May- Wrist/Hand

[Kyle Feldman]

An 18 year old high school male golfer presents to the clinic direct access with a 4 month history of ulnar/dorsal-sided wrist pain and recurrent swelling since the injury. He reports during his district playoff match he hit an iron shot but on impact he hit a root in the ground that he did not see under the ball. He describes his pain as sharp initially, but can linger as a deep ache after activity. Aggs include golf, especially when hitting the ground on impact, picking up moderate to heavy objects with his right hand (>10#), and weight-bearing through his hand when standing, getting out of bed. He is currently in season and unable to play or workout due to pain, but wants to return to play as soon as possible.

Questions for thought
Please discuss further relevant subjective questions and objective testing that would lead you to your differential diagnosis list. Include your differential list.
What are some key clinical examination tools that you would use or have used with similar patients?
No imaging has been performed, what would drive you to refer for an orthopedic exam and imaging?
Have a read of the following two articles to help review. Both are from the Journal of Hand Therapy – Special Issue Wrist in 2016

Articles-
https://pubmed.ncbi.nlm.nih.gov/27264898/
https://pubmed.ncbi.nlm.nih.gov/27112270/

[Sarah Frunzi]

Hey Kyle!

Some further questioning I would like to ask is when does his swelling onset? You had mentioned it is recurring, so I would like to know if it is primarily after activity or if there is a 24hour pattern associated with it. I would also like to ask if he has any resting pain as well, or is it just a sharp and lingering pain when provoked by activity and use? Key clinical examination tools or methods I would use would be swelling measurements, grip strength testing, observation of any abnormalities, palpation, as well as the usual AROM/PROM/OP measurements and end-feels comparing bilaterally. The top hypothesis and differentials on my list are TFCC injury, UCL injury, and fracture. Another follow up question that I didn’t see mentioned was if symptoms were getting better, worse or staying the same at 4 month into recovery? If symptoms are staying the same and/or getting worse, I think Ortho should be brought on the team to get adjunct treatment. The recurrent swelling and longer duration of symptoms up to 4 months now, paired with pain with weightbearing and limited ability to lift over 10#, would prompt me to refer out to see Ortho for imaging and a more team based approach to make sure there aren’t any missing pieces or additional treatments that can expedite his recovery to return to play while he is in season for his sport.

These are my thoughts!

Sarah

[Kyle Feldman]

swelling is usually about 1 hour after playing and sometimes it starts at about hole 16

He has some constant pain when swollen, but once that goes away he do not have constant pain

So far symptoms are maybe slightly better but about the same as when he injured it because it keep happening when playing. It is better because for about 2 weeks he could not play.

Great idea getting ortho involved. We did that and imaging showed swelling in the TFCC region. We did not DC but worked with him during this process

any other thoughts after providing this information?

[David Brown]

Hey all,

Very interesting case for sure! Thank you Sarah for raising many of the same questions that I would have. I think I would like to know a little more about the pain cycle such as how pain levels/levels of stiffness in the wrist (if any) occurs more in the morning or the evening hours. I am concerned for a traumatic injury that is not healing due the persistent nature of the pain and the initial MOI. I would also like to know what hand positions specifically bring on symptoms besides gripping >10#. If positions of greater ulnar variance such as forearm pronation produce pain, that would immediately lead me more in the direction of TFCC injury. Like Sarah, I would like to take measurements or photos of the swelling to track progression/regression. I would also like to perform a typical APR exam with the goal of trying to differentiate between a tendinopathy, ligamentous injury (scapholunate ligament), and/or fracture of the distal RUJ or carpels, or an injury to the TFCC. I think a tuning fork test and scaphoid shift test will be helpful with my differential. I also think imaging would be very important at this point as the patient would not want to discontinue their sport but given how long this injury has persisted, imaging would be an important tool with trying to establish prognosis. I would advise a MRI to be able to pick up on any soft tissue insults that could be easily overlooked with standard plain film radiography.

[Kyle Feldman]

David- good points.

Worse after golf and more at night vs in the AM

Any RD and UD with weight increases the pain also.

We did try the tuning fork and his symptoms were very inconsistent so it was not a clear positive sign.

[David Brown]

Kyle,

Is the pain worse in the evening even days of lower activity/no golfing? With the tuning fork being inconclusive and in the absence of MRI imaging I am curious what types of treatment worked (relieved sx) and did work as this can sometimes be diagnostic in itself. Sometimes when I am unsure I heavily rely on test-treat-retest. At this point I am starting to think there is something ligamentous such as the scapholunate ligament as I would not think that radial deviation even with load would produce TFCC mediated pain. Very interesting case thus far!

[Kyle Feldman]

only worse on no golfing days after he had golfed but golf was a main trigger

Manual and exercise only helped temporarily

He ended up being splinted and rested with an injection for 3 weeks

after that we slowly worked back into activity.

[David Brown]

Kyle,

That’s great, sounds like the injection helped him. What did you ultimately think was implicated and driving his pain? I am curious now!

[Kyle Feldman]

Based on our eval and the ortho MDs evals we both felt TFCC.

I saw him 2 years later and he still would get some pain with a jammed swing but about 95% improved

[Author]

Posts