Differential Diagnosis of Radial-Side Wrist Pain [+FREE EBOOK]
The wrist is a complex joint, consisting of a large number of ligaments, joints, tendons and neurovascular structures that make an accurate diagnosis a difficult task. In order to understand the carpus and prescribe correct treatment, it is essential to know the anatomy, biomechanics and the most relevant provocative and diagnostic tests.
To facilitate this process, we have decided to create three posts on our blog, dividing the possible diagnoses and their evaluation tests by regions: Radial-Side Wrist Pain, Central-Side Wrist Pain and Ulnar-Side Wrist Pain.
Before moving on the assessment of wrist pain, it is important to outline some basics for assessment process which, although some are common to other body segments, has some peculiarities to be taken into account.
Let´s Go!
Principles for a successful diagnosis of wrist pain
Clinical History
A detailed anamnesis will be important to guide our subsequent clinical examination. It is essential that our questions battery includes information about the patient’s dominant hand, occupation, hobbies, sports and possible history of previous injuries. It will also be of interest to ask about the 4 most important symptoms for which a patient may come for consultation: 1) Pain, 2) Stiffness, 3) Weakness or 4) Clicking.
We can ask for pain location (radial, central, ulnar, volar or dorsal), the trigger (progressive, related to trauma, etc.), the nature of the pain (dull, sharp or associated with movement), whether it is radiating or not, factors that relieve it (rest, analgesia, movement, etc.) and the impact on daily life (work, domestic activities, self-care, etc.).
Ashley Newton et al (2017) published this summary outline of possible diagnoses based on the location of the pain:
General Examination
Before starting, it´s important that both the patient and the therapist are in a comfortable position. For this purpose, it is recommended that the patient sits facing the therapist with a table between them, where the patient can rest his or her elbows. This position is important because: it allows us to see the patient’s face for possible signs of pain or discomfort, and to be able to assess the forearm comfortably.
ALWAYS start with inspection, palpation and mobility, before proceeding with special or provocative tests that may irritate the tissues.
Visual Inspection
We should be on the lookout for skin alterations (scars, lesions, ulcers, etc.), oedema, muscular atrophy and deformities. Specific signs may include: inflammation (e.g. first extensor compartment tendon, radial extensor tendon, etc.), masses (e.g. ganglions, rheumatoid nodules, deformities, osteophytes, heberden’s nodules, etc.), deformities (e.g. radial wrist deviation, “Z” thumb, etc.), scars (e.g. surgery for radial fractures, carpal tunnel syndrome, etc.) or loss of muscle mass (e.g. in the tenar eminence or the first dorsal interosseous).
Palpation
Within palpation we will look for tender or painful regions, signs of joint instability, crepitus or clicking. The authors Newton A et al 2017 proposed a specific order of palpation of the wrist in the Radial Region:
1.First Metacarpal Joint
2.Scapho-Trapezio-Trapezoid joint
3.Radial Styloid
4.First Extensor Compartment
5.Second Extensor Compartment
6.Scaphoid
7.Flexor Carpi Radialis Tendon
It will also be important to assess the radial and ulnar arterial pulses, and the sensory regions of the median, ulnar and radial nerves. In an older post, we discussed the well-known Allen test and its clinical validity. Is it really feasible to use?
Range of Motion
Wrist mobility arises from multiple joints, resulting in flexion-extension, ulnar-radial deviation and pronation-supination movements, which should be compared with the contralateral side.
Flexion-extension originates at the radiocarpal and midcarpal joints (between the first and second carpal rows), so loss of mobility suggests involvement of this region. Pronation-supination occurs at the distal radioulnar joint, so alterations in these movements may indicate lesions at this level.
Another MUST-HAVE movement to assess, and often overlooked, is the functional Dart Throwing Motion. As we can guess, the wrist does not move in the pure planes of motion described above, but uses combinations to perform daily activities. This is the plane in which we usually perform gripping or drinking from a bottle, which combines Radial Deviation-Extension and Ulnar Deviation-Flexion. It is a movement that mainly involves the midcarpal joint, so that alterations in this region could condition this mobility.
👉We have previously discussed the Dart Throwing motion in depth and its biomechanical implications in Scapholunate ligament injuries.
Diagnostic Tests for Radial-Side Wrist Pain
Osteoarthritis of the Trapeziometacarpal Joint or Rhizatrosis of the Thumb
The TMC joint of the thumb is one of the most frequently affected regions of the upper limb. Patients often report pain in the radial aspect of the dorsum of the wrist, somewhat centred over the trapeziometacarpal joint, or in the area of the tenar eminence. The pain is often aggravated by pinching, grasping or twisting of the thumb, such as opening jars or doors. Crepitus, oedema, joint pain or limited mobility, especially on extension and abduction, may also occur.
In advanced cases it is characteristic to observe the characteristic “Z” deformity, which is characterised by:
1) Dorso-Radial subluxation of the base of the metacarpal.
2) Adduction of the metacarpal towards the hand axis
3) Compensatory hyperextension of the metacarpophalangeal joint.
Specific tests for Osteoarthritis of the thumb include:
1) Grind test: the test is performed by applying axial pressure on the thumb while rotating the metacarpal itself. It will be positive in the event of pain, with or without crepitus.
2) Reduction Manoeuvre for Trapeziometacarpal Osteoarthritis: by grasping the patient’s thumb, longitudinal traction of the thumb is performed. Palmar pressure is then applied to the dorsal aspect of the base of the thumb metacarpal, correcting the dorsal subluxation and returning it to its anatomical position. The appearance of pain is usually indicative of this condition.
The work of Mailey B et al 2019 published in the Journal of Hand Surgery, indicated that the Reduction Manoeuvre is the most useful test for this diagnosis, presenting favourable data on sensitivity, specificity and ability to detect in early stages the presence of Thumb osteoarthritis.
3) Thumb Adduction Test : while with one hand, the therapist holds the ulnar aspect of the patient’s wrist for stability, the other hand firmly directs a downward adduction force on the metacarpal head until it is parallel to the mid-axis of the index metacarpal or until a firm stop is reached. The appearance of pain is indicative of trapeziometacarpal osteoarthritis.
👉 Do you have patients with Thumb Osteoarthritis? Then find out the 3 Exercises you MUST prescribe for your patients with osteoarthritis of the base of the Thumb or Rhizarthrosis.
DeQuervain´s Tenosynovitis
It´s a tendon disorder of the first extensor compartment, which contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. It most commonly affects women aged 30-50 years, with a gradual onset of pain in the region of the first extensor compartment at the level of the radial styloid. Occasionally oedema will appear.
Finkelstein manoeuvre: This has traditionally been erroneously described. The technique involves grasping the patient’s thumb and deviating the hand ulnarly, which, if positive, will produce pain in the radial styloid region.
Eichhoff manoeuvre: this is the manoeuvre that has traditionally been confused with the Finkelstein manoeuvre. It is performed by asking the patient to insert their thumb between their fingers and make a fist: then he or she is asked to perform an ulnar deviation. The appearance of pain will test positive for the presence of DeQuervain’s tenosynovitis. However, it is important to highlight that given the nature of the test, it may result in false positives for other pathologies affecting the radial region of the wrist.
WHAT test (Wrist Hyperflexion and Abduction of the Thumb): is aimed at actively assessing the action of the APL and EBP tendons. To do this, the patient is asked to place the hand in flexion, the thumb in abduction and the MTP and interphalangeal joints in extension. From this position, the resistance of the thumb in abduction/extension is assessed, with a positive result in the event of pain in the region of the first extensor compartment.
👉6 Interesting facts about DeQuervain’s tenosynovitis – do you know them?
Scaphoid Fracture
It is the most common fracture of the carpus (50-70%), usually affecting young people after a high-energy fall with outstretched hand (Sabbagh MD 2019).
The classic finding in this fracture is the presence of pain at the level of the anatomical snuffbox. In order to directly palpate the scaphoid, it is important to position the wrist. It is recommended that the palpation is performed with the wrist in neutral extension and ulnar deviation, as it allows the scaphoid to be positioned more dorsally (up to 6 times compared to the wrist in radial deviation) for palpate it easily.
Another sign associated with this fracture is pain on direct palpation of the scaphoid tubercle.
Another test used is the Axial Thumb Compression test. In this, axial compression is applied from the metacarpal of the thumb, which stresses the scaphoid itself. The presence of pain will indicate a fracture.
Obviously, if there is any suspicion, referral for radriographic tests should be performed. Even if it is not seen in the image, if the suspicion persists, the imaging test should be repeated after 4 weeks.
👉 ¡8 Points You Need to Know about Scaphoid Fractures of the Wrist! [+CLINICAL CASES]
Distal Radius Fractures
Distal Radius fractures are the most frequently fracture that reaches the emergency services. It has two peaks of incidence in the population: population aged 5-24 years following a high-energy accident or fall, or older population (more predominant in women) due to low-energy falls or accidents (Wolfe SE et al 2010).
Pain, oedema, loss of strength and function will be some of their symptoms. Painful palpation of Lister’s tubercle of the radius or radial styloid is characteristic.
The arrow above marks the Radial Styloid and the arrow below the Lister’s Tubercle.
👉We have previously talked about the types of radius fractures (Colles, Smith or Barton among others) and their treatment applying the latest trends in the treatment of the sensorimotor system.
Scapho-Trapezium-Trapezoid Arthritis
This joint disorder is usually associated with advanced stages of thumb osteoarthritis. Its clinical manifestations are similar (pain and weakness on gripping) although it is usually associated with carpal mobility rather than the thumb itself. If both arthritis coexist (Trapeziometacarpal OA of the thumb and STT) it might be difficult to differentiate.
Pain in cases of STT osteoarthritis usually occurs in the basilar region of the thumb at the level of the scaphoid tubercle or in the dorsal and radial region of the wrist. The patient will refer to palpation of the scapho-trapezio-trapezoid joint as painful.
Radial Grind Test: a test to assess the irritability of this joint, which consists of bringing the patient’s wrist into radial deviation, with the aim of stressing and loading the STT joint. It will be positive with the onset of pain.
In these patients, the Dart Throwing Motion will also often be limited and painful, given the relationship of the STT joint to the midcarpal joint.
Distal Intersection Syndrome
It consists of irritation at the crossover of the tendons of the First (APL and EPB) and Second Extensor Compartment (Extensor Carpi Radialis Longus and Brevis), due to friction between those two structures. It is located 4 cm proximal to the Lister Tubercle of the Radius.
It is often associated with repetitive wrist extension gestures, and specifically in sports such as rowing, racket sports, weightlifting and skiing.
Symptoms are similar to the localised pain of DeQuervain’s tenosynovitis, although it is more relevant in wrist flexion and extension gestures, and not so much in the thumb. The patient may present with oedema accompanied by pain and crepitus in the distal forearm, associated with wrist movements.
Wartenberg Syndrome
This is a rare compressive neuropathy of the superficial sensory branch of the radial nerve. It is frequently trapped by the tendons of the brachioradialis and extensor carpi radialis longus during pronation.
Tinel’s test may be positive at the radial styloid or distal to the brachioradialis muscle belly. Symptoms are worsened by combining ulnar deviation of the wrist with pronation of the forearm.
The symptoms are very similar to those produced by DeQuervain’s tenosynovitis, so this should be taken into account during the assessment.
This concludes our review of the possible conditions that can cause pain in the radial-side of the wrist.
ReHand in Radial Wrist Pain Diagnoses
ReHand is a new technology that combines the latest evidence in the sensorimotor system approach with artificial intelligence, and pathologies such as radius fractures, DeQuervain’s tenosynovitis and all those we have seen, can benefit from its use.
ReHand is a digital tool that allows you to prescribe, treat and monitor your patients objectively. It also increases adherence to treatment and improves health outcomes by speeding up recovery times.
Check it out and ask for your demo! 💢
References
Wu JC, Calandruccio JH. Evaluation and Management of Scaphoid-Trapezium-Trapezoid Joint Arthritis. Orthop Clin North Am [Internet]. 2019;50(4):497–508. Available from: https://doi.org/10.1016/j.ocl.2019.05.005
Reavey PL, Hammert WC. Examination of the Wrist. Plast Reconstr Surg. 2021;284E-294E.
Newton AW, Hawkes DH, Bhalaik V. Clinical examination of the wrist. Orthop Trauma [Internet]. 2017;31(4):237–47. Available from: http://dx.doi.org/10.1016/j.mporth.2017.05.009
Mailey B, Naram A, Cheng J. Comparison of provocative manoeuvres in diagnosing thumb carpometacarpal joint arthritis. J Hand Surg (European Vol. 2019;0(0):175319341984951.
Pablo Rodríguez Sánchez-Laulhé
Physiotherapist, PhD Candidate and Health Researcher | Hand Therapy and Digital Health
