What causes pain in the proximal phalange and dorsal wrist, excluding the MCP joint?

Differential Diagnosis and Workup for Mid-Proximal Phalangeal and Dorsal Wrist Pain

Begin with plain radiographs (PA, lateral, and oblique views) as the initial imaging study, followed by MRI without contrast if radiographs are normal or nonspecific, as this accurately depicts bones, ligaments, tendons, and soft tissues that commonly cause this pain pattern. 1

Most Likely Diagnostic Considerations

Extensor Tendon Pathology

• Extensor tenosynovitis or tendinopathy is a primary consideration for dorsal wrist pain, particularly with overuse activities 2
• The mid-proximal phalanx location suggests possible extensor hood injury or sagittal band pathology, which can cause pain along the dorsal aspect of the finger 1
• MRI demonstrates extensor system abnormalities with sensitivity ranging from 28% to 85% for extensor hood injuries 1

Trigger Point Referral Pattern

• Third or fourth dorsal interosseous muscle trigger points can produce referred pain to the dorsal wrist and interdigital spaces, mimicking structural pathology 3
• This referred pain pattern affects 55-65% of patients with these trigger points and can extend to the ulnar side of the wrist 3
• Consider this diagnosis when structural imaging is negative but pain persists 3

Inflammatory Arthritis

• Early inflammatory arthritis (particularly rheumatoid arthritis) commonly affects the wrist and proximal interphalangeal joints with pain preceding visible radiographic changes 1
• MRI with IV contrast is superior for detecting active synovitis and bone marrow edema (osteitis), which is the strongest predictor of disease progression 1
• Inflammatory markers (ESR, CRP) are typically elevated and help differentiate from degenerative conditions 1

Dorsal PIP Joint Tenderness

• Dorsal PIP tenderness occurs in approximately 47% of patients with hand pathology and can persist as a source of chronic pain 4
• This finding is associated with prolonged pain lasting up to 3 months and should be specifically assessed on examination 4

Imaging Algorithm

Initial Study

• Radiographs with 3 views (PA, lateral, oblique) are the appropriate first-line imaging 1, 5
• Look specifically for: joint space narrowing, erosions, soft tissue swelling, and alignment abnormalities 1

Second-Line Imaging (if radiographs normal/nonspecific)

• MRI without IV contrast is usually appropriate as the next study for chronic wrist and hand pain 1
• MRI accurately depicts ligaments, TFCC, tendons, cartilage, and bone marrow edema that radiographs miss 1
• In a retrospective review, MRI changed clinical management in 69.5% of cases referred to hand surgeons 1

Specialized Imaging Considerations

• Ultrasound is reasonable for evaluating tendon pathology, tenosynovitis, and soft tissue abnormalities, with 76% contribution to clinical assessment 1
• MRI with IV contrast should be added if inflammatory arthritis is suspected, as it better quantifies active synovitis and predicts disease progression 1
• MR arthrography has higher sensitivity than non-contrast MRI for intrinsic ligament tears if this is the suspected pathology 1, 6

Critical Clinical Pearls

Red Flags Requiring Urgent Evaluation

• Median nerve distribution symptoms suggest carpal tunnel syndrome, which can cause proximal pain in 40-50% of cases extending beyond the wrist 7
• Proximal pain in CTS patients correlates with milder nerve damage and extramedian symptom spread 7
• Ulnar-sided symptoms with fourth and fifth digit sensory changes suggest ulnar neuropathy, particularly in patients with repetitive wrist extension activities 2

Physical Examination Specifics

• Palpate the dorsal PIP joint directly for tenderness, as this finding affects prognosis and treatment expectations 4
• Assess for trigger points in the third and fourth dorsal interosseous muscles, as these can mimic C7/C8 radiculopathy or ulnar neuropathy 3
• Evaluate for inflammatory signs: morning stiffness >30-60 minutes, improvement with NSAIDs/corticosteroids (not opioids), and joint swelling 1

Common Diagnostic Pitfalls

• Do not assume all dorsal wrist pain is carpal pathology—extensor tendon disorders and muscle trigger points are frequently overlooked 2, 3
• Avoid missing early inflammatory arthritis by relying solely on radiographs, as MRI detects bone marrow edema before erosions appear 1
• Consider overlapping pathologies—patients may have both structural abnormalities and myofascial pain contributing to symptoms 3

When Conservative Imaging is Insufficient

• If MRI is contraindicated or produces excessive artifact from metallic implants, CT arthrography may be appropriate for evaluating articular cartilage and ligamentous structures 1
• Electrodiagnostic testing should be obtained if nerve entrapment is suspected based on sensory distribution of symptoms 2
• Consider diagnostic injection (local anesthetic ± corticosteroid) to differentiate intra-articular from extra-articular pain sources 8