CASE REPORT

Differentiating common causes of radial wrist pain Waqas Shuaib, MD; Zia Mohiuddin; Freddie R. Swain, MD; Faisal Khosa, MD

ABSTRACT Radial wrist pain is a common patient complaint with a broad differential. Because treatment and prognosis differ, determining the underlying cause is key. This article reviews a case of intersection syndrome and compares it to other causes of radial wrist pain. Keywords: radial wrist pain, sports injury, intersection syndrome, MRI, trauma, repetitive motion

CASE A 30-year-old right-handed woman presents to the ED with a 3-day history of pain and swelling in the right dorsal forearm. She states that the pain increases with movement, specifically ulnar deviation and wrist extension. She has no previous history of trauma and does not report any parasthesias or weakness. The patient reported practicing for the annual racquetball tournament 2 days before the pain started. A physical examination of the right upper extremity revealed an area of pain and swelling at the intersection point 5 cm proximal to the radiocarpal joint. Crepitus was noted on palpation, and further elicited with wrist extension. Suspicious that a soft tissue mass was causing the swelling, the physician ordered an axial MRI, which revealed T2-weighted signal surrounding the extensor carpi radialis brevis and longus at the musculotendinous junction (Figure 1). WHICH IS A POSSIBLE DIAGNOSIS? • De Quervain tenosynovitis • scaphoid fracture • intersection syndrome • radial styloid fracture Waqas Shuaib is a senior research associate in the radiology department at Emory University Hospital in Atlanta, Ga. Zia Mohiuddin is a student intern at Emory Orthopedics & Spine Center and a student in the Emory University PA program, both in Atlanta. Freddie R. Swain and Faisal Khosa are assistant professors in the emergency radiology department at Emory University Hospital. The authors have disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000451875.71319.17 Copyright © 2014 American Academy of Physician Assistants

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FIGURE 1. A T2-weighted signal around the extensor carpi

radialis brevis and longus at the musculotendinous junction (arrow)

• ganglion cyst • scapholunate instability • radiocarpal osteoarthritis DISCUSSION Radial wrist pain can be caused by sprains, strains, trauma, fractures, or from a repetitive wrist movement causing an overuse syndrome of the wrist. This patient was diagnosed with intersection syndrome, a type of repetitive motion injury. First described in 1841, intersection syndrome has a prevalence of 11.9% and is a noninfectious inflammatory process of the second extensor compartment tendons of the forearm.1,2 The condition is characterized by pain and swelling proximal to the Lister tubercle of the distal radius.1,2 Symptoms are present at the point of intersection between the first extensor compartment tendons (the abductor pollicis longus and the extensor pollicis brevis tendons), crossing over the second extensor compartment tendons (the extensor carpi radialis longus and the extensor carpi radialis brevis tendons) as a result of an overuse or trauma. The key to making the right diagnostic and therapeutic judgment lies in understanding the anatomy of the wrist (Figure 2). Previous studies have suggested ultrasound and MRI as the diagnostic imaging modalities of choice.3,4 Volume 27 • Number 9 • September 2014

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Differentiating common causes of radial wrist pain

Key points Radial wrist pain may be caused by sprains, strains, trauma, fractures, or repetitive wrist movement causing an overuse syndrome. Because the causes of radial wrist pain often have subtle differences, a detailed history, physical examination, and imaging studies can aid in diagnosis and management.

De Quervain syndrome Another type of repetitive motion injury, De Quervain syndrome is a tenosynovitis of the first extensor compartment (abductor pollicis longus and extensor pollicis brevis), and is commonly seen in athletes and new mothers who present with pain, swelling, tenderness, and limited wrist movement. Overuse, arthritis, and hormonal changes observed in pregnant women are documented causes of De Quervain syndrome.5 A positive Finkelstein test is pathognomonic. Ultrasound is accurate at revealing presence and extent of tenosynovitis, and conventional radiography may reveal soft-tissue swelling. Therapeutic management generally consists of hand immobilization and nonsteroidal anti-inflammatory drugs (NSAIDs). Ganglion cyst Appearing as a bump on physical examination, a ganglion cyst is a fluid collection connected by a narrow neck to a joint or tendon sheath dorsal or volar to the wrist. This type of repetitive motion injury may be painful, particularly if it is in a tendon sheath (known as a retinacular cyst). This pain is typically evoked with gripping motions. Teardrop-shaped ganglion cysts are often associated with ligament tear and are mostly asymptomatic. However, when large enough, the cyst may compress the median nerve, causing pain, tingling, and muscle weakness. Plain radiographs are generally not useful in diagnosing ganglion cysts, but can help rule out other pathologic

FIGURE 2. Anatomy of the six extensor compartments of the wrist

The muscles are the extensor carpi ulnaris (1), extensor digiti minimi (2), extensor digitorum communis (3), extensor indicis proprius (4), extensor pollicis longus (5), extensor carpi radialis brevis (6), extensor carpi radialis longus (7), extensor pollicis brevis (8), and abductor pollicis longus (9). JAAPA Journal of the American Academy of Physician Assistants

FIGURE 3. A T2-weighted axial image showing a fluid-filled

ganglion cyst (arrow)

processes. MRI (Figure 3) and ultrasonography are diagnostic and can help locate the cyst’s neck or the pedicle. The neck often points to the origin of the cyst, which can be important presurgical information. Most cysts resolve spontaneously. In recurring cases, the underlying ligament tear must be repaired.6 Scaphoid fracture The most common wrist fracture, a scaphoid fracture, occurs as a result of a traumatic fall on an outstretched hand. Injury to scaphoid may lead to carpal instability. A common complication of scaphoid fracture, avascular necrosis is location-dependent.7 Injury to the proximal pole, which is dependent entirely on intraosseous blood flow, can result in protracted healing or osteonecrosis. Common presentation may include anatomic snuffbox tenderness, limited range of motion, reduced grip strength, pain over the distal scaphoid tubercle, and axial compression of the thumb. Using multiple views, conventional radiography is diagnostic (Figure 4). Up to 5% of fractures may not appear initially; in these patients, anatomic snuffbox tenderness can warrant casting of the fracture along with imaging follow-up in 5 to 7 days.8 Casting is favored in stable cases (nondisplaced fracture); surgical intervention is suitable in unstable cases (displaced fracture, delayed union, symptomatic malunion/nonunion, or osteonecrosis). Radial styloid fracture This type of traumatic injury accounts for about 17% of all wrist fractures and is more common in women.9,10 Trauma and falls are among the common causes (specifically, ulnar deviation and supination of the wrist).11 Radial styloid fractures can occur in isolation or as part of a multifaceted articular distal radius fracture pattern. Radiographic evaluation of radial styloid fractures should include a supinated view so that scapholunate instability is ruled out—dislocation of the lunate frequently accompanies styloid fractures. www.JAAPA.com

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CASE REPORT

ties, and osteophytes usually is sufficient to make the diagnosis. Splint or cast immobilization, NSAIDs, and selective intra-articular corticosteroidal injections may alleviate pain and improve wrist function. Severe cases involving the entire carpus and distal radius may require a total wrist arthrodesis. TREATMENT The case patient’s hand was immobilized and NSAIDs were prescribed. The patient was told to rest the wrist and avoid stressful repetitive wrist movements. A week after the initial visit, the patient had fully recovered. FIGURE 4. Subtle linear lucency through the scaphoid body, best seen on oblique view (arrow) Had she not recovered after 2 to 3 weeks of conservative management, These fractures must be assessed and treated individually, anesthetic-corticosteroid injections would be considtaking into account patient profile, medical history, and ered. JAAPA injury characteristics. Fracture displacement, size, and comminution must be well thought-out while the clinician REFERENCES is preparing a treatment plan. All radial styloid fractures, 1. Palmer DH, Lane-Larsen CL. Helicopter skiing wrist injuries. A case report of “bugaboo forearm.” Am J Sports Med. 1994;22 excluding tip fractures, are intra-articular, and operative (1):148-149. intervention should be considered when articular incongru2. Grundberg AB, Reagan DS. Pathologic anatomy of the ity is greater than 2 mm. Fixation techniques are more forearm: intersection syndrome. J Hand Surg Am. 1985;10 appropriate for complex distal radius fractures. (2):299-302. Scapholunate joint injury The most frequent source of 3. Costa CR, Morrison WB, Carrino JA. MRI features of intersection syndrome of the forearm. AJR Am J Roentgenol. 2003;181 carpal instability, injury to the scapholunate joint often is (5):1245-1249. overlooked as “wrist sprain” when no fracture is observed 4. Montechiarello S, Miozzi F, D’Ambrosio I, Giovagnorio F. The during initial imaging.12 The patient may report a traumatic intersection syndrome: ultrasound findings and their diagnostic event, which the clinician must further investigate to detervalue. J Ultrasound. 2010;13(2):70-73. mine the resultant force vector. In addition to pain, the 5. Schumacher HR Jr, Dorwart BB, Korzeniowski OM. Occurrence of De Quervain’s tendinitis during pregnancy. Arch Intern Med. patient’s wrist may make a clicking or snapping noise on 1985;145(11):2083-2084. physical examination. Abnormal carpal alignment (static 6. Thornburg LE. Ganglions of the hand and wrist. J Am Acad or dynamic) with associated intrinsic and/or extrinsic ligaOrthop Surg. 1999;7(4):231-238. ment injuries is the best diagnostic imaging clue on standard 7. Yin ZG, Zhang JB, Kan SL, Wang XG. Diagnosing suspected radiographic examination.13 If conservative management scaphoid fractures: a systematic review and meta-analysis. Clin Orthop Relat Res. 2010;468(3):723-734. with activity modification, NSAIDs, corticosteroid injection, 8. Steinmann SP, Adams JE. Scaphoid fractures and nonunions: and wrist immobilization does not provide relief, consider diagnosis and treatment. J Orthop Sci. 2006;11(4):424-431. surgical management with internal fixation or ligament 9. Falch JA. Epidemiology of fractures of the distal forearm in reconstruction. Oslo, Norway. Acta Orthop Scand. 1983;54(2):291-295. Degenerative disease Radiocarpal osteoarthritis accounts 10. Owen RA, Melton LJ 3rd, Johnson KA, et al. Incidence of Colles’ fracture in a North American community. Am J Public for 57% of all cases of osteoarthritis.14 The nature of its Health. 1982;72(6):605-607. development is due to intra-articular mechanical distur11. Helm RH, Tonkin MA. The chauffeur’s fracture: simple or bances caused by idiopathic and traumatic origins. Unlike complex? J Hand Surg Br. 1992;17(2):156-159. intersection syndrome, which occurs over 2 to 3 days, 12. Kuo CE, Wolfe SW. Scapholunate instability: current concepts in radiocarpal osteoarthritis is characterized by gradually diagnosis and management. J Hand Surg Am. 2008;33(6):998increasing pain and stiffness along with associated swelling. 1013. Before deciding on appropriate therapeutic options, 13. Kindynis P, Resnick D, Kang HS, et al. Demonstration of the scapholunate space with radiography. Radiology. 1990;175(1): perform a thorough physical examination and radiographic 278-280. evaluation. Palpate the joints of the wrist to locate the area 14. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced of interest. Conventional radiography showing joint space collapse pattern of degenerative arthritis. J Hand Surg Am. narrowing, subchondral bone sclerosis or erosion, deformi1984;9(3):358-365. 36

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Volume 27 • Number 9 • September 2014

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Differentiating common causes of radial wrist pain.

Radial wrist pain is a common patient complaint with a broad differential. Because treatment and prognosis differ, determining the underlying cause is...
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