Differential diagnosis of chronic wrist pain with most discriminating features in the history, examination and imaging for each diagnosis
| Diagnosis | History | Examination | Imaging | |||
|---|---|---|---|---|---|---|
| Intra-capsular | ||||||
| Fracture | traumatic event | point tenderness | SR, SV (carpal tunnel) or CT | |||
| Ligament tear | clicking, (unnoticed) traumatic event | point tenderness ST: Watson’s test (scaphoid), | SR: malalignement (lateral “zigzag”) or dissociation carpal bones | |||
| McMurray’s test (TFCC) | AG: leakage between different compartments of wrist | |||||
| DRUJ subluxation | painful pronation and supination | prominent ulnar head | SR: lateral view unreliable | |||
| ST: DRUJ compression during pro- and supination | CT: axial view | |||||
| Arthritis | spontaneous swelling, symptomatology other joints or systemic complaints | swelling, warmth, erythema, decreased painful range of movement | SV: decreased mineralisation, cortical interruption or crystal deposits | |||
| US: hydrops or synovial proliferation | ||||||
| US punction/biopsy | ||||||
| Osteoarthritis | (gradually) progressive pain and stiffness | decreased passive range of movement, crepitus | SR: with PA oblique (CMC-I, STT) or AP oblique (pisotriquetral) | |||
| ST: (pisiform) Grind test | ||||||
| Neoplasm | ND | ND | SR | |||
| (osteoid osteoma) | (pain at night, relief of salicylates) | CT/MRI: determining extent lesion and effect on surrounding neurovascular structures | ||||
| (SR/CT: nidus with radiolucent or sclerotic centre) | ||||||
| Ganglia | localised painful swelling | tense discrete subcutaneous swelling | US: anechoic cyst area | |||
| MRI: occult or intraosseus | ||||||
| Avascular necrosis | pain without swelling | decreased painful range of movement | SR: subtly increased radiodensity | |||
| BS: increased uptake | ||||||
| MRI: abnormal | ||||||
| Other | ND | ND | SR | |||
| (carpal boss) | (swelling base 2nd or 3th metacarpal) | (tender bony prominence) | (SV: carpal boss view) | |||
| Extra-capsular | ||||||
| Neuropathy | paresthesia, nocturnal excacerbation of symptoms, metabolic disease | atrophy | SR: PA view | |||
| ST: Tinel and Phalen tests, diagnostic lidocaine injection (neuroma) | SV: carpal tunnel view | |||||
| EMG: abnormal nerve conduction time | ||||||
| US: swelling/flattening median nerve and increased palmar bowing retinaculum | ||||||
| Tendinopathy | burning pain, highly repetitious and forceful motions | swelling, crepitus, snapping, | SR: calcifications | |||
| ST: isometric function tests, forced stretching (Finkelstein’s test) | US: thickened tendon with peritendinous effusions | |||||
(ST: stress test, ND: non-discriminating, SR: standard radiograph, SV: supplemental view, EMG: electromyelogram, AG: arthrography, US; ultrasonography, BS: bone scan, MRI: magnetic resonance imaging).