Evaluation of the adult with subacute or chronic wrist pain

INTRODUCTION — Due to its location and anatomy, the wrist is susceptible to a range of injuries and overuse syndromes, and chronic wrist pain is a common presenting complaint in primary care and sports medicine clinics. Such pain may result from the residual effects of past trauma or nontraumatic conditions. Generally, we define chronic conditions are those that have been present for longer than three months, acute conditions as those present for less than two weeks, and subacute conditions as those present for two weeks to three months.

The common causes of chronic wrist pain and an approach to diagnosing these problems is provided here. Acute wrist pain, wrist anatomy and biomechanics, and more detailed discussions of specific wrist problems are reviewed separately. (See "Evaluation of the adult with acute 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 (see "Evaluation of the adult with acute wrist pain")

●Chronic wrist pain

●Wrist pain without trauma or overuse, possibly associated with systemic symptoms (see "Evaluation of the adult with acute wrist pain", section on 'Wrist pain not associated with trauma or overuse')

The first important distinction to make when establishing the diagnostic category is whether the pain is acute or chronic. Chronic pain is typically defined as pain that has persisted for approximately three months or longer. 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 following sections of this topic provide information and guidance about how to work through the common and important diagnoses within the category of chronic or subacute wrist pain. 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.

HISTORY — Obtaining a thorough history is important for determining the source of chronic wrist pain. The history is taken in an orderly sequence and should emphasize questions that have the greatest clinical relevance. When evaluating chronic 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. Such presentations warrant a thorough evaluation and are discussed separately. (See "Evaluation of the adult with acute wrist pain", section on 'Wrist pain not associated with trauma or overuse'.)

●What is the patient’s age?

Degenerative conditions such as osteoarthritis are more likely to be seen in an older patient.

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

Wrist injuries can be missed during an initial evaluation. As examples, a fall onto an outstretched hand (FOOSH) may lead to injuries that are missed initially, including scaphoid fracture, lunate dislocation, or scapholunate dissociation. If the patient was involved in a motor vehicle accident, the impact of the wrist on the steering wheel may have injured the carpal ligaments. (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 generalized 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, whereas a condition involving nerve compression creates more diffuse symptoms (eg, carpal tunnel syndrome creates pain and paresthesias along the volar surface of the wrist and thenar region).

●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.

●Describe the pain? Is it cramping, dull, aching, sharp, shooting, severe, 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.

●Has this condition (or constellation of symptoms) occurred before? What treatments were used to alleviate the condition?

Some recurring conditions, such as carpal tunnel syndrome, may warrant surgical referral. As another example, the patient with a wrist ganglion that has been aspirated several times before may need a surgical referral for more definitive treatment.

●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.

●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. 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. American football lineman and defensive backs often jam opponents with their extended arms while their wrist is held in dorsiflexion with their palms open. Such repetitive trauma can lead to chronic dorsal wrist pain. Platform divers may have similar dorsal wrist complaints as well as thumb pain from the repeated impact on their hands as they enter the water. Field hockey players are at risk for wrist injury because they constantly hit a hard ball without protective gloves.

With tennis players, it is helpful to ask what type of grip they use and whether they recently changed their grip. Many players select a relatively small racquet grip size because they feel this gives them greater control. However, this can be harmful because the smaller the grip the tighter the player must squeeze the racquet to maintain control during impact, and the resulting chronic overexertion of the hand, wrist, forearm, and elbow can lead to tendinopathy, most often at the origin of the wrist flexors. (See "Elbow tendinopathy (tennis and golf elbow)".)

Wrist injuries in golfers generally occur from overuse and involve the flexor or extensor tendons. Such overuse syndromes are typically amenable to treatment with physical therapy, but may require the patient to abstain from golf for a period of time. Many of these wrist problems stem from one of the following causes: a strong grip (left hand positioned clockwise on the golf club handle), over-gripping (ie, too tight a grip), golf club grips in poor repair, or poor swing technique. Among golfers, the most common bony injury of the wrist is fracture of the hook of the hamate. This injury is a source of chronic ulnar-sided wrist pain and is often diagnosed late or goes undiagnosed [1].

●Does the pain interfere with the patient’s work?

In cases of work-related pain, including disability issues, it is important to obtain a detailed history of any injury or repetitive activity, including the mechanism of any injury, the duration of any repetitive activity both on a daily basis and overall (ie, cumulative performance), and the pattern of symptom progression. Imaging studies are usually required to complete the data collection and may be necessary to determine the affect of wrist symptoms upon the capacity to work. Obtaining as much objective data as possible, including a careful history, physical examination, and radiographic studies, is helpful when secondary gain may be an issue (eg, cases of workman’s compensation or litigation).

●Inquire about past medical and surgical conditions, family history, and medications.

Systemic and local disease can manifest with wrist pain. Examples include median neuropathy from diabetes and joint pain from gout.

PHYSICAL EXAMINATION — Examination of the wrist is performed systematically, and includes inspection, palpation, range of motion, and relevant special tests [2]. 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.

The coronavirus disease 2019 (COVID-19) pandemic has ushered in an increased use of telemedicine for musculoskeletal evaluation [3]. Using telemedicine, clinicians can perform an assessment of the hand and wrist, including inspection, motor function, sensation, and some specialized testing [4]. While they cannot replicate all aspects of a thorough, in-person examination, telemedicine assessments are a viable option in some circumstances.

Inspection — Inspection begins by looking at the patient’s willingness and ability to use the hand. Comparison with the surface anatomy of the unaffected side may reveal obvious deformities or subtle differences in appearance. Pay special attention to the loss of normal contours, as may occur with swelling or muscle atrophy. Inspect the skin for pallor, surgical scars, bruising, erythema, or other lesions. These may provide clues about systemic illness, associated conditions, or injuries.

●Dorsal aspect – Inspect the dorsal aspect of the wrist with the patient’s forearm pronated. The most prominent bony landmark of the dorsal wrist is the head of the distal ulna (figure 1 and picture 1). Diffuse swelling over the dorsum of the wrist is common in rheumatoid arthritis. Diffuse swelling following trauma raises suspicion for a fracture or ligamentous injury. Because the metacarpals are subcutaneous, angulation associated with fractures is usually visible. A localized spherical mass is most often a ganglion cyst. (See "Clinical manifestations of rheumatoid arthritis" and "Distal radius fractures in adults" and "Ganglion cysts of the wrist and hand", section on 'Definition'.)

●Radial (lateral) aspect – Inspect the radial aspect of the wrist starting distally at the base of the first metacarpal and working proximally to the distal radius (figure 2 and picture 2). Look for a hollow depression, known as the “anatomic snuffbox,” which is bound by the first and third dorsal wrist compartments (picture 3 and picture 4). The scaphoid resides within the anatomic snuffbox. Observe the contours of the metacarpophalangeal (MCP) and carpometacarpal (CMC) joints to see if they are smooth; excessive “squaring” suggests degenerative joint disease.

●Volar (palmar) aspect – The visible flexion crease where the hand joins the forearm marks the proximal limit of the flexor retinaculum (transverse carpal ligament) (figure 3 and picture 5). The palmaris longus tendon is present in 80 percent of individuals and runs parallel and ulnar to the flexor carpi radialis tendon. The median nerve travels below the depression between the palmaris longus and the flexor carpi radialis tendons. The clinician should note any atrophy of the thenar eminence, which may indicate median nerve entrapment seen with carpal tunnel syndrome.

●Ulnar (medial) aspect – The ulnar aspect of the wrist is most easily inspected by having the patient flex the elbow until the ulnar surface faces the examiner. The location of the head of the ulna, hypothenar eminence, and fifth metacarpal should be easily visualized (picture 6). Atrophy of the hypothenar eminence may indicate entrapment or injury of the ulnar nerve.

Palpation — Clinicians with a good understanding of surface anatomy can palpate the carpal bones individually (figure 4 and image 1).

●Scaphoid – To palpate the scaphoid, place your thumb in the anatomic snuffbox and move the index finger to the proximal thenar eminence such that the patient’s scaphoid is between the index finger and thumb (picture 3 and picture 4). Focal tenderness at the snuffbox following trauma suggests scaphoid injury. (See "Scaphoid fractures".)

●Lunate – The lunate can be palpated on the dorsum of the wrist just distal to the radius (picture 7 and picture 1 and figure 5). Palpate Lister’s Tubercle with your thumb, and then slide your thumb distally to the proximal carpal row in line with the middle finger to find the lunate. The lunate becomes more prominent with volar flexion of the wrist.

●Triquetrum – The triquetrum can be appreciated on the dorsum of the wrist, just distal to the ulnar prominence (picture 8 and figure 5).

●Pisiform – The pisiform is palpated on the volar aspect of the hand (picture 9 and picture 5). This prominent round bone is found at the intersection of a line from the fifth phalanx with the distal wrist crease. The pisiform is a sesamoid bone and can be moved easily when the wrist is in flexion, but becomes fixed with the wrist in extension.

●Trapezium – The trapezium is best located by palpating proximally from the thumb metacarpal (picture 10 and picture 11 and figure 2). Moving proximally along the metacarpal, the clinician first encounters the first carpometacarpal joint and then the trapezium immediately proximal.

●Trapezoid – The trapezoid is more difficult to palpate but should be appreciable on the dorsal wrist just proximal to the index finger metacarpal (picture 12 and figure 3).

●Capitate – The capitate is a relatively long and slender bone lying proximal to the base of the middle finger metacarpal (figure 1). In many individuals, the most proximal aspect of the middle metacarpal is more prominent.

●Hamate – The hamate can be appreciated dorsally just proximal to the base of the fifth metacarpal (figure 3). Palpation is possible around the ulnar border of the hand but becomes more difficult on the volar aspect due to the presence of the muscle and tissue of the hypothenar eminence. The hook of the hamate is clinically important, as it can easily be fractured. It is palpated by placing the interphalangeal (IP) joint of the thumb over the pisiform and rolling the thumb toward the space between the index and middle fingers (picture 13). Deep palpation is often required, and this pressure is often uncomfortable even in the uninjured hand.

Range of motion — The normal range of motion for each major wrist movement is provided below:

●Flexion (volar/palmar flexion) – 80 to 90 degrees (picture 14).

●Extension (dorsiflexion) – 60 to 80 degrees (picture 15). When a passive force is applied to the wrist, such as while performing a push up, extension may increase to 90 degrees.

●Radial deviation – 20 degrees (picture 16).

●Ulnar deviation – 30 to 40 degrees (picture 17).

Once passive and active motion are assessed, the clinician can provide manual resistance and assess wrist strength in each orientation.

Special tests

●Tinel test – Tinel test is a technique for detecting inflamed nerves. It is performed by lightly percussing over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve. Most commonly it is used to evaluate the median nerve in carpal tunnel syndrome (picture 18). (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis", section on 'Provocative maneuvers'.)

●Phalen maneuver – Phalen maneuver is used to evaluate for median nerve compression in carpal tunnel syndrome. The test is described as positive when full flexion of the wrist for 60 seconds causes paresthesias in the distribution of the median nerve (picture 19). The Reverse Phalen Test is performed by having the patient maintain full wrist and finger extension for two minutes without pause. Paresthesias in the distribution of the median nerve represent a positive test. The sensitivity and specificity of the Phalen maneuver and the other tests for carpal tunnel described here are limited. The performance and characteristics of these tests are reviewed separately. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis", section on 'Provocative maneuvers'.)

●Carpal compression test – This test is performed by applying direct pressure over the patient’s median nerve in the carpal tunnel with the examiner’s thumbs for 30 seconds. A positive test occurs when there are paresthesias in the distribution of the median nerve.

●Combined Phalen and Compression Test – This is test is performed by holding the patients wrist in flexion while applying direct pressure over the patient’s median nerve (picture 20). A positive test occurs when there are paresthesias in the distribution of the median nerve.

●Finkelstein test – Finkelstein test is used to assist in the diagnosis of de Quervain tendinopathy. The patient forms a fist around the thumb. The examiner stabilizes the forearm while holding the patient’s fist with their other hand. The examiner then moves the wrist into ulnar deviation (picture 21). The test is positive if the maneuver causes increased pain along the length of the extensor pollicis brevis and abductor pollicis longus tendons. (See "de Quervain tendinopathy", section on 'Diagnosis'.)

●Scaphoid shift test (Watson test) – The scaphoid shift test (sometimes called the Watson test) may be used to detect laxity of the scaphoid ligaments. However, rigorous study of the maneuver’s test characteristics are lacking and its specificity is probably limited [5-11].

The test is performed by the examiner passively moving the patient's hand from a position of ulnar deviation to radial deviation, while the thumb of the clinician's other hand maintains firm pressure on the volar aspect of the scaphoid, as shown in the following photographs (picture 22 and picture 23 and picture 24 and picture 25). Pain at the scaphoid with radial deviation signifies a positive test. The examiner can then release pressure on the scaphoid and, if laxity is present, the subluxed scaphoid will move back into alignment with a palpable "clunk." Clinicians should compare injured to uninjured wrists.

●Extensor carpi ulnaris (ECU) synergy test ‒ The ECU synergy test is useful for diagnosing ECU tendinopathy [12]. It is performed with the patient's elbow resting on a table and flexed at a right angle, the forearm supinated, and the fingers in full extension. The examiner uses one hand to grasp the adducted thumb and adjacent fingers (index and middle), while the fingers of the other hand are placed along the ECU tendon. While the patient attempts to abduct (radially deviate) their thumb against the examiner’s resistance, the examiner palpates the ECU tendon as the muscle contracts isometrically. Pain along the tendon (dorsal ulnar aspect of the wrist) during the maneuver marks a positive test.

●Shuck test – The Shuck test is useful for assessing midcarpal or radiocarpal instability [13]. Starting with the patient’s wrist and fingers flexed, the examiner asks the patient to actively extend fingers against resistance provided by the examiner’s hand placed over the middle and distal phalanges. Pain over the dorsal wrist marks a positive test suggestive of ligamentous injury, and may help to distinguish such injuries from minor carpal soft tissue problems.

●Piano key sign – The piano key sign tests the stability of the distal radioulnar joint (DRUJ). With the patient’s elbow flexed and their forearm pronated, the examiner grasps the ulnar head between their index finger and thumb, and the distal radius with their opposite index finger and thumb (picture 26). The examiner then pushes the distal ulna dorsal and ventral in relation to the distal radius. The maneuver is repeated with the opposite wrist. An increase in translation, or clicking, popping, or pain elicited during the maneuver, suggests instability and marks a positive test for radioulnar (DRUJ) instability. Small observational studies suggest this test is specific but not sensitive for injury [14].

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 6).

Extensor carpi ulnaris tendinopathy and subluxation — The extensor carpi ulnaris (ECU) is a long thin muscle originating from the lateral epicondyle of the elbow and inserting on the base of the fifth metacarpal (figure 6 and image 2). The ECU tendon sheath can be irritated by repetitive flexion and extension of the wrist while it is held in supination. Pain most commonly develops where the tendon bends as it exits the fibro-osseous tunnel on the ulna. ECU tendinopathy is common among people who play racquet sports or golf, as well as those who frequently use a computer mouse or keyboard with their wrist poorly positioned (eg, in excessive dorsiflexion) [15-17]. Computer keyboards placed too low or too high can contribute to these problems. During the wrist examination, the clinician can often reproduce tendinopathy pain by performing the ECU synergy test. (See 'Special tests' above.)

Mild cases of ECU tendinopathy can be treated with rest, nonsteroidal antiinflammatory drugs (NSAIDs), and immobilization in a wrist splint that restricts radial and ulnar deviation for approximately four weeks. Severe cases may be treated with glucocorticoid injection or surgery to repair the tendon and its sheath. Patients must be warned about the possibility of tendon rupture from glucocorticoid injection. (See "Joint aspiration or injection in adults: Complications", section on 'Noninfectious complications'.)

The ECU tendon can sublux or dislocate from its groove on the distal ulna. This condition is more common in athletes who play racquet sports, such as tennis and golf, or contact sports in which a ball is carried tightly, such as rugby and American football. 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. In tennis, the former mechanism occurs during a double-handed backhand stroke, as the dominant hand moves forcefully from pronation to supination in order to put spin on the ball. In American football or rugby, the latter mechanism occurs when a ball carrier clutches the ball with the forearm in maximal supination and the wrist in flexion and ulnar deviation. A sudden increase in the force of the isometric contraction of the ECU as the player attempts to grip the ball more tightly may result in a traumatic tear of the sheath, leading to subluxation of the ECU tendon [16]. Tear of the sheath resulting in subluxation may also occur in patients with rheumatoid arthritis [18].

Patients with an ECU tendon subluxation or dislocation typically 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. Conservative management, including immobilization, rest, and NSAID therapy, is typically sufficient; in rare instances, surgery is needed. A primary care provider with limited experience managing such orthopedic problems may want to refer this injury to a hand surgeon. 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 [19].

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 [20,21]. 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. Carpenters, plumbers, and individuals regularly performing similar manual tasks who often stress the wrist may develop chronic ulnar wrist pain from degeneration of the TFCC.

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 holding the forearm and placing an axial load on the wrist (ie, compressing the joint with an axial load) while it is held in a position of ulnar deviation and extension (picture 27). Alternatively, the clinician can ask the patient to rise from a chair using their hands to push off from the armrests and see if this reproduces their symptoms. This movement compresses the ulnar aspect of the wrist with the joint in extension.

Plain radiographs of the wrist demonstrating an ulnar styloid fracture suggest a TFCC injury, but these studies appear normal if there is ligamentous instability without a fracture. Plain anteroposterior (AP) radiographs can be used to determine ulnar variance, which refers to the relative distance between the articular surfaces of the ulna and the radius (image 3). This distance affects the fraction of any load placed upon the wrist that is transmitted through the distal ulna. The load placed upon the ulna and the TFCC increases with positive ulnar variance and during wrist pronation, thereby increasing the risk for TFCC injury. In neutral ulnar variance (articular surfaces are at the same level), approximately 20 percent of a load is transmitted through the ulna. With negative ulnar variance (ulnar articular surface is proximal to that of the radius) the load across the ulna and the TFCC diminishes. This decrease in force transmission also occurs during supination because the radius moves distally on the ulna during this movement.

Magnetic resonance imaging (MRI) arthrography can be helpful for diagnosing a TFCC tear (image 4 and image 5) [22,23]. Tears in the TFCC contain high signal fluid on fat-suppressed T1-weighted images. With a traumatic TFCC tear, fluid or contrast material is usually present in the distal radioulnar joint and other signs of associated local tissue injury may be seen. Limitations of MRI arthrography include its additional cost and the need to inject contrast medium into the joint. If the wrist is stable, treatment of a TFCC injury consists primarily of a temporary splint worn for four weeks. If pain persists after four weeks of splinting, referral to a hand surgeon is indicated. Surgical repair is needed if ligamentous tears have produced wrist instability.

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

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 (FOOSH) 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 3). Radiographs confirm the diagnosis, but may be negative immediately following the fall (image 6). 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. Both the direction of the traumatic forces and the relative weakness of the volar ligaments contribute to dorsal displacement. 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 [24]. 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 [24]. 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. Paradoxical motion of the scaphoid is another useful diagnostic test for instability. To perform this maneuver, the examiner places their thumb in the anatomic snuff box and has the patient repeatedly flex the thumb. If the scapholunate ligaments are intact, the body of the scaphoid will move dorsally against the thumb during flexion. If there is ligamentous dissociation, the body of the scaphoid moves away from the examiner’s thumb. (See 'Special tests' above.)

Imaging studies should be obtained when scapholunate ligamentous injury is suspected (image 7). An interosseous distance greater than 3 mm between the scaphoid and lunate on plain radiograph suggests a ligamentous injury (image 8 and image 9). In addition, if the lunate appears triangular rather than quadrangular this suggests abnormal positioning due to ligamentous instability. A clenched fist view can be obtained to check for scapholunate joint space widening (image 10). Scapholunate dissociation and related injuries are difficult to manage and should be referred to a hand surgeon.

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. Patients with de Quervain tendinopathy typically note pain at the radial side of the wrist during pinch grasping (pinching an object between the tips of the thumb and index finger) or thumb and wrist movement. Pain may radiate to the thumb or along the volar aspect of the wrist. Ultrasound can assist with diagnosis (image 11 and image 12). de Quervain tendinopathy is reviewed in detail separately. (See "de Quervain tendinopathy".)

Carpal metacarpal osteoarthritis — Osteoarthritis is a common cause of pain at the base of the thumb metacarpal (carpometacarpal [CMC] joint) (image 13). 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 "Clinical manifestations and diagnosis of osteoarthritis" and "Evaluation of the patient with thumb pain", section on 'Arthritis'.)

Radiocarpal arthritis — Pain, swelling, and loss of range of motion at the wrist are characteristic of radiocarpal arthritis. Osteoarthritis of the wrist is uncommon and almost always the result of injury (eg, multiple wrist sprains, fracture of the scaphoid or distal radius, or dislocation of the carpal bones) (image 14). Rheumatoid arthritis commonly affects the wrist, although most commonly it is associated with symmetrical involvement and involvement of other joints. Crystal-induced arthropathy may present with similar symptoms and is diagnosed by examination of fluid aspirated from the wrist joint. Septic bacterial arthritis is rare. (See "Septic arthritis in adults".)

Volar-sided wrist pain — The structures involved in common causes of volar-sided wrist pain include those found in the accompanying graphic (picture 5).

Carpal tunnel syndrome — Carpal tunnel syndrome (CTS) refers to the complex of symptoms and signs brought on by compression of the median nerve as it travels through the carpal tunnel (figure 9). Patients commonly experience pain and paresthesia, and less commonly weakness, in the median nerve distribution. Symptoms are typically worse at night. A positive Phalen or Tinel test suggests the diagnosis (picture 19 and picture 18). 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".)

Hook of the hamate fracture — Fractures of the hook of the hamate often result from a fall onto an outstretched hand (FOOSH) (image 15). 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 13). Hamate fractures are reviewed in detail separately. (See "Hamate fractures".)

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'.)

Flexor carpi radialis and flexor carpi ulnaris tendinopathy — These subacute causes of volar-sided wrist pain occur less often than the others but can often be diagnosed based on the clinical presentation and findings on musculoskeletal ultrasound [25].

Disorders of the flexor carpi radialis tendon may manifest as pain from tendinopathy or a synovial sheath cyst, with or without associated pathology at the scaphoid-trapezoid-trapezium joint. Patients with tendinopathy often complain of pain in the radial-volar region of the wrist where the tendon passes over the trapezium [26,27]. Pain increases with resisted wrist flexion and radial deviation. Swelling may be present in the area of maximal tenderness. The condition is associated with activities involving frequent wrist flexion, such as basketball and racquet sports.

Tendinopathy of the flexor carpi ulnaris is uncommon. Pain develops at the ulnar-volar aspect of the wrist and is associated with activity [27,28]. Tenderness is typically present at the portion of the tendon a few centimeters proximal to its insertion on the pisiform. Pain increases with resisted wrist flexion and ulnar deviation. The condition has been reported in tennis players.

The flexor carpi radialis brevis is an anomalous muscle that can compress space in the volar wrist and cause pain [29].

Dorsal-sided wrist pain — The structures involved in common causes of dorsal-sided wrist pain include those found in the accompanying graphic (picture 1).

Ganglion cyst — A ganglion is a cystic swelling overlying a joint or tendon sheath. The pathogenesis of ganglia is not well understood, but one common theory is that they arise due to herniation of synovial tissue through a joint capsule or tendon sheath. They are commonly seen at the dorsum of the wrist (picture 28 and image 16). Volar ganglia are uncommon, and they most often occur at the base of the thumb adjacent to the insertion of the flexor carpi radialis tendon and the radial artery. Ganglia are discussed in greater detail separately. (See "Ganglion cysts of the wrist and hand", section on 'Definition'.)

Carpal boss — The carpal boss is a bony prominence located on the dorsum of the wrist at the base of the second and third metacarpals, adjacent to the capitate and trapezoid bones [30]. This bony prominence may represent degenerative osteophyte formation or the presence of an os styloideum, an accessory ossification center that appears during embryonic development.

Patients with carpal boss typically complain of pain and restricted motion of the affected hand. Symptoms may result from an overlying ganglion or bursitis, an exterior tendon slipping over this bony prominence, or from osteoarthritic changes at the site. A carpal boss is often misdiagnosed as a ganglion cyst, but cysts are mobile and mucus-filled and therefore relatively soft compared to the fixed, firm, bony prominence of a carpal boss.

Diagnosis is often made with plain radiographs (image 17). A lateral view of the wrist with the forearm in 30 degrees of supination and the wrist in ulnar deviation is best for visualizing a carpal boss. The best treatment for carpal boss remains unclear but management can include nonsteroidal antiinflammatory drugs (NSAIDs), wrist splinting, or surgical excision. The primary care provider may attempt treatment by splinting the wrist splint in neutral position and prescribing a short course of nonsteroidal antiinflammatory medication. If there is no improvement after a few weeks of splinting, the patient should be referred to a hand surgeon.

Kienböck disease (avascular necrosis) of the lunate — Kienböck disease is a progressive collapse of the lunate (figure 11). 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 [31-34]. The most common symptoms are dorsal wrist pain with mild swelling. Over time, the pain becomes persistent and is accompanied by crepitation, stiffness, and decreased range of motion. There may be associated weakness or difficulty grasping heavy objects. The progression of Kienböck disease varies but usually occurs over several years.

The diagnosis of Kienböck disease is made radiographically [35]. In the earliest stages, radiographs are normal but a bone scan shows increased uptake and MRI shows decreased signal in the lunate on T1 images (image 18). With progression over months to years, there is increased density in the lunate (Stage 2), followed by bony collapse (Stage 3), and then carpal instability and arthritis (Stage 4). Kienböck disease is similar to other forms of avascular necrosis in that patients often present after the condition has been present for some time. Increased bone density on plain radiographs (seen in Stage 2) appears before signs of bony collapse (seen in Stage 3). Early referral to a hand surgeon is essential. (See "Clinical manifestations and diagnosis of osteonecrosis (avascular necrosis of bone)".)

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) [36,37]. 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. Typically, patients present within a few weeks of the onset of symptoms, but delayed presentations may occur. The examiner may note redness, warmth, or crepitation at the site. The patient may describe a “squeaking” sound emanating from the tendon sheaths during repetitive wrist extension. Intersection syndrome is often confused with de Quervain tendinopathy. The distinguishing feature is the location of the pain: intersection syndrome is more dorsal (picture 29) while de Quervain’s is more radial (picture 30). Treatment includes rest, activity modification, bracing, and nonsteroidal antiinflammatory drugs. A glucocorticoid injection may be used in cases where more conservative treatments have not alleviated the symptoms.

IMAGING

Approach to imaging — A good history and physical examination help to localize the source of pain and narrow the differential diagnosis of chronic 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.

Plain radiographs — Posteroanterior (PA), lateral, and oblique views of the wrist are usually obtained as part of the initial evaluation of patients with chronic wrist pain (image 1 and image 19). Correct positioning for each of these views is important to ensure that all structures are properly examined.

In the PA view, the wrist is held in neutral, with 0 degrees of rotation to evaluate the relative lengths of the radius and ulna. The PA film should be examined for breaks in Gilula’s lines, which are the arcs formed by the proximal and distal articular surfaces of the proximal row of carpal bones and the proximal articular surfaces of the distal row of carpal bones (image 20) [38]. An increased joint space between carpal bones or a break in Gilula’s lines suggests carpal instability.

The lateral radiograph is especially important for assessing carpal alignment (image 19). The lateral view must be obtained with the wrist in 0 degrees of rotation and the radial shaft and third metacarpal long axis collinear. True lateral views show the pisiform projected over the scaphoid tubercle. A scapholunate angle greater than 60 degrees suggests possible scapholunate instability (image 21). An angle of less than 30 degrees suggests ulnar-sided wrist instability [39].

Additional views to look for specific abnormalities include:

●Scaphoid view (wrist in ulnar deviation) to check for scaphoid fractures (image 22)

●Clenched fist view to check for scapholunate joint space widening seen with ligament disruptions

●Carpal tunnel view (image 23)

●‘‘Hook’’ view to check for hook of the hamate fractures (image 15)

Osteoarthritis of the radiocarpal joint is characterized by narrowing of the joint space and sclerosis of the articular surfaces (image 14).

Computed tomography — Computed tomography (CT) is used to evaluate osseous and articular morphology, injury, healing, and pathologic changes (eg, cysts and tumors). CT is most effective for evaluating bone healing following a fracture or surgery. Standard radiographs can be misleading in this setting, but CT reconstructions can provide images in any plane. This is particularly important when examining the scaphoid, because of its oblique axis and palmar angulation. CT is also useful for evaluation of suspected fractures of the hook of the hamate [40].

Magnetic resonance imaging — Magnetic resonance imaging (MRI) is most useful for evaluating the soft tissues of the wrist and the vascularity of the carpal bones. T1-weighted images offer the best resolution and are used for assessing anatomy; T2-weighted images are better for demonstrating fluid, cysts, and tumors.

When considering soft tissue injuries, MRI is an accurate method for evaluating the triangular fibrocartilage complex (TFCC), but unenhanced imaging of the scapholunate ligament is less useful, with sensitivity ranging from 52 percent to 86 percent and specificity ranging from 34 to 100 percent [41,42]. MR arthrography significantly improves sensitivity in the evaluation of the scapholunate ligament, but does not significantly improve the ability to evaluate the central disk of the TFCC or the lunotriquetral ligament [43]. MRI provides clear visualization of ganglia, soft-tissue tumors, tendinitis, and joint effusions.

MRI is useful for assessing the vascular status of the carpal bones, including the scaphoid, and capitate [44]. Aside from a biopsy, MRI is the most accurate method for assessing the vascularity of the lunate and is more specific than bone scan when evaluating possible Kienböck disease [45]. Bone bruises, ligamentous injuries, and microfractures can be diagnosed with MRI, and it is particularly useful for diagnosing occult scaphoid fractures.

Diagnostic ultrasound — Ultrasound is a valuable technique for evaluating the painful wrist and is used to diagnose soft tissue injury, tendon pathology, arthritis, soft-tissue masses, swelling, nerve entrapment, effusion, and bone injury [46]. In the hands of clinicians experienced in its use, ultrasound may replace standard plain radiographs as the initial test of choice when soft tissue and or tendon pathology is suspected (image 7). The ultrasound appearance of each wrist compartment is reviewed separately. (See "Anatomy and basic biomechanics of the wrist", section on 'Wrist compartments'.)

Ultrasound enables the knowledgeable clinician to correlate the site of pain with the underlying sonographic appearance. In addition, ultrasound allows for dynamic assessment (ie, performing a study while the patient or clinician manipulates the wrist) and examination of the contralateral asymptomatic wrist for comparison. Dynamic imaging may demonstrate pathology, such as tendon subluxation, that may not be detected with static imaging. Other advantages include cost effectiveness, absence of ionizing radiation, accessibility, and the ability to interact with the patient while performing the study. The disadvantages are that it is highly operator dependent and bony detail may not be as good when looking for carpal fractures.

Ultrasound accurately characterizes masses of the hand and wrist as cystic or solid and can be used to determine the diagnosis for the majority of these lesions (image 16). Multiple studies have demonstrated that ultrasound’s sensitivity and specificity are comparable to MRI in such cases [47-49].

Foreign bodies are often difficult to localize with radiographs if the objects are nonradiopaque (wood, vegetable matter) or only a few millimeters in size. Ultrasound is the most accurate modality for detecting and localizing such foreign bodies, allowing for both diagnosis and operative planning. Most foreign bodies are echogenic with variable shadowing and signs of surrounding inflammation [50].

Although ultrasound is not widely used to diagnose carpal tunnel syndrome, the presence of median nerve enlargement proximal to the carpal tunnel on ultrasound suggests the disorder. Various cutoff values for nerve cross-sectional area have been used, but commonly cited values range between 10.5 and 12 mm². (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis", section on 'Imaging'.)

Ultrasound is used in the evaluation of inflammatory arthritis. Findings include joint space widening, loss of cartilage definition, bony erosion, and changes in tendons and tendon sheath appearance. Color Doppler can quantify blood flow to inflamed tissues. (See "Musculoskeletal ultrasonography: Clinical applications".)

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 subacute or chronic 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 subacute or chronic wrist complaints. The following flow chart provides an overview of our approach to wrist pain diagnosis (algorithm 1).

Determine whether cause is traumatic or nontraumatic — The first step in determining the cause of subacute or chronic 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. General questions to ask about wrist trauma include the following:

●Did your symptoms begin soon after an injury?

●Describe how you injured your wrist? Where was the impact? What part of the forearm, wrist, or hand was injured?

●What limits in wrist function and general activity have been caused by the injury?

Some patients with chronic wrist pain may not recall a specific injury, possibly because they never sought medical attention or the event was not memorable. In such circumstances, the clinician may need to ask questions specifically to prompt the patient’s memory. These questions might include:

●Do you remember ever injuring your forearm, wrist, or hand before?

●Do you remember “spraining” your wrist but not seeking medical attention at the time?

The most common wrist injuries sustained from minor trauma, usually a fall onto an outstretched hand (FOOSH), include scaphoid fracture, triangular fibrocartilage complex (TFCC) tear, and ligamentous injury (eg, scapholunate). However, 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, which reveal most fractures and other bony pathology. Physicians experienced with ultrasound often use it to evaluate the wrist. Ultrasound is often helpful for assessing tendon pathology, arthritis, soft-tissue masses, swelling, nerve entrapment, effusion, and bone injury. Additional imaging studies may be needed depending upon the location of symptoms and the primary diagnoses being entertained. As examples, if a scaphoid fracture is suspected despite normal plain radiographs, magnetic resonance imaging (MRI) is obtained; if a hook of the hamate fracture is suspected despite normal plain radiographs, a computed tomography (CT) scan is preferred.

Determine whether nontraumatic pain is from overuse or nerve compression — If no traumatic causes are identified by history, the clinician should next determine whether overuse accounts for the patient’s symptoms. The most common causes of subacute or chronic nontraumatic wrist pain are tendon degeneration related to overuse and nerve compression.

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 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".)

Chronic wrist pain unrelated to overuse or nerve compression may be caused by carpal boss, carpometacarpal (CMC) osteoarthritis, Kienböck disease, and ganglion cysts. These conditions may stem from repetitive microtrauma in the past but they present months to years after any initial injury.

Chronic or subacute wrist pain associated with constitutional symptoms, such as fevers, night sweats, chills, malaise, weight loss, or chronic fatigue, or with bilateral wrist symptoms or symptoms in additional joints, strongly suggests that the problem is systemic. Such presentations are discussed separately. (See "Evaluation of the adult with acute wrist pain", section on 'Wrist pain not associated with trauma or overuse'.)

Correlate history and location of symptoms and signs — Most causes of subacute or chronic 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. Below, the common causes of subacute and chronic wrist pain are organized by location and accompanied by a brief clinical description featuring elements of particular importance for diagnosis. The following flow chart provides an overview of our approach to wrist pain diagnosis (algorithm 1).

●Ulnar sided wrist pain

•Extensor carpi ulnaris (ECU) tendinopathy and subluxation – ECU tendinopathy can develop from any repetitive motion that entails rotation or dorsiflexing of the wrist (eg, playing racquet sports, using a computer mouse). Resisted extension and/or forceful pronation of the wrist may elicit pain lateral to the ulnar styloid (over sixth compartment) (image 2). (See 'Extensor carpi ulnaris tendinopathy and subluxation' above.)

Subluxation or dislocation 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. With repeated motion of the wrist from pronation and flexion to supination and extension, popping or movement of the ECU tendon is noted lateral to the ulnar styloid.

•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. MRI confirms the diagnosis (picture 27 and figure 7 and figure 8). (See 'Triangular fibrocartilage complex injury' above.)

●Radial sided wrist pain

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

•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" and 'Special tests' above.)

•Carpometacarpal osteoarthritis – Osteoarthritis of the carpometacarpal (CMC) joint is common in older patients. 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 or ultrasound confirms the diagnosis. (See 'Carpal metacarpal osteoarthritis' above.)

●Volar (palmar) sided wrist pain

•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 19 and picture 18). (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis" and "Carpal tunnel syndrome: Pathophysiology and risk factors" and "Carpal tunnel syndrome: Treatment and prognosis".)

•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 13). (See "Hamate fractures".)

•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'.)

•Flexor carpi radialis and flexor carpi ulnaris tendinopathy – These subacute causes of wrist pain occur less often than the others; musculoskeletal ultrasound is helpful for diagnosis [25]. Patients with flexor carpi radialis tendinopathy typically complain of pain in the region of the radial-volar region of the wrist. Pain increases with resisted wrist flexion and radial deviation [26,27]. Swelling may be present in the area of maximal tenderness. Tendinopathy of the flexor carpi ulnaris causes tenderness at the ulnar-volar aspect of the wrist. Tenderness is typically present at the tendon a few centimeters proximal to its insertion on the pisiform [27,28]. Pain increases with resisted wrist flexion and ulnar deviation. (See 'Flexor carpi radialis and flexor carpi ulnaris tendinopathy' above.)  

●Dorsal sided wrist pain

•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 28 and image 16). 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 disease – Kienböck disease is a progressive collapse of the lunate that develops over years. The most common symptoms are dorsal wrist pain with mild swelling followed by persistent pain, crepitation, stiffness, and decreased range of motion. There may be associated weakness or difficulty grasping heavy objects. The diagnosis is made radiographically. Typically, there is tenderness at the proximal carpal row just distal to Lister’s tubercle. (See 'Kienböck disease (avascular necrosis) of the lunate' above.)

•Carpal boss – The carpal boss is a bony prominence that presents like a ganglion on the dorsum of the wrist at the base of the second and third metacarpals, but it is firm rather than cystic and soft. Patients typically complain of pain and restricted motion. The diagnosis is made radiographically (image 17). Swelling that is firm and immobile helps differentiate this condition from a ganglion cyst. (See 'Carpal boss' above.)

•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 (picture 30), 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 (picture 29). (See 'Intersection syndrome' above.)

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

●History – The wrist is susceptible to a range of injuries and overuse syndromes. Obtaining a clear history and correlating the history and symptom location with wrist anatomy are important elements of diagnosis. Important elements of the history include mechanism of injury, hand dominance, and occupation and recreational activities. The following flow chart provides an overview of our approach to wrist pain diagnosis (algorithm 1). (See "Anatomy and basic biomechanics of the wrist" and 'History' above.)

●Physical examination – A systematic examination of the wrist includes inspection, palpation, range of motion, and relevant special tests. It is often helpful to compare affected and unaffected wrists. 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. (See 'Physical examination' above.)

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

•Ulnar sided wrist pain: Extensor carpi ulnaris tendinopathy or subluxation, or triangular fibrocartilage complex injury (see 'Ulnar-sided wrist pain' above)

•Radial sided wrist pain: Scaphoid fracture, scapholunate instability, de Quervain tendinopathy, carpal metacarpal osteoarthritis (see 'Radial-sided wrist pain' above)

•Volar sided wrist pain: Carpal tunnel syndrome, hook of the hamate fracture, ulnar neuropathy (see 'Volar-sided wrist pain' above)

•Dorsal sided wrist pain: Ganglion cyst, carpal boss, Kienböck disease of the lunate, intersection syndrome (see 'Dorsal-sided wrist pain' above)

●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. 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. (See 'Imaging' above.)

●Approach to diagnosis – A systematic approach to diagnosing the adult with subacute or chronic wrist pain is provided in the text. Three important steps in making the diagnosis are: determining whether the cause of symptoms is most likely 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. The following flow chart provides an overview of our approach to wrist pain diagnosis (algorithm 1). (See 'Approach to diagnosis' above.)