00:01
Ouch.
00:03
Let’s talk about pain of the hand and wrist.
00:05
All right, here we go.
00:07
We’re going to talk about how to
distinguish different types of wrist pain,
and so – and hand pain.
00:11
So, therefore,
we’re going to start with
our differential diagnosis.
00:15
The main cause of hand and wrist pain
that include osteoarthritis,
rheumatoid arthritis,
tendinopathies, of which there are several,
acute injuries,
fractures and sprains,
and overuse injuries.
00:26
And we’re going to highlight, I think,
one of the most important for you to understand,
the ones that can be a little bit difficult to discriminate,
and what of course maybe on
USMLE exam as we go through.
00:37
So, physical examination,
inspection is where you start
looking for any gross deformities,
looking for swelling,
range of motion.
00:46
Especially when you’re talking about
range of motion of the fingers,
you can easily identify tendon rupture with
the inability to either extend or flex the fingers.
00:56
We’ll talk about some provocative tests,
such as Finkelstein's that you can
use for specific conditions,
and then a neurovascular exam
is almost always indicated
just checking for sensation to light touch at least,
if not two-point discrimination,
and making sure that capillary refill
and the radial pulses are strong.
01:13
And the reason to pay attention in a special way to the
anatomic snuffbox is the risk of a scaphoid fracture.
01:19
Now, scaphoid is the most common fractured
carpal bone and it's a very common mechanism.
01:25
Fall on to an outstretched hand.
01:27
And you can see in the image there,
a fracture of the scaphoid bone.
01:31
It's right through the body
of the bone in this.
01:34
So, really you’re going to
pay attention to this anatomic snuffbox
which is illustrated right here.
01:40
That's the snuffbox.
01:41
Tenderness in this area after a fall makes
you have to consider a scaphoid fracture.
01:46
So, in addition to your normal anterior,
posterior and lateral views of the wrist,
you’re going to want to
include a navicular view
to help give a special image of that bone.
01:56
And the important thing
to understand about scaphoid fractures
is that there's a high risk of non-union and there
is also a higher risk of avascular necrosis.
02:05
So, this can be a common injury
and usually something that
heals fairly well with the right treatment
into something that's a lot more
serious and chronic over time.
02:15
So, it's important to always
immobilize the thumb.
02:18
So, when you're unsure as to
whether the patient has a fracture or not,
make sure they get
not just a wrist splint,
but a thumb spica splint as well.
02:28
That's going to protect that scaphoid bone
from suffering avascular necrosis.
02:32
And because the initial radiographs can be negative,
in a decent proportion of patients
with a scaphoid fracture,
repeat radiographs are
necessary for two weeks.
02:42
If after they’ve been in the
splint for two weeks
and their x-ray is still negative,
there is not going to be a fracture there and then
they’re safe to begin range of motion exercises
and go through physical therapy.
02:53
A lot of times the patients are going to
feel a lot better at that point anyway,
two weeks after their injury.
02:59
So, that's high-yield stuff.
03:01
The other thing about the snuffbox
is that it is an area for
De Quervain's tenosynovitis.
03:06
This is a radial pain that's just limited
to that first extensor compartment.
03:12
Patients often have a history of overuse,
but not always.
03:17
Sometimes, it just arises from nowhere.
03:21
And the pathology is an inflammation of the extensor pollicis brevis and abductor pollicis longus tendons as well.
03:29
The important thing to
know I think for your exam,
and also clinically, with this condition,
there is a very specific exam for it.
03:37
So, thumb is tucked in here
under your second finger
and then it’s just a ulnar flexion,
and that pulls on those
endons and should hurt.
03:47
And sometimes,
it really hurts patients.
03:49
And so, pain over the anatomic
snuffbox with this maneuver,
it’s De Quervain's tenosynovitis,
and that's called Finkelstein's test.
03:57
It has a good sensitivity
and specificity overall.
04:01
So, the treatment for
De Quervain's tenosynovitis,
splinting can be helpful.
04:06
I find in my practice a lot of patients don't like to
use it because it limits the rest of their function,
and especially if they are at work
or they are taking care of their kids,
they want their hands free.
04:17
Rest, of course, if there's something that's an
overuse injury that’s promoting the tenosynovitis,
but this is one of those types of conditions
they can actually go right to injection.
04:27
Injecting a little bit of corticosteroid,
along with lidocaine,
right along the tendon sheath
can be curative for many patients.
04:34
They can become recurrent.
04:36
Once you have one episode of De Quervain's,
you’re much more likely to have another.
04:40
But if it's four to six months later,
repeating the injection is a
reasonable option for those patients.
04:47
Another common wrist and hand disorder,
carpal tunnel syndrome.
04:52
This slide just reviews the
distribution of the median nerve,
which is the one that's affected.
04:57
So, in the palmar surface,
it really includes these three fingers right here
plus part – the middle part of this fourth digit,
but really it can at times
involve the whole hand.
05:11
And if it’s more severe,
it can involve not just sensory symptoms,
but motors symptoms as well.
05:16
It does not involve the
dorsum of the hand, though.
05:18
It’s really the palmar surface that's affected –
or ventral surface that’s affected.
05:22
There is a distribution in green that you can expect,
but I have seen cases that
also involve the entire fourth digit.
05:29
And as I mentioned,
there can be a motor component to it as well.
05:34
So, things that we look for is tapping over
the medial wrist here, medially like so,
and that’s called Tinel sign.
05:45
Holding the wrists in that position like this for
30 seconds and for reproduction of the symptoms
and then a direct impression of both
sides of the carpal tunnel simultaneously
can elicit symptoms as well.
05:59
Just to describe the prevalence,
it's really common, 3 to 6% of adults.
06:03
And you can also see it outside
that median nerve distribution.
06:07
So, be aware of that.
06:09
These patients often have
decreased two-point discrimination.
06:12
That’s where that test
can be particularly helpful.
06:15
Thumb abduction, in particular, may be reduced
among patients with carpal tunnel syndrome.
06:22
And then if you have those things,
there is not much reason to add Tinels and Phalens
because they’re not really going to add a lot,
but I always do Tinel and Phalen
maneuvers on patients with CTS.
06:33
And that might come up in your exam,
something along the lines of,
you have a patient with wrist pain,
they put their wrist together,
what do you think the diagnosis –
and it reproduces the symptoms,
what do you think the diagnosis is?
Carpal tunnel syndrome.
06:47
All right.
06:47
So, ways to treat carpal tunnel.
06:50
First of all, you have to
address overuse.
06:53
This is a real problem for my patients who use their
hands and wrist repetitively and that’s part of their job.
06:59
Can be difficult.
07:00
Splinting, using it for a limited amount of time.
07:05
I like to use it mostly at night.
07:07
And the reason is that I don't
want that wrist to freeze up.
07:10
Again, the wrist has a lot of
range of motion to it.
07:13
You want to preserve that range of motion,
but also give it some time to rest.
07:16
That's why I splint at night.
07:17
Works for a lot of people.
07:18
Adherence is much better
than during the day.
07:20
You can use oral corticosteroids for the short-term
for very severe cases.
You can calm them down,
You can use oral corticosteroids for the short-term
for very severe cases.
You can calm them down,
so patients can return to function,
NSAIDs are relatively
ineffective for this condition.
07:31
And you can also consider injecting
for those patients who don't respond
well to conservative treatment alone,
which is mostly just
splinting and rest.
07:39
Injecting with triamcinolone, for example.
07:43
And a small percentage of patients actually
need to have that carpal tunnel released
or open carpal tunnel surgery.
07:53
So, those are some of the big
causes of hand and wrist pain.
07:56
I try to focus on things you
see commonly in your clinical practice,
but are also high-yield for USMLE.
08:03
Do keep that in mind
as you move forward.