The presentation, diagnosis and management of non-traumatic wrist pain: an evaluation of current practice in secondary care in the UK NHS

Key points

1. 01Osteoarthritis was the single most common diagnosis (31%), followed by other causes (25%), ulnar-sided pain (17%), ganglion (14%) and tendinopathy (13%).
2. 02Patients with osteoarthritis tended to be older (median 64 years) and male (69%), while other diagnoses were mostly in younger women.
3. 03Steroid injection was the most-used non-surgical treatment (39%), then physiotherapy (32%), splints (31%) and analgesics (12%).
4. 04About 27% of patients went on to surgery, and all of them had tried non-surgical treatment first.
5. 05Non-traumatic wrist pain made up about 13% of all new hand and wrist referrals, an estimated 4228 new referrals per year in the UK.

How it was conducted

Design

Retrospective multi-centre service evaluation (audit) across 16 UK NHS hospitals

Participants

160 patients (the first 10 consecutive non-traumatic wrist pain referrals per hospital), 100 female and 60 male, median age 49 years

Inclusion

New non-traumatic wrist pain referrals to specialist hand/wrist clinics from 1 January 2017; trauma, prior wrist surgery, inflammatory arthritis, suspected carpal tunnel, thumb base degeneration and second-opinion referrals excluded

Follow-up

Tracked from first appointment to discharge or 12 months after the initial appointment, whichever came first

Diagnostic groups

Five consensus categories: OA, tendinopathy, ulnar-sided pain, ganglion, and other

What they found

• Diagnoses were OA 49 (31%), other 40 (25%), ulnar group 28 (17%), ganglion 22 (14%) and tendinopathy 21 (13%).
• Non-traumatic wrist pain was a mean 12.9% of hand and wrist clinic referrals over a mean 106-day review period, estimated at about 4228 new UK referrals per annum.
• The dominant wrist was affected in 60% of cases and mean symptom duration was 13.3 months (S.D. 11.3).
• OA patients were significantly older (median age 64 years) than other groups (median 41 to 44 years), P < 0.001.
• OA was significantly more male (69%) versus a female predominance of 67 to 91% in other groups, P < 0.001.
• Plain radiographs were used in 89% overall and 98% in OA; MRI in 44% overall (82% in ulnar-sided pain, 60% in other); ultrasound in 21% overall (57% in tendinopathy, 32% in ganglion).
• Non-surgical treatments were CS injections 39%, physiotherapy 32%, splints 31% and analgesics 12%; 43% had two or more non-surgical interventions.
• 27% (43 of 160) underwent surgery; all had received prior non-surgical treatment but 42% had only one non-surgical intervention.
• Use of MRI but not ultrasound was associated with discharge within the year (P = 0.003), and not having an X-ray was associated with discharge (P = 0.0001).
• There were five surgical complications (one infection, two failed bone grafts, one instability, one broken screw), three of which required secondary surgery.
• Discharge by 12 months differed by group, highest in tendinopathy (76%) and lowest in ulnar-sided pain (32%), P = 0.026.

Limitations

• Retrospective design relying on clinical documentation, so undocumented care (for example analgesia) was treated as not occurring and is likely underestimated.
• Small convenience sample of 160 patients from 16 hospitals that may not be representative of the whole UK.
• Diagnoses were grouped into broad consensus categories and the final stated diagnosis was assumed accurate, despite limited evidence on wrist diagnostic accuracy.
• Descriptive study with no comparison of treatment outcomes, so it cannot show which treatments work best.

Why it matters

For patients

If you have ongoing wrist pain without an injury, expect imaging such as an X-ray or MRI and a trial of non-surgical care like an injection, physiotherapy or a splint before surgery is considered.

For clinicians

The data describe real-world referral burden and practice patterns and highlight that osteoarthritis dominates, that injections and physiotherapy are first-line, and that non-surgical documentation (including analgesia) is often incomplete.

For readers

It maps how non-traumatic wrist pain is currently handled in the NHS and underscores how little high-quality evidence exists to guide wrist care, especially for wrist osteoarthritis.