Orthopaedic Surgery - Wrist Pain

Basics

Wrist pain is a common clinical complaint with many possible causes, including:

Trauma

Overuse

Degenerative disease

Inflammatory disease

Infection

and

Neurologic disorders.

A detailed history and focused physical examination are essential for establishing the:

Correct diagnosis

and selecting appropriate:

Treatment.

History

Important historical features include:

Onset

Duration

Frequency

and

Exact location of pain.

Additional symptoms should be documented, including:

Swelling

Erythema

Clicking or snapping

Loss of motion

Numbness or tingling

Weakness

and relationship to:

Specific activities.

General Medical History

Ask about conditions that may contribute to wrist disease, including:

Rheumatoid arthritis

Osteoarthritis

Gout

Diabetes

Immunosuppression

and previous:

Infection or trauma.

Classification

Wrist pain can broadly be classified as:

Traumatic

Inflammatory

Degenerative

Infectious

or

Neurologic.

Common Causes

Frequent causes include:

Fracture

Fracture nonunion

Arthritis

Tendinitis or tendinopathy

and

Ligament injury.

Epidemiology

Wrist pain is particularly common among:

Athletes

and individuals involved in repetitive:

Upper-extremity activity.

Athletes

Historical studies have reported wrist pain in approximately:

32–73% of young athletes

depending on the sport and population studied.

Emergency Department Visits

In the United States, wrist injuries have historically accounted for approximately:

2.5% of emergency department visits.

Pregnancy Considerations

Pregnant patients with wrist discomfort accompanied by:

Numbness

or

Tingling

should be evaluated for:

Carpal tunnel syndrome.

Fluid retention during pregnancy can increase pressure within the:

Carpal tunnel.

Associated Conditions

Systemic disorders associated with wrist pain include:

Rheumatoid arthritis

Osteoarthritis

Gout

and

Infection.

Diagnostic Approach

The location of pain is highly useful for narrowing the:

Differential diagnosis.

Wrist pain can be categorized anatomically as:

Radial-sided

Dorsal

Ulnar-sided

Volar or palmar

or

Diffuse.

Radial-Sided Wrist Pain

Important causes include:

de Quervain tenosynovitis

Intersection syndrome

Scaphoid fracture

Scapholunate ligament injury

Wartenberg syndrome

and

Thumb CMC or STT arthritis.

de Quervain Tenosynovitis

de Quervain disease is a stenosing tenosynovitis involving the:

First dorsal compartment.

The affected tendons are:

Abductor pollicis longus

and

Extensor pollicis brevis.

Typical History

Patients often report repetitive:

Thumb

or

Wrist activity.

Pain is localized near the:

Radial styloid.

Eichhoff / Finkelstein-Type Maneuver

With the thumb flexed into the palm and the wrist moved into:

Ulnar deviation

sharp pain over the first dorsal compartment supports the diagnosis.

The commonly performed thumb-in-fist maneuver is more accurately termed the:

Eichhoff test.

Alternative Provocative Testing

Wrist hyperflexion combined with thumb abduction may also reproduce:

First-compartment pain.

Intersection Syndrome

Intersection syndrome is an overuse disorder occurring where the:

First dorsal compartment tendons

cross the:

Second dorsal compartment tendons.

Location

Pain is typically located approximately:

4 cm proximal to the dorsal wrist.

Cause

It is usually associated with repetitive:

Wrist extension

and

Forearm motion.

Scaphoid Fracture

Patients typically report trauma, especially:

A fall on an outstretched hand.

Examination

Suggestive findings include tenderness at the:

Anatomic snuffbox

Scaphoid tubercle

and pain with:

Axial compression of the thumb ray.

Active thumb motion may also produce:

Pain.

Scapholunate Ligament Injury

Scapholunate ligament injury can produce:

Radial-dorsal wrist pain

and

Mechanical instability.

Watson Test

The:

Scaphoid shift or Watson test

is used to assess:

Scapholunate instability.

Pain, abnormal scaphoid translation, or a reproducible:

Clunk

may support the diagnosis.

Definitive Diagnosis

When uncertainty remains, wrist:

Arthroscopy

remains the most definitive method of directly evaluating the:

Scapholunate ligament.

Wartenberg Syndrome

Wartenberg syndrome results from irritation of the:

Superficial radial sensory nerve.

Cause

Mechanical compression can occur from:

Watches

Bracelets

or other constrictive objects.

Symptoms

Patients experience:

Burning

Numbness

or

Tingling

over the:

Dorsoradial wrist and hand.

Thumb CMC and STT Arthritis

Arthritis involving the:

First carpometacarpal joint

or

Scaphotrapeziotrapezoid joint

can cause radial-sided wrist pain.

Grind Test

A positive:

CMC grind test

supports symptomatic thumb:

CMC arthritis.

Dorsal Wrist Pain

Important causes include:

Extensor tenosynovitis

Ganglion cyst

and other dorsal:

Tendon or ligament disorders.

Extensor Tenosynovitis

Patients typically report:

Dorsal wrist pain

that may radiate:

Proximally

or

Distally.

Cause

The condition is often associated with:

Repetitive activity

and

Overuse.

Examination

Pain may occur with:

Wrist flexion

Wrist extension

and particularly:

Resisted extension.

Synovial Thickening

In some cases, thickened extensor synovium can be palpated during:

Wrist motion.

Ganglion Cyst

A ganglion cyst is the most common mass found on the:

Dorsal wrist.

Origin

Many dorsal ganglia arise near the:

Scapholunate ligament.

Examination

Ganglion cysts are often:

Mobile

and may:

Transilluminate.

Their size may change:

Over time.

Imaging of Ganglion Cyst

Diagnosis is usually clinical.

If uncertain, or if the lesion is in an unusual location,:

Ultrasound

or

MRI

may be useful.

Ulnar-Sided Wrist Pain

Important causes include:

Distal radioulnar joint instability or arthritis

FCU tendinopathy

ECU tendinopathy

Hook of hamate fracture

TFCC tear

Ulnocarpal impaction

and

Lunotriquetral ligament injury.

Distal Radioulnar Joint Instability

Pain is usually localized over the:

Distal radioulnar joint

and is worsened by:

Pronation

and

Supination.

DRUJ Examination

Instability may be assessed by translating the:

Ulna

relative to a stabilized:

Radius.

Piano-Key Sign

Abnormal mobility of the distal ulna may produce a:

Piano-key sign.

DRUJ Imaging

Radiographs may demonstrate abnormal:

Distal radioulnar spacing or alignment.

If radiographs are inconclusive,:

CT

can help evaluate:

DRUJ congruity and instability.

DRUJ Arthritis

Degenerative changes may include:

Joint-space narrowing

Subchondral sclerosis

and

Osteophytes.

Flexor Carpi Ulnaris Tendinopathy

FCU tendinopathy produces pain near the:

Volar-ulnar wrist.

Examination

Pain is typically reproduced by:

Resisted wrist flexion

and

Ulnar deviation.

Extensor Carpi Ulnaris Tendinopathy

ECU tendinopathy causes pain along the:

Dorsal-ulnar wrist.

Examination

Pain may be reproduced by resisted:

Ulnar deviation

particularly with the forearm in:

Supination.

Hook of Hamate Fracture

This injury is particularly important in athletes such as:

Golfers

and

Racquet-sport players.

Mechanism

The injury may result from direct pressure or impact through:

A club

Bat

or

Racquet handle

against the:

Ulnar palm.

Examination

Tenderness is present over the:

Hook of the hamate.

Pain may also be reproduced with resisted flexion of the:

Ring and small fingers.

Imaging

A:

Carpal tunnel view

or CT may be needed because standard radiographs may fail to show the:

Fracture.

TFCC Tear

A triangular fibrocartilage complex tear typically causes:

Ulnar-sided wrist pain

often accompanied by:

Clicking.

TFCC Provocative Test

Pain may be reproduced by:

Axial loading

while rotating an:

Ulnar-deviated wrist.

Ulnocarpal Impaction

Ulnocarpal impaction syndrome causes pain with:

Grip

particularly when the forearm is:

Pronated.

Ulnar Variance

The condition is more common when there is:

Positive ulnar variance.

Lunotriquetral Ligament Injury

Lunotriquetral ligament injury may produce:

Ulnar-sided wrist pain

and

Instability.

LT Shuck Test

The lunate and triquetrum are moved in opposite directions.

Findings such as:

Pain

Crepitus

or excessive:

Translation

support an LT ligament injury.

Volar Wrist Pain

Common causes include:

Flexor tenosynovitis

Carpal tunnel syndrome

and

Volar ganglion cyst.

Flexor Tenosynovitis

Patients usually describe:

Palmar wrist pain

associated with repetitive:

Overuse.

Examination

Pain is worsened by:

Wrist motion

and

Resisted wrist flexion.

Symptoms may radiate:

Proximally

or

Distally.

Carpal Tunnel Syndrome

CTS is the most common:

Compression neuropathy of the upper extremity.

Symptoms

Patients may report:

Wrist discomfort

Numbness

Tingling

Clumsiness

and

Weakness.

Sensory Distribution

Symptoms typically involve the:

Thumb

Index finger

Middle finger

and

Radial half of the ring finger.

Nocturnal Symptoms

Patients frequently awaken at night with:

Numbness or paresthesias.

Provocative Tests

Useful maneuvers include:

Tinel sign

Phalen test

and

Flexion-compression testing.

Late CTS Findings

Advanced median neuropathy may produce:

Reduced sensation

and

Thenar atrophy.

Generalized Wrist Pain

Diffuse pain may result from:

Osteoarthritis

Inflammatory arthritis

or

Infection.

Osteoarthritis

Degenerative arthritis may affect the:

Radiocarpal

Intercarpal

or

CMC joints.

History

Patients may have a history of:

Previous trauma

or longstanding:

Degeneration.

Examination

Typical findings include:

Pain

Stiffness

Swelling

and

Reduced range of motion.

Osteoarthritis Radiographs

Common findings include:

Joint-space narrowing

Subchondral sclerosis

and

Osteophyte formation.

Inflammatory Arthritis

Inflammatory disorders such as:

Rheumatoid arthritis

may cause:

Synovitis

Tendon-sheath swelling

and later:

Joint deformity.

Inflammatory Arthritis Radiographs

Possible findings include:

Joint-space narrowing

Periarticular osteopenia

Bone erosions

and

Deformity.

Wrist Infection

Septic arthritis of the:

Radiocarpal joint

is uncommon but potentially destructive.

Risk Factors

Risk is increased in:

Immunocompromised patients

and individuals with a history of:

Intravenous drug use.

Signs of Infection

Possible findings include:

Severe pain

Swelling

Erythema

Warmth

and

Marked reduction in motion.

Pain With Motion

Severe pain with:

Passive and active wrist motion

is particularly concerning for:

Septic arthritis.

Laboratory Findings

Possible abnormalities include elevated:

White blood cell count

ESR

and

CRP.

Normal serum tests do not completely exclude:

Infection.

Joint Aspiration

When septic arthritis is suspected, the joint should be:

Aspirated urgently.

Synovial fluid should be sent for:

Cell count

Differential

Gram stain

and

Culture.

Synovial WBC

A very high synovial leukocyte count with a predominance of:

Neutrophils

strongly supports infection.

Historical thresholds such as:

>80,000 cells/µL with >75% polymorphonuclear cells

have been described, but no single value alone confirms or excludes:

Septic arthritis.

Laboratory Tests

Laboratory evaluation is most useful when:

Infection

or systemic inflammatory disease is suspected.

Infection Markers

Obtain:

CBC

ESR

and

CRP

when evaluating possible:

Septic arthritis.

Imaging

Plain Radiographs

Initial imaging usually includes:

PA

Lateral

and

Oblique wrist radiographs.

Scaphoid View

A dedicated:

Scaphoid view

is useful when a:

Scaphoid fracture

is suspected.

Carpal Tunnel View

A:

Carpal tunnel view

can improve visualization of the:

Hook of hamate.

MRI

MRI, preferably with high-resolution technique, may be useful for suspected:

TFCC

Scapholunate

or

Lunotriquetral ligament tears.

Limitations of MRI

MRI findings should be interpreted in combination with:

History

and

Physical examination

because incidental abnormalities can occur.

Differential Diagnosis

Radial-Sided Pain

Consider:

de Quervain tenosynovitis

Scaphoid fracture or nonunion

Scapholunate ligament injury

Thumb CMC arthritis

STT arthritis

Radiocarpal arthritis

and

Wartenberg syndrome.

Dorsal Pain

Consider:

Extensor tenosynovitis

Ganglion cyst

and

ECU tendinopathy.

Ulnar-Sided Pain

Consider:

DRUJ instability

FCU tendinopathy

ECU tendinopathy

Hook of hamate fracture

TFCC tear

Ulnocarpal impaction

and

Lunotriquetral ligament injury.

Volar Pain

Consider:

Flexor tenosynovitis

Carpal tunnel syndrome

and

Volar ganglion cyst.

Generalized Pain

Consider:

Osteoarthritis

Inflammatory arthritis

and

Infection.

Treatment

Treatment depends entirely on the:

Underlying diagnosis.

Tendinitis and Tenosynovitis

Initial treatment may include:

Rest

Activity modification

Cold therapy

Immobilization

and

NSAIDs.

Corticosteroid Injection

Selected persistent tendon-sheath disorders may benefit from:

Local corticosteroid injection.

Nondisplaced Fractures

Stable nondisplaced fractures are generally treated with:

Immobilization

and appropriate:

Analgesia.

Rheumatoid Arthritis

Rheumatoid wrist disease requires treatment of the underlying systemic:

Inflammatory disorder.

Management should be coordinated with a:

Rheumatologist.

Ganglion Cyst

Observation is appropriate for many asymptomatic:

Ganglion cysts.

Aspiration

Dorsal ganglia may be:

Aspirated

but recurrence is:

Common.

Excision

Surgical excision generally has a lower recurrence rate than:

Aspiration

but still carries risks of:

Stiffness

scar sensitivity

and

Recurrence.

Carpal Tunnel Syndrome

Mild to moderate CTS can initially be treated with:

Neutral-position wrist splinting

Activity modification

and selected:

Corticosteroid injection.

Role of Injection

Steroid injection may provide substantial:

Temporary symptom relief

and can delay or occasionally avoid:

Surgery.

It does not reliably provide permanent cure in all:

Patients.

Wrist Infection

Suspected septic wrist requires urgent:

Hospital-based treatment.

Aspiration and Cultures

Synovial fluid should be obtained for:

Gram stain

and

Culture

before antibiotics whenever this can be performed without delaying:

Treatment.

Antibiotics

After cultures are obtained,:

Intravenous antibiotics

should be started promptly.

Surgical Drainage

Many septic wrists require:

Arthroscopic or open irrigation and debridement.

Serial Aspiration

Repeated aspiration may be appropriate in selected:

Patients

when adequate drainage can be achieved and close monitoring is:

Available.

Rehabilitation After Infection

Once infection is controlled, early:

Range of motion

is important to minimize:

Joint stiffness.

Medication

First-line medication depends on the diagnosis.

Possible therapies include:

NSAIDs

Local corticosteroid injection

and

Intravenous antibiotics

for septic arthritis.

Surgery

Operative treatment is reserved for specific:

Structural or refractory conditions.

de Quervain Surgery

Persistent de Quervain disease despite adequate nonoperative management may require:

First dorsal compartment release.

Scaphoid Fracture Surgery

Displaced scaphoid fractures commonly require:

Internal fixation.

Selected nondisplaced fractures may be treated with:

Cast immobilization

or

Internal fixation

depending on location, patient factors, and functional demands.

DRUJ Instability

Persistent DRUJ instability may require:

Arthroscopy

TFCC repair

or open:

Reconstruction.

Fracture-Associated DRUJ Instability

If instability accompanies fractures of the:

Distal radius

or

Ulna

fracture fixation may be required.

Temporary:

DRUJ pinning

may be used in selected unstable injuries.

Hook of Hamate Fracture

Hook fractures have a relatively high risk of:

Nonunion.

Small Hook Fragment

A persistently symptomatic small fragment may be treated with:

Surgical excision.

Base Fracture

A fracture through the base of the hook may be treated with:

Open reduction and internal fixation

when appropriate.

Flexor Tenosynovitis

Chronic refractory flexor tendon adhesions or mechanical restriction may occasionally require:

Tenolysis

although treatment depends on the specific:

Pathology.

Carpal Tunnel Release

Surgical decompression is considered when:

Nonoperative treatment fails

or when advanced median nerve dysfunction is present.

Advanced CTS Findings

Indications include:

Persistent sensory loss

Thenar weakness or atrophy

and significant abnormalities on:

Nerve conduction studies or EMG.

Arthritis Surgery

Severe wrist arthritis that does not respond to conservative care may require:

Arthroplasty

Resection procedures

or

Partial or total wrist fusion.

Follow-Up

Follow-up is determined by:

Diagnosis

Treatment

and progression of:

Symptoms.

Prognosis

Most causes of wrist pain can be substantially improved when the underlying disorder is:

Correctly identified

and treated appropriately.

Clinical Summary

First step: Localize the pain as radial, dorsal, ulnar, volar, or diffuse.

Radial pain: Think de Quervain disease, scaphoid fracture, scapholunate injury, CMC/STT arthritis, and Wartenberg syndrome.

Dorsal pain: Common causes include extensor tenosynovitis and ganglion cyst.

Ulnar pain: Consider TFCC tear, DRUJ pathology, ECU/FCU tendinopathy, hook of hamate fracture, ulnocarpal impaction, and lunotriquetral injury.

Volar pain: Common causes are flexor tenosynovitis and carpal tunnel syndrome.

Diffuse pain: Consider osteoarthritis, inflammatory arthritis, and infection.

Imaging: Begin with PA, lateral, and oblique wrist radiographs; add scaphoid, carpal tunnel, CT, or MRI views as dictated by the suspected diagnosis.

Red flag: Severe pain with passive motion, swelling, warmth, erythema, or systemic illness should raise concern for septic arthritis and prompt urgent aspiration and treatment.

Treatment: Most diagnoses begin with activity modification, immobilization, analgesia, and diagnosis-specific therapy, while surgery is reserved for unstable, displaced, compressive, infectious, or refractory pathology.

Key Principle

Wrist pain is a symptom rather than a diagnosis, and the most useful first step is careful:

Anatomic localization.

Radial, dorsal, ulnar, volar, and generalized pain patterns each have characteristic:

Differential diagnoses and provocative findings.

A thorough examination should assess:

Tenderness, motion, tendon function, ligament stability, nerve symptoms, and joint inflammation.

Plain radiographs are the initial imaging study for most patients, while:

CT

MRI

or

Arthroscopy

may be required for selected fractures, ligament injuries, or unclear diagnoses.

Urgent recognition of:

Infection, unstable fracture, neurovascular compromise, or advanced nerve compression

is essential to prevent long-term:

Loss of wrist and hand function.