Wrist and hand pain

Associate Editor-In-Chief:

Overview
The wrist contains eight carpal bones. These bones are aligned by a sequence of ligaments and cartilaginous connective tissue. Though pain and numbness is a frequent presentation, carpal tunnel syndrome is the most common diagnosis.

Extremities

 * Tinel's sign
 * Positive when pain occurs if anterior wrist is tapped.


 * Phalen's sign
 * Positive if flexing the wrist for more than 30 seconds causes pain or numbness

Laboratory Findings

 * Typically unnecessary though some tests may include:
 * Rheumatoid factor
 * ANA
 * ESR
 * CBC
 * Uric acid
 * TSH
 * Pregnancy test

X Ray

 * PA
 * Lateral
 * Oblique

MRI and CT

 * Rarely used
 * May be needed to diagnose masses causing nerve problems or compromise of the vascular system

Other Imaging Findings

 * Bone scan may be needed to asess potential avascular necrosis, occult fracture or infections of the bone.

Other Diagnostic Studies

 * If carpal tunnel syndrome or other neuropathy is suspected, EMG and nerve conduction studies should be performed.
 * If warmth and redness are present in wrist and MCP joints, Arthrocentisis with crystal analysis may be necessary

Differential Diagnosis of Causes of
Causes include;


 * Carpal Tunnel Syndrome
 * Most frequent cause of wrist discomfort and morbidity
 * Linked to repetative activities
 * For example: writing, typing, etc.
 * Symptoms are a consequence of the mendian nerve becoming trapped beneath the transverse ligament cause pain and numbness.


 * Injury due to overuse
 * Osteoarthritis
 * Tenosynovitis or DeQuervain's of the radial wrist
 * Caused by the inflammation in the tendon sheaths of the extensor pollicis brevis and abductor pollis longus


 * Ganglion cysts
 * Growths common to the wrist area taking place on the dorsal and ventral surfaces.
 * These cysts are round, tender to touch and movable.


 * Trauma
 * Falling on the wrist is the most common method of injury
 * The scaphoid bone is the most commonly injured
 * Other means of trauma include:
 * direct hit
 * crush
 * fall when wrist is in a vulnerable position
 * twisted wrist


 * Fibromyalgia
 * Keinböck's Disease
 * Compartment Syndrome
 * Compression of the lymphatic system or venous system due to chest or shoulder masses
 * Venous thrombosis in subclavian veins and distal veins
 * Paralysis (flaccid) after CVA
 * Quinke's disease resultant of hymenoptera sting
 * Rhumatologic disease
 * Insect sting/bite
 * Infections

Treatment

 * Carpal Tunnel Syndrome
 * Corticosteroid injection makes progress in more than half of patients


 * Tenosynovitis
 * Corticosteroid injection alongside the tendon sheaths

Acute Pharmacotherapies

 * Carpal Tunnel Syndrome
 * NSAIDs reduce inflammation


 * Stings
 * Antihistamines and steroids

Indications for Surgery

 * Ganglion cysts
 * require a minimally invasive prcedure that includes draining fluid from the cyst and injecting a steroid.
 * Surgery to remove Ganglion cysts is occasionally required


 * Carpal Tunnel Syndrome
 * Surgery is potentially needed to remove the pressure from the nerve area and remove the transverse ligament from beneath the median nerve

Device Based Therapy

 * Carpal Tunnel Syndrome
 * cock-up splints relieve pressure and strain during repetative activities


 * Tenosynovitis
 * Thumb spica splint


 * Fracture
 * Casting and X-ray in 7-9 days in order to avert complications of occult fractures