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A Clinical Approach to Diagnosing Wrist Pain TODD A A Clinical Approach to Diagnosing Wrist Pain TODD A. FORMAN, M.D., M.S.ED., The Keck School of Medicine, University of Southern California, Los Angeles, California SCOTT K. FORMAN, M.D., Newport Beach, California NICHOLAS E. ROSE, M.D., Harbor-University of California, Los Angeles, Medical Center, Torrance, California A detailed history alone may lead to a specific diagnosis in approximately 70 percent of patients who have wrist pain. Patients who present with spontaneous onset of wrist pain, who have a vague or distant history of trauma, or whose activities consist of repetitive loading could be suffering from a carpal bone nonunion or from avascular necrosis. The hand and wrist can be palpated to localize tenderness to a specific anatomic structure. Special tests can help support specific diagnoses (e.g., Finkelstein’s test, the grind test, the lunotriquetral shear test, McMurray’s test, the supination lift test, Watson’s test). When radiography is indicated, the posterior-anterior and lateral views are essential to evaluate the bony architecture and alignment, the width and symmetry of the joint spaces, and the soft tissues. When the diagnosis remains unclear, or when the clinical course does not improve with conservative measures, further imaging modalities are indicated, including ultrasonography, technetium bone scan, computed tomography, and mag- netic resonance imaging. If all studies are negative and clinically significant wrist pain continues, the patient may need to be referred to a specialist for further evaluation, which may include cine- roentgenography, diagnostic arthrography, or arthroscopy. (Am Fam Physician 2005;72:1753-8. Copyright © 2005 American Academy of Family Physicians.) Members of various rimary care physicians often are the complaint involving the upper extremity. family medicine depart- first to evaluate and treat a patient The proximal row of bones in the wrist ments develop articles for “Problem-Oriented with wrist pain. Although the wrist (i.e., scaphoid, lunate, triquetrum, and pisi- Diagnosis.” This is one consists of a complicated group of form) articulate with the distal ends of the in a series from the Pbony articulations and soft tissues, many radius and ulna in a constrained space to Department of Family Medicine at the University family physicians often use wastebasket diag- allow three degrees of freedom at the wrist of Southern California, noses such as “wrist sprain” or “tendonitis” (Figure 1). Relative to the forearm, these Los Angeles. Coordinator that do little to identify the true pathol- hand movements include flexion-extension, of the series is Ricardo G. ogy of the condition. Despite the challenges pronation-supination, and radial or ulnar Hahn, M.D. this complex of joints presents, physicians deviation. Relative stability of such mobility are gaining a better understanding of wrist requires a coordinated system of ligaments, pathophysiology through an array of diag- muscles, and tendons. nostic capabilities. Hand and wrist injuries have a major eco- Generally, the causes of wrist pain can be nomic impact through health care costs and divided into three categories: mechanical, workers’ compensation claims. A study12 of neurologic, and systemic. Table 11-11 lists workers’ compensation claims in Washing- common mechanical causes of wrist pain, ton state from 1987 to 1995 demonstrated an their clinical presentations, and suggested incidence rate for hand and wrist disorders imaging work-ups. Table 21,2 lists other com- of 98.2 cases per 10,000 persons, higher than mon causes of wrist pain. Psychosocial fac- any other musculoskeletal condition related tors can also have a profound influence on to an industrial injury claim. Furthermore, wrist pain, particularly when the patient the average claim was around $7,500.12 For may be eligible for workers’ compensation. carpal tunnel syndrome alone, direct annual With the dawn of the computer age, wrist costs in the United States are estimated at and hand pain became the most common $1 billion.13 November 1, 2005 U Volume 72, Number 9 www.aafp.org/afp American Family Physician 1753 Wrist Pain TABLE 1 Mechanical Causes of Wrist Pain Cause Clinical presentation Imaging Fracture History of trauma and bony tenderness Radiography Occult fractures identified with delayed radiography, CT, MRI, or bone scan Nonunion of scaphoid History of trauma with TTP at the anatomic Radiography (“scaphoid view” [scaphoid] or hook of the hamate snuffbox (scaphoid) and the proximal or the carpal tunnel and supinated hypothenar area 1 cm distal to flexion oblique views [hamate]) crease of the wrist (hamate) MRI Avascular necrosis of the scaphoid Variable history of trauma with TTP at the Delayed radiography (Preiser’s disease) or the lunate scaphoid or lunate MRI (Kienböck’s disease) Ligament tear Triangular fibrocartilage TTP in distal hollow between pisiform MRI complex and ulnar styloid Arthroscopy may be necessary to rule out a false-negative MRI Distal radioulnar joint Pain, instability with radioulnar Radiography (widened distal radioulnar subluxation “grind” test joint space on PA view—usually normal) MRI, cineroentgenography, or arthroscopy Carpal instability Midcarpal TTP with a painful and audible Cineroentgenography “clunk” on ulnar deviation Scapholunate dissociation TTP at scapholunate interval Radiography (“clenched-fist” and supinated oblique views) De Quervain’s tenosynovitis TTP along radial aspect of distal radius Ultrasonography may show synovial thickening Intersection syndrome TTP and crepitus along dorsal aspect — of distal radius Neoplasm or ganglion Mass and TTP Ultrasonography CT = computed tomography; MRI = magnetic resonance imaging; TTP = tenderness to palpation; PA = posterior-anterior. Information from references 1 through 11. History If the wrist has sustained direct trauma, the nature of A detailed history alone may lead to a specific diagnosis the injury must be considered, including the force, fre- in approximately 70 percent of wrist pain cases.1 The quency, and direction of the event. Direct palmar trauma physician must characterize the precise nature of the from swinging a baseball bat or golf club may result in pain, including its quality, radiation, severity, and timing, a hook-of-the-hamate fracture (i.e., golfer’s fracture). as well as palliative and aggravating factors. In addition, Patients presenting with a spontaneous onset of wrist the patient should point with one finger to the most pain- pain and a vague or distant history of trauma or repeti- ful area and indicate where the pain radiates. tive loading activities could be suffering from a carpal A mechanical cause of wrist pain is suggested when bone nonunion or avascular necrosis. The scaphoid and the wrist has sustained a specific trauma. It is important hamate are the most common bones to have nonunion to have patients describe the injury in their own words; after a fracture because their blood supplies are delicate acting out the traumatic event can be particularly use- and prone to complete disruption.14 An idiopathic avas- ful. The physician must consider the age of the patient cular necrosis usually occurs at the lunate (Kienböck’s when evaluating the mechanism of injury. For example, disease) or the scaphoid (Preiser’s disease). Symptoms the injury resulting from a fall on the outstretched hand of nonunion and avascular necrosis may not become with wrist extended will vary depending on the patient’s apparent for years after injury because dead bone frag- age. This dorsiflexion injury will typically cause a green- ments cause chronic hypermobility or irritation, which stick fracture in a toddler, a growth plate fracture in an eventually leads to inflammation and arthritis with adolescent, a scaphoid fracture in a young adult, and swelling, pain, and loss of grip strength.1,15 a Colles’ (distal radius) fracture in an older adult with When a patient presents with excessive extension and osteoporosis. with ulnar or radial deviation following an acute injury 1754 American Family Physician www.aafp.org/afp Volume 72, Number 9 U November 1, 2005 Wrist Pain TABLE 2 Additional Causes of Wrist Pain Neurologic causes Distal posterior interosseous nerve syndrome common in gymnasts and in racquetball, tennis, and Injury of median nerve (carpal tunnel syndrome) hockey players; based on history alone, it is difficult to Injury of radial nerve differentiate from extensor carpi ulnaris, tendonitis, or Injury of ulnar nerve (Guyon’s canal) subluxation.14 Thoracic outlet compression syndrome Tendinopathy can occur with underlying bony or Systemic causes soft tissue injuries. For example, a tear of the extensor Amyloidosis pollicis longus can occur with a minimally displaced 17 Granulomatous disease (e.g., sarcoid, tuberculosis) distal radius fracture. An extensor tendon rupture is Hematologic disease (e.g., leukemia, multiple myeloma) common in patients with rheumatoid arthritis, particu- Metabolic conditions (e.g., acromegaly, diabetes, gout, larly when accompanied by clinically evident extensor hyperparathyroidism, hypocalcemia, hypothyroidism, tenosynovitis.18,19 A flexor tendon laceration may occur Paget’s disease, pregnancy, pseudogout) with repetitive attrition of a tendon against a hook-of- Osteomyelitis the-hamate nonunion.20 Peripheral neuropathy If the patient has not experienced a specific trauma, Reflex sympathetic dystrophy (complex regional pain the physician must consider the patient’s vocational and syndrome) recreational activities for possible causes
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