What is the best course of action for a patient with persistent wrist pain following a pulling injury, not improving with conservative measures for 6 months, and experiencing pain during push-ups?

Wrist Pain Following Pulling Injury: Management After 6 Months of Failed Conservative Treatment

At 6 months without improvement, you must obtain MRI without IV contrast to identify the underlying structural pathology—occult dorsal ganglion cysts, scapholunate ligament tears, TFCC injuries, or occult fractures are highly likely and require definitive diagnosis before further treatment. 1, 2

Immediate Diagnostic Workup

If Not Already Done: Plain Radiographs First

• Obtain standard posteroanterior, lateral, and dedicated scaphoid views immediately if radiographs haven't been performed 1, 3
• These establish baseline bony architecture and identify fracture malunion, carpal malalignment, or arthritis 1
• However, radiographs will miss most soft tissue pathology causing your patient's symptoms 1

Proceed Directly to MRI Without IV Contrast

• MRI is the definitive next study when pain persists beyond 6 months with normal or nonspecific radiographs 1, 3
• MRI accurately depicts occult fractures, bone marrow edema, ligament tears (especially scapholunate and TFCC), tendon pathology, and occult dorsal ganglion cysts 1, 3, 2
• In patients with dorsal wrist pain during push-ups specifically, MRI demonstrates identifiable dorsal abnormalities in 84% of cases 2

Most Likely Diagnoses Based on Mechanism

Occult Dorsal Ganglion Cyst (Most Common)

• Occult dorsal ganglion cysts are the most common cause (76%) of dorsal wrist pain during extended wrist loading positions like push-ups 2
• These are often not palpable on examination but clearly visible on MRI 2
• Pain occurs specifically with wrist extension under load 2

Scapholunate Ligament Injury

• Partial scapholunate tears are the second most common finding in patients with push-up-related wrist pain 2
• Pulling injuries create traction forces that can tear intercarpal ligaments 4
• Delayed diagnosis can lead to progressive carpal instability and arthritis 5, 6

TFCC Tear

• Forceful pulling with ulnar-sided loading commonly causes TFCC tears 4
• These require MRI or MR arthrography for definitive diagnosis 1

Occult or Stress Fracture

• Scaphoid fractures are particularly concerning as they can progress to nonunion and avascular necrosis if missed 1, 3
• Repetitive loading during push-ups can cause stress fractures not visible on initial radiographs 3
• MRI is highly sensitive for detecting occult fractures and bone bruises 3

Critical Management Decision Point

When Conservative Measures Fail at 6 Months

• The British Pain Society guidelines explicitly state that when management has not been effective at 6 months, you must reassess the patient, re-evaluate the management plan, and consider referral to specialist care 1
• Continuing the same conservative approach beyond 6 months without advanced imaging or specialist input is inappropriate 1

Referral to Hand Surgeon or Wrist Specialist

• Refer when all imaging studies are negative but clinically significant wrist pain continues, or when MRI reveals structural pathology requiring surgical consideration 5
• Specialist evaluation may include diagnostic arthrography or arthroscopy 5
• Specific structural lesions (ganglion cysts, ligament tears, TFCC tears) often require surgical intervention for definitive treatment 2

Common Pitfalls to Avoid

Do Not Continue Indefinite Conservative Treatment

• Pain persisting beyond 4-6 weeks crosses into "chronic wrist pain" requiring systematic diagnostic approach, not continued conservative measures 3
• Home exercises alone show comparable results to therapist-led therapy but have limited overall effectiveness for chronic wrist pain 7

Do Not Rely on Clinical Examination Alone

• Ligamentous injuries, TFCC tears, and occult ganglion cysts require imaging for diagnosis—clinical examination is insufficient 1, 4
• Physical examination may miss 84% of structural abnormalities in patients with push-up-related dorsal wrist pain 2

Do Not Miss Occult Scaphoid Fractures

• Scaphoid fractures may not be visible on initial radiographs and require MRI or dedicated scaphoid views 4, 3
• Delayed diagnosis leads to nonunion, avascular necrosis, and chronic disability 3, 5, 6

Do Not Assume All Symptoms Are From the Pulling Injury

• Consider that the pulling mechanism may have unmasked pre-existing pathology 4
• Evaluate for cervical radiculopathy if there are neurological symptoms, as neck pathology can mimic wrist conditions 4

Algorithmic Approach

1. Obtain plain radiographs if not already done (PA, lateral, scaphoid views) 1, 3
2. Proceed immediately to MRI without IV contrast given 6-month duration and failed conservative treatment 1, 3
3. Based on MRI findings:
   • Structural lesion identified (ganglion, ligament tear, TFCC tear, fracture) → Refer to hand surgeon 5, 2
   • MRI negative but pain persists → Refer to specialist for consideration of diagnostic arthrography or arthroscopy 5
4. Do not continue conservative treatment beyond 6 months without advanced imaging and specialist consultation 1