Wrist Pain

Anatomy

• Mnemonic: Some Lovers Try Positions That They Can’t Handle

• Proximal row (radial to ulnar): Scaphoid, Lunate, Triquetrum, Pisiform

• Distal row (radial to ulnar): Trapezium, Trapezoid, Capitate, Hamate

• The scaphoid has a precarious blood supply, predisposing it to avascular necrosis

• The lunate articulates with the radius and can be vulnerable to compromised circulation

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Differentials

• Scaphoid fracture: Snuffbox tenderness, risk of avascular necrosis, may have normal initial X-ray

• Distal radius fracture (Colles’): Fall on an outstretched hand, dorsal angulation

• Scapholunate dissociation: Scapholunate gap >3 mm on X-ray, dorsal wrist pain, clunk with movement

• Kienbock’s disease: Avascular necrosis of the lunate leading to chronic pain and possible carpal collapse

• OA at the first CMC: Thumb base pain aggravated by pinching or gripping

• Rheumatoid arthritis: Symmetrical wrist pain, morning stiffness, systemic features

• Gout: Acute redness, swelling, intense pain, often affecting single joint

• TFCC injury: Ulnar-sided wrist pain, clicking, reduced grip strength

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Clinical Tips

• Watson’s test: Pain or clunk during ulnar to radial deviation under scaphoid pressure, indicating scapholunate instability

• High index of suspicion for scaphoid fractures if tenderness persists despite normal X-rays

• Snuffbox or scaphoid tubercle tenderness warrants repeat imaging or MRI

• Assess grip strength and range of motion to evaluate functional impairment

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Investigations

• X-ray with PA, lateral, and dedicated scaphoid views for suspected fracture or scapholunate gap

• MRI if X-rays are inconclusive but suspicion of occult scaphoid fracture or Kienbock’s disease remains

• Ultrasound for tendon pathology, ganglia, or synovitis

• Blood tests (FBC, ESR, CRP, urate) if inflammatory arthritis or gout is suspected

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Management

• Thumb spica cast or splint for suspected scaphoid fracture to prevent nonunion

• Casting or bracing for distal radius fracture based on degree of displacement

• NSAIDs for pain and inflammation in mild arthritis or soft tissue injuries

• Corticosteroid injections for severe 1st CMC osteoarthritis or persistent inflammatory conditions

• Surgical referral for significant scapholunate ligament tears, nonunion fractures, or advanced Kienbock’s disease

• Hand therapy or physiotherapy for strengthening, range of motion, and functional recovery