Hand and Wrist Pain

Overview

History

Up to 70% of cases of hand or wrist pain can be determined by history alone.

• Systemic associations may stem from systemic illness.
• Recent trauma can lead to acute injuries and even fractures.
  • Fall on outstretched hand → scaphoid fracture, lunate dislocation, or scapholunate dissociation
• Location and description of pain
• Painful movements
• Patient occupation and sports/recreation

Physical examination

• Inspection
• Range of motion: can easily identify tendon rupture
• Examine the snuffbox to detect scaphoid fracture or De Quervain’s tenosynovitis
• Neurovascular exam
• Finkelstein’s test:
  • Differentiation between De Quervain’s tenosynovitis and arthritis of the first metacarpal
  • Instruct the patient to deviate the wrist to the ulnar aspect while grasping the thumb.
  • Pain over the radial styloid is suggestive of tenosynovitis.

Diagnostic workup

• X-ray: 
  • Radiography is usually negative in acute fractures.
  • Delayed radiographic images can confirm the diagnosis in retrospect.
• Computed tomography (CT) scan: confirms nonunion of a fracture, avascular necrosis, and acute fractures
• Magnetic resonance imaging (MRI): superior to other imaging modalities in the visualization of soft tissues such as ligaments and tendons 
• Nerve conduction studies: diagnostic study for carpal tunnel syndrome
• Blood work-ups: ordered in cases where systemic causes are suspected
  • CBC
  • Autoimmune assays
  • Renal and liver function tests

Differential Diagnosis

Mechanical causes

• Fractures: history of recent trauma and point-tenderness over a certain bony structure
  • Scaphoid fracture: 
    • Most commonly fractured carpal bone
    • History of falling onto an outstretched hand
    • Tenderness upon palpation of snuffbox
    • Fracture may not be immediately apparent in X-ray.
    • To confirm the diagnosis early, perform a CT scan or MRI, or repeat X-rays within 2 weeks.
    • High risk of nonunion and avascular necrosis (osteonecrosis) due to retrograde blood supply from a branch of the radial artery
    • Management includes thumb spica splint for 2 weeks (then repeat X-ray), immobilization with a cast for non-displaced fractures, or surgical intervention for displaced fractures.
  • Hook of hamate fracture: may cause ulnar nerve injury
• Dislocations:
  • Lunate dislocation: may cause acute carpal tunnel syndrome
• De Quervain’s tenosynovitis:
  • Entrapment tendonitis or tenosynovitis of the abductor pollicis longus tendon and the extensor pollicis brevis tendon
  • Patient presents with pain over the distal radius.
  • Classically affects new mothers who hold their infants with the thumb outstretched (abducted and extended), but a history of overuse is not necessary.
  • Diagnosis:
    • Finkelstein’s test: With the forearm in neutral position, place it on a desk or table with the hand hanging off the edge. The physician will perform passive and slow ulnar deviation of the hand, extend the thumb, and flex it into the palm. The test is positive if the patient reports aggravation of pain over the radial styloid process.
    • Ultrasonography can reveal synovial thickening.
  • Treatment includes splints (adherence is inconsistent), rest, and steroid injection.

Neurologic causes

• Carpal tunnel syndrome
  • A peripheral neuropathy caused by compression of the median nerve by the flexor retinaculum, or transverse carpal ligament
  • Presents as sensory disturbances (e.g., tingling, numbness) and weakness of the palmar surface of the thumb, index, and middle finger, and radial half of the ring finger
• Thoracic outlet compression syndrome 
  • Group of conditions that involve the compression of neurovascular structures, such as the subclavian vessels or brachial plexus, as they pass from the lower neck into the axilla
  • The thoracic outlet consists of the scalene muscles, first rib, and clavicle. 
  • May be caused by trauma, tumors, or the presence of a cervical rib

Systemic causes

• Amyloidosis: a disorder of misfolded proteins that are usually by-products of other pathologic processes that deposit and accumulate in certain tissues
• Leukemia: the unregulated proliferation of white blood cells that can result in hand pain due to bone invasion and metastasis
• Multiple myeloma: can result in hand pain due to lytic changes 
• Osteomyelitis: an infection of the bone most commonly caused by Staphylococcus aureus
• Peripheral neuropathy: peripheral nerve damage that presents as distal sensory loss, burning sensation, and/or weakness and may be caused by systemic conditions, such as diabetes mellitus or vitamin deficiency
• Regional pain syndrome: a condition characterized by pain that is more severe or has lasted longer than would be expected from the causative injury
• Rheumatologic disorders: Inflammation of the synovium is responsible for the pain that the patient may experience.
  • Rheumatoid arthritis: an inflammatory polyarthritis that presents with pain in joints that are warm and “boggy” to touch 
  • Systemic lupus erythematosus (SLE): a chronic inflammatory condition characterized by clinical involvement of the skin, joints, kidneys, blood cells, and central nervous system
  • Raynaud’s phenomenon: an exaggerated vascular response of the fingers to cold temperatures or emotional stress that results in sequential digital ischemia, hypoxia, and hyperemia
• Osteoarthritis: the most common form of arthritis, due to progressive wasting of articular cartilage and surrounding joint structures with minimal inflammation

Management

Initially, diagnose and treat the underlying condition. General principles of hand and wrist pain management are done according to the RICE principle, as follows:

• Rest:
  • Immobilization of the involved hand for days or hours 
  • Allows for scar tissue to form and unite the separated parts of a structure to avoid any further damage
  • Below-elbow cast is mostly used
• Ice application:
  • Works by inducing vasoconstriction and hypoxic injury and reduces the level of inflammation and smaller hematoma formation
  • Accelerates regeneration of cells
• Compression:
  • Reduces the amount of fluid or blood accumulated in edema and hematomas
• Elevate the limb:
  • Decreases the hydrostatic pressure so that the limb is less oedematous

Clinical Relevance

The following are possible etiologies of hand and wrist pain:

• Carpal tunnel syndrome: The carpal tunnel is formed anteriorly by the flexor retinaculum and posteriorly by the carpal bones. The median nerve and the tendons of the flexor digitorum longus travel to the fingers through the carpal tunnel. Carpal tunnel syndrome occurs from narrowing of the tunnel and subsequent compression of the structures within it, particularly the median nerve.
• Ulnar nerve injury: The ulnar nerve may be injured in multiple positions, including a fractured or dislocated hook of the hamate. Features include a loss of sensation in the fourth and fifth fingers of the hand, weakness that worsens with physical activity, and a claw hand. 
• Thoracic outlet syndrome: Thoracic outlet syndrome is caused by compression of the neurovascular structures at the thoracic outlet, especially those passing through the inter-scalene triangle. Signs and symptoms in the patient are produced according to the structures involved (i.e., neurogenic, arterial, and venous symptoms). The syndrome is classified on the basis of the structures involved.
• Osteoarthritis: degenerative disorder of the articular cartilage, along with the subchondral bones and other joint structures. It is the most common type of joint disease and is the leading cause of disability in older adults. The main risk factors for osteoarthritis are a family history of the disease, female gender, past trauma to the involved joint, aging, and obesity.
• Rheumatoid arthritis: chronic inflammatory systemic disease that proceeds progressively in stages. The basis of the disease is an inflammation of the synovial membrane, i.e., the inner layer of the joint capsule. Attributed to synovitis, rheumatoid arthritis can lead to secondary diseases such as arthritis, bursitis, or tenosynovitis.
• Systemic lupus erythematosus: an autoimmune disease with wide variation in signs and symptoms. Symptoms range from mild conditions to severe organ manifestations, which sometimes makes the diagnosis difficult. Systemic lupus erythematosus may affect all joints of the human body, so patients may present with joint pain, including wrist pain.