Evaluation of the adult with acute wrist pain

INTRODUCTION — Due to its location and anatomy, the wrist is susceptible to a range of injuries, and acute wrist pain is a common presenting complaint in primary care and sports medicine clinics. Such pain often results from trauma but may stem from nontraumatic conditions.

This topic review will provide an overview to acute wrist pain or injury in the adult. Subacute and chronic causes of wrist pain and specific wrist injuries are discussed in detail separately. (See "Evaluation of the adult with subacute or chronic wrist pain" and "Overview of carpal fractures" and "Distal radius fractures in adults" and "Scaphoid fractures".)

ANATOMY AND BIOMECHANICS — The anatomy and biomechanics of the wrist are reviewed in detail separately. (See "Anatomy and basic biomechanics of the wrist".)

DIAGNOSTIC CATEGORIES AND OVERALL APPROACH — Using information from the history, key symptoms, and findings from the basic wrist examination, the clinician can usually select one of three common diagnostic categories that best fits the patient. The following flow chart provides an overview of our approach to wrist pain diagnosis (algorithm 1).

The three major categories of wrist pain are:

●Acute wrist pain, either from trauma or associated with overuse.

Acute conditions of the wrist are typically defined as present for less than two weeks, subacute conditions as present for two weeks to three months, and chronic conditions as present for longer than three months.

●Chronic wrist pain – Chronic causes of wrist pain are discussed in detail separately (see "Evaluation of the adult with subacute or chronic wrist pain")

●Wrist pain without trauma or overuse, possibly associated with systemic symptoms (see 'Wrist pain not associated with trauma or overuse' below)

The first important distinction to make when establishing the diagnostic category is whether the pain is acute or chronic. Keep in mind that acute pain may reflect an exacerbation of a chronic condition. Once a major diagnostic category is identified, the next step is to determine the region of the wrist that is affected, and then the precise diagnosis. The major diagnostic categories are described further below.

While inspection, range of motion, and basic strength and neurovascular testing are typically performed in every patient with wrist pain, provided excessive pain does not preclude such examination, the clinician determines which specific structures warrant more thorough evaluation, including which special wrist examination maneuvers to perform, based upon the most likely diagnostic category.

Acute wrist pain associated with trauma or overuse — A history of acute wrist pain associated with trauma is usually clear-cut, although the precise mechanism may be difficult to establish. Such a history combined with the major site of pain allows the clinician to focus on the wrist structures most likely to have been injured.

Patients with acute wrist pain that developed or increased abruptly after excessive activity, but who clearly have not sustained direct trauma, often suffer from acute-on-chronic pain related to overuse. Acute pain associated with overuse typically arises towards the end of an activity that exceeds what the patient is used to doing. A classic example is the patient with carpometacarpal (CMC) osteoarthritis. Such a patient may have mild underlying chronic pain that does not bother them enough to take medication or seek medical evaluation, but after an entire day spent, for example, doing yard work or painting their house, the pain can suddenly become severe. Such patients typically complain of acute pain that began on a particular day, but the underlying osteoarthritis causing the pain is a chronic condition.

The same principle applies to acute exacerbations of a wrist tendinopathy. When asked, these patients often report a progressive pain pattern that preceded any acute increase in pain and had caused increasing functional limitations or complete cessation of a particular activity. Although the history may be different, as these vignettes suggest, the evaluation and management of acute exacerbations of pain from chronic overuse are generally the same as those for the chronic conditions themselves.

Once the patient’s wrist pain is placed into one of the three categories, the location of the pain is key to determining the differential diagnosis, and ultimately a diagnosis.

Chronic wrist pain — Chronic wrist pain associated with overuse is the major diagnostic category to consider if pain has persisted for approximately three months or longer and there has been no sudden inciting trauma associated with the development of pain. The causes and approach to chronic wrist pain are discussed in detail separately. (See "Evaluation of the adult with subacute or chronic wrist pain".)

Wrist pain not associated with trauma or overuse — Chronic or acute wrist pain in an adult without inciting trauma or a history of overuse is a “red flag” that a more extensive evaluation is required, particularly if the pain is associated with constitutional symptoms. The cause of such pain is much more likely to arise from a systemic illness rather than an isolated musculoskeletal injury or condition.

The presence of constitutional symptoms, such as fevers, night sweats, chills, malaise, weight loss, or chronic fatigue, or bilateral wrist symptoms, strongly suggests that the problem is systemic, although some patients with systemic rheumatologic disease may present initially without such findings and complain only of isolated, monoarticular pain. In patients with wrist pain unrelated to trauma or overuse but associated with systemic symptoms, a thorough history and physical examination should be performed, in addition to careful assessment of the wrist. Depending upon the history and examination findings, additional testing including diagnostic imaging and appropriate laboratory studies is likely to be necessary.

Determining whether an effusion is present is an important part of the evaluation of the patient with an acutely painful wrist unrelated to trauma or overuse. This can be accomplished in the office using ultrasound. Localized warmth, erythema, and swelling over the wrist suggest a joint effusion and the need to aspirate the wrist joint to evaluate for infection and inflammatory disease. If the wrist is aspirated, it is critical that all necessary tests be performed on the synovial fluid obtained. If the joint fluid examination is benign and the patient is not systemically ill, advanced imaging may be pursued on a routine timeline, and if necessary laboratory analysis may consist of a few simple screens for systemic infection. However, systemic symptoms or concerning synovial fluid results (eg, elevated white blood cell count) should prompt urgent evaluation. (See "Joint aspiration or injection in adults: Technique and indications" and "Synovial fluid analysis".)

A history of repeated flares of pain or swelling in both wrists, or other joints in addition to the wrist, particularly if these flares are increasingly severe, suggests a rheumatologic or autoimmune condition. As an example, calcium pyrophosphate crystal deposition disease (pseudogout) can present with monoarticular wrist pain. Gout may present with monoarticular wrist pain and swelling, but wrist involvement is more common with recurrent episodes. Systemic lupus erythematosus (SLE) too may present with bilateral wrist pain and swelling. (See "Monoarthritis in adults: Etiology and evaluation" and "Evaluation of the adult with polyarticular pain" and "Clinical manifestations and diagnosis of calcium pyrophosphate crystal deposition (CPPD) disease" and "Clinical manifestations and diagnosis of gout".)

Infrequently, acute nontraumatic wrist pain may be caused by leukemia and other malignancies, Lyme disease, or rheumatoid arthritis. Lyme disease often goes unrecognized and late manifestations may include acute joint pain. Although not common, rheumatoid arthritis can presents as a monoarticular arthritis before full blown disease develops. (See "Malignancy and rheumatic disorders" and "Clinical manifestations of Lyme disease in adults" and "Clinical manifestations of rheumatoid arthritis".)

HISTORY — Obtaining a thorough history is important and a detailed history alone may lead to a specific diagnosis in approximately 70 percent of wrist pain cases [1]. The mechanism of injury often helps to determine management. The history is taken in an orderly sequence and should emphasize questions that have the greatest clinical relevance. When evaluating acute wrist pain, the following questions are of particular importance:

●Is the pain associated with any systemic features (eg, fever, night sweats)? Does pain occur in both wrists or in other joints in addition to the wrist?

The presence of systemic features or pain in both wrists or additional joints suggests that the pain may stem from a systemic illness. (See 'Wrist pain not associated with trauma or overuse' above.)

●Did pain begin following trauma? If so, what was the mechanism of injury?

Wrist injuries can represent a wide variety of conditions and can be missed during an initial evaluation. As examples, a fall onto an outstretched hand (FOOSH) may lead to injuries such as scaphoid fracture, lunate dislocation, or scapholunate dissociation. The degree of force and the position of the wrist during an acute injury determine the site of greatest impact and the structures most likely to be injured. A force loading the radial side of an extended, pronated wrist (eg, falling forward) is more likely to injure the scaphoid, while a force loading the ulnar side of an extended, supinated wrist (eg, falling back) is more likely to injure the triquetrum or lunate. If the patient was involved in a motor vehicle accident, the impact of the wrist on the steering wheel may have injured carpal ligaments [2,3]. (See "Scaphoid fractures".)

●Which is the patient’s dominant hand?

The dominant hand is more likely to be injured, and the functional loss usually is greater.

●Where on the wrist is the patient experiencing symptoms?

Have the patient point to the site of greatest discomfort, or allow them to determine if symptoms are spread over a wider area. Although the degree of pain is subjective, the location of symptoms can help to narrow the differential diagnosis. As examples, pain from a ligamentous disruption is typically localized (eg, scapholunate dissociation causes pain over the radial aspect of the wrist), whereas a condition involving nerve compression creates more diffuse symptoms (eg, compression of the ulnar nerve in Guyon's canal can occur from trauma and produce paresthesias and hypesthesias in the small and ring fingers). (See "Ulnar neuropathy at the elbow and wrist".)

●What exact movements or activities elicit pain? Also, what movements or activities (including rest) relieve the pain?

Any movement that elicits or increases pain should be among the last things tested by the clinician. Premature testing can lead to guarding by the patient and limit the usefulness of the rest of the examination (eg, ulnar deviation may reproduce the pain from a TFCC tear).

●Describe the pain? Is it sharp, shooting, severe, dull, or diffuse?

Pain caused by direct injury to a nerve tends to be sharp and burning, and travel along the nerve’s distribution. Pain caused by a fracture is usually deep, boring, and fairly constant. Pain from a ligamentous injury often waxes and wanes depending upon activity.

●What is the patient’s occupation?

Many occupational and recreational activities can affect wrist function. As examples, prolonged typing and working with machinery may involve repetitive motion that produces wrist pain, while other hobbies, such as knitting or sewing, can produce a compressive neuropathy. These chronic conditions can lead to an acute exacerbation, which ultimately leads the patient to present for medical attention.

●What does the patient do for sport or recreation? More specifically, one might ask what position on a sports team do they play?

Such sport-specific information can help the clinician to determine if a wrist injury stems from repetitive stress or from direct trauma (table 1). Contact sports, such as American football or rugby, may involve wrist trauma, while noncontact sports, such as golf and tennis, involve repetitive stress of the wrist. Repetitive or acute trauma from a club, racquet, or bat can cause a hamate hook fracture. Chronic wrist pain can lead to an acute event, such as a stress reaction developing into a stress fracture (eg, repetitive wrist impact from competitive divers hitting the water may lead to a carpal bone stress reaction or fracture). (See "Hamate fractures".)

PHYSICAL EXAMINATION — Examination of the wrist is performed in standard fashion and includes inspection, palpation, range of motion, and relevant special tests [4], although the assessment may be limited by the injury and patient discomfort. A detailed description of how to perform the wrist examination is found separately. (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Physical examination'.)

The history and initial examination findings determine which special tests should be performed. In all cases, a screening neurovascular assessment of the involved extremity should be performed, as well as an evaluation for fractures, particularly of the scaphoid. Some specific points about examining the acutely painful wrist are discussed below. (See "Scaphoid fractures".)

With acute wrist injuries, the flexor and extensor tendons should be tested actively against resistance. Partial tendon lacerations are best identified through opposition testing. (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Range of motion'.)

Motor nerve testing is important in the setting of acute wrist pain:

●Radial nerve (figure 1): To test the radial nerve, have the patient extend their wrist and digits against opposition.

●Median nerve (figure 2): To test the median nerve, have the patient flex the distal interphalangeal joint of the index finger and the interphalangeal joint of the thumb (picture 1). To test for median nerve injury at the wrist, have the patient press the distal fat pad of the thumb against that of the ring finger. Feel for a contracted abductor pollicis brevis along the thumb metacarpal (figure 3), which indicates normal nerve function.

●Ulnar nerve (figure 4): To test the ulnar nerve, have the patient flex the tips of their ring and small fingers until they touch the distal palm. Next, spread these fingers apart while the patient resists; with the other hand, palpate for a tensed flexor carpi ulnaris tendon at the wrist (figure 5 and figure 3), which indicates normal nerve function.

DIFFERENTIAL DIAGNOSIS BY REGIONS OF THE WRIST

Ulnar sided wrist pain — The structures involved in common causes of ulnar sided wrist pain include those found in the accompanying graphic (picture 2).

Extensor carpi ulnaris subluxation and tendinopathy — The extensor carpi ulnaris (ECU) tendon can sublux or dislocate from its groove on the distal ulna, which can cause acute discomfort (figure 6 and image 1). Patients describe the sensation of clicking or popping as the wrist is actively moved into supination and extension, along with pain in the area of the ulnar styloid. The usual mechanisms of injury involve either loading of the wrist while it is held in a position of flexion, supination, and ulnar deviation, or the sudden application of a force to the wrist while the ECU tendon is performing an isometric contraction. The sensation of the tendon snapping out of position may be accentuated if this movement is resisted by the examiner. Passive range of motion does not usually dislocate the tendon.

Conservative management, including immobilization, rest, and nonsteroidal antiinflammatory drugs (NSAIDs), is typically sufficient to treat this condition; in rare instances, surgery is needed. Early immobilization for ECU tendon instability involves the use of a long arm splint or cast with the forearm in pronation and the wrist in neutral position. If immobilization fails to alleviate the instability, surgery to reconstruct the ECU sheath is indicated [5].

Any repetitive action that entails repeated twisting and dorsiflexing of the wrist can strain the ECU tendon. ECU tendinopathy is usually a subacute or chronic condition common among people who play racquet sports, as well as those who frequently use a computer mouse or keyboard with their wrist poorly positioned (eg, excessive dorsiflexion) [6]. This condition is reviewed separately. (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Extensor carpi ulnaris tendinopathy and subluxation'.)

Triangular fibrocartilage complex injury — The triangular fibrocartilage complex (TFCC) stabilizes the wrist at the distal radioulnar joint and ulnocarpal articulations while allowing for adequate wrist motion, and is a focal point for force transmission across the ulnar aspect of the wrist [7]. Acute injury to the triangular fibrocartilage complex involves tears of the fibrocartilage articular disc and the tissue that connects the disc to the triquetrum and other carpals (figure 7 and figure 8). Trauma, such as a fall forward onto an outstretched hand, is the most common mechanism. The hand is usually in a pronated (palm down) position during the fall. Wrist pain along the ulnar aspect of the wrist is the primary symptom of TFCC injury. Pain typically increases with any activity that requires forearm rotation and ulnar deviation of the wrist. A clinician may provoke the symptoms of a TFCC injury by hyper-supinating the forearm and loading the wrist (ie, compressing the joint with an axial load) while it is held in a position of ulnar deviation and extension (picture 3). TFCC injury is reviewed in greater detail separately. (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Triangular fibrocartilage complex injury'.)

Triquetral fracture — Triquetral fractures typically occur from a hyperextension injury with the wrist in ulnar deviation (image 2). The patient typically presents with a history of injury and pain at the ulnar aspect of the wrist. On examination, there is usually pain and point tenderness dorsally or along the ulnar border of the wrist, 1 to 2 cm distal to the most distal aspect of the ulna or the ulnar styloid. Wrist extension may reproduce or exacerbate pain. (See "Triquetrum fractures".)

Ulnar styloid impaction syndrome — Ulnar styloid impingement (or impaction) syndrome occurs in individuals with, an excessively long ulnar styloid, which in certain positions can cause compression of the TFCC between it and the triquetrum [8-10]. One mechanism for such compression involves repetitive flexion and ulnar deviation of the wrist while the forearm is pronated and the elbow is flexed at 90 degrees. Another mechanism involves supination, extension, and ulnar deviation of the wrist. Maneuvers that recreate these positions and movements can be used to help diagnose the condition as well. The condition is relatively common among gymnasts, who assume such positions while placing their entire body weight on their wrists while performing such exercises as the pommel horse and balance beam. A standard posteroanterior (PA) radiograph that reveals an ulnar styloid longer than 6 mm helps to confirm the diagnosis. A magnetic resonance imaging (MRI) arthrogram can be used to identify associated TFCC tears. The condition is managed conservatively with activity modification (avoid repetitive flexion/ulnar deviation of the wrist), occupational therapy, wrist bracing, and oral antiinflammatory medications. Should pain persist longer than six months despite appropriate treatment, partial resection of ulnar styloid may be needed.

Radial sided wrist pain — The structures involved in common causes of radial sided wrist pain include those found in the accompanying graphic (picture 4).

Scaphoid fracture — Scaphoid fractures are common following wrist trauma and the scaphoid is at relatively high risk for avascular necrosis following such a fracture. Scaphoid fractures frequently occur following a fall onto an outstretched hand and can be misdiagnosed as a wrist sprain acutely. Thus, due to delayed diagnosis, the fracture itself or AVN can present as chronic wrist pain. Examination generally reveals focal tenderness at the anatomic snuffbox (picture 5). Radiographs confirm the diagnosis, but may be negative immediately following the fall (image 3 and image 4). This topic is reviewed in detail separately. (See "Scaphoid fractures".)

Scapholunate instability — A fall back onto an outstretched, extended wrist that disrupts the supporting ligaments forces the carpal bones to shift dorsally. Depending upon the amount of force involved and the position of the wrist during the fall, a range of possible injuries may occur. Of the potential ligamentous injuries, disruption of the ligaments stabilizing the lunate and scaphoid bones is most common (image 5) [11]. With more forceful trauma, dissociation of the lunate and capitate and/or triquetrum can occur. The symptoms associated with scapholunate dissociation vary with the severity of the injury [11]. Patients may complain of swelling and pain over the dorsoradial aspect of the wrist (overlying the scaphoid and lunate), grip weakness, and painful or decreased wrist motion. Tenderness over the scapholunate junction is common. The scaphoid shift test can help detect ligamentous instability (picture 6 and picture 7 and picture 8 and picture 9). This injury is reviewed in greater detail separately. (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Scapholunate instability'.)

Trapezium fracture — Trapezium fractures are uncommon, but trauma involving axial loading of the thumb or a direct blow may cause such injuries (image 6 and image 7). The patient typically presents with minimal swelling, but may have significant discomfort (more than expected from other carpal bone fractures). There is pain and weakness with pinching (eg, making an "OK" sign, or touching the thumb to the tip of the fifth digit). Pain with resisted wrist flexion from a dorsiflexed start position or tenderness at the base of the thenar eminence may indicate a fracture of the trapezial ridge. (See "Trapezium and trapezoid fractures".)

de Quervain tendinopathy — de Quervain tendinopathy refers to entrapment tendonitis or tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons at the styloid process of the radius (figure 6). Chronic overuse is the usual cause but acute exacerbations can occur. Patients with de Quervain tendinopathy typically note pain at the radial side of the wrist during pinch grasping or thumb and wrist movement. Pain may radiate to the thumb or along the volar aspect of the wrist. Ultrasound can assist in making the diagnosis (image 8 and image 9). de Quervain tendinopathy is reviewed in detail separately. (See "de Quervain tendinopathy".)

Carpometacarpal osteoarthritis — Osteoarthritis is a common cause of pain at the base of the thumb metacarpal (carpometacarpal or CMC, joint) (image 10). Although osteoarthritis is a chronic condition, relatively rapid increases in symptoms may lead patients to present for evaluation complaining of “acute” wrist pain. Inspection of the hand may reveal a prominent CMC joint. Symptoms often include diffuse pain that is aggravated by sustained grasping or pinching (eg, sewing), or by forceful use of the thumb, such as turning a key. Patients may sense thumb weakness or the joint “slipping.”

The metacarpal may enlarge at its base, creating a mild deformity. There is typically no local warmth at the joint, but it is tender to palpation along the volar side. Applying an axial load on the metacarpal with slight rotation (the “grind test”) elicits pain. Crepitation may also be noted. Strength testing frequently reveals loss of pincer strength. The evaluation and treatment of osteoarthritis is discussed separately. (See "Evaluation of the patient with thumb pain", section on 'Arthritis' and "Clinical manifestations and diagnosis of osteoarthritis" and "Overview of the management of osteoarthritis".)

Volar sided wrist pain — The structures involved in common causes of volar sided wrist pain include those found in the accompanying graphic (picture 10).

Hook of the hamate fracture — Fractures of the hook of the hamate often result from a fall onto an outstretched hand. They may be misdiagnosed initially as a wrist sprain and can present with chronic pain localized over the hypothenar eminence; swelling may be minimal or absent. An important clinical test is for the examiner to place the PIP of their thumb on the patient’s pisiform and flex their thumb forcefully into the palm, which generally elicits pain if a fracture is present (picture 11). Hamate fractures are reviewed in detail separately. (See "Hamate fractures".)

Pisiform fracture — Most commonly the pisiform is injured in a fall on the outstretched hand with the wrist in extension or if the heel of the hand is used like a hammer to strike an object. When the wrist is in this position, the pisiform is compressed between the flexor carpi ulnaris tendon and the triquetrum. These mechanisms can create an avulsion fracture of the distal aspect of the pisiform, a linear fracture, or a chondral injury to its dorsal surface. Patients present with pain and swelling at the palmar and ulnar aspects of the wrist. Tenderness is present directly over the pisiform and over the hypothenar eminence. Typically, there is no loss of motion in the wrist and no deformity is seen. (See "Pisiform fractures" and "Overview of carpal fractures".)

Carpal tunnel syndrome — Carpal tunnel syndrome (CTS) refers to a complex of symptoms and signs brought on by compression of the median nerve as it travels through the carpal tunnel (figure 9). CTS is usually a chronic condition but there are circumstances when acute CTS can develop, such as fractures and fracture-dislocations at the wrist, or hemorrhagic or vascular disorders [12]. Patients commonly experience pain and paresthesia, and less commonly weakness, in the median nerve distribution. Symptoms are typically worse at night. Positive Phalen or Tinel tests suggest the diagnosis (picture 12 and picture 13). CTS is reviewed in detail separately. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis" and "Carpal tunnel syndrome: Pathophysiology and risk factors" and "Carpal tunnel syndrome: Treatment and prognosis".)

Ulnar neuropathy (Guyon’s canal syndrome) — Injury to the terminal branches of the ulnar nerve at the wrist typically present with hand weakness and atrophy, loss of dexterity, and variable sensory involvement (figure 10). The condition often develops after prolonged compression of the ulnar nerve during activities such as cycling or racquet sports. Physical examination is often unremarkable with this condition. Ulnar neuropathy is reviewed in detail separately. (See "Ulnar neuropathy at the elbow and wrist", section on 'Ulnar neuropathy at the wrist'.)

Dorsal sided wrist pain — The structures involved in common causes of dorsal sided wrist pain include those found in the accompanying graphic (picture 14).

Wrist sprain — A sprained wrist involves injury to the supporting ligaments of the radiocarpal joint. Following trauma, wrist sprain is a diagnosis of exclusion and more severe injuries such as scaphoid fracture must be ruled out. Most sprains occur when the patient lifts something heavy overhead and the wrist gives way while the arms are extended. Sprains are associated with mild pain or stiffness and normal range of motion, although loss of flexion and extension can occur with more severe sprains. The majority of sprains resolve within two weeks with conservative therapy (ice, immobilization, gentle passive stretching exercises) [13]. Additional support during recovery and the resumption of activity may be helpful (picture 15 and picture 16).

Distal radius fracture — Fracture of the distal radius typically follows a fall onto an outstretched hand. It commonly occurs in young active patients and in the elderly, particularly those with osteoporosis. Swelling, deformity, and a palpable bony step-off are often present, but the extremity may appear normal. Diagnosis is generally made by plain radiograph. Although frequently referred to as Colles fractures, fractures of the distal radius comprise several types and their management is not uniform. To avoid confusion, it is best to avoid the use of eponyms when communicating with a consultant and simply to describe the characteristics of the fracture. (See "Distal radius fractures in adults".)

Carpal fractures

Capitate fracture — The patient with a capitate fracture typically presents with pain and swelling on the dorsum of the wrist or proximal hand (image 11). There is tenderness dorsally over the capitate (which lies just proximal to the third metacarpal and in line with Lister’s tubercle). A number of mechanisms can cause these injuries, which rarely occur in isolation. (See "Capitate fractures" and "Overview of carpal fractures".)

Lunate fracture — Acute lunate fractures most often occur as the result of a fall onto an extended wrist or some other wrist hyperextension injury. Patients may not recall a specific traumatic incident, but typically present with wrist pain aggravated by wrist motion or gripping something tightly with the affected hand. (See "Lunate fractures and perilunate injuries" and "Overview of carpal fractures".)

Trapezoid fracture — Fractures of the trapezoid generally occur with axial loading of the second (index) metacarpal, or (rarely) secondary to direct trauma to the dorsum of the wrist. Patients usually have some degree of swelling on the dorsum of the hand, and point tenderness dorsally just proximal to the base of the second metacarpal. Resisted wrist dorsiflexion may cause pain, as the extensor carpi radialis inserts on the proximal aspect of the index metacarpal, which is closely fixed to the trapezoid by firm intercarpal ligamentous attachments. (See "Trapezium and trapezoid fractures" and "Overview of carpal fractures".)

Perilunate and lunate dislocations — Perilunate and lunate dislocations are caused by trauma, often a fall back onto an outstretched hand with the wrist extended. Both involve significant ligamentous damage and may be associated with carpal fractures [14-18]. The forces from a fall onto an outstretched, extended wrist disrupt the supporting ligaments and may cause the carpal bones to shift dorsally. Both the direction of the force and the relative weakness of the volar ligaments lead to the dorsal displacement.

The most common of the ligamentous injuries is disruption of the ligaments that stabilize the lunate and scaphoid, resulting in a scapholunate dissociation. With more forceful trauma, dissociation between the lunate and the capitate and/or triquetrum can occur. Diagnosis is usually made using the lateral radiograph, which in the case of a perilunate dislocation shows the lunate in normal or near normal alignment but the remainder of the carpus and metacarpals displaced dorsally (image 12), or in the case of lunate dislocation, shows the lunate displaced volarly (so-called “spilled teacup” sign) but the distal radius, carpus, and metacarpals in otherwise normal alignment (image 13). The lateral wrist radiograph best confirms the injury and its direction of displacement of carpal bones, but anteroposterior (AP) and fist views may be helpful in detecting questionable cases and can suggest a higher degree ligamentous injury. Referral to a hand surgeon is important to reduce the long-term risk of avascular necrosis.

Ganglion cyst — A ganglion is a cystic swelling overlying a joint or tendon sheath (picture 17 and image 14). Ganglia are thought to arise due to herniation of synovial tissue through a joint capsule or tendon sheath and are commonly seen at the dorsum of the wrist. Ganglia are discussed in greater detail separately. (See "Ganglion cysts of the wrist and hand", section on 'Definition'.)

Kienböck's disease of the lunate — Kienböck's disease is a progressive collapse of the lunate (figure 11 and image 15). This is a chronic condition but it can have acute exacerbations. The mechanism remains unclear but appears to involve disruption of the blood supply, possibly related to undiagnosed fractures of the lunate, repetitive trauma, or abnormal biomechanical loading patterns at the radiocarpal joint [19-21]. The most common symptoms are dorsal wrist pain with mild swelling. (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Kienböck disease (avascular necrosis) of the lunate'.)

Intersection syndrome — Intersection syndrome is a painful condition that affects the dorsum of the forearm a few centimeters proximal to the wrist joint at the intersection of the muscle bellies of the abductor pollicis longus and extensor pollicis brevis, where they cross over the extensor carpi radialis longus and the extensor carpi radialis brevis tendons (figure 12 and figure 6) [22,23]. The mechanism of injury usually involves repetitive resisted wrist extension such as with rowers and weight lifters, but can occur with any activity that involves a substantial increase in the use of the wrist extensors. Patients typically present within a few weeks of the onset of symptoms (although later presentations may occur) and may describe hearing “noise” when they extend their wrist repeatedly. The examiner may note redness, warmth, or crepitation at the site. Intersection syndrome is often confused with de Quervain tendinopathy. The distinguishing feature is the location of the pain: intersection syndrome is more dorsal (picture 18) while de Quervain’s is more radial (picture 19). Treatment includes rest, activity modification, bracing, and nonsteroidal antiinflammatory medications. A glucocorticoid injection may be used in cases where more conservative treatments have not alleviated the symptoms.

Nonspecfic wrist pain — Occult cartilage injury in one of the carpal joints may cause acute pain following injury that is not easily localized. Cartilage injuries are seen in anywhere between 17 and 32 percent of all wrist arthroscopies after trauma [24].

IMAGING

Approach to imaging — A good history and physical examination will help localize the source of pain and narrow the differential diagnosis of acute wrist pain, but imaging is often necessary to make a definitive diagnosis. The first diagnostic imaging studies obtained in most cases are standard plain radiographs. Additional imaging studies may be needed depending upon the location of symptoms and the primary diagnoses being entertained. The types of imaging studies used to evaluate the wrist and the conditions for which each study is best suited are discussed separately. (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Imaging'.)

Additional ultrasound resources — Instructional videos demonstrating proper performance of the ultrasound examination of the wrist and related pathology can be found at the website of the American Medical Society for Sports Medicine: volar wrist US exam, dorsal wrist US exam, ulnar wrist US exam, sports US wrist-hand pathology, US guided interventional procedures of the wrist and hand. Registration must be completed to access these videos but no fee is required.

APPROACH TO DIAGNOSIS — It can be difficult to evaluate patients with acute wrist pain. The anatomy of the wrist is complex and the differential diagnosis broad. Fortunately, patients with wrist pain generally present with one of several common combinations of symptoms and signs that suggest the diagnosis. By following the basic approach outlined here, clinicians should be able to diagnose and either manage or refer appropriately the great majority of patients with acute wrist complaints. Chronic and subacute causes of wrist pain are discussed separately. The following flow chart provides an overview of our approach to wrist pain diagnosis (algorithm 1). (See "Evaluation of the adult with subacute or chronic wrist pain".)

Determine whether cause is traumatic or nontraumatic — The first step in identifying the cause of acute wrist pain is to determine whether the symptoms can be traced to an episode of direct trauma to the wrist. Most often this determination is straightforward based upon the patient's history. The clinician may need to ask questions to help the patient remember details. Useful questions include:

●When did the injury or onset of pain occur?

●What was the mechanism of injury?

●What part of the forearm, wrist, or hand was injured?

●Is there one spot that is most tender?

●What limitations to function and activity has the wrist pain caused?

●Was this forearm, wrist, or hand ever injured before?

●Did the patient note any swelling or warmth at the site of injury?

●Does the patient have rest or night pain, or does pain develop only with activity?

The most common wrist injuries from minor trauma, usually a fall onto an outstretched hand, include fractures of the scaphoid or distal radius, triangular fibrocartilage complex (TFCC) tears, and ligamentous injuries. Injuries may be missed initially leading to delayed presentations. Examples of commonly missed injuries include scaphoid or hook of the hamate fractures, ligamentous injuries (eg, scapholunate), and TFCC tears. In these cases, the patient is nearly always able to localize the pain and examination reveals focal tenderness and possibly deformity. Imaging studies make or confirm the diagnosis.

The first diagnostic imaging studies obtained in most cases are standard plain radiographs. A physician with ultrasound experience often evaluates the wrist with ultrasound. Additional imaging studies may be needed depending upon the location of symptoms and the primary diagnoses being entertained. As examples, if the clinician suspects a scaphoid fracture but plain radiographs are unrevealing, a magnetic resonance imaging (MRI) study is obtained; if a hook of the hamate fracture is suspected but plain radiographs are unremarkable, a computed tomography (CT) scan is obtained.

Determine whether nontraumatic pain is from overuse or nerve compression — If no traumatic causes are identified by history, the clinician should next determine whether acute exacerbation of a more chronic condition accounts for the patient’s symptoms. The most common causes of chronic nontraumatic wrist pain are tendon degeneration related to overuse and nerve compression. The patient may have been ignoring chronic but minor underlying wrist pain until it suddenly increased in intensity, and now presents with an “acute” episode.

Conditions involving tendon degeneration include extensor carpi ulnaris (ECU) tendinopathy, intersection syndrome, de Quervain tendinopathy, and less commonly tendinopathy involving the common extensor tendons (fourth wrist compartment). Conditions related to nerve compression include carpal tunnel syndrome and ulnar neuropathy (ie, Guyon’s canal syndrome). The history and physical examination, along with a basic knowledge of wrist anatomy, are generally sufficient to diagnose these conditions. Nerve compression syndromes generally involve pain and paresthesias in the distribution of the involved nerve, whereas pain from tendon damage increases when the tendon is stressed. (See "Anatomy and basic biomechanics of the wrist".)

Acute wrist pain unrelated to overuse or nerve compression may be caused by a sudden increase in pain from conditions such as carpal boss, carpometacarpal (CMC) osteoarthritis, Kienböck’s disease, and ganglion cysts. These conditions may stem from repetitive microtrauma in the past but they present months to years after any initial injury. More typically these conditions present with chronic or subacute pain, and they are discussed separately. (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Dorsal-sided wrist pain'.)

Wrist pain not associated with trauma or overuse, but associated with systemic symptoms or pain in additional joints, suggests a rheumatologic, infectious, or possibly oncologic cause. General guidance about these conditions is provided above and in separate UpToDate topics devoted to these conditions. (See 'Wrist pain not associated with trauma or overuse' above.)

Correlate history and location of symptoms and signs — Most causes of acute wrist pain present at specific locations. It is important to use the location of symptoms, in addition to the information gained from the history and examination, to establish the diagnosis. The following flow chart provides an overview of our approach to wrist pain diagnosis (algorithm 1). Below, the common causes of acute wrist pain are organized by location and accompanied by a brief clinical description featuring elements of particular importance for diagnosis:

●Ulnar sided wrist pain

•Extensor carpi ulnaris (ECU) tendinopathy ‒ ECU tendinopathy can develop from any repetitive motion that entails rotation or dorsiflexion of the wrist (eg, playing racquet sports, using a computer mouse). Palpation of the distal lateral wrist, resisted wrist extension and/or forceful pronation of the wrist may elicit pain lateral to the ulnar styloid (over sixth wrist compartment). Ultrasound demonstrating a “halo sign” in compartment 6 confirms the diagnosis. Relief of pain with a lidocaine injection into the ECU sheath, if necessary, helps to confirm the diagnosis [25]. (See 'Extensor carpi ulnaris subluxation and tendinopathy' above.)

•Extensor carpi ulnaris subluxation ‒ Subluxation of the ECU tendon can occur when the tendon is stressed with the wrist supinated. Patients describe the sensation of clicking or popping as the wrist is actively moved into extension and supination. They may note sharp pain with these movements. With repeated motion of the wrist from pronation and flexion to supination and extension, popping of the ECU tendon is noted lateral to ulnar styloid. A dynamic ultrasound showing the motion of the ECU tendon can confirm the diagnosis.

•Triangular fibrocartilage complex (TFCC) injury – TFCC injury usually occurs from a fall forward onto an outstretched hand. Wrist pain directly over the ulnar aspect of ulnar-carpal joint that radiates along the ulnar aspect of the wrist is the primary symptom. Pain typically increases with any activity that requires forearm rotation and ulnar deviation of the wrist. Direct compression of the TFCC with an axial load, while the wrist is in ulnar deviation and the forearm supinated, will usually elicit significant pain. Magnetic resonance imaging (MRI) confirms the diagnosis. (See 'Triangular fibrocartilage complex injury' above.)

•Triquetral fracture ‒ Triquetral fractures typically occur from a hyperextension injury with the wrist in ulnar deviation. On examination, there is usually pain and point tenderness dorsally or along the ulnar border of the wrist, 1 to 2 cm distal to the most distal aspect of the ulna or the ulnar styloid. Wrist extension may reproduce or exacerbate pain. (See "Triquetrum fractures" and "Overview of carpal fractures".)

•Ulnar styloid impaction syndrome ‒ Ulnar styloid impingement, or impaction syndrome occurs in individuals with, an excessively long ulnar styloid, which in certain positions can cause compression of the TFCC between it and the triquetrum [8-10]. These positions include repetitive flexion and ulnar deviation of the wrist while the forearm is pronated and the elbow is flexed. Maneuvers that recreate these positions and movements can be used to help diagnose the condition as well. The condition is relatively common among gymnasts. A standard posteroanterior (PA) radiograph that reveals an ulnar styloid longer than 6 mm helps to confirm the diagnosis. (See 'Ulnar styloid impaction syndrome' above.)

●Radial sided wrist pain

•Scaphoid fracture – Scaphoid fractures usually involve a history of a fall onto an outstretched hand and present with focal tenderness at the anatomic snuffbox. Tenderness in the anatomic snuffbox requires a workup to confirm or exclude scaphoid fracture (picture 5). Radiographs confirm the diagnosis but may be negative immediately following the fall (image 3). (See "Scaphoid fractures".)

•Scapholunate instability – A fall back onto an outstretched, extended wrist can disrupt the supporting ligaments of the carpal bones, most often those that stabilize the scaphoid and lunate. Patients may complain of swelling and pain over the dorsoradial aspect of the wrist (overlying the scaphoid and lunate), grip weakness, and painful or decreased wrist motion. The scaphoid shift test and tenderness at the proximal carpal row just distal to Lister’s tubercle are suggestive findings that indicate the need for further work-up. Plain radiographs that include a fist view help to distinguish ligamentous instability from a fracture. (See 'Scapholunate instability' above.)

•Trapezium fractures – Trauma involving axial loading of the thumb or a direct blow may cause a trapezium fracture. The patient typically presents with minimal swelling, but may have significant discomfort (more than expected from other carpal bone fractures). There is pain and weakness with pinching (eg, making an "OK" sign, or touching the thumb to the tip of the fifth digit). Pain with resisted wrist flexion from a dorsiflexed start position or tenderness at the base of the thenar eminence may indicate a fracture of the trapezial ridge. (See "Trapezium and trapezoid fractures" and "Overview of carpal fractures".)

•de Quervain tendinopathy – de Quervain tendinopathy usually causes distal radial-sided wrist pain that increases with ulnar deviation. Distal radial sided swelling and a positive Finkelstein test strongly suggest the diagnosis. Ultrasound can confirm the diagnosis. (See 'de Quervain tendinopathy' above.)

•Carpometacarpal osteoarthritis – Osteoarthritis of the carpometacarpal (CMC) joint is common in older patients and usually presents as chronic pain. However, patients can have an acute flair of this chronic condition. Symptoms often include diffuse pain focused at the base of the thumb metacarpal that is aggravated by sustained grasping or pinching (eg, when sewing) or by forceful use of the thumb (eg, turning a key). Key examination findings include some irregularity (“squaring”) at the CMC joint and pain referred to this area with resisted thumb flexion or extension. Plain radiograph (image 10) or ultrasound confirms the diagnosis. (See 'Carpometacarpal osteoarthritis' above.)

●Volar (palmar) sided wrist pain

•Hook of the hamate fracture – Fractures of the hook of the hamate often result from a fall onto an outstretched hand (FOOSH). They may be misdiagnosed initially and often present with chronic pain localized over the hypothenar eminence; swelling may be minimal or absent. An important clinical test is for the examiner to place the PIP of their thumb on the patient’s pisiform and flex their thumb forcefully into the palm, which generally elicits pain if a fracture is present (picture 11). (See "Hamate fractures".)

•Pisiform fracture – The pisiform is typically injured from a fall onto an outstretched hand (FOOSH) with the wrist in extension, or when the heel of the hand is used like a hammer to strike an object. When the wrist is in slight extension and the hypothenar surface sustains a forceful impact, the flexor carpi ulnaris tendon compresses the pisiform against the triquetrum. Such trauma can cause an avulsion fracture of the distal portion of the pisiform, a linear fracture, or a chondral injury to the bone’s dorsal surface. Patients present with pain and swelling at the ulnar aspect of the volar wrist. Tenderness is present directly over the pisiform and hypothenar eminence. (See "Pisiform fractures" and "Overview of carpal fractures".)

•Carpal Tunnel Syndrome – Carpal tunnel syndrome (CTS) causes paresthesias and pain in the median nerve distribution (typically involving the thenar eminence, thumb, index, and middle fingers). Symptoms are typically worse at night. Key physical findings include positive Phalen and Tinel’s tests (picture 12 and picture 13). An ultrasound examination showing proximal enlargement of the median nerve before it is compressed by the trans-palmar ligament helps confirm the diagnosis. On a longitudinally oriented ultrasound scan the nerve sometimes appears to taper like an hourglass. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis" and "Carpal tunnel syndrome: Pathophysiology and risk factors" and "Carpal tunnel syndrome: Treatment and prognosis".)

•Ulnar nerve compression (Guyon’s canal syndrome) – This syndrome presents with hypothenar numbness after prolonged compression of the ulnar nerve during activities such as cycling or racquet sports (figure 10). Often the physical examination is unremarkable. (See "Ulnar neuropathy at the elbow and wrist", section on 'Ulnar neuropathy at the wrist'.)

●Dorsal sided wrist pain

•Wrist sprain – A sprained wrist involves injury to the supporting ligaments of the radiocarpal joint. Most sprains are associated with mild pain or stiffness and normal range of motion, although loss of flexion and extension can occur with more severe sprains.

•Distal radius fracture – Fracture of the distal radius typically follows a fall onto an outstretched hand. It commonly occurs in young active patients and in the elderly, particularly those with osteoporosis. Swelling, deformity, and a palpable bony step-off are often present, but the extremity may appear normal. Diagnosis is generally made by plain radiograph. (See "Distal radius fractures in adults".)

•Carpal fractures

-Capitate fracture – The patient with a capitate fracture typically presents with pain and swelling on the dorsum of the wrist or proximal hand. There is tenderness dorsally over the area of the capitate (just proximal to the third metacarpal and in line with Lister’s tubercle). A number of mechanisms can cause capitate fracture and rarely occur in isolation. (See "Capitate fractures" and "Overview of carpal fractures".)

-Lunate fracture – Acute lunate fractures most often occur as the result of a fall onto an extended wrist or some other wrist hyperextension injury. Patients may not recall a specific traumatic incident, but typically present with pain in the wrist area that is aggravated by wrist motion or gripping. (See "Lunate fractures and perilunate injuries" and "Overview of carpal fractures".)

-Trapezoid fracture – Fractures of the trapezoid generally occur with axial loading of the second (index) metacarpal, or may rarely occur secondary to direct dorsal trauma. Patients usually have some degree of swelling on the dorsum of the hand, and point tenderness dorsally just proximal to the second metacarpal base. Resisted wrist dorsiflexion may cause pain as the extensor carpi radialis inserts on the proximal aspect of the index metacarpal, which is closely fixed to the trapezoid by firm intercarpal ligamentous attachments. (See "Overview of carpal fractures" and "Trapezium and trapezoid fractures".)

•Perilunate and lunate dislocations – Perilunate and lunate dislocations are caused by trauma, often a fall back onto an outstretched hand with the wrist extended. Both involve significant ligamentous damage and may be associated with carpal fractures [14-17]. The most common of the ligamentous injuries is a scapholunate dissociation. With more forceful trauma, dissociation between the lunate and the capitate and/or triquetrum can occur. Diagnosis is usually made using the lateral radiograph, which in the case of a perilunate dislocation shows the lunate in normal or near normal alignment, but the remainder of the carpus and metacarpals displaced dorsally (image 12), or in the case of lunate dislocation shows the lunate displaced volarly (so-called “spilled teacup” sign) but the distal radius, carpus, and metacarpals in otherwise normal alignment (image 13). Anteroposterior (AP) and fist views may be helpful in detecting questionable cases. (See 'Perilunate and lunate dislocations' above.)

•Ganglion cyst – A ganglion is a soft cystic swelling overlying a joint or tendon sheath that commonly develops at the dorsum of the wrist (picture 17 and image 14). Ganglions can cause pain and their size may increase or decrease depending upon activity. (See "Ganglion cysts of the wrist and hand", section on 'Definition'.)

•Kienböck's disease of the lunate ‒ Kienböck's disease is a progressive collapse of the lunate (figure 11 and image 15). This is a chronic condition, but it can have acute exacerbations. The mechanism may involve disruption of the blood supply, possibly related to undiagnosed fractures of the lunate, repetitive trauma, or abnormal biomechanical loading of the radiocarpal joint [19-21]. The most common symptoms are dorsal wrist pain with mild swelling. (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Kienböck disease (avascular necrosis) of the lunate'.)

•Intersection syndrome – Intersection syndrome is caused by repetitive resisted wrist extension. It is often confused with de Quervain tendinopathy. The distinguishing feature is the location of the pain: symptoms from de Quervain’s develop along the radial aspect of the wrist while the most common area of discomfort from intersection syndrome is the dorsum of the wrist about 2 to 3 cm proximal to the radiocarpal joint in line with the index finger distally. (See 'Intersection syndrome' above.)

INDICATIONS FOR IMMEDIATE SURGICAL REFERRAL — The indications for immediate referral to a hand surgeon vary according to the nature of the injury and the structures involved. The basic indications for emergency (ie, immediate) referral remain unchanged and include any persistent vascular or neurologic deficit, open fracture, and the development of any significant complication, such as signs of infection.

As described above, a number of conditions warrant timely but not immediate surgical referral. In addition, referral is reasonable whenever the clinician has difficulty establishing a specific diagnosis in the setting of acute injury and pain. Occult cartilage injury in one of the carpal joints may be the cause of symptoms in such cases. (See "General principles of fracture management: Early and late complications" and "Distal radius fractures in adults" and "Distal forearm fractures in children: Initial management".)

Unstable fractures and those at high risk for complications (eg, avascular necrosis, nonunion) should be referred to a hand surgeon. Fracture instability is poorly defined and what is considered unstable varies with patient age and activity. Clinicians should be particularly concerned about patients who are physiologically young and have sustained high-energy, comminuted injuries. Examples of injuries that warrant urgent referral (within two to three days) include the following:

●Palmarly (volarly) displaced radius and ulna fracture or any displaced carpal bone (see "Distal radius fractures in adults", section on 'Diagnostic imaging')

●Articular step-off greater than 2 mm

●Large ulnar styloid fractures (ie, fracture fragment comprises most or all of the styloid) with or without displaced fragments at the styloid base (these are associated with an increased risk of distal radioulnar joint [DRUJ] instability)

●Fracture dislocations

●Distal radius fractures associated with scaphoid fractures or scapholunate ligament injuries (radial styloid fractures are often associated with scapholunate injuries and such fractures are generally referred to a hand surgeon)

●Fractures with significant displacement or comminution (such fractures are unstable and likely to lose position even if initial reduction is near-anatomic). Examples include a distal radius or ulna fracture with greater than 2 mm displacement, or a scaphoid fracture with any displacement

●Fractures likely to be unstable and not amenable to conservative treatment

●Radial fractures with associated flexor tendon tears (a rare complication) [26]

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues in muscle and tendon injury diagnosis and management" and "Society guideline links: Muscle and tendon injuries of the upper extremity (excluding shoulder)".)

SUMMARY AND RECOMMENDATIONS

●Anatomy, biomechanics, and history – The wrist is susceptible to a range of acute injuries and conditions. Obtaining a clear history and correlating the history and symptom location with wrist anatomy are important elements of diagnosis. Mechanism of injury, hand dominance, and occupation and recreational activities are important elements of the history, which is described in detail in the text. Chronic conditions may masquerade as acute injuries due to a sudden increase in pain. The following flow chart provides an overview of our approach to diagnosis (algorithm 1). (See "Anatomy and basic biomechanics of the wrist" and 'History' above.)

●Physical examination – Examination of the wrist is performed systematically, and includes inspection, palpation, range of motion, and relevant special tests. It is often helpful to compare affected and unaffected wrists. In the setting of trauma, motion and strength testing may be limited. In all cases, a screening neurovascular assessment of the involved extremity should be performed. (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Physical examination'.)

●Anatomy-based differential diagnosis – A useful way to organize the differential diagnosis is by location. Relatively common and important causes include the following:

•Ulnar sided wrist pain: Extensor carpi ulnaris tendinopathy or subluxation, triangular fibrocartilage complex injury, triquetral fracture (see "Evaluation of the adult with subacute or chronic wrist pain", section on 'Ulnar-sided wrist pain')

•Radial sided wrist pain: Scaphoid fracture, scapholunate instability, trapezium fracture, de Quervain tendinopathy, carpometacarpal (CMC) osteoarthritis (see "Evaluation of the adult with subacute or chronic wrist pain", section on 'Radial-sided wrist pain')

•Volar sided wrist pain: Hook of the hamate fracture, pisiform fracture, carpal tunnel syndrome, ulnar neuropathy (see "Evaluation of the adult with subacute or chronic wrist pain", section on 'Volar-sided wrist pain')

•Dorsal sided wrist pain: Wrist sprain, distal radius fracture, carpal fractures, ganglion cyst, carpal boss, Kienböck's disease of the lunate, intersection syndrome (see "Evaluation of the adult with subacute or chronic wrist pain", section on 'Dorsal-sided wrist pain')

●Diagnostic imaging – The history and physical examination help to localize the source of pain and narrow the differential diagnosis, but imaging is often necessary to make a definitive diagnosis, particularly those involving trauma. Standard plain radiographs are generally the first studies obtained. Additional studies may be needed depending upon the location of symptoms and the primary diagnoses being entertained. (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Imaging'.)

●Fall on outstretched hand – Injuries to the wrist often occur following a fall onto an outstretched hand. Potential injuries in this setting include sprain, scaphoid fracture, distal radius fracture, ligamentous injury (eg, scapholunate dislocation), and fractures of other carpal bones.

●Diagnostic approach – A systematic approach to diagnosis is provided in the text. Three important steps in making the diagnosis are: determining whether the cause of symptoms is traumatic or nontraumatic; if nontraumatic, determining whether pain stems from an overuse syndrome or nerve compression; and correlating the history and the location of symptoms and signs. (See 'Approach to diagnosis' above.)