Vol 8, No 1, January/February 2000 45 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, palpation, and manipulation. History A thorough history is essential, which should include the past medi- cal and surgical 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. Mikic 1 and Viegas et al 2 demonstrated 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 tomography, cinearthrography, 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 Evaluation of Chronic Wrist Pain 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. Chronic Wrist Pain Journal of the American Academy of Orthopaedic Surgeons 46 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 al 5 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 Daniel J. Nagle, MD Vol 8, No 1, January/February 2000 47 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 al 8 cited 100% sensitivity for the TFCC Òpress test,Ó 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 performing 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 Lister 9 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 al 11 have 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 Chronic Wrist Pain Journal of the American Academy of Orthopaedic Surgeons 48 in the evaluation of chronic sublux- ation of the distal radioulnar joint. Wechsler et al 13 and 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. Daniel J. Nagle, MD Vol 8, No 1, January/February 2000 49 Table 2 Radiographic Views of the Wrist View Technique Area of Interest/ Significant Finding PA wrist Center beam on radiocarpal joint Radioulnar tilt, 12-22 degrees PA with radial deviation Center beam on radiocarpal joint, Break in GilulaÕs lines may indicate wrist radially deviated lunatotriquetral instability PA with ulnar deviation Center beam on radiocarpal joint, Scapholunate interval widens in wrist ulnarly deviated scapholunate instability Clenched-fist view PA view of wrist, center beam on Scapholunate interval widens in scapholunate joint scapholunate instability Lateral wrist Neutral forearm rotation, wrist in Scapholunate angle, 30-60 degrees; neutral, third metacarpal aligned radioscaphoid angle, 30-60 degrees; with radius radiolunate angle, 0-15 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 Pisiform Oblique with hand in 30 degrees Pisiform and pisotriquetral joint of supination are seen Scaphoid PA with ulnar deviation, 60 degrees Scaphoid is seen in profile of pronation Dorsal stress Lateral with dorsally directed force Capitolunate instability across palmar capitate Carpal tunnel PA with wrist hyperextended and Hook of the hamate and beam at 30 degrees to palm carpal tunnel Fourth and fifth PA with ulnar aspect of hand Fracture dislocation, distal radioulnar carpometacarpal joints elevated off film joint disorder Second and third PA with radial aspect of hand elevated Fracture dislocation, distal radioulnar carpometacarpal joints off film joint disorder First carpometacarpal joint Eaton stress view Subluxation and arthrosis 90 × 90 Shoulder abducted to 90 degrees, Ulnar variance 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 radio- 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 Benson 16 found that, compared with arthros- copy, arthrography was accurate and complete in only 11% of cases. Chung et al 17 noted similar limita- tions. In another study, Vanden Eynde et al 18 reported that arthrog- raphy had a sensitivity of 52%, a specificity of 50%, a positive predic- tive value of 92%, and a negative 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 al 19 found no correlation between the arthrographic location of incomplete TFCC and ligament tears and the patientÕs symptoms. Yin et al 20 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 patients. Kirschenbaum et al 21 reported a 27% incidence of ligament perforations in asymptomatic subjects between the ages of 20 and 25 years. Brown et al 22 noted an even higher incidence of ligament tears in asymptomatic wrists. Herbert et al 23 noted 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, 1 and Tan et al. 24 These authors studied the inci- dence of TFCC tears as a function of Chronic Wrist Pain Journal of the American Academy of Orthopaedic Surgeons 50 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. A B C 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 al 32 reported a sensitivity of only 44% and a specificity of 75% for detecting TFCC lesions. In anoth- er study, 33 the accuracy of MR imag- ing in evaluating 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 al 34 considered 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 dystrophy 35 ; 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 al 36 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 al 37 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 al 38 reported that 21 of 22 carpal hot spots on bone scintig- Daniel J. Nagle, MD Vol 8, No 1, January/February 2000 51 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 al 39 demonstrated 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 al 41 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 al 43 reported that the sensitivity, specificity, and accuracy of triple- injection cinearthrography in detect- ing tears of the scapholunate liga- ment, lunatotriquetral ligament, 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 Chronic Wrist Pain Journal of the American Academy of Orthopaedic Surgeons 52 A B 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 Heusden 44 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- Daniel J. Nagle, MD Vol 8, No 1, January/February 2000 53 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. A B Chronic Wrist Pain Journal of the American Academy of Orthopaedic Surgeons 54 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. 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