What is the best course of treatment for a patient with intermittent pain and loss of strength in the left wrist, with X-ray findings suggesting an old injury to the radial styloid process, possibly representing a prior fracture with callus formation?

Treatment Order for Left Wrist Brace

For a patient with an old radial styloid injury showing callus formation and presenting with intermittent pain and weakness, immobilize the wrist with a brace and obtain follow-up radiographs at 3 weeks to assess healing status. 1

Immediate Management

Wrist Immobilization

• Order a left wrist brace (thumb spica or wrist immobilization brace) for continuous wear during symptomatic periods 1
• The brace should provide adequate support to the radial styloid region while allowing finger motion 1

Symptomatic Relief

• Apply ice to the affected wrist at regular intervals (specifically at 3 and 5 days if this represents acute-on-chronic symptoms) for pain control 1

Active Range of Motion

• Instruct the patient to begin active finger motion exercises immediately to prevent stiffness, which is one of the most functionally disabling complications of distal radius injuries 1
• Finger exercises should be performed even while the wrist is braced 1

Follow-Up Imaging Protocol

Radiographic Surveillance

• Schedule repeat three-view wrist radiographs (posteroanterior, lateral, and 45-degree semipronated oblique) at 3 weeks post-bracing to assess healing progression and rule out secondary displacement 1, 2
• Three-view radiography is essential as two-view imaging alone is inadequate for detecting wrist pathology 2

Additional Considerations

Adjunctive Treatments

• Consider vitamin C supplementation for prevention of disproportionate pain (moderate strength recommendation from orthopedic guidelines) 1
• Low-intensity ultrasound may provide short-term improvement in pain and radiographic union, though long-term benefits remain unproven 1

Carpal Tunnel Syndrome Evaluation

• If symptoms persist or worsen despite bracing, carpal tunnel syndrome should be diagnosed primarily through clinical evaluation combined with electrophysiologic studies 3
• Further imaging for carpal tunnel syndrome is usually not needed, but in selected circumstances, either wrist ultrasound or MRI without contrast may be appropriate 3

Critical Pitfall to Avoid

• Do not dismiss the possibility of occult fracture or ligamentous injury based solely on the presence of old callus formation 2
• The intermittent pain and loss of strength may indicate incomplete healing, instability, or associated soft tissue pathology requiring advanced imaging if conservative management fails 3, 2

If Symptoms Persist Beyond 3 Weeks

• MRI without IV contrast is the appropriate next imaging study when radiographs remain normal or equivocal and the patient has persistent radial-sided wrist pain 3, 2
• This can identify ligamentous injuries, occult fractures, or soft tissue masses (such as ganglion cysts) that commonly cause radial-sided symptoms 2