the wrist, is described as an "aching pain", is worsened by movement of the wrist, and
is associated with swelling and decreased range of motion of the wrist limited by pain.
Sometimes there is a decrease in grip strength. Because osteoarthritis (degenerative)
is so common, it is the major cause of wrist pain. But there are other types of arthritis
which may lead to wrist pain including trauma to the writis, rheumatoic arthritis,
psoriasis with arthritis, collagen vascular diseases such as Lupus or scleroderma,
infection, etc. Usually collagen vascular diseases produce arthritis seen in several
joints at the same time. Treatment of wrist arthritis is with analgesics, possibly with
topical analgesics (compounded) or over the counter topical analgesics (menthols),
and injection of the wrist occasionally with local anesthetics and steroids.
Carpal tunnel syndrome is a commonly occuring pain in the wrist, especially at the base
of the thumb and the 1st three fingers. There may be numbness and "paresthesias"
(electric like shock sensations), and weakness in the hand, wrist, and first 3 fingers.
Occasionally in severe cases, the pain will radiate to the forearm. The syndrome is
often diagnosed by a Phalen's test: the back of the hands are placed against each
other with the fingers on each hand pointing downwards. If there is entrapment of the
median nerve (the cause of carpal tunnel syndrome), then the Phalen's test will
reproduce the usual pain in the hands and fingers. Often, an EMG (electromyelogram)
will be used to make the diagnosis of carpal tunnel syndrome. The syndrome is caused
by repetitive wrist motions, especially when the
wrist is very extended due to poor positioning during typing, computer keyboarding, or
manual labor. Carpal tunnel syndrome is often confused with cervical radiculopathy
(pain referred to the wrist from the neck). Carpal tunnel syndrome however is not
associated with any reflex or motor changes on physical examination. The syndrome is
also confused with diabetic neuropathy, however the latter involves the entire hand
rather than the median nerve distribution of pain described above. Mild carpal tunnel
syndrome is treated by wearing splints to prevent hyperextension or hyperflexion of
the wrist, avoidance of repetitive activities such as keyboarding or hammering, and
injections of the carpal tunnel with steroids. A study published in the Feb 2005 edition
of Arthritis and Rheumatism found in patients without significant weakness or muscle
wasting in the hand, patients who had injection of steroids in the carpal tunnel fared as
well as those who had surgery at points in time 3 months and 12 months later.
Occasionally surgery including both open and endoscopic techniques have been used
successfully to treat the pain of carpal tunnel syndrome, especially when weakness is
starting to occur. Left untreated, the syndrome may cause muscle wasting in the
hands, loss of grip strength, and sensory losses all of which may become permanent.
de Quervain's Tenosynovitis is a condition due to inflammation of the tendons of the
thumb with resultant pain on the border of the wrist and thumb. When inflammation
results in severe thickening of the tendon sheath, the person may develop arthritis and
a "trigger thumb" with a locking of the thumb and inability to move the thumb away
from the hand. The pain from this condition may be severe on the outside of the wrist
and thumb, and is made worse by repetitive activities that include grasping of the
hands or twisting of the wrist such as using a wrench, scooping ice cream, shaking
hands repeatedly such as politicians, etc. The pain is constant and is made worse with
pinching activities of the thumb or movement of the wrist to the opposite side of the
thumb. Grasping items becomes increasingly more difficult over time (such as holding a
coffee cup or turning a screwdriver). The Finkelstein test involves placing the thumb
under the fingers which are curled over the thumb. The test is positive if severe pain is
produced in the thumb and wrist area when the wrist is rotated away from the thumb
side. Other diagnoses which may be confused with this condition include entrapment of
the radial nerve at the wrist (Cheiralgia paresthetica, cervical radiculopathy from the
C6-7 spine, and entrapment of a cutaneous nerve of the thumb. Treatment is with
antiinflammatory drugs, injections, and rare surgery. Also a hand splint which
immobilizes the thumb can be helpful.
Trigger thumb is the term used to describe a pain in the palm of the hand at the base of
the thumb associated with a "catching" or "locking" of the thumb. Usually the
syndrome is due to inflammation of a tendon as it passes over bones. The cause is
repetitive motion (such as pinching, shaking hands, thumb movements eg. piano
lessons, videogames, etc) or pressure chronically over the tendon (flexor pollicis
longus) from the metacarpal bones of the hand. In many cases, the triggering or
locking is due to nodules (inflammation enlargement points) of the tendons as they
pass through sheaths. The nodules do not move freely through the tendon sheaths.
The pain is made worse by pinching with the thumb and first finger with tenderness
over the palmar part of the base of the thumb. Occasionally there is a creaking sound
or sensation with flexion and extension of the thumb. Other problems which may
present similarly are arthritis of the metocarpo-carpal joint of the thumb and gout of
the first metacarpal joint. Treatment is with NSAIDS or COX2 inhibitors, heat, gentle
range of motion, and occasionally injection directly into the tendon with steroids. Risks
of this injection include tendon rupture, bleeding, infection, increase in pain in 25%.
Trigger finger is a painful condition involving the fingers which tend to lock in the
partially flexed position due to flexor tendon inflammation and nodule formation similar
to trigger thumb. The nodules on the tendon moving back and forth through the
sheath surrounding and lubricating the tendon get stuck much as a knotted rope gets
stuck moving through a pulley. Tight gripping of hammers or other equipment or
steering wheels may cause trigger finger. Often patients awaken from sleep with a
locked finger. Pain from trigger finger is usually located near the junction of the palm
of the hand with the finger with the maximum tenderness at the same location. The
condition may be confused with arthritis of the hand. Treatment is with NSAIDS and
range of motion physical therapy. Trigger finger injections may be both diagnostic and
therapeutic. Rarely surgery will be required.
Ganglion cysts of the hand and wrists are usually not severely painful but the skin over
the cyst is frequently bumped against things causing some pain. Most of these cysts
are located over the back of the hand (dorsum) at the wrist joint. They form from
tendons or from the joints of the hand as a herniation of the synovial tissue which
lubricates the joints or tendons. The tissue becomes irritated and produces increased
amounts of joint fluid. A one way valve mechanisms may prevent the cyst from
draining and therefore the cyst gradually and slowly progressively enlarges. Extreme
flexion or extension of the wrist causes increased pain as does pressure placed on the
cyst. The ganglion is smooth and not associated with multiple nodules. If conservative
treatments such as NSAIDS, physical therapy, limitation of extreme motion, and a night
time splint do not resolve the symptoms, injections of steroids and drainage of the cyst
are used. If these measures fail, then surgery is sometimes indicated. During surgery
(which is often done with a special type of anesthesia called a Bier block), the ganglion
is explored at its roots all the way into the joint or tendon.
Dupuytren's Contracture is a commonly encountered problem affecting the ring and
little finger in males, usually over age 40. It results in increasing progressive flexion of
these fingers towards the palm and pain in the palm of the hand. The condition is due
to progressive scar tissue of the palmar fascia which is a thick tissue over the muscles
and bones in the palm of the hand. The scar tissue develops as a result of genetics
(Swedish, Norwegian, Danish, etc), trauma to the palm, diabetes or alcoholism.
Usually the condition is painful only during the initial stages and as it progresses, the
pain becomes less and less as the flexion deformity of the fingers becomes
progressively worse. Usually tight fibrous bands in the palm may be felt late in the
course of the condition whereas early in the condition, only nodules may be felt.
Usually the patient will seek care not due to pain but due to inability to perform daily
tasks such as putting on a glove, buckling a belt, typing, etc. Treatment of the
contractures involve injections of steroids into the fibrosis of the palm, injections of
agents to break up the scar tissue, and physical therapy. Usually surgery is ultimately
performed. Recovery is usually complete from surgery.
Peripheral neuropathy is damage to the peripheral nerves resulting in the production
ofburning numbing of the hands and/or feet. The nerve damage comes from any of a
variety of diverse causes, but all with the same end result. The most common cause is
diabetes mellitus which results in a burning pain in the distribution of a glove on the
hand and usually involves the feet also in a distribution of the socks. Often patients
suffering with diabetes will experience severe burning pain at night. Other causes of
peripheral neuropathy are compression or entrapment, direct trauma, penetrating
injuries, contusions, fracture or dislocated bones; pressure involving the superficial
nerves (ulna, radial, or peroneal) which can result from prolonged use of crutches or
staying in one position for too long, or from a tumor; intraneural hemorrhage;
exposure to cold or radiation or, rarely, certain medicines or toxic substances such as
lead poisoning; and vascular or collagen disorders such as atherosclerosis, systemic
lupus erythematosus, scleroderma, sarcoidosis, rheumatoid arthritis, or polyarteritis
nodosa. Treatment involves Cymbalta, removal of sources of compression, physical
therapy, anticonvulsant drugs, and rarely decompressive surgery. If there is an
offending toxin such as lead, occasionally chelation therapy may be appropriate.
Carpal tunnel syndrome is a form of peripheral neuropathy.
Reflex sympathetic dystrophy, also known as RSD or CRPS (complex regional pain
syndrome) is an extremely painful and debilitating disorder, usually induced by surgery
or trauma. Typically, there is pain out of proportion to the original injury or surgery,
swelling of the hand, hypersensitivity to touch, shiny skin, "white hands: or other
alternating color changes from white to red to blue, and decreased motion of the hand
with guarding due to extreme pain. There may be xray evidence of bone loss in the
affected area, and there is often a temperature difference between the RSD hand and
the normal hand. The pain may go on for years and may result in complete loss of the
use of the hand or arm. In 5% of patients, the condition will spread to another
extremity. Treatment is best initiated early after recognition of the condition and
should include mobilization physical therapy, stellate ganglion or thoracic sympathetic
blockade, peripheral nerve blockade, and occasionally, spinal cord stimulator implants.
