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Wrist Pain Causes

Wrist pain can origin from various structures at the wrist joint, Wrist Pain location can be radial, ulnar, volar or dorsal wrist pain.

Non-modifiable factors associated with wrist pain include:

  1. Increased age
  2. Female sex.

Modifiable risk factors of wrist pain include:

  1. High job physical strain
  2. High job psychological strain
  3. Abnormal physeal morphology in children/adolescents
  4. High frequency impact tool use
  5. Effort reward imbalance.
See Also: Wrist Anatomy
wrist pain causes
Wrist pain causes

Radial Wrist Pain Causes

Radial Wrist Pain can be due to:

  1. Scaphoid fracture or non-union,
  2. Styloid fracture,
  3. SLAC (scapholunate advanced collapse) lesion,
  4. Scapholunate instability,
  5. Radiocarpal arthritis,
  6. Scapho-trapezio-trapezoid
  7. Arthritis (Triscaphe),
  8. Trapeziometacarpal arthritis,
  9. Tendonitis: de Quervain’s tenosynovitis and flexor carpi radialis tendonitis.
  10. Peritendinitis crepitans (intersection syndrome).
  11. Superficial branch radial neuritis (Wartenberg’s chieralgia).

Wartenberg’s chieralgia characterized by pain and tenderness 1 to 2 cm proximal to the radial styloid, and radicular pain distally along the course of the superficial radial nerve elicited by percussion. Pain in this structure is much more likely related to a traumatic neuroma.

How to assess the radial wrist pain?

Palpate the distal palmar tuberosity of the scaphoid. Curl one’s fingers about the radial aspect to the dorsum of the patient’s wrist while the thumb is palmar and points distally. This is located immediately proximal to the thenar eminence and immediately radial to the flexor carpi radialis tendon. Use the opposite hand to move the patient’s hand/wrist unit into flexion-extension and radioulnar deviation. If one is palpating the distal pole of the scaphoid, this small bony lump will move, demonstrating that it is part of the carpus and not the radius. More importantly, the distal pole will become prominent palmarly with wrist flexion and with radial deviation as the scaphoid rotates into flexion.

Palpation of distal tuberosity of scaphoid
Palpation of distal tuberosity of scaphoid

Adjacent and immediately ulnar to the scaphoid tuberosity is the tendon of the flexor carpi radialis (FCR). This can often be visualized proximally, and if’ not, it can be palpated. Follow it proximally by laying three fingers on it while palmar and dorsiflexing a clenched fist. FCR tendonitis can manifest as tenderness upon palpation distally near the fibro-osseous tunnel in the trapezium as it dives to insert into the base of the second metacarpal. There is usually localized pain with hyperextension of the wrist caused by tendon stretch and with resisted wrist flexion and radial deviation.

Immediately radial to this point and distal to the scaphoid tuberosity is the scaphotrapezial (ST) joint. At this location, place your thumb nail transversely and at 90° to the long axis of the forearm. Ask the patient to move his thumb. There will be an appreciation of movement distally while the scaphoid tuberosity remains still. This will be useful for localizing pain related to ST arthritis, a common cause of radial palmar wrist pain, and to localize the entry point for an injection into that joint.

See Also: Finkelstein's Test
See Also: De Quervain's tenosynovitis

Tenderness in anatomical snuffbox and axial loading of first metacarpal can cause pain at dorsoradial aspect of wrist. Examiner’s index finger palpating just distal to radial styloid with wrist moved passively from radial to ulnar deviation can palpate articular/non-articular junction of scaphoid. It is painful in scaphoid nonunion, periscaphoid synovitis, scaphoid instability or SLAC changes at styloid.

STT (scapho-trapezio-trapezoid) joint pathology: This joint is felt by following the course of 2nd metacarpal proximally with examiner’s thumb until it falls into a recess. It is painful in STT synovitis, degenerative disease or other scaphoid pathology.

scapho-trapezio-trapezoid joint
Scapho-trapezio-trapezoid joint

Scapholunate joint pathology: Follow the course of 3rd metacarpal proximally until the examiner’s thumb falls into a recess over capitate. Scapholunate joint is just proximal between extensor carpi radialis brevis and 4th dorsal compartment. It is tender in Keinbock’s disease and scapholunate dissociation.

Ulnar Wrist Pain

The conditions that may cause ulnar wrist pain are:

  1. Triangular fibrocartilage complex injuries (TFCC) more common in radial fracture malunion,
  2. Tendonitis,
  3. Ulna-carpal abutment syndrome or impaction syndrome,
  4. Pisotriquetral arthritis,
  5. Triquetrolunate instability (VISI),
  6. Hamate fracture,
  7. Extensor carpi ulnaris subluxation
  8. Caput-ulna in rheumatoid arthritis.

Triangular fibrocartilage complex (TFCC)

Triangular fibrocartilage complex (TFCC) consists of articular disk, meniscus homologue, ulnar carpal ligament, dorsal and volar radioulnar ligaments, and extensor carpi ulnaris sheath. It is important in loading and stabilizing the distal radioulnar joint. It can get torn due to degeneration or trauma. This is assessed by elbow resting on the table, holding the hand in ‘shakehand position’, the other hand supporting the forearm apply axial load in ulnar deviation of the hand and do supination-pronation movement. This produces extreme ulnar wrist pain on the ulnar aspect of wrist. This “grind test” will be positive in ulnocarpal impaction or TFCC tear.

With the forearm pronated, palpate ulnar and distal to the ulnar head. Deviate the wrist radial and ulnar, and feel the tendon of the extensor carpi ulnaris (ECU) become prominent on ulnar deviation. Trace this tendon distally to its insertion into the dorsoulnar base of the fifth metacarpal. Tenderness along the tendon sheath indicates tendonitis.

TFCC test
TFCC test

Ulnar Styloid (US)

The ulnar styloid (US) is best felt when the forearm is pronated. It is distal to the ulnar head and palmar to the ECU. It is slightly obscured by the ECU when the forearm is supinated. It should not be tender to palpate unless there has been a recent fracture or ulnar styloid-triquetral impaction (USTI) is present.

To search for clinical support for USTI, a Ulnar Styloid Triquetral Impaction provocative test is performed. This USTI test is based on the fact that the US is ulnar in pronation, and is more central and dorsal in supination. Thus it is evident that to approximate the US to the triquetrum, one needs to bring the US closer to the carpus by supinating the forearm, and bring the carpus closer the wrist dorsiflexed and the forearm pronated, and simply add one motion, supination, while maintaining dorsiflexion.

To support the diagnosis the US should also be tender exactly over its tip. This is tested in pronation and neutral wrist flexion. The patient may indicate from the history that this test produces ulnar wrist pain. The pain with the hand in the back pocket, repetitive page turning, or the distal supinated hand on the ice hockey stick may be historical evidence of a positive USTI provocative test.

ulnar styloid fracture
Ulnar styloid fracture

Lunotriquetral (LT) joint

The lunotriquetral (LT) joint can be localized, it is a depression just distal to the radial side of the ulnar styloid, because the head of the ulna articulates with one half of the lunate and one half of the triquetrum. Direct palpation of the LT joint may be tender when LT pathology is present.

Lunotriquetral (LT) joint
Lunotriquetral (LT) joint

Dorsal Wrist Pain

Scapholunate Interval

Move ulnarly and place your thumb just distal to the dorsal lip of radius in line with the long metacarpal. Flex and extend the wrist and feel a poorly defined hard lump becoming prominent in flexion. This is the dorsal pole of lunate. It is covered by capsule, extensor digitorum longus, tenosynovium, and retinaculum, and is not felt very distinctly-but it is felt. Pressure on this area is generally not painful unless a fracture or Kienbock’s disease is present.

Appreciate the hard fullness felt with palmar flexion and move back and forth between the dorsal pole of the lunate and proximal pole of the scaphoid. Palpate the intervening SL area. Appreciate the slight valley that exists. This area should not be painful unless there is a recent SL ligament tear or a chronic occult ganglion. This is usually the area where the dorsal ganglion becomes obvious.

Scapholunate joint
Scapholunate joint

Fourth and Fifth Extensor Compartment

The extensor digitorum communis (EDC) tendons (fourth compartment) and their tenosynovium is easily appreciated by flexing and extending the fingers at the MCP joints. This can be done as a unit but is better appreciated if done in rhythmical consecutive fashion. Similarly, place the fingers in a “piccolo” fashion longitudinally between the EDC and head of ulna, and flex and extend the little digit. The tendon of the extensor digiti minimi (EDM) can be felt moving. Tenosynovitis is a common source of dorsal wrist pain, swelling, and tenderness over the wrist. Ganglion cysts and vestigial wrist extensor muscles (extensor digitorum brevis minus) are less common but may have a similar presentation.

See Also: Extensor Compartments of the Wrist

Carpometacarpal Joints

Sprains of the second through fifth CMC joints can be associated with localized tenderness and swelling. Stressing the joint by flexion, extension, and rotational forces may add additional information. A bony prominence at the base of second or third metacarpal, often involving the CMC joints, is called a carpal boss. The cause and significance of this prominence is unknown, and caution is suggested when considering any surgical treatment.

Ganglion

It is a cystic, well-localized swelling with positive transillumination test. Dorsal ganglion results from cystic myxomatous degeneration within the dorsal scapholunate ligament and may be related to scapholunate instability.

wrist ganglion
Wrist Ganglion

Keinbock’s disease

It is avascular necrosis of the lunate and is associated with ulna minus variant. Clinically patient will have tenderness on mid-dorsum over the lunate bone.

Palmar Wrist Pain

In the palmar ulnar aspect hold the pisiform between the index finger and thumb. Flex and extend the wrist and move the pisiform medially and laterally while applying dorsally directed pressure, compressing the pisiform on the triquetrum, to search for articular cartilage crepitus or pain associated with pisotriquetral degenerative joint disease. This is referred to as the pisotriquetral grind test.

pisotriquetral grind test
Pisotriquetral grind test

Palpate the hook of the hamate just distal and radial from the pisiform. It is localized by placing the IP joint of the examiner’s thumb over the more superficial pisiform, with the tip of the thumb directed toward the metacarpal head of the long finger. Deep palpation with the tip of the examiner’s thumb reveals the hook of the hamate. This can be tender in the setting of fracture or nonunion of the hook of the hamate. Remember that this is the area of the ulnar nerve, and deep palpation onto this nerve is usually painful.

Palpate the flexor carpi ulnaris (FCU) proximally from the pisiform. It is most prominent by having the patient make a clenched fist during mild wrist flexion. Tenderness along the tendon sheath or pain and weakness with resisted wrist flexion and ulnar deviation suggest tendonitis. With the tip of the thumb on the radial palmar side of the pisiform, add deep pressure. The uncomfortable sensation is related to pressure on the ulnar nerve. Although one cannot objectively feel this nerve, this means of localization will be of value for assessing symptoms or injecting local anesthetic.

The palmaris longus (PL) tendon is central and superficial in the palmar distal forearm. It stands out with a flexed grip, and can be visualized and palpated. It may be absent. At the wrist crease between the PL and FCR, an astute examiner can often palpate it fine snapping of the palmar cutaneous branch of the median nerve. This subtle finding is aided by tensioning the nerve with dorsiflexion of the wrist and then drawing the tip of the examining digit across the interval with slight deep pressure. Finally, circumferential wrist compression with the thumb and index will produce pain when a synovitis and effusion is present.

Palmar wrist pain can be from palmar ganglion that arises from scaphotrapezial ligament or a compound palmar ganglion from radial bursitis in rheumatoid or tuberculous synovitis (presence of cross-fluctuation proximal and distal to flexor retinaculum). Rarely it can be referred pain.

References

  1. Clinical Assessment and Examination in Orthopedics, 2nd Edition Book.
  2. Ferguson R, Riley ND, Wijendra A, Thurley N, Carr AJ, Bjf D. Wrist pain: a systematic review of prevalence and risk factors- what is the role of occupation and activity? BMC Musculoskelet Disord. 2019 Nov 14;20(1):542. doi: 10.1186/s12891-019-2902-8. PMID: 31727033; PMCID: PMC6857228.
  3. DiFiori JP, Puffer JC, Mandelbaum BR, Mar S. Factors associated with wrist pain in the young gymnast. Am J Sports Med 1996;24(1):9–14. PubMed PMID: 8638761.
  4. DiFiori JP, Puffer JC, Aish B, Dorey F. Wrist pain in young gymnasts: frequency and effects upon training over 1 year. Clin J Sport Med 2002;12(6):348–353. PubMed PMID: 12466689.
  5. DiFiori JP, Puffer JC, Aish B, Dorey F. Wrist pain, distal radial physeal injury, and ulnar variance in young gymnasts: does a relationship exist? Am J Sports Med 2002;30(6):879–885. PubMed PMID: 12435656. Epub 2002/11/19. eng.
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