Evaluation of Chronic Wrist Pain

Differential Diagnosis

The Differential Diagnosis is extensive, and varies with location. Generally most chronic wrist pain is either due to overuse syndromes or in-completely healed acute injury.

History

• Presence of a prior acute injury

• Aggravating and alleviating factors

• Morning stiffness

• Pain with repeated movement

• Clicking

• Night Pain

• Paresthesias

• Elbow or neck pain

Examination

Always remember to examine the joint above (Elbow)

Inspection

1. Scars or stretch marks

2. Wasting of muscles

3. Obvious Deformity

4. Swelling in region of scaphoid

5. Ganglion on dorsum of wrist

6. Swelling over radial styloid (deQuervain's Tenosynovitis)

7. Muscle wasting on thenar eminance (median nerve compression)

8. Muscle wasting on the hypothenar eminance (ulnar nerve compression)

Palpation

1. Distal Forearm

2. Radial Snuffbox (this is the area surrounded by Extensor Pollicis Longus, Extensor Pollicis Brevis, and Abductor Pollicis Longus)

3. Base of metacarpals

4. Lunate: Palpated as a bony prominance proximal to the capitate sulcus on the dorsal aspect. On the radial side of the lunate lies the scapholunate joint.

5. Head of Ulna

6. Radio-Ulnar Joint

7. Scapholunate Joint

8. Triangular Fibrocartilage

9. Hamate: Hook of Hamate is 1cm distal and radial to the Pisiform.

10. Pisiform: Palpated at the flexor crease of the wrist on the Ulnar side.

11. Tuberosity of the trapezium: Located at the base of the Thenar Emminance. Tenderness proximal to the tuberosity may be present in flexor carpi radialis tendinopathy. Tenderness distal to the tuberosity may indicate injury of the carpomentacarpal ligament of the thumb.

Motion

Note that range of movement is measured determined actively first, if there is a deficiency, move on to passive range of motion. Any deficits should be measured with a goniometer. Note should be made of discrepence between active and passive movement.

Muscles

Measurement of muscle strength using the Oxford (MRC) Scale.

1. Flexion

2. Extension

3. Radial Deviation

4. Ulnar Deviation

NeuroVascular

1. Check and Grade reflexes (biceps (C5), brachioradialis (C6), and triceps (C7)

2. Check Pulses.

3. Sensation in radial / ulnar / median nerve

4. Strength in radial / ulnar / median nerve

Special Tests

1. Finkelstein's Test for deQuervain's Tenosynovitis

2. Tinnel's Sign for carpal Tunnel Syndrome.

Investigations

1. Plain Films: Should be obtained for any trauma. Note that the proximal pole of the lunate fits into the concavity of the distal radius. In turn, the convex head of the capitate fits into the distal concavity of the lunate. These bones must line up with the third metacarpal.

2. Scaphoid Views:

3. Bone Scan: may be necessary to rule out subtle fractures.

4. CT scanning: particularly useful for evaluation of the distal radio-ulnar joint and the hamate / trapezium.

5. MRI

6. Arthrography: may be useful for ligamentous injury and triangular fibrocartilage tears.

7. Arthroscopy: Excellent for early scapholunate ligament tears. May be diagnostic and therapeutic.

Appendix

Wrist Joint Mechanics

Index

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