What is the best course of treatment for a 43-year-old active duty male with bilateral wrist pain, worsened by lifting or gripping, and a history of degenerative changes in the left wrist, presenting with pain in the scaphoid area, distal radius, and lateral styloid, and full range of motion (ROM) but pain with resistance?

Treatment Approach for Bilateral Wrist Pain with Degenerative Changes

Begin with conservative management including wrist splinting in neutral position, NSAIDs, activity modification, and physical therapy, while obtaining bilateral three-view wrist radiographs to characterize the known degenerative changes and exclude other pathology. 1

Initial Conservative Treatment (First 6-8 Weeks)

• Wrist splinting in neutral position to reduce mechanical stress on the degenerative joints, particularly important given the pain pattern that worsens with lifting and gripping 1
• NSAIDs for pain control and inflammation management 1
• Activity modification is critical for an active duty service member—avoid repetitive wrist motions, heavy lifting, and hard gripping activities that provoke symptoms 1
• Physical therapy should focus on range of motion exercises once acute pain subsides, then progress to strengthening exercises at 8-12 weeks 1

Diagnostic Imaging Strategy

Immediate Radiographic Evaluation

• Obtain bilateral three-view wrist radiographs (posteroanterior, lateral, and oblique views) to characterize the extent of degenerative changes beyond the previously documented first carpal joint calcification 2, 3
• Radiographs should assess for joint space narrowing, ulnar variance, alignment abnormalities, and progression of degenerative changes at the scaphoid-trapezium-trapezoid (STT) joint and other carpal articulations 2, 3
• The bilateral nature and specific pain localization (scaphoid area, distal radius, lateral styloid) suggests possible STT arthritis or early SLAC (scapholunate advanced collapse) pattern, which follows specific degenerative patterns in 95% of wrist arthritis cases 4

Advanced Imaging if Conservative Treatment Fails

• MRI without IV contrast is the next appropriate study if pain persists beyond 6-8 weeks of conservative treatment with normal or nonspecific radiographs 1, 3
• MRI can identify bone marrow edema, early cartilage loss, ligamentous injuries, tendon pathology, and synovitis that may not be apparent on radiographs 3
• Use a dedicated wrist coil, preferably with a 3.0T magnet, for optimal diagnostic accuracy 3

Clinical Reasoning for This Patient

Key Diagnostic Considerations

• The bilateral presentation with known degenerative changes in the left first carpal joint space suggests STT (triscaphe) arthritis, which accounts for 26% of wrist arthritis cases and causes pain at the scaphoid area with gripping activities 4
• The morning stiffness pattern that improves throughout the day is characteristic of degenerative arthritis 5
• Pain with resistance during flexion and radial/ulnar deviation with preserved ROM and strength suggests early-stage degenerative disease without significant structural instability 5
• The absence of trauma history with bilateral involvement points toward primary degenerative changes rather than post-traumatic arthritis 6

Important Clinical Pitfalls to Avoid

• Do not skip radiographs and proceed directly to MRI—radiographs establish the diagnosis in many cases and are essential baseline imaging 3
• Do not routinely order MRI with IV contrast, as it adds minimal diagnostic value unless inflammatory arthritis is specifically suspected 3
• Do not delay conservative treatment while waiting for imaging results—begin splinting, NSAIDs, and activity modification immediately 1

Surgical Referral Indications

Refer to orthopedic surgery if: 1

• Persistent symptoms after 6-8 weeks of appropriate conservative treatment
• Progressive functional impairment affecting military duties despite conservative measures
• Confirmed ligamentous injury or advanced degenerative changes on imaging

Surgical Options for STT Arthritis (If Conservative Treatment Fails)

• Distal scaphoid excision with or without void filling 5
• STT arthrodesis (fusion of scaphoid, trapezium, and trapezoid) for isolated triscaphe arthritis 5, 4
• Total wrist denervation provides pain relief in 80% of cases while preserving motion and strength, with no age limit 7, 6
• Four-corner fusion with scaphoid excision if SLAC pattern develops 6

Prognosis and Expectations

• Conservative treatment success rate: Approximately 80% of patients with early degenerative wrist arthritis respond to conservative management 7
• Surgical outcomes: STT arthrodesis and partial wrist fusion procedures result in pain-free wrists in 80% of cases with 50% of mobility preserved and stable results for at least 10 years 7
• For an active duty service member, early aggressive conservative management is essential to maintain military readiness and potentially avoid surgical intervention 1