What is the initial assessment and management plan for a teenager presenting with wrist pain?

Assessment and Management of Wrist Pain in a Teenager

Begin with standard radiographs (posterior-anterior, lateral, and oblique views) as the initial imaging study, as this establishes specific diagnoses in the majority of cases and guides all subsequent management decisions. 1

Initial Clinical Assessment

History - Key Elements to Elicit

• Mechanism of injury: Fall on outstretched hand suggests scaphoid fracture (most common carpal fracture), which conventional radiography misses in up to 30% of cases initially 2
• Timing of onset: Acute trauma versus insidious onset without definite injury 2, 3
• Activity patterns: Repetitive wrist extension (cycling, baseball catching) increases risk of ulnar neuropathy; repetitive thumb/wrist use suggests De Quervain tenosynovitis 2
• Pain location: Radial-sided (De Quervain, scaphoid fracture), ulnar-sided (TFCC tear, ulnar neuropathy), or central (ganglion cyst, Kienböck disease) 4, 5
• Associated symptoms: Sensory changes in 4th/5th digits indicate ulnar neuropathy; numbness in thumb/index/middle fingers suggests carpal tunnel syndrome 2

Physical Examination - Specific Maneuvers

• Anatomic snuffbox tenderness: Scaphoid fracture until proven otherwise 2
• Finkelstein test: De Quervain tenosynovitis (radial-sided pain) 2, 3
• Grind test: First carpometacarpal arthritis 2
• Palpation of specific structures: Localize tenderness to guide imaging and diagnosis 3, 6
• Stress positions: Detect dynamic instability not visible on standard radiographs 4, 5

Imaging Algorithm

Step 1: Initial Radiographs (Always First)

Obtain posterior-anterior, lateral, and oblique views in all cases. 1, 4

• Lateral view is critical for identifying malalignments and soft-tissue swelling 4, 5
• For suspected scaphoid fracture, add specialized views (posteroanterior in ulnar deviation, pronated oblique) 2
• If initial radiographs negative but scaphoid fracture suspected clinically, repeat radiographs in 10-14 days 2

Step 2: Advanced Imaging Based on Clinical Suspicion

If radiographs are normal or nonspecific:

For Soft Tissue Pathology (Ligament/TFCC Tears, Occult Fractures)

• MRI without IV contrast is the next appropriate study 4, 5
• MRI accurately depicts bones, bone marrow, articular cartilage, ligaments, TFCC, synovium, tendons, and neurovascular structures 4, 5
• For scaphoid fracture that cannot be confirmed on plain films, MRI or bone scan can be used 2

For Suspected Inflammatory Arthritis

• MRI with IV contrast if inflammatory arthritis suspected based on clinical presentation 1, 4
• Bone marrow edema (osteitis) on MRI is the best predictor of future rheumatoid arthritis progression and functional deterioration 1
• Laboratory tests: ESR, CRP, rheumatoid factor, anti-citrullinated protein antibodies, and consider ANA if connective tissue disease suspected 4

For Specific Conditions

• Ultrasound for suspected ganglion cysts (accuracy similar to MRI), tendon abnormalities, or to measure median nerve size in carpal tunnel syndrome 1, 4, 7
• CT scanning preferred for suspected distal radioulnar joint subluxation (obtain both wrists in supination and pronation) 1, 4

Management Plan

Conservative Treatment (First-Line for Most Conditions)

• NSAIDs or acetaminophen for pain control 4
• Physical activity and exercise for mechanical/degenerative causes 4, 5
• Immobilization: Thumb spica splint for suspected scaphoid fracture until diagnosis confirmed 2
• Orthotics (splints, braces) if pain impedes functioning 4

Condition-Specific Management

• De Quervain tenosynovitis: Splinting, NSAIDs; surgical release if conservative measures fail 2
• Ganglion cysts: Observation acceptable; surgical excision most effective for preventing recurrence (7-39% recurrence rate) 7, 5
• Inflammatory arthritis: Pharmacological treatment per rheumatology guidelines plus physical activity 4, 5

Critical Pitfalls to Avoid

• Never dismiss scaphoid fracture based on initial negative radiographs alone - up to 30% are missed initially; immobilize and repeat imaging or obtain MRI/bone scan 2
• Do not obtain MRI as first-line imaging - radiographs must come first to guide appropriate advanced imaging selection 1
• Recognize that detailed history alone leads to specific diagnosis in approximately 70% of cases - invest time in thorough history taking 3
• If diagnosis remains unclear after initial workup and conservative treatment fails, refer to orthopedic specialist for consideration of arthrography or arthroscopy 8, 3