Evaluation of Left Wrist Pain with Known Calcification
Start with standard three-view radiographs (posteroanterior, lateral, and oblique) immediately to characterize the calcification pattern and exclude other pathology, then proceed to MRI without contrast if symptoms persist or radiographs are inconclusive. 1
Initial Imaging Approach
Obtain three-view wrist radiographs first to assess the calcification you've already identified and evaluate for additional pathology 1, 2. The standard posteroanterior, lateral, and oblique views allow assessment of:
- Calcification pattern and location to distinguish acute calcific periarthritis from chronic degenerative calcification 3, 4
- Joint spaces, alignment, and ulnar variance 1
- Bone architecture to exclude fracture, arthritis, or impaction syndromes 1
- Soft tissue swelling patterns 1
Understanding the Calcification
Given the history of calcification, you're likely dealing with one of two entities:
Acute Calcific Periarthritis
- Presents with sudden-onset severe pain, swelling, and erythema that can mimic infection 3, 5, 4
- Radiographs show juxtaarticular amorphous calcium hydroxyapatite deposits near tendon insertions 4
- Self-limited condition with symptom reduction within 4-7 days and radiographic resolution in 2-3 weeks 4
- Treatment is conservative: NSAIDs and splinting provide complete resolution 5
Chronic Calcific Tendinitis
- More indolent presentation with chronic or recurrent pain 3
- Calcifications persist on radiographs for months 4
When to Advance to MRI
If radiographs show only the known calcification but don't explain persistent pain, proceed to MRI without IV contrast 1. This is the most appropriate next study because it accurately depicts 1:
- Bone marrow edema suggesting occult fracture or stress injury
- Ligamentous injuries (scapholunate, lunotriquetral, TFCC)
- Tendon pathology beyond simple calcification
- Cartilage abnormalities
- Synovitis or inflammatory changes
Use a dedicated wrist coil and preferably 3.0T magnet for optimal diagnostic accuracy 1
Alternative Imaging Considerations
Ultrasound
Consider ultrasound if you suspect 1:
- Ganglion cyst (accuracy similar to MRI)
- Tendon sheath pathology or De Quervain tenosynovitis
- Guidance for therapeutic injection of the calcific deposit
CT Without Contrast
Reserve CT for specific scenarios 1:
- Suspected occult fracture when MRI unavailable
- Evaluation of fracture healing if prior trauma
- Distal radioulnar joint subluxation (can image both wrists in supination/pronation)
Critical Clinical Pitfalls
Do not mistake acute calcific periarthritis for infection 3, 5, 4. The combination of acute pain, swelling, erythema, and periarticular calcification on radiographs mimics septic arthritis but requires only conservative treatment, not antibiotics or surgery 3, 4.
Do not obtain MRI with IV contrast routinely 1. There is no literature supporting its use as initial imaging for chronic wrist pain, and it adds minimal diagnostic value unless inflammatory arthritis is specifically suspected 1.
Do not skip radiographs and proceed directly to advanced imaging 1. Radiographs establish the diagnosis in many cases and are essential before considering MRI or CT 1, 6.
Management Algorithm Based on Findings
If Radiographs Show Acute Calcific Periarthritis Pattern
- Treat conservatively with NSAIDs and splinting 5
- Expect symptom improvement within 4-7 days 4
- Follow-up radiographs in 2-3 weeks should show resolution or marked decrease in calcification 4
If Radiographs Are Normal or Show Only Chronic Calcification
- Proceed to MRI without contrast to identify soft tissue pathology 1
- Consider ultrasound if ganglion cyst or specific tendon pathology suspected 1
If All Imaging Is Negative but Pain Persists
- Refer to hand specialist for consideration of diagnostic arthrography or arthroscopy 6