific Pathology

• Fracture identified: Refer to orthopedics for definitive management 7
• Arthritis confirmed: Treat with acetaminophen, NSAIDs, physical activity, and exercise; consider orthotics if pain impedes functioning 2
• Kienböck disease visible: Further imaging usually not necessary; refer to hand surgery 1

If Radiographs Are Normal or Equivocal

For radial-sided pain:

• Order MRI without IV contrast to evaluate for tendinopathy, ligamentous injury, or early inflammatory changes 1, 2

For ulnar-sided pain:

• Order either MRI without IV contrast OR MR arthrogram of the wrist 1
• Consider CT in supination and pronation if distal radioulnar joint subluxation suspected 2

For suspected ganglion cyst or palpable mass:

• Order one of: MRI without contrast, MRI with contrast, or wrist ultrasound 1
• Ultrasound is particularly useful for examining extra-articular soft tissues 2, 5

For suspected carpal tunnel syndrome:

• Diagnosis is primarily clinical combined with electrophysiologic studies 1, 6
• Imaging usually not needed, but ultrasound (to measure median nerve size) or MRI without contrast may be appropriate in selected cases 1, 5
• Conservative treatment includes wrist splints, steroid injection, NSAIDs, and pyridoxine; reexamine in 3 weeks 6

For suspected inflammatory arthritis:

• Order MRI with or without IV contrast if guidance for management or prognostication is needed 1
• Obtain ESR, CRP, rheumatoid factor, and anti-citrullinated protein antibodies 2
• Consider ANA if connective tissue disease suspected; HLA-B27 if spondyloarthropathy suspected 2
• Perform joint aspiration and synovial fluid analysis if joint effusion present 2

Critical Pitfalls to Avoid

• Never rely on only 2 radiographic views—this is inadequate for detecting wrist fractures, especially scaphoid injuries 3
• Missed scaphoid fractures lead to significant morbidity including nonunion, avascular necrosis, and post-traumatic arthritis 3, 7
• Delayed diagnosis of Kienböck's disease can result in long-term deformity or disability 7
• If clinical suspicion remains high despite negative radiographs, do not dismiss the patient—proceed to MRI without contrast (sensitivity 94.2%, specificity 97.7% for occult fractures) 3

Disposition from Urgent Care

• Refer to hand surgery or orthopedics if radiographs show fracture, suspected ligamentous injury requiring repair, or other surgical pathology 3
• Refer to rheumatology if inflammatory arthritis suspected based on clinical findings and laboratory results 2
• Provide conservative treatment and arrange follow-up for non-urgent conditions like De Quervain tenosynovitis or mild osteoarthritis 2, 6
• Order advanced imaging (MRI) and arrange specialist follow-up if radiographs are normal but symptoms persist and diagnosis remains unclear 1, 2