Radial-Sided Wrist Pain

Ask the mechanism before touching the wrist, and ask specifically about a fall on the outstretched hand however trivial it sounded.

A fall on the outstretched hand aged 15-40 puts scaphoid fracture at the top and it stays there until excluded. A high-energy dorsiflexion injury with dorsal pain raises scapholunate dissociation. No trauma at all shifts you to tendinopathy, arthritis, nerve or Preiser's.

Have the patient put ONE FINGER on the worst spot, then confirm it yourself against the named landmarks - styloid, snuffbox floor, volar tubercle, metacarpal base, four to six centimetres proximal.

At the radial styloid over the tendons equals de Quervain's. In the snuffbox AND at the volar tubercle equals scaphoid. One centimetre distal at the metacarpal base equals CMC arthritis. Four to six centimetres proximal equals intersection syndrome. Volar over flexor carpi radialis equals FCR tendinopathy. This single step does more work than every provocative test that follows.

Perform Eichhoff or Finkelstein, the grind test and the scaphoid shift - and interpret each against its known accuracy rather than as a yes-or-no.

Eichhoff plus styloid tenderness supports de Quervain's, but Eichhoff is ALSO positive in CMC arthritis and scaphoid nonunion because it simply loads the radial column - the grind test is what separates them, and the two conditions frequently coexist. A positive Watson shift with a painful clunk points to scapholunate instability, but its sensitivity against arthroscopy is only 0.50 and its specificity 0.62, so a negative test settles nothing.

Test sensation in the dorsal first web, tap over the superficial radial nerve where it emerges from under brachioradialis, and screen the neck.

Burning, paraesthesiae and numbness in the dorsal first web with a positive Tinel indicate Wartenberg's - and the first compartment is NOT tender, which is the discriminator. Sensory symptoms extending above the wrist with neck-provoked pain indicate C6 radiculopathy. Neither responds to a first-compartment injection.

Establish whether the physes are open, and in an adult look for thumb adduction and weak key pinch.

Open physes in a loading athlete means distal radial physeal stress injury - gymnast's wrist. Over 50 with adduction deformity and weak key pinch means CMC arthritis. Aged 20-40 with insidious pain and no trauma, consider Preiser's or an occult ganglion.

Take the temperature, look at the skin, test passive motion, and ask about other joints and morning stiffness.

Fever, erythema, rest pain and refusal of passive motion mean septic arthritis or pyogenic tenosynovitis - aspirate and wash out, do not inject. Symmetrical polyarticular morning stiffness with radial pain means inflammatory arthropathy; check serology and examine the ulnar side too.

Load the wrist two different ways - through the tendon (resisted thumb extension) and through the joint (axial grip) - and see which reproduces it.

Pain only at end-range radial deviation suggests radial styloid impingement or radioscaphoid arthritis. Pain at full extension with a mass appearing on flexion suggests an occult dorsal ganglion. Pain on axial grip loading rather than tendon loading points to bone or joint, not tendon - and that distinction is what stops a tendon injection being given for an arthritic joint.