Adult patients with nontraumatic localized wrist and hand pain symptoms |
Radiographs not initially indicated (D) |
General indications for radiographs include:
- No response to care after 4 wk
- Significant activity restriction >4 wk
- Non mechanical pain (unrelenting pain at rest, constant or progressive symptoms and signs, pain not reproduced on assessment)—(e.g., Keinbock's disease)
- Red flag indicators
- Signs and Symptoms (S&S) of cancer, unexplained deformity, palpable enlarging mass, or swelling, significant unexplained wrist pain with no previous films (tumor?)
- Red skin, fever, systemically unwell (infection?)
- History of noninvestigated trauma, loss of mobility in undiagnosed condition, loss of normal shape (unreduced dislocation? Instability?) (Trauma section)
- Trauma, acute disabling pain and significant weakness
- Unexplained significant sensory or motor deficit (neurological lesion at the wrist?)
- Suspected associated inflammatory arthropathies of wrist and hand
Specific indications for radiographs include:
- Noninvestigated chronic wrist and hand pain
- Multiple sites of Degenerative joint disease (DJD) as visualized on radiographs
- Possible Triangular fibrocartilage complex (TFCC) abnormality
- Possible wrist instability, including perilunate instability, dorsal and volar intercalated segmental instability, scapholunate advanced collapse, scapholunate dissociation, ulnar translocation of the wrist—Trauma section
- Possible operative candidate
Consult clinical presentation with related specific clinical diagnoses for additional help in decision making
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If radiographs are indicated (C)
PA, lateral, and medial oblique views of the wrist
Additional views: Radial and ulnar deviation views or clenched fist views are reserved for more subtle problems
Special investigations (D)
- The combination of standard radiographs and US can diagnose a wide variety of disorders.
- MRI is the procedure of choice to exclude osteonecrosis, marrow, and joint disease including infection.
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Specific Clinical Diagnoses |
1. Tendinopathy of the wrist
Pain and tenderness over a specific tendon or tendon group are the hallmarks of this condition. Other findings include localized swelling, impaired function, crepitus, pain with passive stretching of the tendon, and positive provocative testing. Tendinosis, however, can be asymptomatic.
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Radiographs not initially indicated (D)
If radiographs are indicated (D)
PA, lateral, and medial oblique views of the wrist
Consider conventional radiography, in persistent painful "soft tissue injuries," not only to exclude bony injury but also to aid diagnosis (Dx) of rare cases of acute spontaneous calcific peritendinitis of the hand and wrist
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2. De Quervain's tenosynovitis (stenosing tenosynovitis or tenovaginitis)
Pain over the radial styloid AND tender swelling of first extensor compartment AND EITHER pain reproduced by resisted thumb extension OR positive Finkelstein's test
Associated symptoms include warmth and crepitus (Naredo et al, 2002)
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Radiographs not initially indicated (D) |
3. Carpal Tunnel Syndrome (CTS)
Pain OR paraesthesia OR sensory loss in median nerve distribution in at least 2 of the first 4 fingers AND either one positive Tinel's or Phalen's, Thenar atrophy, female gender, obesity (body mass index ≥30), worsening of symptoms at night/awakening, or abnormal nerve conduction time
Clinical prediction rule (level IV):
- Age >45 y
- Shaking hands for symptom relief
- Reduced median sensory field of thumb
- Wrist ratio index (carpal canal volume) >.67
- Symptom Severity Scale (SSS) score (Brigham and Women Hospital) >1.9
Likelihood of CTS increase with number of positive tests (18.3 or 90% when all 5 tests positive)
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Radiographs not initially indicated (C)
Special investigations (D)
Advanced imaging reserved for patients with equivocal presentation or with diabetes and diffuse peripheral neuropathy that confounds electrodiagnostic studies
- MRI may be used to image anatomical abnormality (e.g., space-occupying lesion such as a ganglion).
- US may be a useful alternative.
- High-resolution sonography may show median nerve enlargement and increased hypoechogenicity
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4. Osteoarthritis
- History: age >50 y, morning joint stiffness <30 minutes (min)
- Physical examination: crepitation, bony tenderness, bony enlargement, no palpable warmth
Other characteristics include: long standing pain, no extraarticular symptoms; nonresponsive to Nonsteroidal Antiinflammatory Drugs (NSAIDs), or corticosteroid medication; relieved with rest; deformity or fixed contracture, joint effusion; insidious onset
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Radiographs not initially indicated (D)
It is common to have incomplete concordance between pathologic changes, radiographic and clinical features in osteoarthritis (OA).
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5. Inflammatory or crystal induced arthropathy (excluding Rheumatoid arthritis[RA])
Gout, Calcium pyrophosphate dihydrate crystal deposition disease (CPPD), etc
Dx of inflammatory arthritis is primarily based on history and physical examination:
- Unrelenting morning stiffness >30 min
- Pain at rest
- Pain or stiffness better with light activity (during remission)
- Polyarticular involvement, especially the hands
- Palpable warmth
- Joint effusion
- Diffuse tenderness
- Decreased ROM
- Fever/chills or other systemic symptoms
- Responsive to NSAID or corticosteroid medication
- Flexion contracture in long-standing arthritis
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Radiographs indicated (C)
PA, lateral, and medial oblique of the wrist and hand
Special investigations (C)
- If routine radiographs are normal or nondiagnostic, MRI is the study of choice; biopsy/aspiration to rule out (R/O) infection
- Gadolinium-enhanced MRI of the hand and wrist is a superior technique for detection of tenosynovitis in inflammatory arthritis
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6. RA
Symmetrical involvement of wrist, metacarpophalangeal and proximal interphalangeal finger joints
RA diagnostic criteria (≥4/7 required):
- Morning joint stiffness >1 hour (h)
- Arthritis involving ≥3 joints for at least 6 wk
- Hand arthritis (wrist, metacarpophalangeal joint (MCP), proximal interphalangeal joint [PIP])
- Symmetric arthritis
- Rheumatoid nodules
- Serum Rhesus (Rh) factor
- Radiographic changes
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Radiographs indicated (C) PA, lateral, and medial oblique views of the wrists and hands (Norgaard's/ball catcher projection)
Radiographs of the hands, feet, and chest are recommended at the initial evaluation
Special investigations (C)
- MRI is the modality of choice in early Dx and management of RA. MRI helps differentiate erosive from nonerosive disease.
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7. Osteonecrosis (avascular necrosis [AVN])
Nonmechanical pain
- Unrelenting pain at rest
- Constant or progressive symptoms and signs
- Pain not reproduced on assessment
- Swelling, tenderness
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Radiographs indicated (C)
PA, lateral, and medial oblique
Special investigations (D)
MRI modality of choice to evaluate bone marrow changes in early stages
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8. Complex regional pain syndrome (CRPS)
Synonyms:
- Reflex sympathetic dystrophy
- Sudek's atrophy
At least 4 of the following must be present in order for a Dx of CRPS to be made:
Examination findings:
- Temperature/color change
- Edema
- Trophic skin, hair, nail growth abnormalities
- Impaired motor function
- Hyperpathia/allodynia
- Sudomotor changes
Associated conditions:
- Fractures or other trauma
- Central nervous system (CNS) and spinal disorders
- Peripheral nerve injury
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Radiographs indicated (D)
PA, lateral, and medial oblique
Special investigations (D)
- MRI is useful in detecting numerous soft tissue and earlier bone and joint processes that are not depicted or as well characterized with other imaging modalities
- 3-phase Nuclear medicine (NM) scan recommended if radiograph is not diagnostic
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9. Suspected Triangular fibrocartilage complex
(TFCC) lesion (articular disk)
Typically produces ulnar-sided wrist pain, which may become chronic and associated with clicking or popping sounds with certain movements
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Radiographs indicated (D)
PA, lateral, and medial oblique
Special investigations (D)
MRI and gadolinium-enhanced MRI
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10. Trigger finger (TF) (stenosing tenosynovitis)
Intermittent, troublesome locking of the digit in flexion. More common in women 40-60 YOA and in patients with diabetes, RA, gout, and other connective tissue disorders
Patients typically present with an insidious onset of morning pain and snapping, clicking, locking, or stiffness in the affected digit. A painful nodule may be palpable at the distal palmar crease. The nodule may move during active movement
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Radiographs not initially indicated (D) |
Acute wrist trauma in the adult patient
The following evaluation helps predict or rule out (R/O) fractures when no deformity is present:
- Pain on passive and active motion
- Localized tenderness and edema
- Pain with grip and resisted supination
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Radiographs indicated (C)
PA, lateral and pronation-oblique views (medial oblique) of the wrist
- Additional views (D) PA ulnar deviation (20°), lateral oblique, maximal wrist extension and ulnar deviation
- Additional views (D) stress tests (include PA with closed fist to stress scapholunate ligament)
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A. Carpal navicular (scaphoid) fracture:
Accounts for 70%-80% of all carpal fractures; Most common (MC) in young active males
Anatomical snuffbox tenderness
Longitudinal thumb compression
Resisted supination
B. Suspected lunate instability:
Pain centered over the dorsal wrist immediately ulnar to the extensor carpi radialis tendons; pain and abnormal movement noted on Watson test; Specialized testing may be indicated earlier in such case.
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Special investigations (C)
Increasing use of MRI as only examination for:
- Scaphoid fractures
- Pisiform and hamate
- Scaphotrapezium-trapezoid joint
- Scapholunate instability
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Acute hand and finger trauma in the adult patient
Traumatic injuries to the hand can be evaluated routinely by conventional radiography.
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Radiographs indicated (D)
- Hand: PA, lateral and pronation-oblique (medial oblique)
- Isolated finger: PA, lateral, pronation-oblique (AP for the thumb)
Additional views (GPP) Stress view of the thumb to identify gamekeeper's thumb (possible avulsion fracture of the thumb proximal phalangeal base)
Special investigations (D)
- Consider advanced imaging (MRI, US, or arthrography) in suspected Stener lesion (entrapment of the ulnar collateral ligament) with gamekeeper's fractures.
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