Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Wrist Pain

Basics

Description
  • Wrist pain, a common symptom, may be caused by different conditions, including trauma, overuse, and infection.
    • It is important to obtain a detailed history to make the correct diagnosis and to provide appropriate treatment.
    • The history should include onset, duration, frequency, and location of the pain.
    • Information regarding swelling, erythema, abnormal clicks, aggravating activities, ROM, sensory changes, motor strength, and general health conditions is essential.
  • Classification:
    • Traumatic
    • Inflammatory
    • Degenerative
    • Infectious
    • Neurologic
Pregnancy Considerations
If numbness is present as well, it is most likely CTS.
Associated Conditions
  • Rheumatoid arthritis
  • History of trauma
  • Osteoarthritis
  • Gout
Diagnosis
Signs and Symptoms
  • The location of wrist pain is indicative of the cause.
  • Patients may present with swelling and pain localized as radial wrist pain, dorsal wrist pain, ulnar wrist pain, palmar wrist pain, or general wrist pain.
Physical Exam
  • Radial wrist pain:
    • De Quervain tenosynovitis:
      • Caused by inflammation of the 1st dorsal compartment (extensor pollicis brevis and abductor pollicis longus)
      • The patient may provide a history of repetitive wrist activities.
      • Finkelstein test (with thumb flexed into palm, pain is reproduced by ulnar deviation of the wrist) usually is positive.
    • Scaphoid fracture:
      • Patients usually have a history of trauma, most often a fall on an outstretched arm.
      • Tender to palpation over anatomic snuffbox
  • Dorsal wrist pain:
    • Tenosynovitis of extensor tendons:
      • The patient usually presents complaining of pain in the dorsum of the wrist that may radiate proximally and distally.
      • Usually, the patient has a history of repetitive activities and overuse.
      • Pain occurs on flexion and extension.
      • Pain with resisted extension
      • Sometimes, a sharply demarcated scalloped edge of the extensor synovial sheath can be palpated with wrist motion.
    • Ganglion cyst:
      • This cyst is the most common mass on the dorsal surface of the wrist.
      • Most arise from the scapholunate ligament.
      • Generally, they are movable and transilluminate light.
      • The size of a cyst may vary with time.
    • Extensor carpi ulnaris tendinitis:
      • Pain over this tendon with combined supination and ulnar deviation against resistance
  • Ulnar wrist pain:
    • Distal radioulnar joint instability:
      • Usually history of trauma to the wrist
      • Pain is located at the distal radioulnar joint, especially with pronation and supination.
      • Instability can be palpated or visualized with stress loading.
      • Radiographs may show increased space between the distal radius and ulna; if radiography is inconclusive, CT may be helpful.
    • Flexor carpi ulnaris tendinitis:
      • Pain at the flexor carpi ulnar usually is detected on resisted wrist flexion and ulnar deviation.
    • Fracture of the hook of the hamate:
      • Patients (especially golfers and tennis players) have a history of direct impact to the ulnar palm.
      • Pain occurs on palpation of hamate and resisted flexion of 4th and 5th fingers (1).
      • Radiographs of the wrist in the carpal tunnel view show the fracture.
    • TFCC tear:
      • Ulnar-sided wrist pain, often with clicking
      • Pain with axial load while rotating the ulnar-deviated wrist
  • Palmar wrist pain:
    • Flexor tenosynovitis:
      • Similar to extensor tenosynovitis
      • The patient usually presents with a history of overuse of the wrist.
      • Pain, located on the palmar aspect of the wrist, is aggravated with wrist motion and with resisted wrist flexion; it may radiate proximally or distally.
    • CTS:
      • Most common compression neuropathy in the upper extremity.
      • Patients often complain of pain around the wrist, numbness and tingling in the radial 3 digits, clumsiness, and weakness.
      • Patients frequently wake up at night with numbness in the fingers.
      • Tinel test of the carpal tunnel and Phalen test may be positive.
      • Decreased sensibility in median nerve distribution and thenar atrophy are late signs.
  • General wrist pain:
    • Arthritis:
      • Patients with inflammatory arthritis and osteoarthritis involving the radiocarpal, intercarpal, and CMC joints present with pain in the wrist.
      • Patients with osteoarthritis may have a history of trauma.
      • Swelling, stiffness, and decreased ROM usually are present.
      • Patients with inflammatory arthritis, especially rheumatoid arthritis, have swelling of tendon sheaths and synovial thickening.
      • Deformity of joints is a sign of advanced disease.
      • Radiographs of patients with osteoarthritis generally show narrowing of joint space, subchondral sclerosis, and osteophytes.
      • Radiographs of patients with inflammatory arthritis show narrowing of joint space, osteopenia, bone erosion, and deformity.
    • Wrist infection:
      • Immunocompromised patients or those with a history of intravenous drug use are at higher risk than the general population.
      • Pain, swelling, erythema, decreased ROM, and other cardinal signs of infection may be present.
      • Increased pain with ROM is characteristic.
      • Elevated leukocyte count, ESR, and C-reactive protein are signs of infection.
      • Joint fluid analysis: Findings of >80,000 white blood cells and >75% polymorphs strongly suggest a septic joint. (Absolute white blood cell counts may vary and overlap with other conditions.)

P.485
Tests
Lab
White blood cell count, ESR, and C-reactive protein are indicated to assess for infection.
Imaging
  • Radiography:
    • Plain AP, lateral, and oblique radiographs are obtained to look for fracture, with a carpal tunnel view for fracture of the hook of the hamate.
    • A scaphoid view is used to assess scaphoid fractur.
  • MRI may be useful in the diagnosis of TFCC tear.
Differential Diagnosis
  • Radial wrist pain:
    • De Quervain tenosynovitis
    • Scaphoid fracture or nonunion
    • Thumb CMC arthritis
    • Radiocarpal arthritis
  • Dorsal wrist pain:
    • Tenosynovitis of extensor tendons
    • Ganglion cyst
    • Extensor carpi ulnaris tendinitis
  • Ulnar wrist pain:
    • Distal radioulnar joint instability
    • Flexor carpi ulnaris tendinitis
    • Fracture of the hook of the hamate
    • TFCC tear
  • Palmar wrist pain:
    • Flexor tenosynovitis
    • CTS
    • Palmar ganglion
  • General wrist pain:
    • Arthritis
    • Infection
Treatment
General Measures
  • Tendinitis and tenosynovitis can be treated with rest, modification of activity, ice, immobilization, NSAIDs, and local injection of steroid if warranted.
  • Nondisplaced fractures should be treated with immobilization and NSAIDs.
  • Rheumatoid arthritis of the wrist should be treated by a rheumatologist as a component of general systemic condition.
  • Ganglion cysts may be aspirated (if dorsal) or excised.
  • Patients with mild to moderate CTS symptoms can be treated nonoperatively (oral anti-inflammatory medicine, wrist splint, and activity modification).
    • Nonoperative interventions are unlikely to cure the condition but they may alleviate the symptoms enough to obviate the need for surgical intervention.
    • Injection of cortisone to the carpal tunnel may be indicated for persistent CTS before considering surgical management.
  • Patients with wrist infections should be admitted to a hospital.
    • After joint fluid is sent for culture and sensitivity, intravenous antibiotics should be started as soon as possible.
    • Open irrigation usually is indicated, but serial aspiration of the joint is also an acceptable means of treatment.
    • After hospital discharge, antibiotics usually are continued for several weeks; early ROM is paramount in preserving long-term joint function.
Medication
First Line
  • NSAIDs
  • Local steroid injection for tenosynovitis and tendinitis in persistent case
  • Intravenous antibiotics for wrist infection
Surgery
  • De Quervain tenosynovitis: A few patients require surgical release of the 1st dorsal compartment.
  • Displaced scaphoid fracture: Internal fixation
  • Distal radioulnar joint instability:
    • If the TFCC is involved, treatment is controversial.
    • Patients who cannot be treated by immobilization may require arthroscopy and open repair of the TFCC tear.
    • If accompanied by intra-articular and extra-articular fracture of the distal radius or ulna, fixation of fracture and Kirschner wire pinning of the distal radioulnar joint instability are indicated.
  • Fracture of the hook of the hamate:
    • This fracture tends to be displaced, and the incidence of nonunion is high if it is left untreated.
    • If the fragment is small, its surgical excision is recommended.
    • For a fracture at the hook’s base, open reduction and internal fixation are recommended.
  • Flexor tenosynovitis:
    • Surgical tenolysis is indicated for chronic recalcitrant tendinitis.
  • CTS:
    • Surgical release (considered definitive treatment) is indicated when nonoperative treatment has failed or when signs of advanced CTS (including decreased sensibility, muscle atrophy, and substantial nerve conduction study and electromyographic changes) exist.
  • Arthritis:
    • Surgical intervention (e.g., arthroplasty, resection, fusion) is reserved for patients with severe symptoms in whom nonoperative treatment has failed.
Follow-up
Prognosis
Most cases can be largely alleviated by 1 of the forementioned methods.
Miscellaneous
Codes
ICD9-CM
  • 714.0 Rheumatoid arthritis
  • 727.04 De Quervain tenosynovitis
  • 727.41 Ganglion of joint
  • 814.01 Scaphoid fracture
Patient Teaching
Patients with work-related CTS may alleviate the condition by job modification.
FAQ
Q: What causes radial-side wrist pain?
A: The most common cause is de Quervain tenosynovitis (inflammation of the 1st dorsal compartment tendons characterized by tenderness and a positive Finkelstein test). The 2nd most common cause is thumb CMC arthritis (tender at CMC joint and positive grind test). The 3rd is radiocarpal arthritis (characterized by pain with radial deviation of the wrist). With a history of trauma, one also should consider a scaphoid fracture as a possible diagnosis.
Q: What must be considered in ulnar-side wrist pain?
A: The differential diagnosis includes TFCC, distal radioulnar joint instability, flexor carpi ulnaris tendinitis, and fracture of the hook of the hamate.

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