What is the appropriate evaluation and management for a patient presenting with isolated volar‑ulnar wrist pain without bony tenderness?

Evaluation and Management of Volar-Ulnar Wrist Pain Without Bony Tenderness

Obtain three-view wrist radiographs immediately to exclude fractures and assess ulnar variance, then proceed with 3.0T MRI without contrast as your next imaging study to evaluate for TFCC injury, ECU tendon pathology, and other soft-tissue causes of ulnar-sided wrist pain. 1

Initial Imaging Algorithm

Plain Radiographs (First-Line)

• Order posterior-anterior, lateral, and oblique views to exclude fractures, assess ulnar variance (positive variance suggests ulnocarpal abutment), and identify any static instability patterns 1, 2
• The lateral view is critical for detecting malalignments and soft-tissue swelling 3
• Radiographs are essential for accurate measurement of ulnar variance, which guides differential diagnosis 1, 3

Advanced Imaging (Second-Line)

• 3.0T MRI without contrast is the appropriate next study when radiographs are normal or equivocal 1, 2
• 3.0T systems provide superior accuracy compared to 1.5T for detecting TFCC lesions and ulnocarpal pathology 1, 2
• Standard MRI has 63-100% sensitivity and 42-100% specificity for TFCC tears 1
• Do not routinely order IV contrast—reserve it only for suspected infection or inflammatory arthropathy 1, 2

When to Consider MR Arthrography

• Reserve MR arthrography for specific situations: failed conservative treatment with surgery being considered, equivocal standard MRI findings, or when precise surgical planning requires detailed tear characterization 1
• MR arthrography has higher sensitivity (63-100%) and specificity (89-97%) than standard MRI for TFCC tears 1
• For ulnar-sided TFCC detachments specifically, add a DRUJ injection to the standard radiocarpal injection 1

Alternative Imaging Modalities

• CT arthrography is an excellent alternative when MRI is contraindicated, with nearly 100% sensitivity and specificity for TFCC lesions 1
• Ultrasound by an experienced operator can directly visualize dynamic ECU subluxation during forced supination, providing a bedside diagnostic option 1

Key Differential Diagnoses for Volar-Ulnar Pain

TFCC Injury (Most Common)

• Central disc tears present with ulnar-sided pain, clicking, and weakness 1, 4
• Peripheral tears (Palmer 1B) with foveal detachment compromise DRUJ stability 1
• MRI accurately depicts central TFCC disc lesions using high-resolution sequences 1

ECU Tendon Pathology

• ECU tendonitis, subluxation, or rupture frequently coexists with TFCC tears (found in 11 of 28 surgical cases in one series) 5
• Dynamic subluxation during forced supination produces ulnar-sided pain and limits supination—static MRI frequently misses this, requiring dynamic pronation-supination sequences 1
• ECU pathology is significantly more common in patients with TFCC tears compared to controls 6

Ulnocarpal Abutment Syndrome

• Suspect when positive ulnar variance is present on radiographs 2
• Results from mechanical impaction between the ulnar head and ulnar carpus 2
• 3.0T MRI reveals soft-tissue abnormalities not visible on plain films 2

Flexor Carpi Ulnaris (FCU) Tendonitis

• Presents with volar ulnar pain along the FCU tendon course 4
• Less common than ECU pathology but important to consider 4

Pisotriquetral Arthritis

• Localized tenderness over the pisiform with pain on resisted wrist flexion 4
• Increases with age in both symptomatic and asymptomatic patients 6

DRUJ Instability

• DRUJ arthritis is significantly more common in patients with TFCC tears 6
• CT is the modality of choice for evaluating DRUJ stability—perform bilateral scans in maximal pronation, neutral, and maximal supination 1

Initial Conservative Management Protocol

Immobilization Phase (Weeks 0-4)

• Immobilize the wrist in a custom-fitted splint maintaining neutral wrist alignment and neutral forearm rotation for 4 continuous weeks 1, 2
• Continuous splint wear is critical for successful conservative management 2
• Premature mobilization predicts poor outcomes with persistent pain and functional limitation 2

Mobilization Phase (Weeks 4-8)

• Begin gentle active wrist motion only after completing the full 4-week immobilization period 1, 2
• Initiating motion earlier is associated with treatment failure 2

Strengthening Phase (Weeks 8-12)

• Introduce progressive strengthening exercises between weeks 8 and 12 1, 2
• This gradual loading supports functional recovery after adequate healing 2

Return to Activity

• Resume heavy tasks and sports no sooner than 3 months from treatment initiation, provided all phases are completed without persistent symptoms 2

Common Pitfalls and Caveats

• Do not rely on conventional arthrography alone—it has only 76% sensitivity for full-thickness tears and misses partial-thickness tears entirely 1
• Beware of incidental MRI findings—high rates of asymptomatic TFCC and other pathology exist, so imaging must be clinically correlated 7
• Look for associated pathologies—isolated ECU or TFCC lesions are rare; expect coexistent injuries including lunotriquetral ligament tears (4 of 28 cases), ulnar styloid non-unions (4 of 28 cases), and anomalous tendon slips (7 of 28 cases) 5
• Consider arthroscopy when diagnosis remains unclear—it remains the gold standard for definitive diagnosis and can provide both diagnosis and treatment in the same procedure 1