Musculoskeletal problems of the wrist and hand

Bones

 * Distal Radius
 * Styloid process adds medial stability
 * Distal Ulna
 * Styloid process adds lateral stability
 * Proximal Carpal Row
 * Scaphoid (navicular), lunate, triquetrum, pisiform
 * Scaphoid provides stabilizing articulation between proximal and distal carpals
 * Distal Carpal Row
 * Trapezium, trapezoid, capitate, hamate
 * Articulate with metacarpals
 * Joint Capsules
 * Seven non-communicating compartments of the wrist
 * Negative findings in one compartment do not rule out pathology in another

Tendons

 * Flexor Tendons
 * Majority traverse palmar surface via carpal tunnel
 * Lie between carpal bones dorsally and flexor retinaculum ventrally
 * Extensor Tendons
 * Cross the wrist covered by fascia along the dorsal surface
 * Insertions
 * Major wrist flexors/extensors insert at base of metacarpals, not onto carpal bones

Nerves

 * Median Nerve
 * Runs through carpal tunnel
 * Ulnar Nerve
 * Follows ulnar artery

Painful Movement

 * Dorsal Wrist Pain
 * Most common complaint
 * Traumatic Injury
 * Distal Radial Fracture
 * After fall on outstretched arm (Colles’ fracture)
 * Common in young & in elderly with osteoporosis
 * Scaphoid Fracture
 * Most common bony injury
 * Tenderness in anatomic snuff box
 * Need scaphoid view +/- follow up films at 2 weeks to detect
 * Poor blood supply--risk nonunion, avascular necrosis
 * Perilunate Dislocation
 * After fall on outstretched, extended wrist
 * Dorsal shift of all bones due to severe ligament injury
 * Only lunate remains articulated with radius
 * X-ray with increased interosseous scaphoid-lunate distance
 * Simple Sprain
 * Injury to supporting ligaments of radiocarpal joint
 * Mild pain or stiffness
 * Normal range of motion (ROM) or <10% loss of flexion/extension
 * Resolves within 2 weeks with conservative therapy
 * Atraumatic
 * Radiocarpal arthritis
 * Unilateral usually due to prior trauma--secondary oseoarthritis (OA)
 * Uncommon site for primary OA
 * Bilateral arthritis likely due to RA or crystals
 * Wrist more common site for pseudogout than gout
 * Septic arthritis of wrist rare
 * Pain, swelling and reduced ROM of wrist
 * Radial Wrist Pain and Grip Weakness
 * DeQuervain’s Tenosynovitis
 * Abductor pollicis longus and extensor pollicis (snuffbox) tendons
 * Pain worst over distal radial styloid
 * Pain worsened by activity, relieved by rest; history wrist/hand overuse
 * CMC Arthritis
 * Common, due to repetitive gripping/grasping or vibration exposure
 * Wear and tear of articular cartilage at base of thumb
 * Pain and swelling at base of thumb
 * Gamekeeper’s Thumb
 * Disruption of the ulnar collateral ligament of the MP joint
 * Due to trauma (ski pole injuries) or repetitive use
 * Instability of metacarpal (MP) joint, loss of pinch/opposition function/strength
 * Pain and swelling on ulnar side of MP joint
 * Late degenerative arthritic change
 * Osteonecrosis
 * Usually involves scaphoid and lunate, history trauma in 50%
 * Reduced wrist flexion/extension, decreased grip strength
 * Most severe tenderness over anatomical snuff box
 * Can take 4-8 weeks for X-rays to show lesion; bone scan shows earlier

Dorsal Swelling

 * Localized
 * Ganglion Cyst
 * Painless abnormal accumulation of synovial or tenosynovial fluid
 * Due to subtle abnormalities in wrist or extensor tendon sheath
 * Overproduction of fluid irritates scar tissue and causes cyst formation
 * Small % of patients have pain due to cyst pressure on tendons/radial nerve
 * +/- Paresthesias over back of hand/fingers (pressure on superficial radial nerve)
 * Diffuse
 * Extensor Tenosynovitis
 * Swelling from wrist to back of hand
 * Pain aggravated by movement of fingers

Stiffness

 * Rheumatoid Arthritis (RA)
 * Symmetrical joint symptoms with morning stiffness
 * Carpal Tunnel Syndrome (CTS)
 * Can have stiffness as prominent feature

Sensory Changes with Wrist Use

 * Carpal Tunnel Syndrome
 * Compression neuropathy of the median nerve at the carpal ligament
 * Loss of sensation at the tips of the first 3 fingers
 * Grip weakness, pain at wrist +/- radiation to fingers or forearm
 * Pain may awaken patient at night; may be relieved with wrist motion
 * Usually idiopathic
 * Can be due to reduced space in tunnel
 * Tenosynovitis / inflammatory arthritis
 * Acromegaly
 * Pregnancy (3rd trimester)
 * Hypothyroidism
 * Chronic renal failure
 * Amyloidosis
 * Can be due to increased susceptibility to pressure
 * Diabetes mellitus (DM)
 * Vasculitis
 * Hereditary neuropathy

Wrist Function

 * Range of Motion
 * Radiocarpal joint flexion and extension
 * Normal: flexion 90°, extension 80°
 * Mild pain/stiffness + normal ROM: sprain or mild arthritis
 * Moderate pain/stiffness + 20% loss ROM: arthritis
 * Severe pain/stiffness + 50% loss ROM: acute gout, fracture (navicular/distal radius), dislocation
 * Refusal to move: septic joint, fracture
 * Loss of ROM in only one direction (due to pain)
 * Tendon injury or inflammation
 * Pain with passive stretching of tendon (opposite direction)
 * Grip Strength
 * Indirect measure of strength/integrity of forearm muscles
 * Can be measured objectively using rolled up partly inflated blood pressure (BP) cuff (patient grip measured in mmHg)
 * Reduced Grip Strength
 * Disuse atrophy, arthritis (hand or wrist), CTS, DeQuervain’s, osteonecrosis
 * May also be reduced in C8 radiculopathy, severe epicondylitis

Specific Maneuvers

 * Palpation of the Radiocarpal Joint Line
 * Junction of distal radius, scaphoid & lunate
 * At intersection of index finger extensor tendon & distal radius
 * Mild tenderness: simple sprain
 * Moderate tenderness: osteoarthritis (OA)
 * Severe pain: crystal-induced arthritis, Colles’ fracture, scaphoid fracture, perilunate dislocation
 * Swelling: mild swelling will fill the depression over the navicular (severe swelling causes a bulge)
 * Loss of ROM: significant loss (45° flexion / extension) with advanced disease
 * Palpation of the Scaphoid Bone
 * Scaphoid forms floor of anatomical snuff box (distal radial styloid + base of thumb + abductor pollicis longus + extensor pollicis longus)
 * Tenderness in anatomical snuff box = scaphoid pathology (fracture, osteonecrosis, arthritis)
 * Palpation of the Radial Styloid
 * Pain suggests DeQuervain’s tenosynovitis (friction-induced irritation of anatomic snuffbox tendons)
 * Confirmatory Testing
 * Pain aggravated by thumb extension or abduction against resistance
 * (Abduction = movement of thumb perpendicular to palm)
 * Pain worse with passive stretch of tendons over radial styloid via thumb flexion
 * (Finkelstein’s test)
 * Compression of the Base of Thumb
 * Screen for CMC arthritis (or strain)
 * Pain with compression of the CMC joint in the ante partum (AP) plane suggests CMC arthritis
 * Pressure applied from the snuffbox is much less painful
 * Swelling best seen with wrist turned radial-side-up
 * Crepitation with forcible rotation of metacarpal against trapezium (mortar & pestle sign)
 * Bony protuberance of metacarpal or thenar atrophy: late stages
 * Palpation of Metocarpophalangeal Joint
 * Detect gamekeeper’s thumb (ulnar collateral ligament injury)
 * Local tenderness/swelling along ulnar side of MP joint suggests diagnosis
 * Instability or pain of MP joint with valgus stress (examiner’s thumb at MP joint, index finger at interphalangeal (IP) joint)
 * Loss of MP flexion (normal = 90°) and pinch strength can occur with acute symptoms/swelling
 * Tests for Nerve Compression
 * CTS
 * Sensory loss in the first 3 fingertips: two-point discrimination, light touch, pain decreased
 * Weakness of thumb opposition: best detected when pt holds thumb + 5th finger together
 * Tinel Sign
 * Vigorous tapping over transverse carpal ligament with wrist in extension
 * Positive if reproduces pain and paresthesia
 * Phalen Sign
 * Both wrists held in extreme volar flexion for 30-60 seconds
 * Positive if symptoms reproduced
 * Pronator Teres Compression
 * If no compression detected at wrist, test for proximal compression
 * Apply pressure to forearm 1 to 2 inches distal to antecubital fossa
 * Positive if symptoms reproduced with compression
 * Sensitivity increased by resisting forearm pronation
 * Note: Tests can be totally normal despite significant compression (symptoms vary over time)
 * Sensitivity and specificity of provocative tests low
 * Transillumination
 * Distinguishes between ganglion (transilluminates) and solid mass
 * Ganglion cyst should be highly mobile and fluctuant, not adherent; ROM should be full
 * Aspiration of cyst yields thick, colorless fluid

X-Ray

 * Plain X-Rays
 * Indicated if suspected arthritis (radiocarpal, CMC) or fracture
 * Usual views = Posteroanterior (PA), PA oblique, lateral
 * PA ulnar deviation views views needed for suspected scaphoid fracture; may be negative for 1-2 weeks
 * X-rays should be normal if:
 * Simple sprain
 * CMC strain (vs. CMC OA—abnormal films)
 * DeQuervain’s – films not indicated
 * Gamekeeper’s thumb – films not indicated
 * Carpal tunnel syndrome – films not indicated
 * Dorsal ganglion – films not indicated

Aspiration

 * Wrist Joint
 * If infection or inflammatory or crystal-induced arthritis suspected
 * Dorsal Ganglion
 * Confirms diagnosis (thick, clear, gelatinous fluid)

Nerve Conduction Studies

 * Indicated if suspected median nerve compression
 * Nerve conduction velocity (NCV) decreased in 70% of cases; high PPV, but sensitivity low

Positive Median Nerve Block/or Steroid Injection

 * Can be used to confirm suspected diagnosis of CTS
 * Simultaneous steroid injection is therapeutic as well as diagnostic
 * Significant risk complications (nerve atrophy or necrosis): should only be performed by an expert

Traumatic Injury

 * Fracture
 * Immediate severe pain and swelling
 * Colle’s fracture
 * Fracture of distal radius; most common, easily seen on X-ray
 * Scaphoid Fracture
 * May require special X-ray views to visualize
 * Ligament Rupture or Tear
 * Tendon Injury

Nontraumatic

 * Inflammatory Arthritis
 * Septic, crystal-induced, rheumatoid arthritis (RA)
 * Pain with movement of wrist through its range of motion
 * Synovitis with swelling in setting of inflammatory entities
 * Osteoarthritis
 * Rarely involves wrist except for carpometacarpal (CMC) joint at base of thumb
 * Osteonecrosis (avascular)
 * Localized pain interfering with hand/wrist function
 * Entrapment Syndromes
 * Wrist pain radiating into hand or forearm, +/- sensory or motor deficits
 * Carpal tunnel syndrome
 * Ulnar or interosseous nerve entrapment
 * Tenosynovitis
 * Ganglion Cyst
 * Referred Pain from Cervical-Spine/Shoulder
 * Pain in absence of local findings
 * Symptoms worsened by neck/shoulder movement

Acute Trauma

 * Assess ligamentous, vascular, neurologic integrity
 * X-Rays
 * If fracture suspected
 * Scaphoid views if tenderness in anatomic snuff box
 * If no fracture
 * Rest, ice, splint as below; nonsteriodal anti-inflammatory drugs (NSAIDs)
 * If pain persists, repeat X-rays after 2 weeks to detect fracture not seen on initial films

Empiric Treatment for Mild-Moderate Wrist Pain with Normal ROM

 * Neutral position
 * Avoidance of extremes of movement
 * Can use veclro wrist splint to immobilize in neutral position
 * Restriction of repetitive gripping/grasping and exposure to vibration
 * Restriction of lifting to less than 10 pounds
 * Ice: to dorsal surface of wrist for 15 minutes up to three times a day
 * Stretching: passive stretching in flexion and extension
 * If persistent symptoms (or if traumatic injury, moderate to severe pain or decreased ROM or grip strength), further evaluation +/- X-rays needed

Specific Treatment for Various Syndromes

 * Radiocarpal Arthritis
 * Mild: ice and Velcro wrist immobilizer with metal stay; NSAIDs x 3-4 weeks
 * Moderate to severe: local steroid injection
 * Crystal-induced: usual treatment for gout vs. pseudogout
 * Start flexion/extension passive ROM exercises once acute symptoms controlled
 * Gripping and wrist extension toning exercises after flare resolves
 * If persistent symptoms at 3 months with loss of >50% of ROM, refer to orthopaedist
 * DeQuervain’s Tenosynovitis
 * Ice to radial styloid
 * Restriction of thumb gripping/grasping
 * Buddy-tape thumb to 1st finger
 * Treat with dorsal hood splint
 * Treat with Velcro thumb spica splint
 * If persistent symptoms at 3-4 weeks, prescribe steroid injection
 * 3/8” proximal to tip of radial styloid
 * 25 gauge needle
 * Depo-Medrol 80 mg/mL, ½ mL
 * 2-3 mL anesthetic (lido)
 * May repeat at 4-6 weeks if symptoms persist
 * Once symptoms improved (3-4 weeks), gentle passive stretching exercises of thumb abductor and extensor tendons into the palm (20 stretches every day, each held for 5 seconds)
 * CMC Arthritis
 * Rest + NSAIDs (x 3-4 weeks) + restriction of gripping/grasping
 * Oversized tools and grips
 * Overlap-taping of joint, or
 * Dorsal hood splint, or
 * Velcro thumb spica spliint
 * If symptoms persist at 3-4 weeks, prescribe steroid injection
 * 3/8” proximal to base of metacarpal bone
 * 25 gauge needle
 * Adjacent to abductor tendon in snuffbox
 * ½ mL anesthetic + ½ mL Depo-Medrol 40 mg/mL
 * Repeat at 4-6 weeks if symptoms not reduced by 50%
 * Once pain improved, passive stretching of thumb flexors/extensors
 * Gamekeeper’s Thumb
 * Ice to MP joint + immobilization with overlap taping, dorsal hood splint or thumb spica splint
 * Complete rest needed for 3-6 weeks to allow ligament healing/reattachment
 * Once recovered
 * Passive ROM flexion/extension exercises of thumb
 * Isometric toning of thumb flexion (squeeze tennis ball x 5 sec, repeat 20-25 times)
 * Ganglion Cyst
 * Reassurance: may resolve spontaneously
 * If persistent, aspirate cyst (note: 18 gauge needle needed; anesthetize via 25 gauge needle first)
 * Limit repetitive wrist motions; consider Velcro wrist brace
 * If recurrence after aspiration, repeat aspiration and inject Depo-Medrol 40 mg/mL
 * If further recurrences, consider ortho referral for removal, though may recur even after excision
 * Carpal Tunnel Syndrome
 * Treat any underlying cause (diuretics, antiinflammatories, L-T4, etc.)
 * Reduce repetitive wrist motion: occupational adjustments
 * Velcro wrist splint at night (or day and night if severe sxs)
 * Consider referral for steroid injection or surgery if inadequate symptom improvement
 * Note: 90% respond to steroid injection; surgery may be avoidable with physical therapy (PT) + steroid injection
 * Once symptoms improved (3-4 weeks after pain resolved), passive stretching exercises for flexor tendons