A painful wrist can be a diagnostic and therapeutic challenge. Many pathologies affect the wrist, however a history and careful examination can often establish the diagnosis as signs are usually well localised.
It is useful to consider groups of pathologies based on their location. Common pathologies for each location are listed:
(1) Radial sided Pathology: De Quervain’s Tenosynovitis (proximal to the radial styloid), Osteoarthritis at the first carpometacarpal joint (CMCJ OA) (base of thumb), Scaphoid pathology (snuffbox).
(2) Dorsal / Central Pathology: Dorsal wrist ganglion, Kienbock’s disease (Lunate osteonecrosis), ligament wear and tear between Scaphoid and Lunate.
(3) Ulnar sided Pathology: Distal Radial-Ulnar joint (DRUJ) arthritis, Triangular Fibro-cartilage (TFCC) wear or tear, Extensor Carpi Ulnaris tendonitis.
First Line Investigations:
When to refer?
Chronic wrist pain: Continued pain in the absence of a diagnosis, despite the above investigations and management, warrants further, second line investigation by way of MRI and onward referral to a hand and wrist specialist. Wrist arthroscopy is indicated in unexplained chronic pain for over three months.
What can be done? Wrist arthroscopy technology has advanced considerably. This allows us to visualise the entire wrist joint and is the diagnostic gold standard. Modern instrumentation and techniques allow us to access, repair and debride areas of pathology particularly on the ulnar side of the wrist with reliable outcomes. TFCC pathology, loose bodies, synovectomy and excision of dorsal wrist ganglion can be addressed.
Fig.1: The correct Finklestein’s test is far more specific for De Quervain’s.