Wrist and hand pain

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Wrist and hand pain

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

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]


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.

Diagnosis

Physical Examination

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:

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 Wrist and hand pain

Causes include; [1] [2]

  • 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.
  • 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

Acute Pharmacotherapies

  • Stings

Surgery and Device Based Therapy

Indications for Surgery

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

  • cock-up splints relieve pressure and strain during repetative activities
  • Thumb spica splint
  • Casting and X-ray in 7-9 days in order to avert complications of occult fractures

References

  1. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3 ISBN 140510368X
  2. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016


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