Evaluation of the adult with subacute or chronic wrist pain
- Blake Reid Boggess, DO, FAAFP
Blake Reid Boggess, DO, FAAFP
- Associate Professor of Orthopedic Surgery
- Duke Sports Medicine Team Physician
- Duke University Medical Center
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
Due to its location and anatomy, the wrist is susceptible to a range of injuries and overuse syndromes, and chronic wrist pain is a common presenting complaint in primary care and sports medicine clinics. Such pain may result from the residual effects of past trauma or nontraumatic conditions. Generally, we define chronic conditions are those that have been present for longer than three months, acute conditions as those present for less than two weeks, and subacute conditions as those present for two weeks to three months.
The common causes of chronic wrist pain and an approach to diagnosing these problems is provided here. Acute wrist pain, wrist anatomy and biomechanics, and more detailed discussions of specific wrist problems are reviewed separately. (See "Evaluation of the adult with acute wrist pain" and "Overview of carpal fractures" and "Distal radius fractures in adults" and "Scaphoid fractures".)
ANATOMY AND BIOMECHANICS
The anatomy and biomechanics of the wrist are reviewed in detail separately. (See "Anatomy and basic biomechanics of the wrist".)
DIAGNOSTIC CATEGORIES AND OVERALL APPROACH
Using information from the history, key symptoms, and findings from the basic wrist examination, the clinician can usually select one of three common diagnostic categories that best fits the patient. The three major categories are:
●Acute wrist pain, either from trauma or associated with overuse (see "Evaluation of the adult with acute wrist pain")
- Murray PM, Cooney WP. Golf-induced injuries of the wrist. Clin Sports Med 1996; 15:85.
- Valdes K, LaStayo P. The value of provocative tests for the wrist and elbow: a literature review. J Hand Ther 2013; 26:32.
- Nagle DJ. Evaluation of chronic wrist pain. J Am Acad Orthop Surg 2000; 8:45.
- Garcia-Elias, Marc. Carpal Instability. In: Green's Operative Hand Surgery, 6th ed, Wolfe, SW, Hotchkiss, RN, Pederson, WC, Kozin, SH. (Eds), Elsevier, Philadelphia 2011. Vol I, p.483.
- Wolfe SW, Gupta A, Crisco JJ 3rd. Kinematics of the scaphoid shift test. J Hand Surg Am 1997; 22:801.
- LaStayo P, Howell J. Clinical provocative tests used in evaluating wrist pain: a descriptive study. J Hand Ther 1995; 8:10.
- Wolfe SW, Crisco JJ. Mechanical evaluation of the scaphoid shift test. J Hand Surg Am 1994; 19:762.
- Park MJ. Radiographic observation of the scaphoid shift test. J Bone Joint Surg Br 2003; 85:358.
- Ruland RT, Hogan CJ. The ECU synergy test: an aid to diagnose ECU tendonitis. J Hand Surg Am 2008; 33:1777.
- Daniels JM 2nd, Zook EG, Lynch JM. Hand and wrist injuries: Part I. Nonemergent evaluation. Am Fam Physician 2004; 69:1941.
- Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fractures. J Hand Surg Am 2000; 25:464.
- Montalvan B, Parier J, Brasseur JL, et al. Extensor carpi ulnaris injuries in tennis players: a study of 28 cases. Br J Sports Med 2006; 40:424.
- Campbell D, Campbell R, O'Connor P, Hawkes R. Sports-related extensor carpi ulnaris pathology: a review of functional anatomy, sports injury and management. Br J Sports Med 2013; 47:1105.
- Ek ET, Suh N, Weiland AJ. Hand and wrist injuries in golf. J Hand Surg Am 2013; 38:2029.
- Seki E, Ishikawa H, Murasawa A, et al. Dislocation of the extensor carpi ulnaris tendon in rheumatoid wrists using three-dimensional computed tomographic imaging. Clin Rheumatol 2013; 32:1627.
- Lichtman DM, Schneider JR, Swafford AR, Mack GR. Ulnar midcarpal instability-clinical and laboratory analysis. J Hand Surg Am 1981; 6:515.
- Ahn AK, Chang D, Plate AM. Triangular fibrocartilage complex tears: a review. Bull NYU Hosp Jt Dis 2006; 64:114.
- Squires JH, England E, Mehta K, Wissman RD. The role of imaging in diagnosing diseases of the distal radioulnar joint, triangular fibrocartilage complex, and distal ulna. AJR Am J Roentgenol 2014; 203:146.
- Smith TO, Drew B, Toms AP, et al. Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis. J Bone Joint Surg Am 2012; 94:824.
- Garcia-Elias M. Carpal instability. In: Green's Operative Hand Surgery, 6th, Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH. (Eds), Elsevier, Philadelphia 2011. Vol 1, p.483.
- Park MJ, Namdari S, Weiss AP. The carpal boss: review of diagnosis and treatment. J Hand Surg Am 2008; 33:446.
- Innes L, Strauch RJ. Systematic review of the treatment of Kienböck's disease in its early and late stages. J Hand Surg Am 2010; 35:713.
- Lichtman DM, Lesley NE, Simmons SP. The classification and treatment of Kienbock's disease: the state of the art and a look at the future. J Hand Surg Eur Vol 2010; 35:549.
- Schuind F, Eslami S, Ledoux P. Kienbock's disease. J Bone Joint Surg Br 2008; 90:133.
- Cross D, Matullo KS. Kienböck disease. Orthop Clin North Am 2014; 45:141.
- Arnaiz J, Piedra T, Cerezal L, et al. Imaging of Kienböck disease. AJR Am J Roentgenol 2014; 203:131.
- Hanlon DP, Luellen JR. Intersection syndrome: a case report and review of the literature. J Emerg Med 1999; 17:969.
- Lee RP, Hatem SF, Recht MP. Extended MRI findings of intersection syndrome. Skeletal Radiol 2009; 38:157.
- Mann FA, Wilson AJ, Gilula LA. Radiographic evaluation of the wrist: what does the hand surgeon want to know? Radiology 1992; 184:15.
- Anderson JF, Read JW, Steinweg J. The hand and wrist. In: Atlas of Imaging in Sports Medicine, McGraw-Hill, Sydney 1998. p.17.
- Carroll RE, Lakin JF. Fracture of the hook of the hamate: radiographic visualization. Iowa Orthop J 1993; 13:178.
- Zlatkin MB, Chao PC, Osterman AL, et al. Chronic wrist pain: evaluation with high-resolution MR imaging. Radiology 1989; 173:723.
- Scheck RJ, Kubitzek C, Hierner R, et al. The scapholunate interosseous ligament in MR arthrography of the wrist: correlation with non-enhanced MRI and wrist arthroscopy. Skeletal Radiol 1997; 26:263.
- Haims AH, Schweitzer ME, Morrison WB, et al. Internal derangement of the wrist: indirect MR arthrography versus unenhanced MR imaging. Radiology 2003; 227:701.
- Cristiani G, Cerofolini E, Squarzina PB, et al. Evaluation of ischaemic necrosis of carpal bones by magnetic resonance imaging. J Hand Surg Br 1990; 15:249.
- Szabo RM, Greenspan A. Diagnosis and clinical findings of Kienböck's disease. Hand Clin 1993; 9:399.
- Bodor M, Fullerton B. Ultrasonography of the hand, wrist, and elbow. Phys Med Rehabil Clin N Am 2010; 21:509.
- Jacobson JA. Musculoskeletal ultrasound and MRI: which do I choose? Semin Musculoskelet Radiol 2005; 9:135.
- Lee JC, Healy JC. Normal sonographic anatomy of the wrist and hand. Radiographics 2005; 25:1577.
- Lento PH, Primack S. Advances and utility of diagnostic ultrasound in musculoskeletal medicine. Curr Rev Musculoskelet Med 2008; 1:24.
- Bray PW, Mahoney JL, Campbell JP. Sensitivity and specificity of ultrasound in the diagnosis of foreign bodies in the hand. J Hand Surg Am 1995; 20:661.
- ANATOMY AND BIOMECHANICS
- DIAGNOSTIC CATEGORIES AND OVERALL APPROACH
- PHYSICAL EXAMINATION
- Range of motion
- Special tests
- DIFFERENTIAL DIAGNOSIS BY REGIONS OF THE WRIST
- Ulnar sided wrist pain
- - Extensor carpi ulnaris tendinopathy and subluxation
- - Triangular fibrocartilage complex injury
- Radial sided wrist pain
- - Scaphoid fracture
- - Scapholunate instability
- - de Quervain’s tenosynovitis
- - Carpal metacarpal osteoarthritis
- - Radiocarpal arthritis
- Volar sided wrist pain
- - Carpal tunnel syndrome
- - Hook of the hamate fracture
- - Ulnar neuropathy (Guyon’s canal syndrome)
- Dorsal sided wrist pain
- - Ganglion cyst
- - Carpal boss
- - Kienböck's disease of the lunate
- - Intersection syndrome
- Approach to imaging
- Plain radiographs
- Computed tomography
- Magnetic resonance imaging
- Diagnostic ultrasound
- Additional ultrasound resources
- APPROACH TO DIAGNOSIS
- Determine whether cause is traumatic or nontraumatic
- Determine whether nontraumatic pain is from overuse or nerve compression
- Correlate history and location of symptoms and signs
- SUMMARY AND RECOMMENDATIONS