A Clinical Approach to Diagnosing Wrist Pain - American Family Physician

P rimary care physicians often are the first to evaluate and treat a patient with wrist pain. Although the wrist consists of a complicated group of bony articulations and soft tissues, many family physicians often use wastebasket diagnoses such as “wrist sprain” or “tendonitis” that do little to identify the true pathology of the condition. Despite the challenges this complex of joints presents, physicians are gaining a better understanding of wrist pathophysiology through an array of diagnostic capabilities. Generally, the causes of wrist pain can be divided into three categories: mechanical, neurologic, and systemic. Table 11-11 lists common mechanical causes of wrist pain, their clinical presentations, and suggested imaging work-ups. Table 21,2 lists other common causes of wrist pain. Psychosocial factors can also have a profound influence on wrist pain, particularly when the patient may be eligible for workers’ compensation. With the dawn of the computer age, wrist and hand pain became the most common complaint involving the upper extremity. The proximal row of bones in the wrist (i.e., scaphoid, lunate, triquetrum, and pisiform) articulate with the distal ends of the radius and ulna in a constrained space to allow three degrees of freedom at the wrist (Figure 1). Relative to the forearm, these hand movements include flexion-extension, pronation-supination, and radial or ulnar deviation. Relative stability of such mobility requires a coordinated system of ligaments, muscles, and tendons. Hand and wrist injuries have a major economic impact through health care costs and workers’ compensation claims. A study12 of workers’ compensation claims in Washington state from 1987 to 1995 demonstrated an incidence rate for hand and wrist disorders of 98.2 cases per 10,000 persons, higher than any other musculoskeletal condition related to an industrial injury claim. Furthermore, the average claim was around $7,500.12 For carpal tunnel syndrome alone, direct annual costs in the United States are estimated at $1 billion.13 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 magnetic 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 cineroentgenography, diagnostic arthrography, or arthroscopy. (Am Fam Physician 2005;72:1753-8. Copyright © 2005 American Academy of Family Physicians.)