February – Wrist/Hand

[Laura Thornton]

An 18 year old high school male golfer presents to the clinic via direct access for right dorsal wrist pain and recurrent swelling. During his district playoff match 4 months ago, he hit an iron shot and he accidentally hit a root in the ground during impact. He describes his pain as sharp initially, but can linger as a deep ache afterwards. Aggravating factors include golf, especially when hitting the ground on impact, picking up moderate to heavy objects with his right hand
(greater than 10#), and weight-bearing through his hand such as getting out of bed or off the floor. He is currently in golf season and is unable to play or workout due to pain, but wants to return to play as soon as possible.

Have a read of the following two articles to help review. Both are from the Journal of Hand Therapy – Special Issue Wrist in 2016

Please list your initial differential diagnosis list and RANK from most likely to least likely, with relevant subjective signs/symptoms listed for each. You can also add in subjective questions you would like to ask to help with your list.

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[Farisshd]

Given the chronicity of symptoms, repetitive swelling, pain with passive extension (pushing up from a surface), pain with golf swing (especially impact), and pain picking up heavy objects, and without the description of a lump (bony or resembling a ganglion cyst), paresthesia or nerve related pain descriptors, or radial pain at the base of the thumb, I would initially begin thinking dorsal wrist impingement. Differentials include ganglion cyst (which may accompany this condition), scaphoid impaction syndrome, and carpal boss, as well as wrist extensor tendinopathy, though the pain seems to be more likked with compression than stretch. I would want to see ROM, tolerance of restisted motion and passive stretch to gain more insight to build my case for or against a diagnosis.
Subjective questioning may include a more specific location of pain, and inquiry into the presence of paresthesia, presence of a lump or bump (and location), and severity and distribution of swelling when it occurs.

[zcanova]

Triangular fibrocartilage complex articular disc pathology:

Subjective: location of symptoms, aggravated by weight bearing positions or impact in wrist extension, traumatic compression injury, reposts of mechanical clicking at the wrist

Chronic Distal radioulnar joint instability:

Subjective: pain at distal radioulnar joint, aggravated with holding or manipulating objects (possibly for sport), noticeable loss of grip strength, difficulty supinating/pronating wrist, feeling of instability at wrist

Extensor Carpi ulnaris subluxation and/or tendinopathy:

Subjective: recurrent swelling, pain with activities that require active wrist extension, pain with compressive forces in wrist extension, painful snap at the wrist with supination

Distal ulnar fracture:

Subjective: timeline of symptoms, swelling, traumatic MOI, pain with any impact or loading of the wrist, bruising at original injury, painful with most movements of the wrist

[Kyle Feldman]

Great
you have some different differentials

Next questions:

Can you highlight key clinical examination components that would help the best with narrowing down your differential diagnosis?

No imaging has been performed as of yet, so what would be important points to help decide whether to refer for an orthopedic exam and imaging?

[Farisshd]

A few hey components would be APR testing and noting any pain with passive or active extension, clicking or popping with rotation/circumduction. Grip testing and associated weakness or pain, observation for cyst or other lump or any other obvious deformity, as well as specific location of swelling or redness. Palpation and accessory motion testing to identify specific structures.
TFCC would typically be more ulnar sided pain, many of the symptoms do align there. The prompt isn’t very clear exactly where the pain distribution is, though I didn’t interpret it as ulnar sided initially.

[zcanova]

Key Clinical Examination Findings for Differential:

Triangular fibrocartilage complex articular disc pathology: (+) TFCC grind test, (+) fovea sign, snapping/clicking with A/PROM supination/pronation, (+) test – pain with compression to the TFCC, pain free/decreased grip strength

Chronic distal radioulnar joint instability: hypermobility with the distal radioulnar shift test, pain with pronation and supination, (+) piano key sign

Extensor carpi ulnaris subluxation and/or tendinopathy: pain and possible tendon subluxation/snapping with resisted wrist extension and ulnar deviation, pain with passive wrist flexion and radial deviation

Distal ulnar fracture: swelling/bruising at the distal ulna, global loss of ROM at the wrist, deformity at the wrist depending on the extent of the fracture, pain with all active and resisted movements at the wrist, painful/weak grip strength

Important points to conside when deciding whether or not to refer for imaging would include observable edema/discoloration/bruising, a decreased willingness to move at the wrist, palpable deformity, presence of ROM loss in a capsular pattern, painful/weak grip strength testing, empty or hard end feel with ROM testing. I would also consider subjective findings including MOI, timeline/stability of symptoms (worsening/persistent symptoms raising suspicion), and response to any conservative management performed.

[Kyle Feldman]

Great ideas!

It ended up being TFCC.
He had an MRI due to another injury 2 weeks later.
He had a local injection along with PT and was able to play in his last match of the season.

Please look and respond to the March post next

[Farisshd]

Thanks!

[Farisshd]

Very thorough response Zack!
You hit the nail on the head with your primary Dx.

[Author]

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