BROADENING THE APPROACH TO PERSISTENT WRIST PAIN

ABSTRACT

CASE The patient is a 47-year-old woman with a history of hyperlipidemia, asthma, and psoriatic arthritis (on adalimumab) who presented to clinic with 4 weeks of "sawing" left dorsoradial wrist pain, associated with tingling in the fingers and significant finger, hand and wrist weakness. Exam was notable for full strength and range of motion bilaterally. Tinel's and Phalen's sign were positive for mild tingling radiating to left hand fingers and wrist, and Finkelstein test was positive with significant pain on pinch grasp. An ultrasound was sent to evaluate for de Quervain's tenosynovitis;radiographic imaging was deferred by the patient. Ultrasound did not show evidence of de Quervain's tenosynovitis or radial nerve injury. There was significant delay between the initial visit and imaging, and ultimately the patient was referred to an Orthopedic Hand specialist. Magnetic resonance imaging (MRI) of the wrist was ordered, which showed abnormal signal throughout the lunate sparing the radial aspect, consistent with early osteonecrosis. Follow up radiographs demonstrated lunate sclerosis consistent with osteonecrosis. The patient was diagnosed with Kienbock's disease. IMPACT/DISCUSSION: Unilateral wrist pain in the primary care setting has a wide differential including mechanical causes (e.g. De Quervain's tenosynovitis, fracture, joint instability, neoplasm, or avascular necrosis of the scaphoid (Kienböck's disease) or lunate (Preisers' disease)), neurologic causes (e.g. nerve injury or compression) or systemic causes. While detailed history/exam can help narrow down the diagnosis, radiographs are often necessary to make a definitive diagnosis. Computed tomography (CT) is used to evaluate osseous lesions, whereas MRI is used to evaluate soft tissues of the wrist, and ultrasound can show tendonitis, arthritis, or nerve entrapment. Early referral to a hand surgeon is indicated when pain persists despite splinting for bony fractures, recurrent lesions, or avascular necrosis of the scaphoid or lunate. This case underscored Kienbock disease which is a rare but urgent etiology of wrist pain due to lunate osteonecrosis and can require immediate casting or surgical decompression. A key aspect to the case was the 1 month delay from first visit to initial ultrasound, 1 month delay to specialist evaluation and 1 month delay until final diagnostic MRI, primarily due to the impact of the COVID epidemic on the health care system. As the epidemic ebbs and flows with new variants, we can expect further delays in care, making the initial clinical evaluation even more critical to reduce unneeded imaging. CONCLUSION: -When evaluating wrist pain, if exam and first line images are inconclusive and pain persists, it is key to expedite workup with advanced imaging (MRI or CT) and refer to a specialist. In the primary care setting, it is critical to set realistic expectations with our patients regarding timeline of imaging and workup to maintain the therapeutic alliance and continue to build trust.