How should I assess and initially manage a patient presenting with wrist pain or suspected wrist pathology?

Assessment of the Wrists

Begin with plain radiographs (posterior-anterior, lateral, and oblique views) as the first-line imaging study for all patients presenting with wrist pain, followed by a focused history and physical examination to guide further management. 1, 2

Initial Clinical Assessment

Key History Elements

• Onset and mechanism: Acute trauma (fall on outstretched hand suggests scaphoid fracture), spontaneous onset, or repetitive loading activities may indicate carpal bone nonunion or avascular necrosis 3, 4
• Pain location: Radial-sided pain (De Quervain tenosynovitis, scapholunate ligament injury), ulnar-sided pain (TFCC tears, ulnar nerve entrapment), or dorsal pain (ganglion cysts, Kienböck disease) 2, 5, 4
• Morning stiffness and joint swelling: These symptoms raise concern for inflammatory arthritis and warrant different imaging approach 2
• Sensory symptoms: Tingling in median nerve distribution suggests carpal tunnel syndrome; fourth and fifth digit numbness indicates ulnar neuropathy 5, 4

Physical Examination Maneuvers

• Palpation: Localize tenderness to specific anatomic structures (scaphoid tubercle, anatomic snuffbox, STT joint, TFCC) 3, 6
• Special tests: Finkelstein's test (De Quervain), Watson's test (scapholunate instability), lunotriquetral shear test, grind test (thumb CMC arthritis) 3, 4
• Neurovascular assessment: Tinel's sign at carpal tunnel, two-point discrimination, thenar muscle bulk 5, 4

Initial Imaging Protocol

Standard Radiographs (First-Line for All Patients)

• Views required: Posterior-anterior in neutral position, lateral, and oblique views 1, 2
• Assessment parameters: Bone architecture, alignment, joint space width and symmetry, soft tissues 2, 7
• Diagnostic yield: Identifies fractures, arthritis, bone tumors, impaction syndromes, and static wrist instability 5

Critical pitfall: Conventional radiography alone misses up to 30% of scaphoid fractures; if clinical suspicion is high with negative initial films, obtain specialized views (posteroanterior in ulnar deviation, pronated oblique) and repeat radiography in 10-14 days 4

Advanced Imaging Algorithm

When Radiographs Are Normal or Equivocal

MRI without IV contrast is the next appropriate study for persistent symptoms with unclear diagnosis. 1, 2, 8

• Advantages: Accurately depicts bone marrow abnormalities, cartilage, intrinsic and extrinsic ligaments, TFCC, synovium, tendons, and neurovascular structures 2, 8
• Radial-sided pain: MRI without contrast is usually appropriate, though direct MR arthrography has higher sensitivity for complete and incomplete ligament tears 2, 8
• Ulnar-sided pain: MRI is highly accurate for central TFCC tears; MR arthrography or CT arthrography may be needed for peripheral TFCC tears 2
• Suspected occult scaphoid fracture: MRI or bone scan can identify radiographically occult fractures 5, 4

Inflammatory Arthritis Pathway

For suspected inflammatory arthritis, MRI with IV contrast is recommended, as enhancing bone marrow edema is the best predictor of disease progression in early rheumatoid arthritis. 1, 2

• Alternative: Ultrasound with power Doppler can identify active synovitis and predict erosion progression 1, 2
• Laboratory studies: Order ESR, CRP, rheumatoid factor, and anti-citrullinated protein antibodies only when inflammatory arthritis is suspected 5

Carpal Tunnel Syndrome

Diagnosis requires clinical evaluation combined with electrophysiologic studies (nerve conduction studies and electromyography); imaging is usually not needed. 1, 5

• When imaging is appropriate: In selected circumstances with uncertain clinical diagnosis, either wrist ultrasound or MRI without contrast may be used to confirm median nerve compression 1, 5
• Ultrasound technique: Measuring median nerve size is a validated diagnostic method 1

Specific Clinical Scenarios

Suspected ganglion cyst or palpable mass: MRI without IV contrast, MRI with IV contrast, or wrist ultrasound are all usually appropriate 1

Kienböck disease without radiographic confirmation: MRI without IV contrast is usually appropriate; once radiographically confirmed, further imaging is usually not necessary unless staging is needed (CT or MRI) 1

Prior scaphoid fracture with chronic pain: Either CT or MRI without IV contrast to evaluate for fracture complications (nonunion, avascular necrosis) 1, 7

Common Pitfalls to Avoid

• Do not skip radiographs: Even when clinical diagnosis seems clear, radiographs establish baseline and may reveal unexpected findings 1, 2
• Do not order CT or CT arthrography routinely: These are not first-line studies for chronic wrist pain without specific clinical indication 1
• Do not rely on imaging alone for carpal tunnel syndrome: Electrophysiologic testing is mandatory before treatment 5
• Do not delay specialist referral: When diagnosis remains unclear despite appropriate imaging, or when conservative management fails, refer to hand surgeon for potential arthroscopy or advanced diagnostic procedures 3, 7

Initial Management Considerations

• Suspected infection: Perform aspiration before imaging 1
• Ultrasound-guided injections: Useful for therapeutic intra-articular and soft-tissue injections once diagnosis is established 1
• Timing matters: Delayed diagnosis of certain pathologies (scaphoid nonunion, scapholunate instability) can lead to poor outcomes including diffuse wrist osteoarthritis 7