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There are many causes of pain about the wrist which need to be differentiated before the correct treatment can be instituted. The site of main pain leads the clinician to consider the various structures in the region so that further investigations can be undertaken to make the correct diagnosis. The following lists are not meant to be complete but will cover the more common conditions to think about.
Dorsal wrist Pain
• dorsal ganglion: cysts may form in the dorsal wrist capsule over the scapholunate (SL) ligament, which cause pain with stretching (wrist flexion) or compression (local touch). The ganglion may or may not be so large as to be seen as a swelling.
• dorsal bossing/impingement: the base of the 2nd and 3rd metacarpals may hypertrophy and pinch (impinge on)the dorsal capsule against Lister’s tubercle on the back of the radius.
• extensor tendonitis: inflammation of the common extensor tendons to the fingers distal to the retinaculum may be associated with bursitis or synovitis causing a diffuse swelling over the dorsum of the hand.
• carpal instability:
 • scapholunate: tearing of the ligament allows the carpal bones to move unrestricted by their neighbours and hence the wrist gives way, and is weaker and painful with progression to wear and
tear arthritis.
• midcarpal instability: laxity of the ligaments between the proximal and distal row of carpal bone (often in young gymnastic girls) will cause similar symptoms of giving way, snapping and pain
but more ulnawards over the wrist.
• arthritis
• SLAC (scapholunate advanced collapse) wrist:
with longstanding SL instability there is wearing of rotated scaphoid on radius and the proximal pole of capitate migrating into the SL gap, rubbing on the edge of lunate; joint surfaces are worn and therefore painful.
• STT arthritis: there appears to be a genetic predisposition to this isolated joint arthritis as it is often bilateral. Also occurs with OA ofbasal thumb joint (pantrapezial).
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 Radial wrist pain
• intersection syndrome: 5 cms proximal to the wrist the tendons of the thumb cross wrist abductors with rubbing between the 2 groups (mainly in rowers).
• De Quervain’s tenosynovitis: the tendons to the thumb (abductor and extensor) are inflammed, swell and rub in the tight first
wrist compartment.
• radioscapdoid arthritis/impingement: may occur after fracture of radial styloid or after fusion of STT joint.
• scaphoid fracture: tenderness is over the anatomical snuff box, never swollen, always suspect.
• thumb arthritis: pain over base of the thumb front and back of CMC joint, worse with thumb movements; grinding the bones causes grating and pain
• STT arthritis: felt about 1 cm proximal to CMC mobile joint, worse with stressing thumb in maximal extension.
• volar ganglion: the lump does not always have to be noticeable, but usually is just lateral to the FCR tendon, adjacent to the radial artery.
• FCR tendonitis: FCR tendon sometimes rubs on an osteophyte at STT joint or on edge of tunnel at front of trapezium. Tenderness extends proximally along tendon.
Ulnar wrist pain
• cartilage tear: the central part of the TFC (triangular fibrocartilage) is thin and may tear off the radius; it will not heal and therefore is usually removed. If torn from the ulna or ligaments, it
may be repaired.
• distal radioular joint arthritis/instability: slightly more proximal tenderness and aggrevated by stressing the ulna against the
radius
• ECU tendonitis: swelling usually occurs along the tendon, associated with the pain on this tendon with tension.
Volar wrist pain
• pisotriquetral arthritis: with pressure over the pisifom bone (in the FCR tendon) rubbing against the Triquetral bone there is crepitation and pain.
• carpal tunnel: pain can be felt usually diffusely at the front of the wrist, extends up towards the elbow and rarely as far as the shoulder, this may even occur without the numbness and pins and
needles more commonly reported.
• FCR tendinitis: as above, worse with resisted wrist flexion.
• Fractured hook of hamate: after a fall; pain holding a raquet or bat handle. May be accute but usually presents late with a non union. (rare)
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