Despite the joint’s complexities, hand specialists can diagnose most causes of wrist pain by simply doing a careful patient history and specified physical maneuvers of the fingers and wrist joint to test movement and grip strength.
November 19, 2020
MRI scans for musculoskeletal disorders, especially generic complaints of painful wrists, are overused, abused, and costly to patients and the entire health care system, says noted orthopedic surgeon Alejandro Badia MD.
Even more concerning, these expensive scans often are unable to pinpoint a patient’s wrist problem and can lead to misleading diagnoses and inappropriate treatments, says Dr. Badia, hand and upper limb specialist and author of the recent book Healthcare from the Trenches. He blames “defensive medicine” — fear of litigation; patient demand; physician economic interests in high-priced imaging equipment; and efforts by generalists to treat wrist and other musculoskeletal problems for which they lack training as key reasons for the burgeoning number of unnecessary scans.
“Instead of referring patients immediately to orthopedic surgeons for proper diagnosis, many general physicians try to ‘fix’ the problem themselves and order unnecessary tests,” Dr. Badia says.
Dr. Badia calls the wrist an “engineering marvel.” It is a complicated joint, consisting of eight irregularly shaped bones within a system of ligaments, tendons, and nerves. Despite the joint’s complexities, “hand specialists can diagnose most causes of wrist pain by simply doing a careful patient history and specified physical maneuvers of the fingers and wrist joint to test movement and grip strength,” he says. “Occasionally, a few conventional radiographs (X-rays) may be all that is needed to support or confirm a diagnosis.”
Experts agree. In a study published in a 2019 issue of the Journal of Wrist Surgery, researchers conclude that “clinical assessment and X-rays are typically sufficient for a hand specialist to diagnose and manage chronic wrist pain, and few patients require additional imaging.” Authors of an earlier article in the American Family Physician Journal write that a “detailed [patient] history alone may lead to a specific diagnosis in approximately 70 percent of patients who have wrist pain.”
Painful joints like the wrist are a leading cause for widespread physician ordering of unnecessary MRI scans, says Dr. Badia. This costly type of imaging is one reason why an article in a 2017 issue of the Journal of Health Informatics & Management claims the United States health care system is in “crisis.” The United States “consumes far more resources to produce the same or lesser [patient] outcomes as compared to health care systems elsewhere,” authors write.
In fact, 2019 statistics indicate that the U.S. was second only to Japan in the number of MRI scanners – more than 40 — per one million population. Other numbers indicate this country performs more MRI and CT (computed tomography) scans combined than any other nation in the world. Compared to other imaging technologies, MRIs account for the highest level of expenditures, experts say.
The MRI (magnetic resonance imaging) scanner use powerful magnetic fields and radio waves to peer inside the body and detect abnormalities, particularly in soft tissue and the nervous system. Although appropriate for determining presence of some tumors and cancers, MRI scans are often unreliable and ineffective for diagnosing wrist and other joint pain because they lack the necessary specificity, says D. Badia, founder and chief medical officer of the Florida-based Badia Hand to Shoulder Center and OrthoNOW®.
In cases of wrist ligament or tendon injury, “precise physical examination” is often the most effective method of accurate diagnosis, Dr. Badia states. “Follow-up imaging using less costly conventional radiography may be useful in treatment planning to repair a fracture or break in the scaphoid or other wrist bone.”
The importance of early and quick patient referral to orthopedic specialists — namely, hand surgeons — for acute or chronic injuries of the wrist cannot be overemphasized, according to Dr. Badia. He notes a report, published in a 2018 issue of the journal Plastic and Reconstructive Surgery, in which authors contend that hand surgeons are more likely to order an MRI scan only when it has direct bearing on determining a specific treatment approach rather than simply investigating wrist pain.
“The takeaway: patients should skip the family doctor and go immediately to an orthopedic surgeon — most especially, a hand and upper limb specialist — for first line treatment of wrist pain or other hand and upper limb joint problems,” Dr. Badia emphasizes. He notes that some 20 percent of family doctor office visits are due to musculoskeletal issues.
To help patients minimize costs and maximize treatment outcomes for musculoskeletal disorders, Dr. Badia offers these additional tips:
- Avoid the hospital emergency department unless experiencing uncontrolled bleeding or an injury causing a fractured bone to protrude through the skin. “Emergency departments are noted for long waits, high costs, and care from physicians who lack specialized training in joint problems,” Dr. Badia says.
- If wrist pain is of more urgent nature, again, it’s best to avoid crowded ER which focuses on more severe injuries or the general urgent care with lack of expertise. If your community has an orthopedic urgent care/walk-in center, such as OrthoNOW®, that is your best bet if you can’t secure a prompt appointment with a hand/wrist specialist.
- If the primary care physician orders an MRI for a painful wrist or other joint, question it. Do you really require it? “A patient is not necessarily getting better care because of a high-tech, lavish test. In fact, the test could lead to an inappropriate diagnosis,” Dr. Badia says.
- Find out about other, less expensive, but equally effective options before undergoing an MRI scan.
- Finally, “take charge of your care. Request referral to an orthopedic specialist before undergoing an array of expensive diagnostic tests ordered by your family physician,” Dr. Badia advises.
In conclusion, Dr. Badia notes, “the wrist is a complicated joint and that despite the joint’s complexities, “hand specialists can diagnose most causes of wrist pain by simply doing a careful patient history and specified physical maneuvers of the fingers and wrist joint to assess specific areas of tenderness, test movement and grip strength. Occasionally, a few conventional radiographs (X-rays) may be all that is needed to support or confirm a diagnosis. Furthermore, in office fluoroscopy (live dynamic x-ray), when available, can help avoid further imaging needs”
Bio: Alejandro Badia, MD, FACS, is an internationally renowned hand and upper-limb surgeon and founder of Badia Hand to Shoulder Center and OrthoNOW®, a network of walk-in orthopedic centers. Dr. Badia is the author of Healthcare from the Trenches. http://www.drbadia.com http://www.orthonowcare.com
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