Musculoskeletal problems of the wrist and hand medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Medical Therapy

Management

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 velcro 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 NSAID
      • 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, anti-inflammatories, 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

References

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