Search
wrist & hand pain
Etiology:
1) tendonitis
a) de Quervain's tenosynovitis
b) wrist/finger extensor tendonitis
c) wrist/finger flexor tendonitis
d) intersection syndrome
2) peripheral nerve entrapment
a) median nerve entrapment
1] carpal tunnel syndrome (motor &/or sensory)
2] pronator teres entrapment - generally sensory involvement alone
3] anterior interosseous syndrome (motor)
b) ulnar nerve entrapment
1] ulnar nerve entrapment at the wrist (Guyon's canal) (motor &/or sensory)
2] ulnar nerve entrapment at the elbow
3) ganglion cyst
4) sprain
a) ligament injury to the carpal bones
b) triangular fibrocartilagenous complex
c) radioulnar ligament sprain
d) carpometacarpal sprain
5) fracture
a) carpal navicular fracture
b) scaphoid fracture
c) distal radius fracture
d) ulnar styloid fracture
e) other carpal fractures
6) osteonecrosis (avascular osteonecrosis)
7) arthritis
a) rheumatoid arthritis
b) systemic lupus erythematosus
c) scleroderma
d) gout
e) pseudogout
f) psoriatic arthritis
g) septic arthritis
h) osteoarthritis
Clinical manifestations:
1) general
a) edema
b) echymosis
c) tenderness
d) deformity or atrophy
e) loss of motion
f) loss of strength
g) loss of sensation
h) crepitus
2) atrophy of the thenar eminence suggests involvement of the median nerve
3) atrophy of the hypothenar eminence suggests involvement of the ulnar nerve
4) Tinel's sign
5) Phalen's sign
6) positive Finkelstein's test
7) squeaking with movement suggests tendonitis
8) popping or clicking with movement suggests cartilage tear of ligament laxity
9) grinding sensation with movement suggests arthritis
10) paresthesia, especially at night suggests nerve entrapment
Laboratory:
1) erythrocyte sedimentation rate (ESR)
2) rheumatoid factor (RF)
3) antinuclear antibody (ANA)
4) joint aspiration (arthrocentesis)
Special laboratory:
- electromyography
Radiology:
1) plain radiographs:
a) all patients with a history of trauma & localized tenderness to palpation [2]
b) may need to repeat in 2-8 weeks to rule out navicular or other carpal fractures
2) magnetic resonance imaging (MRI)
3) bone scan
4) arthrography
Management:
1) relative rest, short term immobilization may be helpful
2) pharmacologic agents a non-steroidal anti-inflammatory agents for 7-10 days
b) corticosteroid injections: short-term relief, but may cause tissue degeneration
3) physical modalities:
a) ice, heat
b) high-voltage galvanic stimulation, iontophoresis, & phonophoresis (ultrasound)
4) physical therapy with improvement in pain
5) surgery
a) failure of 3-6 months rehabilitation
b) persistent pain at rest of with activities of daily living
c) unacceptable quality of life
Related
anterior interosseous nerve syndrome; Kiloh-Nevin syndrome
carpal tunnel syndrome (median neuropathy)
de Quervain's tenosynovitis (stenosing tenosynovitis)
Finkelstein's test
intersection syndrome
Phalen's sign
scaphoid fracture
Tinel's sign
General
arm pain
References
- Saunders Manual of Medical Practice, Rakel (ed),
WB Saunders, Philadelphia, 1996, pg 742-44
- Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 18.
American College of Physicians, Philadelphia 2006, 2009, 2012, 2018