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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.
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55