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Annals of the Rheumatic Diseases logoLink to Annals of the Rheumatic Diseases
. 1999 Nov;58(11):665–674. doi: 10.1136/ard.58.11.665

Chronic wrist pain: diagnosis and management. Development and use of a new algorithm

R M van Vugt 1, J Bijlsma 1, A C van Vugt 1
PMCID: PMC1752796  PMID: 10531069

Abstract

OBJECTIVE—Chronic wrist pain can be difficult to manage and the differential diagnosis is extensive. To provide guidelines for assessment of the painful wrist an algorithm was developed to encourage a structured approach to the diagnosis and management of these patients.
METHODS—A review of the literature on causes of chronic wrist pain was undertaken; history taking, physical examination and imaging studies were evaluated systematically to determine which of the many potential conditions was the cause of the wrist pain. Chronic wrist pain was subdivided into pain of probable intra-articular or extra-articular origin. By means of this classification a clinical algorithm was developed to establish a diagnosis and its clinical usefulness was tested in a prospective study of 84 patients presenting to our outpatient clinic.
RESULTS—A definite diagnosis could be established in 59% (49 of 84) of the cases by careful history taking, extensive physical examination, plain radiographs, ultrasound examination and bone scintigraphy. In 19% of the cases (16 of 84) a probable diagnosis was made resulting in a total figure 78% (65 of 84). Additional imaging studies (arthrography, magnetic resonance imaging and computed tomography) increased the definite diagnoses to 70% (59 of 84).
CONCLUSION—The algorithm proved easy to use and by the use of careful history taking, thorough physical examination and simple imaging techniques (ultrasonography and scintigraphy) a diagnosis was made in 78% of cases.



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Figure 1  .

Figure 1  

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Scapholunate dissociation with scapholunate diastasis, "ring sign" (arrow) and foreshortened appearance of the scaphoid.

Figure 2  .

Figure 2  

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Algorithm for chronic wrist pain.

Figure 3  .

Figure 3  

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Ulnocarpal impingement syndrome with ulna-plus variance and cystic changes along the proximal contour of the lunate and triquetrum (arrows).

Figure 4  .

Figure 4  

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Results and final diagnosis using the algorithm.

Figure 5  .

Figure 5  

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Transverse ultrasound scan of flexor tenosynovitis. The thorn (arrow) can be seen as a hyperechoic stripe in a hypoechoic cavity (C). T: tendon.

Figure 6  .

Figure 6  

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Bone scintigram with markedly increased uptake in the region of the scaphoid.

Figure 7  .

Figure 7  

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Arthrogram of the radiocarpal joint showing leakage of contrast through the scapholunate ligament and triangular fibrocartilage (arrows) into the mid-carpal and distal radioulnar joints.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

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