What is the diagnosis and treatment for a female patient with bilateral wrist pain and a bump on the anterior left hand, exacerbated by holding a phone?

Bilateral Wrist Pain with Anterior Hand Bump: Diagnosis and Management

The most likely diagnosis is a ganglion cyst on the anterior left hand causing the palpable bump, with bilateral wrist pain potentially representing either bilateral ganglion cysts, overuse tendinopathy (such as de Quervain tenosynovitis), or carpal tunnel syndrome, and you should start with plain radiographs followed by ultrasound for definitive diagnosis. 1, 2

Initial Diagnostic Approach

Clinical Assessment

• Pain exacerbated by holding a phone suggests repetitive wrist loading or flexion, which points toward overuse tendinopathy, nerve compression, or ganglion cyst as primary considerations 3, 4
• The palpable bump on the anterior left hand is highly suggestive of a ganglion cyst, which is a common cause of chronic wrist pain 1, 2
• Bilateral involvement raises consideration for systemic inflammatory conditions, though the presence of a unilateral mass makes ganglion cyst with bilateral overuse more likely 1

Physical Examination Priorities

• Palpate the bump to confirm it is soft, mobile, and fluctuant (characteristic of ganglion cyst) 2
• Perform Finkelstein's test to evaluate for de Quervain tenosynovitis if pain is radial-sided 5
• Assess for anatomic snuffbox tenderness to rule out scaphoid pathology 3
• Check for median nerve compression signs (Tinel's and Phalen's tests) if symptoms include numbness or tingling 4, 6

Imaging Algorithm

First-Line Imaging

Obtain plain radiographs (posteroanterior and lateral views) as the mandatory initial study for all patients with chronic wrist pain to evaluate bony architecture, rule out fractures, and assess joint spaces 1, 7

Second-Line Imaging

Ultrasound is the recommended next step to confirm the fluid-filled nature of the ganglion cyst, with accuracy similar to MRI and the added benefit of dynamic assessment and contralateral comparison 2, 7, 4

• Ultrasound can simultaneously evaluate extensor and flexor tendon pathology, including de Quervain tenosynovitis 1, 7
• MRI without IV contrast is appropriate if ultrasound is inconclusive or if there is concern about occult pathology such as ligament tears, cartilage abnormalities, or solid tumors 1

Advanced Imaging Considerations

• MRI is particularly useful for suspected occult ganglion cysts or when differentiating from solid tumors 2
• CT arthrography and MR arthrography are not appropriate for initial evaluation and should be reserved for complex cases after consultation 1

Treatment Strategy

For Ganglion Cyst

If the ganglion cyst is causing significant symptoms, treatment options include:

• Initial conservative management with observation, activity modification, and immobilization for patients with mild symptoms 4, 6
• Aspiration can provide temporary relief but has >50% recurrence rate within one year 4
• Corticosteroid injection after aspiration does not provide additional benefit 4
• Surgical excision is the most effective treatment for preventing recurrence, with recurrence rates of 7-39%, and should be considered for severe or persistent symptoms 2, 7

For Bilateral Wrist Pain (If Tendinopathy or Overuse)

Conservative management should include:

• Activity modification to avoid repetitive wrist flexion/extension, particularly reducing phone holding time or using ergonomic supports 7, 4
• NSAIDs for short-term pain relief (2-3 weeks maximum), with topical formulations having fewer systemic side effects 8
• Splinting or bracing to reduce repetitive loading 4, 6
• Physical or occupational therapy with eccentric exercises if tendinopathy is confirmed 7

For Suspected Carpal Tunnel Syndrome

If median nerve symptoms are present:

• Ultrasound-guided corticosteroid injection shows significant improvement over 12 weeks compared to landmark-guided injections 4
• Splinting in neutral wrist position, particularly at night 6
• Surgical referral if conservative treatment fails after 3-6 months 7, 8

Common Pitfalls to Avoid

• Do not dismiss the bilateral nature of pain—while the bump is unilateral, bilateral symptoms may indicate systemic inflammatory arthritis requiring different workup 1
• Do not rely on radiographs alone to diagnose ganglion cysts, as they are often nondiagnostic for soft tissue masses 2
• Do not perform aspiration without ultrasound confirmation of the cystic nature, as solid tumors can mimic ganglion cysts 2
• Do not overlook nerve compression syndromes (carpal tunnel or ulnar neuropathy) in patients with pain exacerbated by specific hand positions like holding a phone 4, 6

Follow-Up Strategy

• If conservative management is chosen, reassess in 6-8 weeks for symptom improvement 4
• For persistent symptoms despite conservative treatment, repeat MRI at least every 6 months until resolution 2
• Refer to hand surgery if pain persists despite 3-6 months of well-managed conservative treatment 7, 8