What is the diagnosis and treatment for lateral wrist pain in an adult patient?

Lateral Wrist Pain: Diagnosis and Treatment

Initial Diagnostic Approach

Begin with standard radiographs (posterior-anterior, lateral, and oblique views) as the first-line imaging study, which can establish specific diagnoses including arthritis, fracture complications, impaction syndromes, static wrist instability, and bone tumors. 1, 2

Key Radiographic Considerations:

• The lateral view is critical for identifying malalignments and soft-tissue swelling 1
• Stress positions and maneuvers should be performed to detect dynamic instability not visible on standard views 1, 2
• Radiographs are necessary for accurate measurement of ulnar variance 1

Location-Specific Differential Diagnosis

Radial-Sided Lateral Wrist Pain:

• De Quervain tenosynovitis (extra-articular pathology) 2
• Scapholunate ligament tears 1
• Ganglion cysts 2, 3

Central Wrist Pain:

• Kienböck disease (avascular necrosis of the lunate) 2
• Ganglion cysts 2, 3

Ulnar-Sided Pain:

• Distal radioulnar joint subluxation 2
• TFCC (triangular fibrocartilage complex) tears 1

Advanced Imaging When Radiographs Are Normal or Nonspecific

MRI without IV contrast is the most appropriate next study for persistent lateral wrist pain with normal radiographs, as it accurately depicts bones, bone marrow, articular cartilage, ligaments, TFCC, synovium, tendons, and neurovascular structures. 1, 2

MRI Indications by Location:

For radial-sided pain:

• Non-contrast MRI is highly accurate for diagnosing scapholunate ligament tears 1
• Direct MR arthrography (with intra-articular contrast injection) has higher sensitivity than non-contrast MRI for complete and incomplete scapholunate ligament tears and allows more accurate determination of which specific ligament segments are torn 1
• CT arthrography may be more sensitive for tears of the biomechanically important dorsal ligament fibers 1

For ulnar-sided pain:

• MRI is highly accurate for TFCC lesions involving the radial (central) zone of the disc, especially with high-resolution sequences 1
• 3.0 T MRI systems may be more accurate than 1.5 T systems for TFCC lesions 1
• Sensitivity for tears of the ulnar attachment and peripheral TFCC attachments is only fair with non-contrast MRI 1

Alternative Imaging Modalities:

Ultrasound is particularly useful for:

• Confirming suspected ganglion cysts (fluid-filled nature) with accuracy similar to MRI 2, 3
• Diagnosing flexor and extensor tendon abnormalities and tenosynovitis 2
• Identifying De Quervain tenosynovitis 2
• Measuring median nerve size if carpal tunnel syndrome is suspected 2

CT scanning is preferred for:

• Suspected distal radioulnar joint subluxation, where bilateral wrist images in supination and pronation are needed 2

When to Consider Inflammatory Conditions

If inflammatory arthritis is suspected based on clinical presentation, obtain MRI with IV contrast to identify active synovitis, inflammatory tenosynovitis, and bone marrow edema (osteitis). 2

Laboratory Testing for Inflammatory Conditions:

• ESR and CRP for diagnosis and prognosis of undifferentiated peripheral inflammatory arthritis 2
• Rheumatoid Factor (RF) and Anti-Citrullinated Protein Antibodies (ACPA) as predictive markers for rheumatoid arthritis 2
• Joint aspiration and synovial fluid analysis when joint effusion is present 2

Treatment Approach

For Mechanical/Degenerative Causes:

• Acetaminophen and NSAIDs for pain control 2
• Physical activity and exercise as recommended by the American College of Radiology 2
• Orthotics (splints, braces) if pain impedes functioning 2

For Ganglion Cysts:

• Surgical excision is the most effective treatment for preventing recurrence (recurrence rates 7-39%) 3
• Ultrasound-guided aspiration may be considered for initial management 3

For Inflammatory Arthritis:

• Pharmacological treatment according to rheumatology guidelines combined with physical activity and exercise 2

Critical Pitfalls to Avoid

• Do not rely on bone scintigraphy, as it lacks specificity and cannot detect soft-tissue abnormalities (ligaments, tendons, cartilage) that commonly cause lateral wrist pain 1
• Conventional x-ray arthrography alone has been largely supplanted by CT arthrography, MRI, and MR arthrography due to limited anatomic detail 1
• Be aware that patients with depression and/or anxiety may report higher pain scores (average 1.2 points higher) and may be less likely to improve with traditional treatments 4