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An 18 year old high school male who plays on the golf team presents to the clinic direct access with a 4 month hx of ulnar/dorsal-sided wrist pain and recurrent localized effusion. During district playoffs 4 months ago, he hit an iron shot but on impact he hit a root on the ground that he did not see. He had initially sharp pain and localized effusion in the area but could finish the round. Since then, he has experienced continued pain in the area that is sharp upon movement and lingers as a deep ache after activity. It can still swell intermittently but mild compared to initially. Aggs include golf, especially when hitting the ground on impact, picking up moderate to heavy objects with his right hand (>10lb), and full weight-bearing through his hand. He is currently still in golf season and is unable to play fully as he is apprehensive during full swings due to pain. He is also unable to participate fully in workouts, especially lifting heavy weights. His goal is to return to play and workouts as soon as possible.
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 that you would ask to help with your rankings.
These two articles are from the Journal of Hand Therapy – Special Issue Wrist from 2016.
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Triangular fibrocartilage complex (TFCC) articular disc tear – location of sx’s, recurrent swelling, traumatic compression injury to medial wrist, aggravated with weightbearing or upon impact in wrist extension (compressive). Does the patient endorse mechanical symptoms such as clicking when moving his wrist?
Chronic distal radioulnar joint (DRUJ) instability – length of time since injury, location of symptoms, aggravated with holding objects or upon impact with golf swing. Has the patient experienced grip weakness since the onset of this injury? Does he feel that he has lost an ability to turn/rotate his wrist? Does his wrist feel unstable?
Extensor Carpi Ulnaris (ECU) subluxation – dorsal directed force with wrist extension MOI, recurrent swelling that has improved with time, pain with active wrist extension and compression in wrist extension while weight bearing or playing golf. Does the patient report a painful snap at his wrist whenever he is turning his palm towards the ceiling? If so, does this improve when turning his palm back towards the floor?
Distal ulnar fracture- length of symptoms, recurrent swelling, traumatic MOI without full resolution of symptoms, pain with any impact, weight bearing, or load through the medial wrist. Did the patient hear a “crack” when the original incident occurred? Does the patient have a history of fractures or bony pathology? Was there any bruising after the initial injury?
Keinbock’s disease – demographics (young, male), traumatic MOI with ongoing chronic symptoms, recurrent swelling, intermittent pain with weightbearing or force through the wrist (golf swing). Has the patient noticed any loss of wrist range of motion since the incident? Has the patient ever injured his wrist in the past?
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Good differentials
Can you highlight key clinical examination components that would help the best with narrowing down your differential diagnosis?
No imaging has been performed, what would be important points to help decide whether to refer for an orthopedic exam and imaging?
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Key examination tests for each differential
TFCC: (+) TFCC grind test for pain and clicking, (+) fovea sign-reproduction of pain with palpation of the fovea
Extensor carpi ulnaris subluxation or tendinopathy: (+) MMT-pain with resisted extension and ulnar deviation, snapping sensation heard or felt with movement if subluxed, TTP of the tendon
Chronic distal radioulnar joint instability: increased laxity or mobility noted with distal radioulnar shift test in comparison to the unaffected sign, and possible pain with testing
Ulnar styloid or distal ulnar fracture: notable swelling and bruising over area of pain along with global loss of ROM in the wrist, possible deformity noted with observation depending on the extent of the fracture
Lunotriquetral pathology: (+) ballottement test-increased laxity and pain compared to the unaffected signIf the patient was presenting with positive signs of fracture as listed above then I would refer them to an orthopedic doctor. Also, if he presents with positive signs of lunotriquetral pathology and symptoms were worsening then I would also want to refer him out to help rule out potential necrosis. Overall, for the other pathologies, I would treat conservatively first and if he was not improving with conservative treatment for 6-8 weeks then I would refer him out.
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Objective exam components in ranking order:
Observation: swelling, discoloration, displacement/deformity (Keinbock’s and distal ulna fracture)
Active, passive ROM and resisted testing: TFCC – snapping/clicking with A/PROM and a springy end feel, pain greatest with pronation/supination; DRUJ instability – AROM loss and pain with pronation/supination and notable ulna dorsal displacement during pronation; ECU subluxation – pain with active wrist extension and supination (may produce a snap), resisted wrist extension, ulnar deviation; Distal ulnar fracture – capsular pattern of significant flexion = extension ROM loss compared to uninvolved side, pain & weakness with all active movements and resisted testing; Keinbock’s disease – decreased ROM into flexion/extension, capsular pattern with PROM.
Grip strength testing: Keinbock’s disease – significant grip strength loss compared to uninvolved side.
Special tests: TFCC – (+) TFCC compression/grind test (pain + click/crepitation), press test; DRUJ instability – (+) piano key sign, DRUJ ballottement test, dorsal RU shift test
Palpation: TFCC palpation, ECU tendon palpation over the ulnar head, dorsal RU ligament palpation with wrist in flexion, ulnar styloid (fracture), dorsal lunate (Keinbock’s)
With all these components, I feel the important points to consider when determining if a referral for imaging is warranted are a combination of decreased willingness to move, passive ROM empty or hard end feel, presence of ROM loss with a capsular pattern when compared to the uninvolved limb, observation of edema/discoloration, and grip weakness. These findings would certainly raise my suspicion that the patient has a pathology that would need to be managed differently than what PT can immediately provide.
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Initial differential diagnoses
1.TFCC lesion
a.MOI with high impact hitting the ground
b.Pain located at ulnar side of wrist
c.Describes pain as sharp and deep ache after activity
d.Pain with full weight bearing through his R hand, high impact with hitting the ground
e.Subjective questions: clicking or popping present as well?2.Extensor carpi ulnaris subluxation or tendinopathy
a.Pain located at dorsal ulnar side of the wrist
b.Pain with gripping, impact with hitting the ground, unable to lift heavy weights due to pain
c.Subjective questions: pain with extending wrist? Ulnar deviating? Snapping sensation in the wrist? (for subluxation)3.Chronic distal radioulnar joint instability
a.Initial trauma with hitting golf club against the root
b.Pain located at dorsal ulnar side of wrist
c.Pain with loading and distraction at the joint with full weight bearing and heavy lifting
d.Subjective questions: limited forearm rotation? Clicking with forearm rotation?4.Ulnar styloid or distal ulnar fracture
a.Initial sharp pain and effusion noted in ulnar side of wrist after trauma with hitting golf club against the root
b.Recurrent sharp pain and localized effusion to that area
c.Pain with weight bearing, high impact with hitting the ground, and with gripping/lifting heavy objects
d.Subjective questions: initial bruising noted with effusion? Audible noise when golf club hit the ground initially?5.Lunotriquetral pathology
a.Initial trauma with hitting golf club against the root
b.Pain in dorsal side of the wrist
c.Pain with full weight bearing and with heavy lifting/gripping
d.Pain that has continued since initial onset, with increased sharp pain with aggs and lingering deep ache
e.Subjective questions: weakness with grip strength? Clicking noise with movement? -
Great job residents
Ended up sending him for imaging.
He had a confirmed TFCC tear
Ortho did an injection and we continued PT.He was able to return to golf in about 8 weeks (sadly he had a flare up on a miss hit and had some regression a few weeks in.)
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Given this patient’s presentation, history, and lack of previous conservative treatment, I would definitely choose the route of PT in isolation prior to any orthopedic referral. I found those articles to be really interesting but also humbling in the sense that I realize I didn’t know much of anything as it relates to treatment at the wrist/hand. They highlight the potential benefits of choosing conservative treatment for CMC OA, especially if initiated early on after the patient’s onset of symptoms.
Considerations that would lead me to PT in isolation over an orthopedic referral for 1st CMC OA include the severity of functional loss, level of pain, ROM loss, and the patient’s preferences/beliefs. In this case, I feel the patient is not at a severe enough point to need a referral and could be managed appropriately with PT, especially to reduce the overload her extrinsic EPL is likely getting due to poor intrinsic stability.
One resource I wanted to re-share that was actually shown to us in the knee OMPTS is the American College of Rheumatology Guideline for OA management in the hand, hip, and knee. I thought this was also helpful for understanding what the research supports for managing hand OA.
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Since the patient has not received any treatment yet, based on the history provided, I would start with her first and not refer her out to an orthopedic right away. Both of the articles attached, along with the article Ian shared support a multimodal conservative approach for the treatment of 1st CMC OA. The interventions included manual, self massage, dynamic stability exercises, and taping which I would incorporate as part of the treatment. If she does not have any significant improvement in pain or function within 6-8 weeks, then I would refer her out to an orthopedic.
Coincidentally, I had an eval about a month ago for a patient in clinic with similar location of pain, except hers is not presenting like true first CMC OA. Unfortunately, she ended up on another therapists schedule for follow-ups due to scheduling, but recently she had a progress note and was not progressing so the therapist asked me if I would recommend an orthopedic referral. To be honest at the time, I was unsure (also not knowing what they have done the past few weeks made it hard to make a recommendation). I’ll have to share the articles with the therapist for additional interventions to try with the patient. I’m interested to know what the orthopedic doctor will recommend.
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Great case Emily. It is a tough treatment.
With this patient, I would consider a 1st CMC brace. They can be valuable like a foot orthotic as a way to calm down symptoms due to so much use.
Amazon has many options and its often trial an error, but if they help, it can calm down symptoms enough to help make the exercises better.
Did your patient try a brace yet?
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Hi Kyle,
I think the PT that she ended up with had her try a brace, but the pressure from the brace aggravated her symptoms so she stopped wearing it. I’m not sure what type of brace she tried wearing though.
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ask which type, sometimes its the right idea, just the wrong one
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Case 1:
TFCC tear d/t subjective relevant info: ulnar sided symptoms, local effusion, 4 month hx, traumatic impact/injury to wrist, quality of symptoms – sharp with movement and lingering ache, WB sensitive.
Q’s Does the pt have any clicking or snapping at the wrist?
Objective: (+) pain with forearm pronation supination, (+)TFCC compression test, (+) pain with palpation, (+) ulnar fovea sign,
DRUJ instability d/t subjective relevant info: ulnar sided symptoms, 4 month history, WB sensitive, weight lifting agg.
Q’s: Does the pt have loss of ROM of wrist? Are symptoms elicited with forearm pron/supination?
Objective: ROM limitations into pron/sup, (+)DRUJ ballotment test,(+) dorsal RU shift test
ECU sublux/instab d/t subjective relevant info: ulnar sided symptoms, MOI involving traumatic impact to wrist in extension, intermittent effusion, pain with golf swing – extension of wrist.
Q’s: Is there pain with extending or ulnar deviating the wrist? Has the pt noticed a snapping sensation at the wrist?
Objective: (+) pain/possible sublux with ext/UD MMT, (+) palpation of tendon for pain
Distal ulnar fracture d/t subjective relevant info: 4 mo hx without relief of symptoms, traumatic impact to wrist, WB sensitive.
Q’s: Was there a “pop” felt/heard with initial injury?
Objective: (+) pain with palpation of distal ulna, ROM loss/pain in all directions, – Pt would be referred out if presentation for this was (+).Case 2:
Barring any clear indications/red flag findings that a pt is not fit for PT treatment, I always feel that trying conservative management before referral is best. I realize this is bias and upon reading these articles, there is actual evidence that would support this decision. This clinical decision making is based on the provided evidence in these articles that symptoms of CMC OA respond positively, in terms of pain levels and function, to conservative management using the dynamic stabilization approach. Due to the pts recent increase in symptoms over the last 3 months from increased activity level involving more lifting and holding she would likely benefit from not only intervention aimed at the CMC but general strengthening for the wrist and forearm as well to support her new lifestyle. With this patient becoming the primary daycare provider for her granddaughter it may also be more difficult for her to pursue the surgical/orthopedic approach and be unable to care for her granddaughter during that time. Looking at this case from a holistic approach there are multiple reasons that considering PT treatment first would be in the patient’s best interest.
Side bar: Sincere apologies for the VERY late response to these posts. I read through all the responses and it was insightful and a great reminder of how little I understand wrist/hand pathologies. I certainly need to brush up on these subjects and this discussion post has been helpful in initiating that.
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Little late, but great reflection! lol
If you do not see these patho’s its easy to forget. Always good to do these things to keep your mind fresh.
In clinic you may not see a pathology for a year. When that happens you need to go back and review your notes. Always relearning
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