What is the diagnosis and treatment for medial wrist pain?

Medial (Ulnar-Sided) Wrist Pain: Diagnosis and Treatment

For medial wrist pain, obtain standard radiographs (PA, lateral, and oblique views) as the initial imaging study, followed by MRI without contrast if radiographs are normal or nonspecific, to evaluate the triangular fibrocartilage complex (TFCC), lunotriquetral ligament, ulnocarpal impaction, and tendon pathology. 1, 2

Initial Diagnostic Approach

First-Line Imaging

• Obtain standard radiographs immediately including posterior-anterior, lateral (in neutral position), and oblique views to evaluate for fractures, arthritis, distal radioulnar joint (DRUJ) subluxation, ulnar impaction syndrome, and bone architecture abnormalities 1, 2
• The lateral view is particularly critical for demonstrating malalignments and soft-tissue swelling 1
• Consider stress positioning during radiography to elicit dynamic DRUJ instability not visible on standard views 1

Key Clinical Distinctions

When evaluating medial wrist pain, focus your history and examination on:

• Acute trauma versus chronic overuse: Acute injuries suggest fractures or ligament tears, while repetitive stress indicates tendinitis or degenerative conditions 3, 4
• Pain with forearm rotation: Suggests DRUJ instability or TFCC pathology 3
• Pain with grip strength: Indicates TFCC tears or lunotriquetral ligament injury, as these structures are critical for grip mechanics 3, 4
• Morning stiffness and joint swelling: Raises concern for inflammatory arthritis requiring different workup 2

Common Causes of Medial Wrist Pain

The differential diagnosis includes:

• TFCC tears: Most common cause of ulnar-sided pain, particularly in athletes performing rotational movements 4, 5
• Ulnocarpal impaction syndrome: Results from positive ulnar variance causing chronic loading 4, 5
• Lunotriquetral ligament tears: Causes instability and pain with ulnar deviation 4, 5
• DRUJ instability: Presents with pain during forearm rotation 1, 5
• Extensor carpi ulnaris (ECU) tendonitis: Extra-articular cause from repetitive wrist extension 5
• Flexor carpi ulnaris (FCU) tendonitis: Overuse syndrome from repetitive flexion 6, 5
• Pisotriquetral arthritis: Degenerative condition at the pisiform-triquetrum articulation 5

Advanced Imaging Selection

When Radiographs Are Normal or Nonspecific

• Order MRI without IV contrast as the next study to evaluate soft tissue structures including TFCC, ligaments, tendons, bone marrow, and cartilage 1, 2
• MRI accurately depicts abnormalities of bones, bone marrow, articular cartilage, intrinsic and extrinsic ligaments, TFCC, synovium, tendons, and neurovascular structures 7, 1
• MRI is highly accurate for central TFCC disc tears 2

For Specific Clinical Scenarios

• CT scanning with bilateral wrist imaging in supination and pronation is preferred when DRUJ subluxation is suspected, as it allows comparison and dynamic assessment 7, 1
• MR arthrography or CT arthrography may be needed for peripheral TFCC tears and has higher sensitivity for complete and incomplete lunotriquetral ligament tears compared to standard MRI 8, 2
• Direct MR arthrography demonstrates higher sensitivity than non-contrast MRI for diagnosing ligament tears 8
• Ultrasound is appropriate for evaluating ECU or FCU tendonitis, tenosynovitis, and can identify active synovitis with power Doppler 1, 2

If Inflammatory Arthritis Is Suspected

• Order MRI with IV contrast as enhancing bone marrow edema (osteitis) is the best predictor of future disease progression in early rheumatoid arthritis 1, 2
• Obtain ESR, CRP, rheumatoid factor, and anti-citrullinated protein antibodies 1
• Perform joint aspiration with synovial fluid analysis if effusion is present 1

Treatment Algorithm

Conservative Management (First-Line)

• Rest with splinting, ice, and NSAIDs for acute tendinitis and overuse syndromes 6
• Acetaminophen or NSAIDs combined with physical activity and exercise for degenerative conditions 1
• Consider orthotics (splints, braces) if pain impedes functioning 1

Surgical Intervention

• Surgical decompression is indicated for chronic or recurrent compression syndromes unresponsive to conservative treatment 6
• Arthroscopic resection of the hamate head for confirmed hamato-lunate impingement with chondromalacia 9
• TFCC repair or debridement, ulnar shortening osteotomy for ulnar impaction, or ligament reconstruction depending on specific pathology identified 4, 5

Critical Pitfalls to Avoid

• Do not rely on radiographs alone for ulnar-sided wrist pain—up to 50% of significant soft tissue pathology (TFCC tears, ligament injuries) will be missed without advanced imaging 4
• Standard MRI may miss peripheral TFCC tears; if clinical suspicion remains high despite negative MRI, proceed to MR arthrography or CT arthrography 2
• Ulnar-sided wrist pain has been termed the "black box" of the wrist due to overlapping anatomy—systematic imaging progression is essential 4