What is the next best step in managing a 33-year-old male with no known past medical history, presenting with right wrist and hand pain, primarily involving the thumb and index finger, with pain radiating up to the elbow, worsened by activity and prolonged computer use, who has shown limited response to initial treatment with prednisone (corticosteroid) 20mg daily and diclofenac sodium (nonsteroidal anti-inflammatory drug)?

Management of Refractory Wrist and Hand Pain with Radial Distribution

The next best step is to obtain plain radiographs of the wrist and hand to rule out structural pathology, followed by focused physical examination maneuvers to differentiate between de Quervain tenosynovitis, thumb carpometacarpal (CMC) joint arthritis, and other radial-sided pathologies. 1, 2

Immediate Diagnostic Approach

Initial Imaging

• Plain radiographs are the most appropriate first imaging study for chronic wrist pain involving the thumb and index finger with radiation to the elbow 1, 3
• Obtain standard posteroanterior and lateral views to evaluate bony architecture, joint spaces, and soft tissue calcification 1, 4
• Radiographs can identify thumb CMC arthritis, occult fractures, or other structural abnormalities that would alter management 1, 2

Focused Physical Examination

After failed conservative treatment, specific examination maneuvers are critical to narrow the diagnosis:

For de Quervain tenosynovitis (most likely given computer mouse use):

• Finkelstein test: Ulnar deviation of the wrist with thumb flexed into palm reproduces pain over the radial styloid 2, 5
• Grind test should be negative to distinguish from thumb CMC arthritis 5
• Tenderness and swelling localized to the first dorsal extensor compartment at the radial wrist 2

For thumb CMC arthritis:

• Grind test: Axial compression with rotation of the thumb metacarpal reproduces pain at the CMC joint base 2
• Affects approximately 33% of postmenopausal women but can occur in younger patients with repetitive use 2
• Radiographs will show joint space narrowing, osteophytes, or subluxation if present 1

For scapholunate ligament instability or scaphoid pathology:

• Watson's test (scaphoid shift test) reproduces pain with dorsal displacement of the scaphoid 3, 6
• Anatomic snuffbox tenderness suggests scaphoid involvement 3, 4

Why Initial Treatment Failed

The lack of response to prednisone and diclofenac suggests:

• Either the diagnosis is incorrect (not primarily inflammatory), or structural pathology is present that requires different intervention 7, 8
• Corticosteroids are more effective for acute flares but do not change long-term outcomes in tendinopathies 8, 9
• NSAIDs provide only short-term pain relief without addressing underlying pathology 8, 2

Next Steps Based on Findings

If de Quervain tenosynovitis is confirmed:

• Corticosteroid injection combined with immobilization relieves symptoms in approximately 72% of patients 2
• Thumb spica splint for 3-6 weeks to reduce repetitive loading 8, 9
• Ergonomic modification of computer workstation and mouse use 2
• If symptoms persist after injection, surgical release of the first dorsal compartment is safe and effective 2

If thumb CMC arthritis is confirmed:

• Thumb spica splinting for immobilization 2
• Intra-articular corticosteroid injection may provide short-term relief for painful flares 1
• NSAIDs and activity modification as conservative measures 1
• Surgery (trapeziectomy or interposition arthroplasty) should be considered for marked pain and disability when conservative treatments fail after 3-6 months 1

If radiographs are normal or nonspecific:

• MRI of the wrist is indicated to evaluate for occult fracture, ligamentous injury, tendon pathology, or early avascular necrosis 1, 4
• MRI is particularly useful for scapholunate ligament tears, triangular fibrocartilage complex injuries, and tendinopathy not visible on plain films 1, 5

Common Pitfalls to Avoid

• Do not continue empiric anti-inflammatory treatment without establishing a specific diagnosis 3, 4
• Delayed diagnosis of scaphoid fracture nonunion can lead to diffuse wrist osteoarthritis 4
• Avoid direct corticosteroid injection into tendon substance, which may inhibit healing and predispose to rupture 9
• Computer mouse use is a specific risk factor for de Quervain tenosynovitis that requires ergonomic intervention, not just medication 2
• Most overuse tendinopathies recover within 3-6 months with appropriate conservative treatment; if not improving, reconsider the diagnosis 9

Referral Considerations

• Refer to hand surgery if diagnosis remains unclear after imaging, symptoms persist beyond 3-6 months of appropriate conservative treatment, or if advanced imaging (CT, MRI) suggests structural pathology requiring surgical intervention 1, 3, 4
• Diagnostic arthroscopy may be needed if all studies are negative but clinically significant pain continues 3