Diff Dx of Dorsal and Radial Sided Wrist Pain : Wheeless' Textbook of Orthopaedics

- Landmarks:
- one can palpate proximally in the snuff box radial styloid and, in mid third, the waist and distal third of the scaphoid;
- at the distal end of the snuff box the STT joint is identified;
- elliptical bony prominence at base of thenar muscles, consisting of trapezoidal ridge and scaphoid tuberosity;

- Diff Dx:
- scapholunate instability:
- patient complains of a popping and clicking in the wrist joint associated with pain and limited motion;
- scaphoid lift test: pain with dorsal volar shifting of the scaphoid;
- scapholunate and lunate injuries cause tenderness just distal to Lister's tubercle;
- marked prominence of the entire carpus dorsally is suggestive of a perilunate dislocation;
- scaphoid shift maneuver
- no tenderness to over navicular tuberosity (snuff box), or tenderness with axial compression of thumb toward the snuff box;
- scaphoid fracture:
- lunate dislocation:
- causes pain on the dorsum of the wrist more to the center of wrist area and less on the radial side;
- neurologic assessment of the median nerve is essential;
- lateral x-ray shows the distal concavity of the lunate may rotated 90 degrees and may be palmar to the capitate;
- rupture of FCR tendon;
- occurs from a fall on an outstretched hand
- separation occurs at the insertion of the F.C.R. deep to the thenar muscle;
- pain is detected over the scaphoid on the palmar surface of the wrist or is present proximally along the course of the FCR;
- this occurs from a fall on the out stretched hand, causing separation of the insertion of FCR deep to the thenar muscles;
- chip of bone may separate w/ tendon, or, in pts > 35 years of age, tendon may rupture partially or completely;
- pain is detected over the scaphoid on the palmar surface of the wrist or is present proximally along the course of the F.C.R.
- radial styloid fracture:
- from a direct blow or fall on the outstretched hand;
- compression of the styloid process may cause pain about the same location as does compression of the scaphoid;
- simultaneous radial styloid frx is relatively common w/ carpal dislocation, & pt w/ radial styloid frx should have radiographs to
                   exclude SLD;
- these radiographs should include AP (supination, palm up) and clenched fist AP in addition to the true lateral;
- trapezium fracture:
- follows a direct blow of the fist or a fall on the on the radially deviated closed hand may resemble findings associated scaphoid
                   fracture (different mechanism from scaphoid frx)
- swelling and pain are usually directed at the base of the thumb, rather than over the scaphoid;
- ECRL avulsion:
- avulses from the base of the second metacarpal occurs as a result of forceful injury with the hand in ulnar deviation;
- there is pain around the anatomic snuffbox near the location that is painful with the scaphoid fracture, however, the palmar
                    aspect of wrist is not painful;
- from the base of 2nd metacarpal occurs as result of forceful injury w/ hand in ulnar deviation or a direct blow or a downward
                    stroke such as might occur while individual is swinging a golf club and strikes the ground;
- ECRB tendon avulsion;
- occurs from a forced palmar flexion injury of the wrist;
- avulsion may occur from a forceful palmar flexion injury of wrist;
- palpation dorsally causes pain at base of 3rd metacarpal, more distal than that which would occur if scaphoid were fractured, &
                     palmar aspect of the wrist is not painful;
- deQuervain's disease
- basilar joint (CMC) Arthrosis