The hand and wrist complex—comprising 27 bones and multiple tendons, muscles, ligaments, and nerves—is integral for performing daily tasks. Injury to any part of the complex can have a major effect on functional activities of daily living. Hand and wrist injuries represent 25% of all sports-related injuries, and the number is rising.¹ Part II of this series on injections of the hand and wrist addresses diagnostic and therapeutic approaches, with or without ultrasound guidance, to conditions affecting the wrist, including carpal tunnel syndrome (CTS), ganglion cyst, intersection syndrome, triangular fibrocartilage complex injury, and de Quervain tenosynovitis. Part I addresses injections for the hand, including trigger finger, first carpometacarpal joint osteoarthritis, and palmar fibromatosis.²

INITIAL EVALUATION OF WRIST PAIN

Point tenderness plays a crucial role in the physical examination when identifying the source of wrist pain.^1,3,4 It is critical to assess passive, active, and resisted movements, including flexion, extension, ulnar, and radial deviation of the wrist joints, followed by evaluating sensation in these areas.³

IMAGING

Radiography is the first-line imaging test to assess for fractures and osseus alignment following a wrist trauma.¹ Radiography can additionally be used to monitor healing of conservatively treated fractures of the wrist.¹ Magnetic resonance imaging (MRI) can be used to assess injuries of the ligamentous structures. Further, MRI and computed tomography can be used to identify occult fractures of the carpal bones.^5,6 Ultrasonography plays a valuable role in providing point-of-care and dynamic evaluation of tendons, nerves, and muscles and can be used to guide injection and aspiration to treat wrist conditions. Although not mandatory, ultrasound guidance can ensure injectates, particularly corticosteroids, are introduced accurately.^7–9

COMMON PATHOLOGIES

Initial imaging of wrist pathologies is usually not needed when the diagnosis is clear. Common wrist pathologies suitable for therapeutic injection include CTS, ganglion cyst, intersection syndrome, triangular fibrocartilage complex injury, and de Quervain tenosynovitis. Table 1 lists injection procedures and techniques for these pathologies.^10–12 Using ultrasonography to guide injections helps ensure precise delivery to targeted areas without damaging nearby tissues in the wrist. Before proceeding with injections, discussion with the patient should include possible complications, including infection, damage to cartilage, collagen breakdown, skin thinning, and changes in skin color (depending on the substance used for the injection).^13–15

CARPAL TUNNEL SYNDROME

CTS is a common condition among adults and has an overall lifetime prevalence of 8%. It occurs nearly twice as often in women than in men.¹⁶ A detailed review of CTS is available in a previous article in American Family Physician.¹⁷

The carpal tunnel is at the volar aspect of the wrist between the carpal bones and flexor retinaculum.¹⁴ CTS is the most commonly diagnosed compressive focal mononeuropathy in clinical settings.¹⁹ Presentation includes symptoms of hand pain, paresthesia, sensory loss, or weakness in the median nerve distribution. Dull discomfort in the arm and hand clumsiness may also be present because of the median nerve being compressed as it navigates through the carpal tunnel.²⁰ Sleep, prolonged positions, or repetitive movements may exacerbate symptoms, and changing hand posture or shaking the hands may relieve them.

Severe CTS may lead to thenar eminence muscle weakness, particularly in thumb movements, with possible atrophy. Phalen and Tinel signs, involving wrist positions and median nerve percussion, respectively, can indicate CTS if pain or paresthesia occurs.

Diagnosis

Electrodiagnostic tests accurately confirm CTS and rule out other diagnoses.²¹ Ultrasonography or MRI should be considered if anatomic irregularities, tumors, cysts, divided median nerve, or bone or joint diseases are suspected, especially if symptoms do not resolve with bracing or physical therapy.²¹

Treatment

Therapeutic glucocorticoid injection can be considered when conservative measures fail or to provide short-term symptom relief, typically 3 months.²² Carpal tunnel injection can be performed with a landmark-guided injection technique. When solely using landmark guidance, 75% of injections are accurately placed; however, as many as 9% penetrate and damage the median nerve.²³ A systematic review showed significant improvement in CTS severity over 12 weeks using ultrasound-guided injections compared with landmark-guided injections.²⁴

The injection site is radial to the palmaris longus tendon or midway between the palmaris longus and flexor carpi ulnaris tendons and 1 cm proximal to the most distal wrist crease²⁵ (Figure 1A²⁶). After using chlorhexidine or povidone-iodine solution to cleanse the area, 0.5 mL of of methylprednisolone, 40 mg per mL and 1 mL of lidocaine 1% without epinephrine is injected with a 25-gauge needle. The needle is directed slowly at a 45-degree angle distally until the tip of the needle lies under the midpoint of the flexor retinaculum (Figure 1B²⁷). Any shock-like pain or paresthesia should stop the injection, indicating radial redirection of the needle.

With ultrasound guidance, the needle can be introduced on the ulnar aspect of the carpal tunnel, with the initial trajectory shallow and superficial to the ulnar artery and nerve penetrating the flexor retinaculum.^18,24,28 The anterior aspect of the radial side of the nerve is injected first, separating it from the anteriorly located flexor retinaculum. This hydrodissection can reduce adhesions. The needle is then redirected deeper on the ulnar side to inject the posterior aspect, surrounding it by injectate. Figure 1C shows a suggested transducer position and needle placement for ultrasound-guided injection of CTS.

GANGLION CYST

Ganglion cysts, the most prevalent soft tissue tumors of the hand, appear across all age groups but are especially common in people in their 20s to 40s, with a slight majority occurring in women.²⁹ The cyst is an outpouching of the synovial joint capsule that fills with mucinous fluid. This outpouching is most commonly observed on the dorsal aspect of the wrist near the scapholunate joint (70%).³⁰ It can also appear on the volar side (20%) or along digital flexor tendon sheaths and less commonly on the foot, knee, shoulder, spine, or other locations.³¹ Digital mucous cysts usually form over the distal interphalangeal joint in older adults, often with osteoarthritis.³¹

Diagnosis

The cyst is usually a painless, but growing, fluid-filled mass that can be confirmed by transillumination. Diagnostic point-of-care ultrasonography with Doppler will reveal a homogenous hypoechoic fluid collection without Doppler signal, which may correlate with a history of trauma or osteoarthritis.^29,32 Diagnostic ultrasonography is not necessary, but it may be helpful in differentiating a ganglion cyst from other soft tissue or solid masses and in identifying nearby blood vessels.³² Cyst aspiration generally does not add diagnostic value unless infection is suspected or other unusual clinical features (e.g., rapid growth, atypical location) are present. In such cases, a surgical biopsy for definitive diagnosis may be warranted.³³

Treatment

After diagnosis of a cyst, point-of-care ultrasonography can be used to perform aspiration, fenestration, and corticosteroid injection.^34,35 Mixed evidence mostly suggests palpation-guided aspiration can be attempted first.^35–37 Aspiration can be helpful for patients with significant symptoms, although more than one-half of ganglion cysts may recur within a year. Fenestration is a technique where a needle is gently passed through abnormal tissue; it may be used in conjunction with corticosteroid injection to reduce the rate of recurrence of a ganglion cyst.³⁵ However, corticosteroid injections of ganglion cysts do not appear to produce additional benefits to aspiration, and the injections increase potential for complications such as fat atrophy and skin discoloration.^29,38 Similarly, hyaluronidase injections have inconsistent success rates, with insufficient evidence to recommend their use.³⁹ Figure 2A shows a suggested transducer position and needle placement for ultrasound-guided aspiration, but palpation-guided aspiration of ganglion cysts is relatively easy to perform and does not require ultrasonography.

INTERSECTION SYNDROME

Intersection syndrome is an overuse injury. It typically occurs with repetitive, resisted wrist extension. The condition is most commonly seen in weight lifters and competitive rowers, and it can arise from any significant uptick in wrist extensor use. Intersection syndrome causes pain on the forearm's dorsum, near the wrist, where the abductor pollicis longus and extensor pollicis brevis muscles intersect with the extensor carpi radialis longus and brevis tendons⁴⁰ (Figure 3⁴¹). Late presentation of the condition may include redness, warmth, or crepitation, and patients may report a “squeaking” sound from the tendons during wrist extension. The pain's dorsal predominance can help distinguish intersection syndrome from de Quervain tenosynovitis.^40,42

Diagnosis

Examination typically reveals pain 4 to 8 cm proximal to the Lister tubercle (the dorsal tubercle of the distal radius) and associated palpable swelling at the irritated site. Crepitus is also a common finding and can guide injection.⁴³ MRI can be used in chronic or recalcitrant cases for definitive diagnosis. Diagnostic ultrasonography is a versatile tool for assessment and can rival MRI when performed by an experienced user.⁴⁴

Treatment

Management involves rest, activity modification, braces, nonsteroidal anti-inflammatory drugs, and physical or occupational therapy. For symptoms not improved by these methods, a glucocorticoid injection may be administered, ideally guided by ultrasonography, to minimize adverse events.^42,45,46 For an ultrasound-guided injection, the patient should be seated or supine with their forearm facing the physician.⁴⁷ The ultrasound transducer should be positioned in the transverse plane, short axis to the intersecting muscle compartments of the extensor carpi radialis brevis and extensor carpi radialis longus.⁴⁸ Using an in-plane or out-of-plane technique, the needle is guided to the intersection site of the first and second dorsal compartment.⁴³ The injection target is where the abductor pollicis longus and extensor pollicis brevis muscles cross over the extensor carpi radialis muscles.

TRIANGULAR FIBROCARTILAGE COMPLEX INJURY

The most common cause of triangular fibrocartilage complex injuries is trauma from falling forward onto an outstretched hand in pronation.⁴⁹ Causes of these injuries include degeneration from repetitive axial loading on the wrist's ulnar aspect and repetitive pronation-supination with an axis of twisting passing through the wrist's articular disk.⁵⁰ Examples of activities with this mechanism include swinging a baseball bat and performing back handsprings. Individuals who regularly perform manual tasks that stress the wrist (e.g., carpenters and plumbers) may also experience chronic ulnar wrist pain due to triangular fibrocartilage complex degeneration.⁵¹

Diagnosis

Tenderness over the palmar extensor carpi ulnaris (ulnar fovea sign) is the most common sign of a triangular fibrocartilage complex injury.⁵² Dorsal radioulnar instability, limitation of pronationsupination range of motion, decreased grip strength, and ulnar-sided pain on passive forearm rotation are other signs.⁵² Ulnar pain with passive maximal ulnar deviation (ulnocarpal stress test or triangular fibrocartilage complex grind test) and pain with full forearm supination to pronation while applying an ulnocarpal joint axial load (e.g., screwdriver test) also suggest this diagnosis.^49,53,54

If history and physical examination are consistent with the diagnosis, plain radiography can indicate ulnar styloid fractures or assess ulnar variance, which influences load distribution and injury risk. Magnetic resonance arthrography is more definitive in identifying triangular fibrocartilage complex tears through high signal fluid in tears.⁵⁵ An MRI with a posteroanterior view and the arm abducted to 90 degrees and forearm in neutral rotation as well as a pronated posteroanterior grip can show increased ulnar variance, which may affect treatment decisions.⁴⁹ Positive ulnar variance is increased length of the ulna (more than 2.5 mm) compared with the length of the radius at the wrist, which increases the risk of triangular fibrocartilage complex tears.⁵⁰ MRI has a diagnostic sensitivity of 100%, a specificity of 86%, and an accuracy of 90%.⁵⁶

Treatment

Immobilization, kinesio taping, relative rest, and analgesics are the usual treatments for triangular fibrocartilage complex injuries. Recalcitrant cases may be treated with corticosteroid injection or platelet-rich plasma injection.⁴⁹ Acute inflammatory pain can be treated with corticosteroid injection guided by palpation of the ulnocarpal junction or with the assistance of ultrasonography into areas of hypervascularity.^49,57

The wrist should be radially deviated and forearm fully pronated, preferably using a pillow, for out-of-plane and in-plane ultrasound-guided injections of the triangular fibrocartilage complex.⁴⁹ For the out-of-plane approach, the ulnar styloid is facing upward, and the linear transducer is placed between the triquetrum and ulnar styloid process parallel to the extensor carpi ulnaris tendon (Figure 2B). The triangular fibrocartilage complex is reached with a 25-gauge needle tip as it is advanced toward the radial aspect of the wrist, deep to the extensor carpi ulnaris tendon. For the in-plane approach, the linear transducer is placed over the dorsal wrist in a horizontal plane as the needle is advanced toward the radial side, deep to the extensor carpi ulnaris tendon, to reach the triangular fibrocartilage complex.

DE QUERVAIN TENOSYNOVITIS

De Quervain tenosynovitis, a prevalent source of wrist pain in adults, is most often identified in women 30 to 50 years of age, including a subset of postpartum women who typically experience symptoms 4 to 6 weeks postdelivery.⁵⁸ De Quervain tenosynovitis, involving the abductor pollicis longus and extensor pollicis brevis tendons at the radius's styloid process, causes pain and tenderness on the wrist's radial side (Figure 4A).⁵⁹ It is often linked to overuse or repetitive wrist or thumb movements, although its exact cause remains unclear.⁶⁰

Diagnosis

In addition to pain associated with chronic repetitive tasks, patients may report localized pulling pain on the radial aspect of the wrist. Physical examination demonstrates pain to palpation and swelling along the first dorsal compartment as well as a positive Finkelstein test.⁶¹

Imaging is usually not needed to diagnose this condition; radiography will be normal. If the diagnosis is unclear, ultrasonography will likely show a thickened extensor retinaculum, increased vascularity, and changes in the abductor pollicis longus and extensor pollicis brevis tendons due to narrowing from the swollen extensor retinaculum.^62,63

Treatment

This condition is typically treated conservatively with palpation- or ultrasound-guided corticosteroid injection, splinting, occupational therapy, and activity modification.^64,65 For a palpation-guided injection, the thumb may be positioned so that the tendons are felt more readily, with the wrist in slight ulnar deviation, and the path of the tendons is followed just beyond the radial styloid process, where the needle is inserted almost parallel to the tendons into the point of maximal tenderness (Figure 4B²⁶). Figure 4C shows a suggested transducer position and needle placement for ultrasound-guided injection of the condition.

This article updates a previous article on this topic by Tallia and Cardone.²⁶

Data sources: The Medline database (1946 to present) was searched, restricted to English language articles, using the Ovid interface. Search terms included MeSH terms and keywords, including wrist, wrist injuries, wrist fractures, hand, hand bones, hand joints, hand injuries, ulnar nerve, finger, knuckle, injection, injectable, microinjection, and their respective synonyms. Studies were critically reviewed that used patient categories such as race and/or gender but did not define how these categories were assigned, stating their limitations, when applicable, in the text. An Essential Evidence Plus summary was also used. Search dates: January 1, 2019, to February 2, 2023; August 29, 2024.

The Scientific Publications staff at Mayo Clinic provided copyediting, proofreading, administrative, and clerical support.

The authors thank Ryan Milon for modeling for the images in Figure 1C, Figure 2, and Figure 4C.