Musculoskeletal problems of the wrist and hand medical therapy: Difference between revisions
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==Medical Therapy== | ==Medical Therapy== | ||
== Management == | ===Management=== | ||
=== Acute Trauma === | ====Acute Trauma==== | ||
* Assess ligamentous, vascular, neurologic integrity | * Assess ligamentous, vascular, neurologic integrity | ||
* X-Rays | * X-Rays | ||
* | ** If fracture suspected | ||
* | ** Scaphoid views if tenderness in anatomic snuff box | ||
* If no fracture | * 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 === | ====Empiric Treatment for Mild-Moderate Wrist Pain with Normal ROM==== | ||
* Neutral position | * 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 repetitive gripping/grasping and exposure to vibration | ||
* Restriction of lifting to less than 10 pounds | * Restriction of lifting to less than 10 pounds | ||
Line 25: | Line 25: | ||
* If persistent symptoms (or if traumatic injury, moderate to severe pain or decreased ROM or grip strength), further evaluation +/- X-rays needed | * 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 === | ====Specific Treatment for Various Syndromes==== | ||
* '''Radiocarpal Arthritis''' | * '''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''' | * '''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''' | * '''CMC Arthritis''' | ||
* | ** Rest + [[NSAID]]s (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''' | * '''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''' | * '''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''' | * '''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 == | == References == | ||
Line 86: | Line 86: | ||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Musculoskeletal Disease]] | [[Category:Musculoskeletal Disease]] | ||
[[Category:Needs overview]] | [[Category:Needs overview]] |
Latest revision as of 22:49, 29 July 2020
Musculoskeletal problems of the wrist and hand Microchapters |
Differentiating Musculoskeletal problems of the wrist and hand from other Diseases |
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Risk calculators and risk factors for Musculoskeletal problems of the wrist and hand medical therapy |
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
- Rest + NSAIDs (x 3-4 weeks) + restriction of gripping/grasping
- 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