St. Lukes COHE 1.

Upper Extremity / Wrist 1.0

Adult patient with wrist pain

Wrist Pain Triage & Initial Management*

DRAWN BY Daniel T. Hansen, DC STATUS: SEED ALGORITHM FOR PUBLICATION (Provider Manual) FILENAME WRI 1 TRIAGECOHE.VSD PAGE 1 OF 1 REVISED 7/16/2007

- Significant History (A) - Significant Physical Exam (B) - Significant imaging (C)

1.2

Differential Diagnosis Evidence of Critical Exclusionary Diagnoses (D) for complicated care based on early clinical assessment?

1.3 1.4

Yes

Consult with or refer to appropriate specialist

Annotations:
(A) Significant History - History of deformity; trauma; Pain-acute or insidious, associated with activity, ache or sharp, location (tendons, global wrist, specific wrist area, radiations), motion (forearm rotation, wrist motion, thumb motion); Presence of mass-acute or insidious, fluctuation in size, location; Abnormal clicks, pops, clunks, snaps with motion, or grinding sensations-occur with wrist range of motion, forearm rotation or thumb range of motion; Sensation of weakness-related to pain or wrist giving way, or associated with clumsiness; Presence of swelling at wrist or along tendons; Presence and distribution of numbness-worse with activity or at night; Constitutional symptoms and/or other sites of infection; History of redness or warmth at wrist. (B) Significant Physical Examination - Deformity; ROM; swelling; mass; tenderness; crepitance; clicking, popping or clunking with wrist motion; pain response to strength change to resisted muscle activity; sensation changes (LT, 2PD); neurologic provocative maneuvers (Tinel's, Phalen's); perfusion status (Allen's, capillary refill, tissue turgor); warmth, redness; grip strength. (C) Significant Imaging - Plain posterior-anterior, oblique and lateral wrist x-rays (incl. hand), when indicated; rarely indicated imaging - MRI, CT. (D) Critical Exclusionary Diagnoses - Acute infection; acute fracture (radius, distal ulna, all carpal bones, bases of metacarpals); acute dislocation (DRUJ, lunate or perilunate, carpometacarpal); acute vascular compromise (ulnar artery occlusion); neoplasm (compare with Differential Diagnosis for "Ganglion"); any acute traumatic episode with swelling and local tenderness; inflammatory and crystal induced arthropathy; acute objective neurologic compromise.

No
1.5

Predominence of clinical evidence of Tendonitis? No Predominence of clinical evidence of Carpal Tunnel Syndrome? No Predominence of clinical evidence of Ligamentous Laxity? No Predominence of clinical evidence of Ganglion Tumor? No Predominence of clinical evidence of Inflam. or Degen. Arthritis? No

Yes

GO TO Wrist Alg 2

1.6

Yes

GO TO Wrist Alg 3

1.7

Yes

GO TO Wrist Alg 4
1.12

Rank differential diagnoses and confirm primary diagnosis

1.8

Yes

GO TO Wrist Alg 5

Manage primary diagnosis and coexisting lesions conservatively

1.13

1.9

Yes

GO TO Wrist Alg 6

1.14

Need specialized or surgical care?

Yes

Consult with or refer to appropriate specialist

1.15

No
1.10

Re-evaluate clinical conclusions and consider psychological status and/or patient credibility

Make appropriate referral or DISCHARGE

1.11

1.16

Condition resolved DISCHARGE

Refer to Wrist specialty pathways

1.17

TRIAGE

URG / EMER CARE

CONSERV. CARE

BEHAV MED

DIFF DX

GEN CLINIC MGMT

* Adapted from AAOS1996: Wrist Pain - Phase 1, with permission.

This pathway/protocol is presented with the intention of clarifying relationships among various clinical management processes for injured workers. This and related pathways are not intended to replace the physician's clinical judgment or to establish the only protocol for diagnosis and/or treatment of patients with any particular clinical presentation.

Status: seed File:wri 1 triagecohe.vsd Copyright 1999 - D T Hansen Spokane, WA dth