A Clinical Approach

to Diagnosing Wrist Pain

TODD A. FORMAN, M.D., M.S.ED., The Keck School of Medicine, University of Southern California,
Los Angeles, California
SCOTT K. FORMAN, M.D., Newport Beach, California
NICHOLAS E. ROSE, M.D., Harbor-University of California, Los Angeles, Medical Center, Torrance, California

A detailed history alone may lead to a specific diagnosis in approximately 70 percent of patients
who have wrist pain. Patients who present with spontaneous onset of wrist pain, who have a
vague or distant history of trauma, or whose activities consist of repetitive loading could be
suffering from a carpal bone nonunion or from avascular necrosis. The hand and wrist can be
palpated to localize tenderness to a specific anatomic structure. Special tests can help support
specific diagnoses (e.g., Finkelstein’s test, the grind test, the lunotriquetral shear test, McMurray’s
test, the supination lift test, Watson’s test). When radiography is indicated, the posterior-anterior
and lateral views are essential to evaluate the bony architecture and alignment, the width and
symmetry of the joint spaces, and the soft tissues. When the diagnosis remains unclear, or when
the clinical course does not improve with conservative measures, further imaging modalities are
indicated, including ultrasonography, technetium bone scan, computed tomography, and mag-
netic resonance imaging. If all studies are negative and clinically significant wrist pain continues,
the patient may need to be referred to a specialist for further evaluation, which may include cine-
roentgenography, diagnostic arthrography, or arthroscopy. (Am Fam Physician 2005;72:1753-8.
Copyright © 2005 American Academy of Family Physicians.)

P
Members of various rimary care physicians often are the complaint involving the upper extremity.
family medicine depart-
first to evaluate and treat a patient The proximal row of bones in the wrist
ments develop articles
for “Problem-Oriented with wrist pain. Although the wrist (i.e., scaphoid, lunate, triquetrum, and pisi-
Diagnosis.” This is one consists of a complicated group of form) articulate with the distal ends of the
in a series from the bony articulations and soft tissues, many radius and ulna in a constrained space to
Department of Family
Medicine at the University
family physicians often use wastebasket diag- allow three degrees of freedom at the wrist
of Southern California, noses such as “wrist sprain” or “tendonitis” (Figure 1). Relative to the forearm, these
Los Angeles. Coordinator that do little to identify the true pathol- hand movements include flexion-extension,
of the series is Ricardo G. ogy of the condition. Despite the challenges pronation-supination, and radial or ulnar
Hahn, M.D.
this complex of joints presents, physicians deviation. Relative stability of such mobility
are gaining a better understanding of wrist requires a coordinated system of ligaments,
pathophysiology through an array of diag- muscles, and tendons.
nostic capabilities. Hand and wrist injuries have a major eco-
Generally, the causes of wrist pain can be nomic impact through health care costs and
divided into three categories: mechanical, workers’ compensation claims. A study12 of
neurologic, and systemic. Table 11-11 lists workers’ compensation claims in Washing-
common mechanical causes of wrist pain, ton state from 1987 to 1995 demonstrated an
their clinical presentations, and suggested incidence rate for hand and wrist disorders
imaging work-ups. Table 21,2 lists other com- of 98.2 cases per 10,000 persons, higher than
mon causes of wrist pain. Psychosocial fac- any other musculoskeletal condition related
tors can also have a profound influence on to an industrial injury claim. Furthermore,
wrist pain, particularly when the patient the average claim was around $7,500.12 For
may be eligible for workers’ compensation. carpal tunnel syndrome alone, direct annual
With the dawn of the computer age, wrist costs in the United States are estimated at
and hand pain became the most common $1 billion.13

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Wrist Pain
TABLE 1
Mechanical Causes of Wrist Pain

Cause Clinical presentation Imaging

Fracture History of trauma and bony tenderness Radiography

Occult fractures identified with delayed
radiography, CT, MRI, or bone scan
Nonunion of scaphoid History of trauma with TTP at the anatomic Radiography (“scaphoid view” [scaphoid]
or hook of the hamate snuffbox (scaphoid) and the proximal or the carpal tunnel and supinated
hypothenar area 1 cm distal to flexion oblique views [hamate])
crease of the wrist (hamate) MRI
Avascular necrosis of the scaphoid Variable history of trauma with TTP at the Delayed radiography
(Preiser’s disease) or the lunate scaphoid or lunate MRI
(Kienböck’s disease)
Ligament tear
Triangular fibrocartilage TTP in distal hollow between pisiform MRI
complex and ulnar styloid Arthroscopy may be necessary to rule out
a false-negative MRI
Distal radioulnar joint Pain, instability with radioulnar Radiography (widened distal radioulnar
subluxation “grind” test joint space on PA view—usually normal)
MRI, cineroentgenography, or arthroscopy
Carpal instability Midcarpal TTP with a painful and audible Cineroentgenography
“clunk” on ulnar deviation
Scapholunate dissociation TTP at scapholunate interval Radiography (“clenched-fist” and
supinated oblique views)
De Quervain’s tenosynovitis TTP along radial aspect of distal radius Ultrasonography may show synovial
thickening
Intersection syndrome TTP and crepitus along dorsal aspect —
of distal radius
Neoplasm or ganglion Mass and TTP Ultrasonography

CT = computed tomography; MRI = magnetic resonance imaging; TTP = tenderness to palpation; PA = posterior-anterior.
Information from references 1 through 11.

History If the wrist has sustained direct trauma, the nature of

A detailed history alone may lead to a specific diagnosis the injury must be considered, including the force, fre-
in approximately 70 percent of wrist pain cases.1 The quency, and direction of the event. Direct palmar trauma
physician must characterize the precise nature of the from swinging a baseball bat or golf club may result in
pain, including its quality, radiation, severity, and timing, a hook-of-the-hamate fracture (i.e., golfer’s fracture).
as well as palliative and aggravating factors. In addition, Patients presenting with a spontaneous onset of wrist
the patient should point with one finger to the most pain- pain and a vague or distant history of trauma or repeti-
ful area and indicate where the pain radiates. tive loading activities could be suffering from a carpal
A mechanical cause of wrist pain is suggested when bone nonunion or avascular necrosis. The scaphoid and
the wrist has sustained a specific trauma. It is important hamate are the most common bones to have nonunion
to have patients describe the injury in their own words; after a fracture because their blood supplies are delicate
acting out the traumatic event can be particularly use- and prone to complete disruption.14 An idiopathic avas-
ful. The physician must consider the age of the patient cular necrosis usually occurs at the lunate (Kienböck’s
when evaluating the mechanism of injury. For example, disease) or the scaphoid (Preiser’s disease). Symptoms
the injury resulting from a fall on the outstretched hand of nonunion and avascular necrosis may not become
with wrist extended will vary depending on the patient’s apparent for years after injury because dead bone frag-
age. This dorsiflexion injury will typically cause a green- ments cause chronic hypermobility or irritation, which
stick fracture in a toddler, a growth plate fracture in an eventually leads to inflammation and arthritis with
adolescent, a scaphoid fracture in a young adult, and swelling, pain, and loss of grip strength.1,15
a Colles’ (distal radius) fracture in an older adult with When a patient presents with excessive extension and
osteoporosis. with ulnar or radial deviation following an acute injury

1754 American Family Physician www.aafp.org/afp Volume 72, Number 9 U November 1, 2005
 Wrist Pain
TABLE 2
Additional Causes of Wrist Pain

Neurologic causes
Distal posterior interosseous nerve syndrome common in gymnasts and in racquetball, tennis, and
Injury of median nerve (carpal tunnel syndrome) hockey players; based on history alone, it is difficult to
Injury of radial nerve differentiate from extensor carpi ulnaris, tendonitis, or
Injury of ulnar nerve (Guyon’s canal) subluxation.14
Thoracic outlet compression syndrome Tendinopathy can occur with underlying bony or
Systemic causes soft tissue injuries. For example, a tear of the extensor
Amyloidosis pollicis longus can occur with a minimally displaced
Granulomatous disease (e.g., sarcoid, tuberculosis) distal radius fracture.17 An extensor tendon rupture is
Hematologic disease (e.g., leukemia, multiple myeloma) common in patients with rheumatoid arthritis, particu-
Metabolic conditions (e.g., acromegaly, diabetes, gout, larly when accompanied by clinically evident extensor
hyperparathyroidism, hypocalcemia, hypothyroidism, tenosynovitis.18,19 A flexor tendon laceration may occur
Paget’s disease, pregnancy, pseudogout) with repetitive attrition of a tendon against a hook-of-
Osteomyelitis the-hamate nonunion.20
Peripheral neuropathy If the patient has not experienced a specific trauma,
Reflex sympathetic dystrophy (complex regional pain the physician must consider the patient’s vocational and
syndrome) recreational activities for possible causes of mechani-
Rheumatologic disorders (e.g., psoriasis, rheumatoid cal problems. For example, activities requiring forceful
arthritis, scleroderma, systemic lupus erythematosus)
grasping with ulnar deviation or repetitive use of the
Information from references 1 and 2. thumb (e.g., caring for a newborn infant, needlepoint,
knitting) can lead to de Quervain’s tenosynovitis with
pain and swelling along the radial tendons.1,2,14
A thorough and accurate medical history and a review
Capitate of systems is key to uncovering potential systemic causes
Trapezoid
of wrist pain. The wrist is often the first site of clinically
Hamate
detectable rheumatoid arthritis.2 Gouty arthritis and
pseudogout can involve the wrist joint, although more
commonly they affect the lower extremities. Patients
Distal carpal row with acute septic arthritis usually present with a history
Trapezium Proximal carpal row of constitutional symptoms or a recent infection and a
Pisiform
barely moveable wrist with severe, deep, and unrelent-
Triquetrum
Scaphoid ing pain.1 Hypothyroidism, pregnancy, and diabetes
Lunate
ILLUSTRATION BY SCOTT BODELL

are predisposing, but not causal, risk factors for carpal

tunnel syndrome. Diabetes also can result in peripheral
Radius Ulna neuropathy in the hand, which may be misdiagnosed as
carpal tunnel syndrome.

Physical Examination
Figure 1. Dorsal view of the bones of the right wrist. After a detailed history and review of systems, the physi-
cian should perform a thorough neurologic and cardio-
to the wrist, a ligament injury is probable, especially if a vascular examination including peripheral pulses and
clicking or popping sound is present with loading.14 The examine other joints, particularly the spinal column,
ligament tears may be partial or complete, depending on when indicated. A comprehensive examination of the
the force involved, and mainly occur in the scapholunate neck and entire upper extremity must be performed
(presents as radial deviation and pain) and lunotriqu- before conducting the wrist examination to rule out
etral (presents as ulnar deviation and pain) ligaments. radiating pain from a more proximal problem, such as a
Physicians should suspect a torn ligament if a patient herniated cervical disc.
has pain that appears out of proportion to the injury.16 Evaluation of the wrist should begin with identifying
Ulnar wrist pain and weakness caused by a fall onto an erythema, swelling, masses, skin lesions, muscle atro-
outstretched hand may suggest injury to the triangular phy, contractures, scars, or other obvious deformities.
fibrocartilage complex (TFCC), which is the primary With acute wrist injury, the severe pain, swelling, non-
stabilizer of the distal radioulnar joint. TFCC injury is specific tenderness, and guarding can limit the value of

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Wrist Pain

examination. In such cases, if radiographs are normal,

the wrist can be splinted and reexamined after a brief
immobilization.21 The injured wrist’s active and pas-
sive range of motion should be evaluated and compared
with the contralateral wrist. Wrist flexion (average
maximum, 70 degrees), extension (70 degrees), ulnar
deviation (40 degrees), and radial deviation (20 degrees)
are evaluated, as well as forearm supination (80 degrees)
and pronation (80 degrees).1
The hand and wrist should be palpated to localize the
tenderness to a specific location. Knowledge of topo-
graphic wrist anatomy is essential (Figure 2). For exam-
ple, tenderness in the anatomic snuffbox may suggest Anatomic
Scapholunate
a scaphoid fracture or Preiser’s disease, whereas lunate snuffbox
interval
tenderness may indicate Kienböck’s disease. Tenderness
in the scapholunate interval (localized 1.5 cm distal to Lister’s tubercle
Lister’s tubercle in the distal radius) may suggest scaph-
olunate dissociation. Tenderness in the distal carpal
Radius Ulna
row may indicate nonunion of the hook of the hamate,
which is localized in the proximal hypothenar area (1
cm distal to the flexion crease of the wrist). The mid-
carpal area is a series of joints between the proximal and
distal carpal rows. Tenderness in this area could indicate Figure 2. Anatomy of the wrist (dorsal view).
a midcarpal strain, instability, or possible arthritis of
the scaphotrapeziotrapezoid joint. Midcarpal instability Next, the distal radius and ulna should be palpated
also presents as a painful and audible “clunk” with ulnar along with the articulation between the two bones (i.e.,
deviation.1,14,22 the distal radioulnar joint). Bony tenderness or palpable
step-offs can signify a fracture or nonunion. The grind
test (i.e., compression of the distal ulnar and radial heads
The Authors with forearm rotation) may identify distal radioulnar
TODD A. FORMAN, M.D., M.S.ED., is assistant professor of clini- joint instability.14 Tenderness along the lateral aspect of
cal family medicine at the Keck School of Medicine, University of the distal radius can indicate de Quervain’s tenosynovi-
Southern California (USC) , Los Angeles, and director of the Family tis.22 Tenderness and crepitus along the dorsal aspect of
Medicine Clerkship and the Eric Cohen Student Health Center. He the distal radius may indicate intersection syndrome (i.e.,
received his medical degree from the University of California, Los
a bursal inflammation of the intersecting tendons of the
Angeles, (UCLA) School of Medicine and completed his residency
at the Santa Monica-UCLA Family Medicine Program. radial wrist extensors and thumb abductor tendons).22
Tenderness over the ulnar styloid can indicate a fracture
SCOTT K. FORMAN, M.D., is in private practice in Newport Beach, or nonunion, whereas tenderness immediately distal in
Calif. He received his medical degree from UCLA. Dr. Forman com- the hollow between the pisiform and ulnar styloid usu-
pleted an orthopedic surgery residency at Columbia Presbyterian
Hospital, New York City, and a fellowship in sports medicine with
ally indicates a TFCC injury. Table 31,2,21-23 outlines the
Doug Jackson, M.D., in Long Beach, Calif. methods and utility of tests that can help support specific
diagnoses.
NICHOLAS E. ROSE, M.D., is in private practice in Newport Beach Psychosocial factors such as secondary gain also must
and serves as a clinical instructor for the Harbor-UCLA Medical
be considered when evaluating wrist pain, particularly
Center Department of Orthopaedic Surgery, Torrance, Calif. He
received his medical degree from UCLA, Harbor-UCLA Orthopaedic in patients who could receive workers’ compensation.
Surgery Residency Program, and completed a hand and upper Factitious injury should be suspected when the patient
extremity fellowship at the University of Texas-San Antonio. demonstrates subjective pain that is disproportionate
to objective findings and if the examination reveals dif-
Address correspondence to Todd A. Forman, M.D., M.S.Ed., The
Keck School of Medicine at the University of Southern California,
fuse tenderness throughout the entire upper extremity
PMB-B205 San Pablo St., Los Angeles, CA 90033 (e-mail: in a nonanatomic pattern. A small cohort study23 has
tforman@usc.edu). Reprints are not available from the authors. shown that the potential for financial workers’ compen-

1756 American Family Physician www.aafp.org/afp Volume 72, Number 9 U November 1, 2005
 Wrist Pain
TABLE 3
Special Maneuvers to Diagnose Wrist Pain

Maneuver Method Utility

Finkelstein’s test Provide ulnar deviation to the wrist while Pain over radial styloid from this provocative stretch
grasping the thumb. maneuver differentiates de Quervain’s tenosynovitis
from arthritis of the first metacarpal.
Grind tests Compress and rotate the first metacarpal Pain and crepitus from this provocative compression
bone along the trapezium. maneuver suggests arthritis or instability.
Compress and rotate the distal radioulnar joint.
Lunotriquetral shear Apply dorsal force to triquetrum and palmar A painful “click” reveals a lunotriquetral ligament tear.
test force over lunate.
McMurray’s test Manipulate the triquetrum against the head of Pain, crepitus, or a snap identifies TFCC lesions.
the ulna with the wrist in ulnar deviation.
Supination lift test Ask the patient to lift examination table with Pain and weakness indicate a TFCC injury.
palm flat on underside of table or to lift
himself off of the table.
Watson’s test Press the scaphoid tuberosity on the palmar A painful “click” or “pop” identifies scaphoid
(scaphoid shift test) aspect while moving the wrist from ulnar to instability or scapholunate separation.
radial deviation.

TFCC = triangular fibrocartilage complex.

Information from references 1, 2, and 21 through 23

sation is inversely related to the likelihood of symptom box tenderness, and the patient should be treated with
resolution, and positive physical findings may be absent appropriate immobilization and follow-up radiographs
in up to 75 percent of persons who are financially two to three weeks after injury.3,5 When a fracture of
compensated for their pain.23 Other red flags for severe the hook of the hamate is suspected, physicians should
psychologic morbidity include weakness inconsistent include the carpal tunnel and supinated oblique views.
with muscle bulk, pain on the nondominant side, pain Stress views, such as the “clenched-fist” view and the
associated with ecchymosis, chronic swelling, and unex- supinated view in ulnar deviation, can help identify
plained ulceration or open wounds.1 scapholunate dissociation14 (Figure 4).
If the diagnosis remains unclear after radiography, or
Imaging if the clinical course does not improve with conserva-
Radiography is the first-line imaging modality for wrist tive measures, further imaging modalities are indicated.
pain, although it is not always indicated. Posterior-ante- For suspected mechanical pathology such as an occult
rior (PA) and lateral radiographic views are essential ganglion, an occult fracture, nonunion, or bone necro-
to evaluate the bony architecture and alignment of the sis, the physician must choose from several modalities
wrist, the width and symmetry of the joint spaces, and
the soft tissues. For example, the lateral view assesses the
radiolunocapitate alignment, which should be collinear,
and the radioscaphoid, lunoscaphoid, and capitoscaph-
oid relations.2 Misalignment implies the presence of an
interosseous ligament tear, which can progress to carpal
instability, chronic osteoarthritis, advanced collapse,
and chronic pain. When a scaphoid fracture or non-
union is suspected, a scaphoid view should be obtained
in addition to the routine views. The wrist should be
prone in ulnar deviation with 30 degrees of supination
for the scaphoid view, because ulnar deviation in the
PA position elongates the scaphoid and improves detec-
tion of subtle fractures (Figure 3).3,4 Unfortunately, 20
percent of radiographs are initially negative for scaphoid
fractures regardless of the view.2 Therefore, scaphoid Figure 3. Routine (left) and scaphoid (right) views of non-
fracture should be presumed in cases of anatomic snuff- displaced wrist fracture (arrow).

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Wrist Pain

Figure 2 reprinted with permission from James Daniels, M.D.

Author disclosure: Nothing to disclose.

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1758 American Family Physician www.aafp.org/afp Volume 72, Number 9 U November 1, 2005