I experienced sudden ulnar‑sided wrist pain while lifting a frying pan; what is the likely diagnosis and recommended evaluation and treatment?

Sudden Ulnar-Sided Wrist Pain While Lifting: Diagnosis and Management

You most likely have a triangular fibrocartilage complex (TFCC) tear, and should begin with three-view wrist radiographs immediately, followed by 3.0T MRI without contrast if radiographs are normal or nonspecific. 1, 2

Most Likely Diagnosis

TFCC injury is the most common cause of acute ulnar-sided wrist pain following a lifting mechanism, particularly when the wrist is loaded in extension and supination (the typical position when lifting a frying pan). 3, 4 The TFCC functions as both a shock absorber across the ulnocarpal joint and a stabilizer of the distal radioulnar joint (DRUJ), making it vulnerable to injury during sudden loading activities. 3, 5

Alternative Diagnoses to Consider

• Extensor carpi ulnaris (ECU) tendon subluxation or tendinopathy can produce similar ulnar-sided pain, especially if you experience symptoms during forearm rotation or supination. 6, 7
• Lunotriquetral ligament tear may present with ulnar-sided pain but is less common than TFCC injury in acute lifting injuries. 4
• Ulnocarpal abutment syndrome typically presents with chronic rather than acute onset pain, though it can be exacerbated by loading. 1

Diagnostic Evaluation Algorithm

Step 1: Initial Imaging (Immediate)

Obtain three-view wrist radiographs (posterior-anterior, lateral, and oblique views in neutral position) to exclude fractures and assess ulnar variance. 1, 2 The lateral view is particularly important for demonstrating soft-tissue swelling and malalignment. 6

Step 2: Advanced Imaging (If Radiographs Normal or Nonspecific)

Order 3.0T MRI without intravenous contrast as your next study. 1, 2, 8 This is the American College of Radiology's recommended approach because:

• 3.0T MRI has 63-100% sensitivity and 42-100% specificity for TFCC tears, superior to 1.5T systems. 2, 8
• It accurately depicts the TFCC, intrinsic and extrinsic ligaments, ECU tendon pathology, and DRUJ stability. 2
• Do not order IV contrast routinely—it provides no diagnostic benefit for mechanical injuries like TFCC tears and only adds cost and gadolinium exposure. 8

Step 3: When to Escalate Imaging

Reserve MR arthrography or CT arthrography for specific situations only: 2, 8

• When conservative treatment has failed and you are considering surgery
• When standard MRI findings are equivocal or non-diagnostic
• For precise surgical planning when you need to characterize the exact tear pattern and location

CT arthrography achieves nearly 100% sensitivity and specificity for both TFCC and ligament tears, outperforming all other modalities, but should be reserved for pre-operative planning. 2, 8

Important Imaging Pitfall

If you suspect ECU tendon subluxation, standard static MRI frequently misses this diagnosis. 2 You need either:

• Dynamic MRI sequences performed in pronation and supination, or
• Dynamic ultrasound during forced supination to visualize tendon subluxation in real-time. 6, 2

Initial Treatment Protocol

Phase 1: Immobilization (Weeks 0-4)

Immobilize your wrist in a custom-fitted splint maintaining neutral wrist alignment and neutral forearm rotation for a full 4 weeks. 1 This is critical—premature mobilization is a predictor of treatment failure and persistent symptoms. 1

During this phase:

• Complete abstinence from activities that stress the wrist (lifting, gym exercises, yoga poses involving wrist loading). 3
• NSAIDs for pain control. 3
• Consider corticosteroid injection in conjunction with physical therapy if symptoms are severe. 3

Phase 2: Mobilization (Weeks 4-8)

Begin gentle active wrist motion only after completing the full 4-week immobilization period. 1 Starting motion earlier is associated with poor outcomes. 1

Phase 3: Strengthening (Weeks 8-12)

Introduce progressive strengthening exercises between weeks 8 and 12. 1

Phase 4: Return to Activity

Resume heavy lifting and full activities no sooner than 3 months from treatment initiation, provided you have completed all phases without persistent symptoms. 1

When Surgery Is Indicated

Surgical intervention is appropriate if: 3, 9

• Conservative management fails to provide relief after completing the full 12-week protocol
• You present with frank DRUJ instability
• MRI or arthrography confirms a peripheral TFCC tear (Palmer 1B) with foveal detachment

Arthroscopic foveal repair with suture anchor is the preferred surgical approach for peripheral TFCC tears, as it restores the anatomic attachment critical for DRUJ stability. 2 Arthroscopy also allows identification of associated ligament injuries that may be missed on imaging. 2

Critical Clinical Pearls

• The combination of ECU tendon pathology and TFCC injury can occur concurrently, particularly in athletes performing forceful rotational movements. 7 If symptoms persist after treating one structure, investigate the other.
• Ulnar variance on radiographs matters: positive ulnar variance increases the risk of ulnocarpal abutment and TFCC degeneration. 1
• Non-contrast MRI has only fair sensitivity for peripheral TFCC attachments, so if your clinical suspicion remains high despite negative standard MRI, escalate to MR arthrography. 8