Causes of Radial-Sided Wrist Pain

Commonly involved structures are tendons of the first and second extensor compartments, the wrist and thumb joints, superficial radial nerves, ganglion cysts, and fractures of local bones.

This brief article addresses tendonitis of the first and second dorsal compartments. These are common both in general practices and workers’ compensation practices, and are often associated with repetitive wrist motion in deviated or extended positions. Direct trauma to the area can also precipitate the disorder.

The extensor tendons at the wrist reside in six unyielding compartments on the dorsum of the wrist, numbered one through six from radial to ulnar. Each tendon is surrounded by a tenosynovial membrane that encourages smooth motion of the tendons. When the membranes become inflamed they produce relative stenosis of the tendon compartment with painful motion, aching and tenderness over the affected compartment.

Tendonitis of the first dorsal compartment is DeQuervain’s disease. The tendons are the abductor pollicis longus (APL) and extensor pollicis brevis (EPB). This compartment runs from the radial styloid obliquely to the dorsal radius. The classic Finklestein maneuver (pain complaints reproduced by wrist ulnar deviation with the thumb held inside the clenched fist) is not specific for DeQuervain’s tendonitis; however, arthritis of the thumb CMC and irritation or entrapment of the superficial radial nerve can also be provoked with this test. Radiographs are typically not diagnostic, but can identify arthritis or fractures.

Tendonitis of the second dorsal compartment is intersection syndrome. The second compartment runs just radial to Lister’s tubercle. It contains the radial wrist extensor tendons. Because the tenosynovium extends proximal to the compartment, tenderness and swelling occurs where the tendons cross under — or “intersect” with — the first dorsal compartment tendons four centimeters proximal to the wrist joint.

Nonsurgical treatment includes splinting and oral or topical NSAIDs. Splinting alone has a modest success rate. Corticosteroid injection can be effective in 50 to 80 percent of cases. Avoid infiltration into the subcutaneous space to reduce the risk of bleaching of the skin and harmful atrophy of the subcutaneous fat and the overlying skin. It can take three weeks to achieve maximum benefit from injection. If long relief is achieved by injection, it can be repeated. Most orthopedic surgeons limit patients to three injections in order to minimize risk to local structures.

When nonsurgical measures fail, surgical release of the affected compartment is indicated. There are a number of common anatomic variations of the tendons that can produce confusion during release. Failure to release an EPB subcompartment is a well-acknowleged cause of persistent symptoms following surgery, as well as injury to branches of the superficial radial nerve and subluxation of the first dorsal compartment tendons.