A Brief Synopsis of AFP's "Evaluation and Diagnosis of Wrist Pain: A Case-Based Approach"

A synopsis of-
Evaluation and Diagnosis of Wrist Pain: A Case-Based Approach
RAMSEY SHEHAB, MD, Henry Ford Health System, Detroit, Michigan 
MARK H. MIRABELLI, MD, University of Rochester Medical Center, Rochester, New York
http://www.aafp.org/afp/2013/0415/p568.pdf
Am Fam Physician. 2013 Apr 15;87(8):568-573.


     Wrist pain can be classified as acute or chronic. Acute pain is typically due to trauma. Chronic pain can be neurologic, systemic, inflammatory, or from an old trauma. History, including the location, timing, and quality of pain can aid in the diagnosis. The diagnoses  that will be discussed here are scaphoid fracture  ulnar neuropathy, and De Quervain tenosynovitis. I will do my best not to use the words "brevis", "minimi", "longus" or "pollicis"
     The lunate and scaphoid are the two carpal bones that articulate with the ulna and radius, respectively. Scaphoid fractures are more common in the young because of the increased surrounding cartilage. The most common presentation is "falling on an outstretched hand". The wrist and anatomical snuff box may be swollen, with tenderness dorsally around the distal radius. Axial pressure on the first metacarpal bone will reproduce pain. With x ray imagining, its is important to order AP, AP in ulnar deviation, lateral, oblique, pronated oblique, and supinated oblique views. They may need to be repeated two weeks later to see if the fracture is healing. A bone scan or MRI may be needed if the x rays are not sufficient. Patients with suspected scaphoid fracture, but negative x rays, should be given a thumb spica cast and repeated in two weeks.
     In the wrist, the ulnar nerve passes through the guyon canal, to the anterior surface of the hand. The nerve splits off and innervates the sensory portion of the medial palm, the muscles of the pinky, and the muscles for thumb flexion and adduction. Compression of the ulnar nerve in the wrist is typically caused by repetitive trauma or a ganglion cyst. The entire length of the nerve should be investigated to rule out issues in the cervical spine, brachial plexus, and ulnar groove . The patient will complain of numbness and/or tingling in the 4th and 5th digits.  Tinel sign and Phalen sign should be part of the exam. X rays should be ordered first. Nerve conduction tests may uncover entrapment in acute injuries. EMG can be used if the issue is chronic. An ultrasound of the nerve may reveal compression. MRI can be a useful if other tests are inconclusive. 
     De quervain tenosynovitis is inflammation of the sheath that encompasses the the tendons of the lateral border or the anatomic snuffbox. Again, the wrist and tissue around the anatomical snuffbox may be swollen. Finkelstein test will be positive. Grind test should be negative (and positive in OA of the thumb MCP joint).  Injection of lidocaine into the joint can rule out arthritis. Appropriate labs may be drawn if an infection is suspected, and further imaging can be considered if needed.