Workup for Tingling in Wrist
Begin with clinical evaluation combined with electrophysiologic studies to diagnose carpal tunnel syndrome, which is the most common cause of wrist tingling, and obtain standard wrist radiographs as the initial imaging study. 1
Initial Clinical Assessment
The most critical step is determining whether this represents carpal tunnel syndrome (CTS), which is characterized by tingling in the median nerve distribution (thumb, index, middle, and radial half of ring finger). 2
Key clinical features to elicit:
- Distribution of tingling (median nerve territory suggests CTS) 2
- Timing of symptoms (nocturnal symptoms are classic for CTS) 3
- Aggravating factors (repetitive wrist movements, prolonged wrist extension) 4
- Associated weakness or motor symptoms 4
- History of trauma, even remote or vague 5
Physical examination maneuvers:
- Tinel's sign at the wrist (tapping over median nerve)
- Phalen's test (wrist flexion provocation)
- Assessment of thenar muscle atrophy 3
- Sensory testing in median nerve distribution 2
Diagnostic Testing Algorithm
For Suspected Carpal Tunnel Syndrome (Most Common)
Electrophysiologic testing is mandatory before initiating treatment. 1, 3 This includes nerve conduction studies and electromyography to confirm median nerve compression and assess severity. 3, 2
Imaging is usually not needed for CTS diagnosis, but in selected circumstances:
- Wrist ultrasound can measure median nerve size (validated technique) 6
- MRI without contrast may be appropriate if diagnosis remains unclear 1
Initial Imaging for All Wrist Tingling Cases
Standard radiographs (posterior-anterior, lateral, and oblique views) are the most appropriate first imaging study. 1, 6 This establishes baseline evaluation and can identify:
The lateral view is particularly important for demonstrating malalignments and soft-tissue swelling. 6, 7
Advanced Imaging (When Radiographs Are Normal/Equivocal)
MRI without IV contrast is the most appropriate next study when symptoms persist with normal radiographs. 1, 6 MRI accurately depicts:
- Bone marrow abnormalities
- Ligament injuries (TFCC, scapholunate)
- Tendon pathology
- Nerve compression
- Ganglion cysts 6, 7
Location-Specific Differential Diagnosis
Radial-sided tingling:
Ulnar-sided tingling:
- Ulnar nerve entrapment (sensory changes in 4th and 5th digits) 4
- Distal radioulnar joint subluxation 6
- TFCC tears 7
Central wrist:
Laboratory Testing
Laboratory studies are indicated only if inflammatory arthritis is suspected (not typical for isolated tingling): 6
- ESR and CRP
- Rheumatoid factor and anti-citrullinated protein antibodies
- ANA if connective tissue disease suspected
- Joint aspiration if effusion present 6
Common Pitfalls to Avoid
- Do not rely on radiographs alone for CTS diagnosis - electrophysiologic testing is essential 1, 3
- Do not order CT, bone scan, or arthrography for CTS evaluation - these are not routinely used 1
- Do not miss scaphoid fractures - conventional radiography misses up to 30% of cases; use specialized views or repeat imaging in 10-14 days if clinical suspicion remains high 4
- Recognize that detailed history alone leads to specific diagnosis in approximately 70% of wrist pain cases - invest time in thorough history-taking 5
Treatment Considerations for CTS
Conservative therapy is appropriate first-line treatment unless severely advanced: 3
- Wrist splinting (especially nocturnal)
- NSAIDs
- Corticosteroid injection
- Pyridoxine 3
Surgical treatment (open release or endoscopic) is indicated for: