What is the recommended assessment and treatment approach for a patient presenting with wrist pain, swelling, or limited mobility, potentially with a history of repetitive strain injuries or conditions such as rheumatoid arthritis?

Wrist Assessment: Evidence-Based Diagnostic Approach

Initial Imaging Protocol

Begin with standard 3-view radiographs (posteroanterior, lateral, and 45° semipronated oblique views), and strongly consider adding a fourth scaphoid view to maximize diagnostic yield for both distal radius fractures and scaphoid injuries. 1

• The lateral view is critical for identifying malalignments and soft-tissue swelling 1, 2
• Two-view radiographs are inadequate and miss significant pathology 1
• Standard radiographs can establish specific diagnoses including arthritis, fractures, bone tumors, impaction syndromes, and static wrist instability 2
• In bilateral presentations, obtain radiographs of both wrists to assess for symmetry of joint space narrowing (suggesting osteoarthritis or inflammatory arthritis) and bone erosions (suggesting rheumatoid arthritis) 3

Clinical History and Physical Examination Priorities

A detailed history alone leads to a specific diagnosis in approximately 70% of patients with wrist pain. 4

Key Historical Elements to Elicit:

• Spontaneous onset or vague/distant trauma history suggests carpal bone nonunion or avascular necrosis 4
• Repetitive loading activities point toward overuse injuries including tendinopathy or De Quervain tenosynovitis 2, 4
• Bilateral presentation is common in systemic conditions like diabetes, hypothyroidism, or inflammatory arthritis 3

Essential Physical Examination Maneuvers:

• Palpate systematically to localize tenderness to specific anatomic structures 4
• Finkelstein's test for De Quervain tenosynovitis 4
• Watson's test for scapholunate instability 4
• Lunotriquetral shear test for lunotriquetral ligament injury 4
• Phalen's test for carpal tunnel syndrome (note: negative test does not exclude carpal tunnel syndrome or other wrist pathology) 3
• Stress positions during examination can elicit dynamic instability not visible on static radiographs 2

Advanced Imaging Selection Algorithm

When Radiographs Are Normal or Nonspecific:

MRI without IV contrast is the most appropriate next imaging study, changing clinical management in 69.5% of cases and providing reassurance that no further follow-up is necessary in 70% of cases. 5, 2, 3

MRI Without IV Contrast Indications:

• Suspected occult fracture (sensitivity 94.2%, specificity 97.7%) 1
• Radial-sided pain suggesting tendinopathy or ligamentous injury 1
• Central wrist pain suggesting Kienböck disease or ganglion cysts 2
• Evaluation of bones, bone marrow, articular cartilage, ligaments, TFCC, synovium, tendons, and neurovascular structures 2
• Worsening pain 2 weeks post-injury despite negative initial radiographs (red flag requiring immediate MRI) 1

MRI With IV Contrast Indications:

• Suspected inflammatory arthritis to identify active synovitis, inflammatory tenosynovitis, and bone marrow edema (osteitis) 2
• Bone marrow edema on MRI in early rheumatoid arthritis is the best predictor of future disease progression 2
• In research settings, contrast-enhanced MRI identifies synovitis, periarticular bone marrow edema, and tenosynovitis correlating with patient pain in hand osteoarthritis 5

Ultrasound as Alternative or Complementary Imaging:

Ultrasound is contributory to clinical assessment in 76% of patients, confirming clinical suspicion or modifying the diagnostic/therapeutic plan in 67% of non-trauma cases. 5

Ultrasound Strengths:

• Identifies synovitis, joint effusion, tenosynovitis, tendinopathy, and tendon injury 5
• Evaluates for carpal tunnel syndrome and median/ulnar nerve entrapment 5
• Examines extra-articular soft tissues including ganglion cysts 2
• Detects erosions and active synovitis (with power Doppler) in rheumatoid arthritis 2
• Validated technique for measuring median nerve size in carpal tunnel syndrome 2

Ultrasound Limitations:

• Not recommended for evaluation of scapholunate instability 5

CT Without IV Contrast Indications:

• Suspected distal radioulnar joint subluxation (obtain images of both wrists in supination and pronation) 2
• Hook of hamate fractures 1
• Occult fractures when MRI is contraindicated or unavailable 1
• Shorter acquisition times and easier in casted patients 1

Stress Radiographic Views:

• Indicated specifically for diagnosis of scapholunate instability 5

Special Considerations for Repetitive Strain and Rheumatoid Arthritis

Repetitive Strain Injuries:

• MRI without IV contrast accurately depicts tendinopathy, tenosynovitis, and intersection syndromes 5
• Ultrasound effectively diagnoses abnormalities of flexor and extensor tendons and tendon sheaths 2

Rheumatoid Arthritis Patients:

• Acute pain may represent disease flare, superimposed infection, or new fracture 1
• Document extent of erosions, joint space narrowing, and alignment abnormalities on radiographs to guide treatment decisions 1
• Consider laboratory testing: ESR, CRP, RF, ACPA, ANA (if connective tissue disease suspected), HLA-B27 (if spondyloarthropathies suspected) 2
• Perform joint aspiration and synovial fluid analysis when joint effusion is present 2

Critical Pitfalls to Avoid

• Never rely on clinical examination alone when bilateral symptoms suggest systemic disease—imaging is essential 3
• Do not assume a negative Phalen test excludes all wrist pathology; this test is specific for carpal tunnel syndrome only 3
• Avoid bone scan—it lacks specificity and cannot detect soft tissue abnormalities responsible for chronic wrist pain 5, 3
• Do not proceed with CT without IV contrast unless evaluating for occult fracture, as it provides no advantage over radiographs for soft tissue evaluation 3
• Missed scaphoid fractures lead to significant morbidity including nonunion, avascular necrosis, and post-traumatic arthritis 1
• If initial radiographs are negative but clinical suspicion remains high, either place patient in short arm cast and repeat radiographs in 10-14 days, or proceed directly to MRI without IV contrast 1
• Avoid delayed diagnosis by proceeding to MRI or ultrasound when radiographs are nondiagnostic and symptoms persist 3

Management Pending Definitive Diagnosis

• Avoid weight-bearing activities with the affected hand until advanced imaging is obtained to prevent displacement of occult fractures 1
• Consider orthotics (splints, braces) if pain impedes functioning 2
• For osteoarthritis: acetaminophen, NSAIDs, physical activity, and exercise 2
• For inflammatory arthritis: pharmacological treatment according to rheumatology guidelines, physical activity, and exercise 2

Referral Indications

• Refer to hand surgery or orthopedics if MRI reveals scaphoid fracture, ligamentous injury requiring repair, or other surgical pathology 1
• If all studies are negative and clinically significant wrist pain continues, refer to specialist for further evaluation including cineroentgenography, diagnostic arthrography, or arthroscopy 4
• Using the structured algorithmic approach described, a definite diagnosis can be established in 70% of cases, with probable diagnosis in an additional 8% 6