What are the likely causes and appropriate work‑up and management for persistent pain after wrist surgery?

Post-Operative Wrist Pain: Diagnostic Approach and Management

Begin with plain radiographs of the wrist to evaluate for hardware complications, fracture healing problems, or alignment issues, as this is the appropriate initial imaging study for post-operative wrist pain. 1

Differential Diagnosis of Post-Operative Wrist Pain

The most critical consideration is distinguishing between expected post-operative pain and complications requiring urgent intervention. Key pathologic causes include:

Surgical Complications Requiring Urgent Evaluation

• Hardware-related problems: Screw prominence, plate irritation, or hardware failure visible on radiographs 2
• Infection: Evaluate for fever >38°C, purulent drainage, spreading erythema, or warmth—these mandate immediate surgical consultation 1, 3
• Complex Regional Pain Syndrome (CRPS): Occurs in 4.0% of wrist fracture surgeries and presents with allodynia, temperature/skin changes, swelling, and disproportionate pain 4, 5
• Nerve compression: Median or ulnar nerve compression can develop post-operatively, confirmed by electrophysiologic testing 6
• Tendon complications: Rupture or tenosynovitis from hardware friction, particularly extensor tendons after distal radius fixation 2
• Nonunion or malunion: Particularly relevant for scaphoid fractures 2

Expected Post-Operative Pain

• Persistent post-surgical pain occurs in 18.9% of patients one year after wrist fracture surgery, with 42.8% reporting neuropathic pain characteristics 4

Initial Work-Up Algorithm

Step 1: Clinical Assessment

Immediately evaluate for red flags that indicate complications rather than routine post-operative pain 1:

• Sudden increase in pain intensity (suggests infection, hematoma, or compartment syndrome) 1, 3
• Fever, purulent drainage, or spreading cellulitis (infection) 3
• Disproportionate pain with allodynia, temperature changes, or skin discoloration (CRPS) 4, 5
• Progressive weakness or paresthesias (nerve compression) 6

Step 2: Imaging Strategy

Plain radiographs are the mandatory first imaging study 1:

• Evaluate hardware position, fracture alignment, and healing 2
• Assess for joint congruence and secondary arthritis 1

Advanced imaging is indicated when radiographs are normal or nonspecific 1:

• MRI without IV contrast for suspected tendon injury, ligament problems, or bone marrow edema 1
• MRI with IV contrast if infection or inflammatory tenosynovitis is suspected 1
• CT without contrast for detailed bone healing assessment or hardware evaluation 1
• Ultrasound for tendon pathology, nerve compression (median nerve enlargement in carpal tunnel syndrome), or soft tissue masses 1

Step 3: Specialized Testing

• Electrophysiologic studies if nerve compression is suspected clinically (Tinel's sign, Phalen's test positive) 6
• Laboratory tests (ESR, CRP, CBC) only if infection is suspected 7

Management Algorithm

Immediate Management (First 72 Hours Post-Op)

• Elevation above heart level continuously to reduce swelling 8
• Multimodal analgesia: Scheduled acetaminophen 1g every 6-8 hours PLUS NSAIDs (ibuprofen 400-600mg every 6-8 hours) unless contraindicated 3
• Short-acting opioids only for breakthrough pain (tramadol 50-100mg every 6 hours or oxycodone 5mg every 4-6 hours), avoiding long-acting formulations 3
• Immobilization as prescribed, keeping splint/dressing dry 8

Pain Escalation Beyond Expected Course

If pain worsens or persists beyond 1 week 1:

1. Reassess for complications with focused physical examination and repeat radiographs 1
2. Obtain MRI without IV contrast if radiographs remain normal but clinical suspicion for soft tissue pathology exists 1
3. Consider CRPS diagnosis if pain is disproportionate with autonomic changes—early diagnosis is critical for optimal outcomes 5

Specific Complication Management

For CRPS 5, 6:

• Early aggressive physical therapy with desensitization
• If clinical and electrophysiologic evidence of concurrent nerve compression exists, nerve decompression surgery may hasten recovery despite traditional teaching to avoid surgery in CRPS 6

For nerve compression 6:

• Confirm with nerve conduction studies
• Surgical decompression if conservative management fails, as this can provide immediate resolution of somatic complaints 6

For infection 3:

• Immediate surgical referral for debridement
• Do not simply escalate pain medications when infection is present 3

Critical Pitfalls to Avoid

• Do not attribute escalating pain solely to "normal post-operative course" without excluding complications—sudden pain increase mandates comprehensive evaluation 1, 3
• Do not prescribe long-acting opioids in the post-operative period due to increased harm 3
• Do not delay CRPS diagnosis—it occurs in 4% of wrist surgeries and early treatment is essential 4, 5
• Do not obtain advanced imaging before plain radiographs except in cases of suspected infection requiring urgent intervention 1
• Inform patients preoperatively that persistent pain at 1 year occurs in nearly 19% of cases 4