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The change in the alignment of the distal radius can cause extrin-sic carpal instability and wrist pain.. Bone Fractures or nonunion Carpal bones Radius Ulnar styloid Malunion Carpal fra

The evaluation of chronic wrist

pain can be challenging The

com-plexity of the carpus, combined

with our incomplete knowledge of

carpal mechanics, renders

diagno-sis of carpal disorders difficult

Therefore, the approach to the

diagnosis of chronic wrist pain

must be systematic A routine

should be established so as to be

certain that all aspects of the wrist

have been evaluated This routine

should include the classic

compo-nents of the history and physical

examination, including

observa-tion, palpaobserva-tion, and manipulation

History

A thorough history is essential,

which should include the past

medi-cal and surgimedi-cal history, family

his-tory, review of systems,

medica-tions, allergies, trauma history, and

reports of any ÒtrickÓ wrist

move-ments The social history is also

im-portant, because avocations can

have an impact on the wrist Contact

sports such as football and rugby are obvious examples of sports that can cause wrist injuries, but golf and tennis, because of their repeti-tive nature, should not be over-looked as possible sources of wrist injury Compressive neuropathies due to excessive knitting or sewing can also masquerade as wrist pain

If a specific traumatic event has initiated the problem, it is impor-tant to comprehend the exact mechanism of injury This mecha-nism must also be kept in mind when interpreting the results of the various diagnostic tests If the apparent abnormalities demon-strated on testing do not correlate with the presumed mechanism of injury, the cause of the pain should

be sought elsewhere The chronol-ogy and evolution of the patientÕs symptoms are important The se-verity of the pain will act as a guide

to the aggressiveness with which diagnostic efforts and treatment should be pursued Patients who are plagued by wrist pain that in-terferes with their work and daily

activities will undoubtedly opt for

a more aggressive approach than will patients with occasional mild nonlimiting discomfort

The patientÕs age and sex should

be considered when evaluating chronic wrist pain Mikic1 and Viegas et al2demonstrated a direct relationship between age and liga-mentous and cartilaginous attrition Clearly, the younger patient popula-tion (<40 years) is more prone to posttraumatic carpal injuries than the older population, in whom the late effects of occult past wrist

trau-ma, as well as the effects of systemic disease and degenerative processes, are more common Nontraumatic de-generative changes, such as those due to osteoarthritis and rheumatoid arthritis, seem to be more frequent in women Even in the younger popu-lation, women have a predisposition

to ligamentous laxity and subtle instabilities, such as midcarpal insta-bility

The past medical history and fam-ily history may reveal a multiplicity

of disorders, as well as a host of sys-temic and hereditary diseases that can affect the wrist (Table 1)

Dr Nagle is Associate Professor of Clinical Orthopaedics, Northwestern University Medical School, Chicago.

Reprint requests: Dr Nagle, Suite 500, 448 E Ontario, Chicago, IL 60611.

Copyright 2000 by the American Academy of Orthopaedic Surgeons.

Abstract

Chronic wrist pain remains a challenge to diagnose and treat A thorough

his-tory and physical examination are key Various imaging techniques are

essen-tial to the evaluation of the patient with chronic wrist pain Standard

radiogra-phy, computed tomograradiogra-phy, cinearthrograradiogra-phy, magnetic resonance imaging,

radionuclide imaging, arthroscopy, and arteriography all may have a role in

assessment, and the orthopaedic surgeon should be familiar with the

indica-tions, strengths, and weaknesses of each Laboratory tests may also be useful in

evaluation No all-inclusive algorithm can be applied in this setting; therefore,

the physician must rely on his or her diagnostic acumen to successfully assess

and treat chronic wrist pain.

J Am Acad Orthop Surg 2000;8:45-55

Daniel J Nagle, MD

It is always important to review any laboratory or imaging tests that were carried out by previous treat-ing physicians, as well as the response to treatment For example,

if diagnostic local anesthetic injec-tions were given, it will be useful to know when and where they were given and what the result was Factitious symptoms and symp-tom magnification in any case of workmenÕs compensation or per-sonal injury litigation may become apparent during the initial or sub-sequent evaluation In such cases, only the most solid objective data can be considered reliable

Physical Examination

Gross deformity of the wrist is usu-ally the result of an obvious patho-logic process It is the wrist without gross deformity that frequently (but not always) presents a diagnostic challenge Wrist deformity usually results from a previous fracture or dislocation or from soft-tissue and/or joint swelling A malunited distal radius fracture is probably the most common cause of wrist defor-mity The wrist will often be radially deviated, and the carpus will ap-pear palmarly displaced on the radius The change in the alignment

of the distal radius can cause extrin-sic carpal instability and wrist pain Disruption of the distal radioulnar joint can also produce wrist defor-mity Rheumatoid arthritis can pro-duce subluxation of the carpus as well as disruption of the distal radioulnar joint, both of which deform the wrist Midcarpal insta-bility can lead to ulnar sag of the carpus, which can be appreciated by comparing the two wrists while the hands are placed one above the other with the ulnar edges of both hands toward the examiner Soft-tissue and joint swelling should be looked for each time the wrist is examined

Bone

Fractures or nonunion

Carpal bones

Radius

Ulnar styloid

Malunion

Carpal fractures

Radial fractures

Osteonecrosis

Kienbšck disease

Preiser disease

Joint

Arthritis

Ankylosing spondylitis

Osteoarthritis

Rheumatoid arthritis

Psoriatic arthritis

Reiter syndrome

Posttraumatic

Lyme disease

Chondromalacia

Posttraumatic synovitis

Scarring

Loose bodies

Interfossal ridge impingement

Chondral fractures

Ligament

Instability (dynamic/static)

Scapholunate

Lunatotriquetral

Ulnocarpal

Midcarpal

Capitolunate

Pisotriquetral

Distal radioulnar joint

Scaphotrapeziotrapezoid joint

TFCC tears (central, peripheral,

ganglion)

Ulnar abutment

Tendon

Tendinitis

Subluxation

Rupture

Scarring

Bone impingement

Skin

Ehlers-Danlos syndrome

Marfan syndrome

Scleroderma

Nervous system Compression Carpal tunnel syndrome GuyonÕs canal

Wartenberg syndrome Proximal compression Cervical radiculopathy Central nervous system (stroke, multiple sclerosis)

Trauma/neuroma Peripheral neuropathy (e.g., due

to diabetes mellitus) Vascular system

Arterial occlusion Hypothenar hammer syndrome Vasculitis

Hematologic Hemophilic arthropathy Hemoglobinopathies Endocrine disorders Systemic disease Gout

Pseudogout Systemic lupus erythematosus Infection

Gonorrhea Tuberculosis Lyme disease Viral arthritis Staphylococcal/streptococcal infection

Pseudoinfection (e.g., pyoderma gangrenosum)

Tumors Soft-tissue tumors Ganglion Giant cell tumor Fibroma Synovial cell sarcoma Synovial hemangioma Bone tumors

Primary Benign Malignant Metastatic Other disorders Reflex sympathetic dystrophy Fibromyalgia

Table 1

Partial List of Conditions Associated With Wrist Pain

Extra-articular causes of chronic

wrist swelling include

tenosynovi-tis, tumors, ganglions, and

myxede-ma Intra-articular disorders can

also produce swelling and can be a

manifestation of a local

phenome-non or a systemic disease Local

arthropathies that can produce

wrist swelling include arthrosis

sec-ondary to carpal instabilities, carpal

fracture nonunions, Kienbšck and

Preiser diseases, osteonecrosis of the

capitate, osteoarthritis, and infection

(e.g., tuberculosis, gonorrhea, or

mycobacterial, fungal,

staphylococ-cal, or viral infection) Systemic

dis-eases (e.g., gout, pseudogout, Lyme

disease, rheumatoid arthritis, lupus

erythematosus, psoriasis, and other

collagen vascular diseases) can also

cause wrist swelling

It can be helpful to ask the

pa-tient to demonstrate movements

that produce the wrist pain or lead

to popping or clicking Patients

with unstable distal radioulnar

joints can occasionally make their

distal radioulnar joint subluxate at

will and produce a clunking sound

The Òcatch-up clunkÓ of midcarpal

instability can help make the

diag-nosis Some patients with

scapho-lunate instability can produce an

audible clunk when they subluxate

and reduce the scaphoid Ulnar

deviation while making a fist can

sometimes produce popping and

crunching at the ulnocarpal joint in

patients with tears of the triangular

fibrocartilage complex (TFCC),

ulnocarpal synovitis, or scarring

Subluxation of the extensor carpi

ulnaris or of other extensor and

flexor tendons is another such

movement

Palpation and Provocative

Tests

A systematic approach to the

pal-pation of the wrist is essential All

joints must be palpated and

appro-priately stressed with the use of

provocative tests.3,4 The examina-tion can be started on the radial side of the wrist and move toward the ulnar side, passing from dorsal

to palmar The importance of local-izing tenderness in a reliable pa-tient cannot be overemphasized; it

is perhaps the key finding in the evaluation Patients often state only that the wrist hurts and can-not identify where it hurts until tenderness is elicited Tenderness

is often the only sign that indicates the relevance of lesions seen on diagnostic tests, such as bone scin-tigraphy, magnetic resonance (MR) imaging, and arthroscopy

Several provocative tests for evaluating the joints of the wrist have been described The carpo-metacarpal joint of the thumb is assessed with the grind test and with manipulation to test stability

Just proximal to the carpometa-carpal joint, the scaphotrapezio-trapezoid joint should be palpated

to assess for arthritis Tenderness in the anatomic snuffbox in a patient with chronic wrist pain is indicative

of scaphoid nonunion, radioscaph-oid arthritis, radiocarpal synovitis, and scapholunate ligament instabil-lity The scapholunate joint should

be manipulated to assess the integ-rity of the scapholunate interos-seous ligament Watson et al5 de-scribed a maneuver in which the distal pole of the scaphoid is stabi-lized to restrict its palmar flexion while the wrist is moved from ulnar

to radial deviation In a wrist with a scapholunate interosseous ligament tear and scapholunate instability, the scaphoid will subluxate dorsally

as the wrist reaches maximum radial deviation, producing dorsal wrist pain Palmar discomfort at the scaphoid tubercle is not suggestive

of scapholunate instability

The integrity of the lunatotrique-tral interosseous ligament can be tested by manipulating the two bones relative to each other This maneuver is referred to as the shear

test or the ballottement test.6 The triquetrum is stabilized by applying palmar pressure at the pisiform and dorsal pressure over the trique-trum The lunate is then manipu-lated relative to the triquetrum by gripping the lunate with the thumb and the index finger of the other hand over the dorsal and palmar poles of the lunate, respectively Discomfort or excessive translation compared with the opposite wrist is

a positive finding

Instability of the midcarpal joint

is suggested by the Òcatch-up clunkÓ produced when the wrist is moved from radial to ulnar devia-tion during axial loading The clunk is produced by the sudden change in position of the proximal carpal row from a flexed position

to an extended position as the tri-quetrum engages the hamate with-out the synchronizing effect of the attenuated ulnar ligaments

Ulnocarpal abutment and TFCC tears are evaluated by ulnar devia-tion of the wrist combined with axial loading This maneuver should be performed with the forearm in neu-tral, supination, and pronation Reproduction of the pain combined with tenderness just distal to the ulnar styloid is consistent with these conditions

Distal radioulnar joint instability

is assessed by manipulating the radius relative to the ulna The ma-neuver should be performed with the forearm in neutral, pronation, and supination, with comparison with the opposite side Distal ra-dioulnar joint arthrosis can be eval-uated by compressing the joint; pain and crepitation are suggestive of arthritis

Tenderness with compression or manipulation of the pisiform may indicate pisotriquetral arthritis Pain on palpation of the hook of the hamate is suggestive of a fracture The specificity of provocative tests has been questioned by North and Meyer.7 Their review of the

data on 109 patients who underwent

arthroscopic examination for chronic

wrist pain disclosed no correlation

between the location of wrist pain

and the site of any ligamentous

in-jury In contrast, Lester et al8cited

100% sensitivity for the TFCC Ịpress

test,Ĩ in which the patient is asked

to push up from a chair by placing

his or her weight on the extended

symptomatic wrist; pain at the

ulno-carpal joint indicates a TFCC tear

To complete the wrist

examina-tion, the tendons, nerves, and

ves-sels must be evaluated The tendons

are palpated and stressed to rule out

tenosynovitis The six dorsal

com-partments are systematically

exam-ined and stressed, as are the wrist

and finger flexors Proximal and

local compressive neuropathies

should be considered, and the

ap-propriate provocative maneuvers

carried out Unusual entrapment

neuropathies, such as compression

of the dorsal branch of the ulnar

nerve, can masquerade as ulnar

wrist pain Compression of the

su-perficial branch of the radial nerve

(Wartenberg syndrome) can cause

radial wrist pain Carpal tunnel

syn-drome can also cause palmar wrist

pain The vascular status of the

hand should be assessed by

evaluat-ing capillary refill and performevaluat-ing

the Allen test to rule out insufficiency

and thrombosis, such as may be

seen in ulnar hammer syndrome,

embolic disease, or collagen vascular

disease

Measurements of Function

Czitrom and Lister9 have reported

that grip strength is a good

indica-tor of true pathologic changes in

the wrist and should be checked in

any patient with chronic wrist

pain Grip-strength measurements

are most valid when they are

col-lected by using the rapid-exchange

grip-strength measurement

tech-nique described by Hildreth et al.10

Measurement of the range of motion of the wrist, including supination and pronation, is also important A decrease in the range

of motion is more often than not a sign of an underlying disorder

However, a normal range of mo-tion cannot be taken as a sign that there are no pathologic changes

Imaging

A good history and physical exami-nation will help localize the source of pain, but imaging is generally neces-sary to arrive at a diagnosis in cases

of chronic wrist pain Standard radio-graphs are nearly always required to evaluate chronic wrist pain

Standard Radiography

Posteroanterior (PA), lateral, and oblique views are appropriate for initial screening and evaluation

They can be used to screen for arthritis, fractures, and bone lesions Additional views, such as the radial and ulnar deviation views and the clenched-fist view, may be helpful in assessing more subtle problems Mann et al11have provided a succinct review of the indices used to evaluate standard wrist x-ray films Several features should be routinely assessed on PA and lateral radiographs The PA film should be examined for breaks

in GilulaÕs lines, which are the arcs formed by the proximal and distal articular surfaces of the proximal row of carpal bones and the proxi-mal articular surfaces of the distal row of carpal bones An increased joint space between carpal bones or

a break in GilulaÕs lines is indicative

of carpal instability The carpal height can be compared with the length of the third metacarpal if carpal collapse secondary to Kien-bšck disease is suspected

The lateral radiograph is espe-cially important for assessing carpal alignment A scapholunate angle

greater than 60 degrees suggests possible scapholunate instability

An angle of less than 30 degrees sug-gests ulnar-sided wrist instability Other measurements can be used to corroborate this diagnosis, such as a radioscaphoid angle greater than 60 degrees and a radiolunate angle greater than 15 degrees

Standard x-ray films are often not diagnostic Special views are occasionally needed, some of which are described in Table 2 Computed tomography, trispiral tomography, cinearthrography, radionuclide scintigraphy, arthroscopy, and, in rare instances, angiography may each have a role in the evaluation of the chronically painful wrist

Computed Tomography

Computed tomography is indi-cated to evaluate osseous and artic-ular morphology, injury, healing, and pathologic changes (e.g., cysts and tumors) It has replaced trispi-ral tomography in most centers, al-though traditional tomography can still be helpful when internal fixa-tion devices obscure the area of interest However, newer CT soft-ware has greatly decreased the x-ray diffraction noted with older CT scans of bone containing metal Computed tomography is most effective in the evaluation of bone healing in the carpus after fracture

or surgery (Fig 1) Standard radio-graphs can be misleading in this setting, but CT reconstruction can provide images in any plane needed This is particularly critical when examining the scaphoid, because of its oblique axis and palmar angula-tion Computed tomography is also useful for evaluation of sus-pected fractures of the hook of the hamate A bone scan may suggest the presence of a lesion in the ulnar aspect of the wrist, but in most cases a CT scan will clearly define the fracture.12

Computed tomography has also become the prime diagnostic tool

in the evaluation of chronic

sublux-ation of the distal radioulnar joint

Wechsler et al13and others have

provided reference points for

as-sessing distal radioulnar joint

sub-luxation

Cineradiography

Cineradiography plays a major role in the evaluation of wrist pain

The dynamic nature of this test is helpful in assessing carpal instabili-ties It can demonstrate

scapholu-nate, lunatotriquetral, midcarpal, capitolunate, and distal radioulnar joint instability It can also be used

to visualize a suspected scaphoid nonunion; radioulnar deviation will show a gap at the fracture site

Table 2

Radiographic Views of the Wrist

Significant Finding

PA with radial deviation Center beam on radiocarpal joint, Break in GilulaÕs lines may indicate

PA with ulnar deviation Center beam on radiocarpal joint, Scapholunate interval widens in

neutral, third metacarpal aligned radioscaphoid angle, 30-60 degrees;

capitolunate angle, 0-15 degrees; palmar radial tilt, 10-25 degrees Lateral with ulnar deviation Neutral forearm rotation, wrist ulnarly Lunate should dorsiflex,

deviated, third metacarpal aligned scaphoid should extend with radius

Lateral with radial deviation Neutral forearm rotation, wrist radially Lunate should palmar-flex,

deviated, third metacarpal aligned scaphoid should flex with radius

Lateral with wrist flexion Neutral forearm rotation, wrist flexed Capitate and lunate flex

Lateral with wrist extension Neutral forearm rotation, wrist extended Capitate and lunate extend

of pronation

across palmar capitate

Second and third PA with radial aspect of hand elevated Fracture dislocation, distal radioulnar

elbow flexed to 90 degrees, wrist palm down, beam centered on ulnocarpal joint

When arthrography is performed

in conjunction with

cineradiogra-phy, there are potential advantages

to the triple-compartment method

Although time-consuming, it is

con-sidered by many to be more

accu-rate than single-injection

tech-niques.14,15 With this technique,

separate injections of radiopaque

dye are made into the three

com-partments of the wrist: the

carpal, midcarpal, and distal

radio-ulnar joints The dye is injected first

into the radiocarpal joint Once the

dye has been eliminated from the

joint (2 to 3 hours), injections are

made into the midcarpal and distal

radioulnar joints The triple-injection

technique may better visualize

sub-tle interosseous ligament and TFCC

tears that may not be seen due to

the ÒtrapdoorÓ effect of some partial

ligament tears Also, the distal

ra-dioulnar joint injection can

demon-strate partial tears on the proximal

surface of the TFCC (Fig 2)

Although arthrography can be very helpful, several studies have demonstrated that it does not al-ways provide an accurate picture of the pathologic changes present in the wrist In a review of 84 wrist arthroscopies, Nagle and Benson16 found that, compared with arthros-copy, arthrography was accurate and complete in only 11% of cases

Chung et al17noted similar limita-tions In another study, Vanden Eynde et al18reported that arthrog-raphy had a sensitivity of 52%, a specificity of 50%, a positive predic-tive value of 92%, and a negapredic-tive predictive value of 8% compared with arthroscopy for all lesions iden-tified, whether they were the source

of the symptoms or not The low negative predictive value suggests that in 92% of the cases with nega-tive arthrographic examinations, an arthroscopic lesion was found

Several authors have reported the poor correlation between the results

of arthrography and the location of the patientÕs symptoms Metz et al19 found no correlation between the arthrographic location of incomplete TFCC and ligament tears and the patientÕs symptoms Yin et al20 per-formed bilateral arthrography on

110 patients and noted that three-compartment injections identified communicating defects in both wrists in the 59 symptomatic pa-tients and 51 asymptomatic papa-tients Kirschenbaum et al21reported a 27% incidence of ligament perforations in asymptomatic subjects between the ages of 20 and 25 years Brown et

al22noted an even higher incidence

of ligament tears in asymptomatic wrists Herbert et al23noted similar findings

The significance of TFCC tears as

a source of chronic wrist pain must

be considered in light of the work

of Viegas et al,2 Mikic,1and Tan et

al.24 These authors studied the inci-dence of TFCC tears as a function of

Figure 1 A, Radiograph of a healed scaphoid fracture B, CT scan of same healed scaphoid fracture shows a posttraumatic cyst that was poorly visualized on a routine x-ray film C, CT scan of the wrist of another patient with scaphoid delayed union after cancellous bone

grafting and Kirschner-wire fixation.

age Viegas et al noted no TFCC

perforations in cadavers below the

age of 30, and Mikic noted none

below the age of 20 years Tan et al

reported an incidence of 23% in

fetal and newborn cadavers They

were unable to explain the

discrep-ancy between their data and those

of Viegas et al and Mikic, except to

speculate that it might be due to

anthropomorphic differences

be-tween Asian and Caucasian

popu-lations Therefore, the presence of a

TFCC tear may not be sufficient to

explain a patientÕs symptoms

Magnetic Resonance Imaging

Magnetic resonance imaging is

important in the evaluation of soft

tissues of the wrist and the

vascu-larity of the carpal bones

Interpre-tation of MR images requires

spe-cific experience and a good

under-standing of the cross-sectional

anatomy of the wrist T1-weighted

images offer the best resolution

and are suited for assessment of

anatomy T2-weighted images

more clearly demonstrate fluid,

cysts, and tumors

Occult ganglions, soft-tissue tu-mors, tendinitis, and joint effusion are well visualized with MR imag-ing, and the vascular status of the carpus, including the lunate, the scaphoid (Fig 3, A), and the capi-tate, can be evaluated accurately.24-27

It is the most accurate modality (other than biopsy) for assessing the vascularity of the lunate and is more specific than bone scanning

in evaluating possible Kienbšck disease (Fig 3, B).28 Bone bruises and microfractures can also be diag-nosed with this modality.29 It is particularly useful for diagnosing occult scaphoid fractures The abil-ity of MR imaging to depict subtle changes in the vascularity of the lunate and the ulnar head make it useful in confirming a diagnosis of ulnar abutment syndrome.30 Several studies have been carried out to evaluate the accuracy of MR imaging in assessing the inter-osseous ligaments of the wrist and the TFCC In one report, MR imag-ing was shown to have a sensitivity

of 90% to 95% in evaluating the integrity of the TFCC.31 However,

Bednar et al32reported a sensitivity

of only 44% and a specificity of 75% for detecting TFCC lesions In

anoth-er study,33the accuracy of MR imag-ing in evaluatimag-ing scapholunate liga-ment tears approached 90%;

howev-er, it dropped to 50% for identifica-tion of lunatotriquetral ligament lesions In a prospective study of 43 wrists in which MR imaging was compared with arthroscopy, John-stone et al34considered MR imaging unhelpful in investigating suspected carpal instability, with a sensitivity

of 80% in evaluating the TFCC, but only 37% in assessing scapholunate disorders and 0% in identifying lunatotriquetral lesions

Radionuclide Imaging

Bone scans are very sensitive but not particularly specific A bone scan can be helpful as a screening test Scintigraphy can be useful in assessing for the presence of the early phases of reflex sympathetic dystrophy35; osteonecrosis of the scaphoid, lunate, and capitate; arthrosis; occult fractures; or any other pathologic condition that causes an increase in bone turn-over

The controversy regarding the usefulness of scintigraphy in the diagnosis of occult scaphoid frac-tures is relevant to the assessment

of the patient with chronic wrist pain Waizenegger et al36 have shown that increased radionuclide uptake by the scaphoid does not always indicate a fracture They found that of 25 Òhot spotsÓ (i.e., areas

of increased radionuclide uptake)

on bone scans of this region, only 7 proved to be due to scaphoid frac-tures Jonsson et al37 suggest that bone scans are not needed in the diagnosis of occult scaphoid frac-tures and recommend that CT be used in cases of suspected scaphoid fracture

In contrast to these studies, Tiel-van Buul et al38reported that 21 of

22 carpal hot spots on bone

scintig-Figure 2 Arthrogram demonstrating a TFCC tear.

raphy could be radiologically

con-firmed as fractures The diagnosis

was missed by CT scan in three

patients with proven fractures on

plain radiographs The authors

con-cluded that, in patients with

nega-tive initial radiographs following

carpal injury, a positive bone scan

must be interpreted as a fracture

Shewring et al39demonstrated that

early bone scans are effective in

diagnosing occult carpal fractures,

but that late scans are less reliable,

due to the increased uptake of the

isotope secondary to disuse An

area of increased uptake is

sugges-tive of a ligamentous injury

The literature is not clear as to

the relative roles of CT and bone

scintigraphy in the diagnosis of

other occult carpal fractures It

seems prudent to rely on the

sensi-tivity of bone scanning or MR

imaging to identify

radiographical-ly undetectable fractures In the

case of a positive scan, detailed CT

scans should then be obtained to

clearly delineate the fracture site.40

Scintigraphy can be useful in

evaluating soft-tissue injuries about

the wrist Pin et al41 found that

scintigrams were abnormal in 93%

of cases involving symptomatic complete intrinsic ligament rup-tures, but correlated poorly with partial intrinsic ligament injuries or synovitis A bone scan can be help-ful in assessing soft-tissue injuries about the wrist; however, bone scans do not demonstrate enhance-ment in TFCC tears unless there are associated degenerative changes

Therefore, it is clear that a normal bone scan does not give license to abandon further investigation of a chronically painful wrist

Osteomyelitis can be a cause of wrist pain Technetium bone scans combined with indium scans can

be helpful in diagnosing and local-izing the site of infection.42

Scintigraphy is a valuable diag-nostic tool It should not be forgot-ten, however, that often all it can do

is help define the area of pathologic change, but not the nature of the pathologic process

Arthroscopy

Arthroscopy is essential for eval-uating wrist pain, as it permits the surgeon to see and assess the

liga-ments and articular surfaces of the carpus It has become the most reliable diagnostic tool for investi-gating intra-articular disorders Just as arthroscopy has replaced arthrography in evaluation of the knee, arthroscopy appears to be gradually replacing arthrography

in evaluation of the wrist It pro-vides direct (Fig 4), rather than indirect, visualization of the wrist joint and, in some cases, allows treatment as well

In a study comparing arthroscopy and arthrography of the wrist, Weiss

et al43 reported that the sensitivity, specificity, and accuracy of triple-injection cinearthrography in detect-ing tears of the scapholunate liga-ment, lunatotriquetral ligaliga-ment, and triangular fibrocartilage were 56%, 83%, and 60%, respectively Al-though arthrography of the wrist is a well-accepted diagnostic modality in the evaluation of pain in the wrist, normal arthrographic findings do not necessarily rule out the possi-bility of internal derangement of the wrist The superiority of wrist ar-throscopy over arthrography is also suggested in the articles by Schers

Figure 3 A,MR image of the wrist shows delayed union of a scaphoid fracture after cancellous bone grafting and Kirschner-wire

fixa-tion Note avascular scaphoid (arrow) B, MR image of a wrist affected by Kienbšck disease shows an avascular lunate (arrow).

and van Heusden44 and Cooney.45

However, the arthroscopist must

rec-ognize (as is true for arthrography)

that many of the lesions seen are not

clinically relevant In fact, because

arthroscopy is more sensitive than

arthrography, a greater incidence of

asymptomatic lesions should be

expected with arthroscopy

Arteriography

Arteriography is occasionally

indicated in cases of suspected

peripheral vascular disease or

thrombosis, such as is seen in the

ulnar hammer syndrome More

often than not, the pain will be in

the fingers of the involved hand,

rather than in the wrist An

arteri-ogram will help localize the

prob-lem and differentiate local vascular

lesions from pathologic changes

due to systemic causes

Diagnostic Injections

Local injections of anesthetic agents

can be useful in localizing sources

of pain They can help differentiate

a midcarpal lesion from a radio-carpal lesion (assuming the inter-osseous ligaments and TFCC are intact) or an intra-articular lesion from an extra-articular lesion Pre-cise placement of the injection may require fluoroscopic control Care must be taken to target only the suspected area of pathologic change and to avoid anesthetizing adjacent areas Patience is required to give the anesthetic time to act The patient should be asked to move or use the wrist to see whether the anesthetic relieves the pain

Laboratory Studies

Imaging techniques are very helpful

in assessing the painful wrist, but occasionally laboratory studies are needed Probably the most fre-quently utilized laboratory tests are those used to screen for rheumatoid arthritis and other inflammatory and collagen vascular diseases

Elevated serum uric acid levels may

suggest gout, and a high erythro-cyte sedimentation rate may indi-cate an infection or other inflam-matory process Lyme disease titers can also be helpful.46 In some cases, joint aspiration and/or tissue

biop-sy and cultures may be needed

Summary

Many studies cited in this discus-sion question the validity of not only the clinical examination but also the interpretation of the results

of currently available diagnostic procedures Radiographs, arthro-grams, CT scans, MR images, and arthroscopic studies may show lesions that have no correlation to the patientÕs pain The physician must therefore be cautious and meticulous in correlating test re-sults with clinical findings The mere presence of a lesion does not mean that it is the source of the patientÕs pain and must be treated For example, many people have a TFCC tear but no discomfort

attrib-Figure 4 A, Arthroscopic view of a wrist demonstrates grade IV changes in the articular cartilage of the lunate B, Arthroscopic view of

another wrist depicts ulnocarpal synovitis.

utable to it Therefore, a

sympto-matic patient with a TFCC tear

should be treated for it only if the

symptoms, physical examination

findings, and mechanism of injury

are persuasive when considered

together

While clinical pathways and

algorithms are intellectually

satisfy-ing, their usefulness in the

diagno-sis of chronic wrist pain remains to

be established Many authors have proposed such algorithms, but none is exhaustive or complete

The differential diagnosis of chronic wrist pain is complex; therefore, a meticulous and orderly approach is necessary No single test can be considered the sine qua non in the diagnostic algorithm A negative

bone scan does not rule out a TFCC tear, nor does a negative arthro-scopic examination eliminate the possibility of midcarpal instability Cinearthrography, CT, and MR imaging are not 100% sensitive or specific In each case, the physician must consider a multiplicity of fac-tors to successfully diagnose and treat chronic wrist pain

References

1 Mikic ZD: Age changes in the

triangu-lar fibrocartilage of the wrist joint J

Anat 1978;126:367-384.

2 Viegas SF, Patterson RM, Hokanson

JA, Davis J: Wrist anatomy: Incidence,

distribution, and correlation of

ana-tomic variations, tears, and arthrosis J

Hand Surg [Am] 1993;18:463-475.

3 Reagan DS, Linscheid RL, Dobyns JH:

Lunotriquetral sprains J Hand Surg

[Am] 1984;9:502-514.

4 Watson HK, Hempton RF: Limited

wrist arthrodeses: I The triscaphoid

joint J Hand Surg [Am] 1980;5:320-327.

5 Watson HK, Ashmead D IV, Makhlouf

MV: Examination of the scaphoid J

Hand Surg [Am] 1988;13:657-660.

6 Reagan DS, Linscheid RL, Dobyns JH:

Lunotriquetral sprains J Hand Surg

[Am] 1984;9:502-514.

7 North ER, Meyer S: Wrist injuries:

Correlation of clinical and arthroscopic

findings J Hand Surg [Am] 1990;15:

915-920.

8 Lester B, Halbrecht J, Levy IM,

Gaudinez R: ÒPress testÓ for office

diagnosis of triangular fibrocartilage

complex tears of the wrist Ann Plast

Surg 1995;35:41-45.

9 Czitrom AA, Lister GD: Measurement

of grip strength in the diagnosis of wrist

pain J Hand Surg [Am] 1988;13:16-19.

10 Hildreth DH, Breidenbach WC, Lister

GD, Hodges AD: Detection of

sub-maximal effort by use of the rapid

ex-change grip J Hand Surg [Am] 1989;

14:742-745.

11 Mann FA, Wilson AJ, Gilula LA:

Radiographic evaluation of the wrist:

What does the hand surgeon want to

know? Radiology 1992;184:15-24.

12 Carroll RE, Lakin JF: Fracture of the

hook of the hamate: Radiographic

visualization Iowa Orthop J 1993;13:

178-182.

13 Wechsler RJ, Wehbe MA, Rifkin MD,

Edeiken J, Branch HM: Computed

tomography diagnosis of distal

radioulnar subluxation Skeletal Radiol

1987;16:1-5.

14 Zinberg EM, Palmer AK, Coren AB, Levinsohn EM: The triple-injection

wrist arthrogram J Hand Surg [Am]

1988;13:803-809.

15 Levinsohn EM, Rosen ID, Palmer AK:

Wrist arthrography: Value of the three-compartment injection method.

Radiology 1991;179:231-239.

16 Nagle DJ, Benson LS: Wrist arthroscopy:

Indications and results Arthroscopy

1992;8:198-203.

17 Chung KC, Zimmerman NB, Travis MT: Wrist arthrography versus ar-throscopy: A comparative study of 150

cases J Hand Surg [Am]

1996;21:591-594.

18 Vanden Eynde S, De Smet L, Fabry G:

Diagnostic value of arthrography and arthroscopy of the radiocarpal joint.

Arthroscopy 1994;10:50-53.

19 Metz VM, Mann FA, Gilula LA: Lack

of correlation between site of wrist pain and location of noncommunicat-ing defects shown by

three-compart-ment wrist arthrography AJR Am J

Roentgenol 1993;160:1239-1243.

20 Yin YM, Evanoff B, Gilula LA, Pilgram TK: Evaluation of selective wrist arthrography of contralateral asymp-tomatic wrists for symmetric

ligamen-tous defects AJR Am J Roentgenol

1996;166:1067-1073.

21 Kirschenbaum D, Sieler S, Solonick D, Loeb DM, Cody RP: Arthrography of the wrist: Assessment of the integrity

of the ligaments in young

asympto-matic adults J Bone Joint Surg Am

1995;77:1207-1209.

22 Brown JA, Janzen DL, Adler BD, et al:

Arthrography of the contralateral, asymptomatic wrist in patients with

unilateral wrist pain Can Assoc Radiol

J 1994;45:292-296.

23 Herbert TJ, Faithfull RG, McCann DJ,

Ireland J: Bilateral arthrography of the

wrist J Hand Surg [Br] 1990;15:233-235.

24 Tan ABH, Tan SK, Yung SW, Wong

MK, Kalinga M: Congenital perfora-tions of the triangular fibrocartilage of

the wrist J Hand Surg [Br] 1995;20:

342-345.

25 Kutty S, Curtin J: Idiopathic avascular

necrosis of the capitate J Hand Surg

[Br] 1995;20:402-404.

26 Cristiani G, Cerofolini E, Squarzina

PB, et al: Evaluation of ischaemic ne-crosis of carpal bones by magnetic

res-onance imaging J Hand Surg [Br]

1990;15:249-255.

27 Reinus WR, Conway WF, Totty WG, et al: Carpal avascular necrosis: MR

imaging Radiology 1986;160:689-693.

28 Szabo RM, Greenspan A: Diagnosis and clinical findings of KienbšckÕs

dis-ease Hand Clin 1993;9:399-408.

29 Kettner NW, Pierre-Jerome C: Mag-netic resonance imaging of the wrist:

Occult osseous lesions J Manipulative

Physiol Ther 1992;15:599-603.

30 Escobedo EM, Bergman AG, Hunter JC: MR imaging of ulnar impaction.

Skeletal Radiol 1995;24:85-90.

31 Golimbu CN, Firooznia H, Melone CP

Jr, Rafii M, Weinreb J, Leber C: Tears

of the triangular fibrocartilage of the

wrist: MR imaging Radiology 1989;

173:731-733.

32 Bednar JM, Bos M, Giacobetti F: Comparison of the accuracy of clinical examination and MRI in diagnosing TFCC lesions Presented at the 52nd Annual Meeting of the American Society for Surgery of the Hand, Denver, September 11-13, 1997.

33 Schweitzer ME, Brahme SK, Hodler J,

et al: Chronic wrist pain: Spin-echo and short tau inversion recovery MR imaging and conventional and MR

arthrography Radiology 1992;182:

205-211.

34 Johnstone DJ, Thorogood S, Smith