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| ==Overview== | | ==[[Musculoskeletal problems of the wrist and hand overview|Overview]]== |
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| Wrist is made up of eight small bones known as carpals. They support a tube that runs through your wrist. That tube, called the carpal tunnel, has tendons and a nerve inside. It is covered by a ligament, which holds it in place.
| | ==[[Musculoskeletal problems of the wrist and hand historical perspective|Historical Perspective]]== |
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| Wrist pain is common. Repetitive motion can damage your wrist. Everyday activities like typing, racquet sports or sewing can cause pain, or even carpal tunnel syndrome. Wrist pain with bruising and swelling can be a sign of injury. The signs of a possible fracture include misshapen joints and inability to move your wrist. Some wrist fractures are a result of osteoporosis.
| | ==[[Musculoskeletal problems of the wrist and hand anatomy|Anatomy]]== |
| == Anatomy ==
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| <gallery>
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| Image:RightHumanPosteriorDistalRadiusUlnaCarpals.jpg|Right Human Posterior Distal Radius, Ulna, Carpals
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| Image:RightHumanAnteriorDistalRadiusUlnaCarpals.jpg|Right Human Anterior Distal Radius, Ulna, Carpals
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| Image:Carpus.jpg|Carpus
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| </gallery>
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| <gallery>
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| Image:Gray334.png|Ligaments of wrist. Anterior view
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| Image:Gray335.jpg|Ligaments of wrist. Posterior view.
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| </gallery>
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| === Bones ===
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| * '''Distal [[Radius]]'''
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| *:* Styloid process adds medial stability
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| * '''Distal [[Ulna]]'''
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| *:* [[Styloid process]] adds lateral stability
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| * '''Proximal Carpal Row'''
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| *:* [[Scaphoid]] ([[navicular]]), lunate, triquetrum, [[pisiform]]
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| *:* [[Scaphoid]] provides stabilizing articulation between proximal and distal carpals
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| * '''Distal Carpal Row'''
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| *:* [[Trapezium]], [[trapezoid]], [[capitate]], [[hamate]]
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| *:* Articulate with metacarpals
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| * '''Joint Capsules'''
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| *:* Seven non-communicating compartments of the [[wrist]]
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| *:* Negative findings in one compartment do not rule out pathology in another
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| === Tendons === | | ==[[Musculoskeletal problems of the wrist and hand classification|Classification]]== |
| * '''Flexor Tendons'''
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| *:* Majority traverse palmar surface via carpal tunnel
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| *:* Lie between carpal bones dorsally and flexor retinaculum ventrally
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| * '''Extensor Tendons'''
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| *:* Cross the wrist covered by fascia along the dorsal surface
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| * '''Insertions'''
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| *:* Major wrist flexors/extensors insert at base of metacarpals, not onto carpal bones
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| === Nerves === | | ==[[Musculoskeletal problems of the wrist and hand pathophysiology|Pathophysiology]]== |
| * '''Median Nerve'''
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| *:* Runs through carpal tunnel
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| * '''Ulnar Nerve'''
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| *:* Follows ulnar artery
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| ==Diagnosis== | | ==[[Musculoskeletal problems of the wrist and hand causes|Causes]]== |
| == History and Symptoms ==
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| === Painful Movement ===
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| * '''Dorsal Wrist Pain'''
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| *:* Most common complaint
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| *:* Traumatic Injury
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| *:*:* Distal Radial Fracture
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| *:*:*:* After fall on outstretched arm (Colles’ fracture)
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| *:*:*:* Common in young & in elderly with osteoporosis
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| *:*:* Scaphoid Fracture
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| *:*:*:* Most common bony injury
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| *:*:*:* Tenderness in anatomic snuff box
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| *:*:*:* Need scaphoid view +/- follow up films at 2 weeks to detect
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| *:*:*:* Poor blood supply--risk nonunion, avascular necrosis
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| *:*:* Perilunate Dislocation
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| *:*:*:* After fall on outstretched, extended wrist
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| *:*:*:* Dorsal shift of all bones due to severe ligament injury
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| *:*:*:* Only lunate remains articulated with radius
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| *:*:*:* X-ray with increased interosseous scaphoid-lunate distance
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| *:*:* Simple Sprain
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| *:*:*:* Injury to supporting ligaments of radiocarpal joint
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| *:*:* Mild pain or stiffness
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| *:*:* Normal range of motion (ROM) or <10% loss of flexion/extension
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| *:*:* Resolves within 2 weeks with conservative therapy
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| *:* Atraumatic
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| *:*:* Radiocarpal arthritis
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| *:*:*:* Unilateral usually due to prior trauma--secondary oseoarthritis (OA)
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| *:*:*:* Uncommon site for primary OA
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| *:*:*:* Bilateral arthritis likely due to RA or crystals
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| *:*:*:* Wrist more common site for pseudogout than gout
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| *:*:*:* Septic arthritis of wrist rare
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| *:*:*:* Pain, swelling and reduced ROM of wrist
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| * '''Radial Wrist Pain and Grip Weakness'''
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| *:* DeQuervain’s Tenosynovitis
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| *:*:* Abductor pollicis longus and extensor pollicis (snuffbox) tendons
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| *:*:* Pain worst over distal radial styloid
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| *:*:* Pain worsened by activity, relieved by rest; history wrist/hand overuse
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| *:* CMC Arthritis
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| *:*:* Common, due to repetitive gripping/grasping or vibration exposure
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| *:*:* Wear and tear of articular cartilage at base of thumb
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| *:*:* Pain and swelling at base of thumb
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| *:* Gamekeeper’s Thumb
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| *:*:* Disruption of the ulnar collateral ligament of the MP joint
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| *:*:* Due to trauma (ski pole injuries) or repetitive use
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| *:*:* Instability of metacarpal (MP) joint, loss of pinch/opposition function/strength
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| *:*:* Pain and swelling on ulnar side of MP joint
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| *:*:* Late degenerative arthritic change
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| *:* Osteonecrosis
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| *:*:* Usually involves scaphoid and lunate, history trauma in 50%
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| *:*:* Reduced wrist flexion/extension, decreased grip strength
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| *:*:* Most severe tenderness over anatomical snuff box
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| *:*:* Can take 4-8 weeks for X-rays to show lesion; bone scan shows earlier
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| === Dorsal Swelling === | | ==[[Musculoskeletal problems of the wrist and hand differential diagnosis|Differentiating Musculoskeletal problems of the wrist and hand from other Diseases]]== |
| * '''Localized'''
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| *:* Ganglion Cyst
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| *:*:* Painless abnormal accumulation of synovial or tenosynovial fluid
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| *:*:* Due to subtle abnormalities in wrist or extensor tendon sheath
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| *:*:* Overproduction of fluid irritates scar tissue and causes cyst formation
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| *:*:* Small % of patients have pain due to cyst pressure on tendons/radial nerve
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| *:*:* +/- Paresthesias over back of hand/fingers (pressure on superficial radial nerve)
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| * '''Diffuse'''
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| *:* Extensor Tenosynovitis
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| *:*:* Swelling from wrist to back of hand
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| *:*:* Pain aggravated by movement of fingers
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| === Stiffness === | | ==[[Musculoskeletal problems of the wrist and hand epidemiology and demographics|Epidemiology and Demographics]]== |
| * '''[[Rheumatoid Arthritis]] (RA)'''
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| *:* Symmetrical joint symptoms with morning stiffness
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| * '''[[Carpal Tunnel Syndrome]] (CTS)'''
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| *:* Can have stiffness as prominent feature
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| === Sensory Changes with Wrist Use === | | ==[[Musculoskeletal problems of the wrist and hand risk factors|Risk Factors]]== |
| * '''[[Carpal Tunnel Syndrome]]'''
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| *:* Compression [[neuropathy]] of the median nerve at the carpal ligament
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| *:* Loss of sensation at the tips of the first 3 fingers
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| *:* Grip [[weakness]], pain at wrist +/- radiation to fingers or forearm
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| *:* Pain may awaken patient at night; may be relieved with wrist motion
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| *:* Usually idiopathic
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| *:* Can be due to reduced space in tunnel
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| *:*:* [[Tenosynovitis]] / inflammatory [[arthritis]]
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| *:*:* [[Acromegaly]]
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| *:*:* [[Pregnancy]] (3rd trimester)
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| *:*:* [[Hypothyroidism]]
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| *:*:* [[Chronic renal failure]]
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| *:*:* [[Amyloidosis]]
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| *:* Can be due to increased susceptibility to pressure
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| *:*:* [[Diabetes mellitus]] (DM)
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| *:*:* [[Vasculitis]]
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| *:*:* Hereditary [[neuropathy]]
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| == Physical Examination == | | ==[[Musculoskeletal problems of the wrist and hand natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| === Wrist Function ===
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| * '''Range of Motion'''
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| *:* Radiocarpal joint flexion and extension
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| *:* Normal: flexion 90°, extension 80°
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| *:* Mild pain/stiffness + normal ROM: sprain or mild arthritis
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| *:* Moderate pain/stiffness + 20% loss ROM: arthritis
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| *:* Severe pain/stiffness + 50% loss ROM: acute gout, fracture (navicular/distal radius), dislocation
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| *:* Refusal to move: septic joint, fracture
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| *:* Loss of ROM in only one direction (due to pain)
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| *:*:* Tendon injury or inflammation
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| *:*:* Pain with passive stretching of tendon (opposite direction)
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| * '''Grip Strength'''
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| *:* Indirect measure of strength/integrity of forearm muscles
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| *:* Can be measured objectively using rolled up partly inflated blood pressure (BP) cuff (patient grip measured in mmHg)
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| *:* Reduced Grip Strength
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| *:*:* Disuse atrophy, arthritis (hand or wrist), CTS, DeQuervain’s, osteonecrosis
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| *:*:* May also be reduced in C8 radiculopathy, severe epicondylitis
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| === Specific Maneuvers === | | ==Diagnosis== |
| * '''Palpation of the Radiocarpal Joint Line'''
| | [[Musculoskeletal problems of the wrist and hand history and symptoms|History and Symptoms]] | [[Musculoskeletal problems of the wrist and hand physical examination|Physical Examination]] |[[Musculoskeletal problems of the wrist and hand laboratory findings|Laboratory Findings]] | [[Musculoskeletal problems of the wrist and hand other imaging findings|Other Imaging Findings]] |[[Musculoskeletal problems of the wrist and hand other diagnostic studies|Other Diagnostic Studies]] |
| *:*:* Junction of distal radius, scaphoid & lunate
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| *:*:* At intersection of index finger extensor tendon & distal radius
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| *:* Mild tenderness: simple sprain
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| *:* Moderate tenderness: [[osteoarthritis]] (OA)
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| *:* Severe pain: crystal-induced arthritis, Colles’ fracture, scaphoid fracture, perilunate dislocation
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| *:* Swelling: mild swelling will fill the depression over the navicular (severe swelling causes a bulge)
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| *:* Loss of ROM: significant loss (45° flexion / extension) with advanced disease
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| * '''Palpation of the Scaphoid Bone'''
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| *:* Scaphoid forms floor of anatomical snuff box (distal radial styloid + base of thumb + abductor pollicis longus + extensor pollicis longus)
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| *:* Tenderness in anatomical snuff box = scaphoid pathology (fracture, osteonecrosis, arthritis)
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| * '''Palpation of the Radial Styloid'''
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| *:* Pain suggests DeQuervain’s tenosynovitis (friction-induced irritation of anatomic snuffbox tendons)
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| *:* Confirmatory Testing
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| *:*:* Pain aggravated by thumb extension or abduction against resistance
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| *:*:*:* (Abduction = movement of thumb perpendicular to palm)
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| *:*:* Pain worse with passive stretch of tendons over radial styloid via thumb flexion
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| *:*:*:* (Finkelstein’s test)
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| * '''Compression of the Base of Thumb'''
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| *:* Screen for CMC arthritis (or strain)
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| *:* Pain with compression of the CMC joint in the ante partum (AP) plane suggests CMC arthritis
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| *:* Pressure applied from the snuffbox is much less painful
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| *:* Swelling best seen with wrist turned radial-side-up
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| *:* Crepitation with forcible rotation of metacarpal against trapezium (mortar & pestle sign)
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| *:* Bony protuberance of metacarpal or thenar atrophy: late stages
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| * '''Palpation of Metocarpophalangeal Joint'''
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| *:* Detect gamekeeper’s thumb (ulnar collateral ligament injury)
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| *:* Local tenderness/swelling along ulnar side of MP joint suggests diagnosis
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| *:* Instability or pain of MP joint with valgus stress (examiner’s thumb at MP joint, index finger at interphalangeal (IP) joint)
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| *:* Loss of MP flexion (normal = 90°) and pinch strength can occur with acute symptoms/swelling
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| * '''Tests for Nerve Compression'''
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| *:* CTS
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| *:* Sensory loss in the first 3 fingertips: two-point discrimination, light touch, pain decreased
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| *:* Weakness of thumb opposition: best detected when pt holds thumb + 5th finger together
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| *:* Tinel Sign
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| *:*:* Vigorous tapping over transverse carpal ligament with wrist in extension
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| *:*:* Positive if reproduces pain and paresthesia
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| *:* Phalen Sign
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| *:*:* Both wrists held in extreme volar flexion for 30-60 seconds
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| *:*:* Positive if symptoms reproduced
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| *:* Pronator Teres Compression
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| *:*:* If no compression detected at wrist, test for proximal compression
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| *:*:* Apply pressure to forearm 1 to 2 inches distal to antecubital fossa
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| *:*:* Positive if symptoms reproduced with compression
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| *:*:* Sensitivity increased by resisting forearm pronation
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| *:* '''Note:''' Tests can be totally normal despite significant compression (symptoms vary over time)
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| *:*:* Sensitivity and specificity of provocative tests low
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| * '''Transillumination'''
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| *:* Distinguishes between ganglion (transilluminates) and solid mass
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| *:* Ganglion cyst should be highly mobile and fluctuant, not adherent; ROM should be full
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| *:* Aspiration of cyst yields thick, colorless fluid
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| === X-Ray ===
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| * Plain X-Rays
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| *:* Indicated if suspected arthritis (radiocarpal, CMC) or fracture
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| *:* Usual views = Posteroanterior (PA), PA oblique, lateral
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| *:* PA ulnar deviation views views needed for suspected scaphoid fracture; may be negative for 1-2 weeks
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| *:* X-rays should be '''normal''' if:
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| *:*:* Simple sprain
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| *:*:* CMC strain (vs. CMC OA—abnormal films)
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| *:*:* DeQuervain’s – films not indicated
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| *:*:* Gamekeeper’s thumb – films not indicated
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| *:*:* Carpal tunnel syndrome – films not indicated
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| *:*:* Dorsal ganglion – films not indicated
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| === Aspiration ===
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| * Wrist Joint
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| *:* If infection or inflammatory or crystal-induced arthritis suspected
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| * Dorsal Ganglion
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| *:* Confirms diagnosis (thick, clear, gelatinous fluid)
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| === Nerve Conduction Studies ===
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| * Indicated if suspected median nerve compression
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| * Nerve conduction velocity (NCV) decreased in 70% of cases; high PPV, but sensitivity low
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| === Positive Median Nerve Block/or Steroid Injection ===
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| * Can be used to confirm suspected diagnosis of CTS
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| * Simultaneous steroid injection is therapeutic as well as diagnostic
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| * '''Significant risk complications''' (nerve atrophy or necrosis): should only be performed by an expert
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| == Differential Diagnosis ==
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| === Traumatic Injury ===
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| * '''Fracture'''
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| *:* Immediate severe pain and swelling
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| *:* Colle’s fracture
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| *:*:* Fracture of distal radius; most common, easily seen on X-ray
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| *:* Scaphoid Fracture
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| *:*:* May require special X-ray views to visualize
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| * '''Ligament Rupture or Tear'''
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| * '''Tendon Injury'''
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| === Nontraumatic ===
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| * '''Inflammatory Arthritis'''
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| *:* Septic, crystal-induced, rheumatoid arthritis (RA)
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| *:* Pain with movement of wrist through its range of motion
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| *:* Synovitis with swelling in setting of inflammatory entities
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| * '''Osteoarthritis'''
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| *:* Rarely involves wrist except for carpometacarpal (CMC) joint at base of thumb
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| * '''Osteonecrosis (avascular)'''
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| *:* Localized pain interfering with hand/wrist function
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| * '''Entrapment Syndromes'''
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| *:* Wrist pain radiating into hand or forearm, +/- sensory or motor deficits
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| *:* Carpal tunnel syndrome
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| *:* Ulnar or interosseous nerve entrapment
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| * '''Tenosynovitis'''
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| * '''Ganglion Cyst'''
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| * '''Referred Pain from Cervical-Spine/Shoulder'''
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| *:* Pain in absence of local findings
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| *:* Symptoms worsened by neck/shoulder movement
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| == Management ==
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| === Acute Trauma ===
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| * Assess ligamentous, vascular, neurologic integrity
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| * X-Rays
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| *:* If fracture suspected
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| *:* Scaphoid views if tenderness in anatomic snuff box
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| * If no fracture
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| *:* Rest, ice, splint as below; nonsteriodal anti-inflammatory drugs (NSAIDs)
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| *:* If pain persists, repeat X-rays after 2 weeks to detect fracture not seen on initial films
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| === Empiric Treatment for Mild-Moderate Wrist Pain with Normal ROM ===
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| * Neutral position
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| *:* Avoidance of extremes of movement
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| *:* Can use veclro wrist splint to immobilize in neutral position
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| * Restriction of repetitive gripping/grasping and exposure to vibration
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| * Restriction of lifting to less than 10 pounds
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| * Ice: to dorsal surface of wrist for 15 minutes up to three times a day
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| * Stretching: passive stretching in flexion and extension
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| * If persistent symptoms (or if traumatic injury, moderate to severe pain or decreased ROM or grip strength), further evaluation +/- X-rays needed
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| === Specific Treatment for Various Syndromes ===
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| * '''Radiocarpal Arthritis'''
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| *:* Mild: ice and Velcro wrist immobilizer with metal stay; NSAIDs x 3-4 weeks
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| *:* Moderate to severe: local steroid injection
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| *:* Crystal-induced: usual treatment for gout vs. pseudogout
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| *:* Start flexion/extension passive ROM exercises once acute symptoms controlled
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| *:* Gripping and wrist extension toning exercises after flare resolves
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| *:* If persistent symptoms at 3 months with loss of >50% of ROM, refer to orthopaedist
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| * '''DeQuervain’s Tenosynovitis'''
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| *:* Ice to radial styloid
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| *:* Restriction of thumb gripping/grasping
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| *:*:* Buddy-tape thumb to 1st finger
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| *:*:* Treat with dorsal hood splint
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| *:*:* Treat with Velcro thumb spica splint
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| *:* If persistent symptoms at 3-4 weeks, prescribe steroid injection
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| *:*:* 3/8” proximal to tip of radial styloid
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| *:*:* 25 gauge needle
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| *:*:* Depo-Medrol 80 mg/mL, ½ mL
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| *:*:* 2-3 mL anesthetic (lido)
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| *:*:* May repeat at 4-6 weeks if symptoms persist
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| *:* Once symptoms improved (3-4 weeks), gentle passive stretching exercises of thumb abductor and extensor tendons into the palm (20 stretches every day, each held for 5 seconds)
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| * '''CMC Arthritis'''
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| *:* Rest + NSAIDs (x 3-4 weeks) + restriction of gripping/grasping
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| *:*:* Oversized tools and grips
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| *:*:* Overlap-taping of joint, or
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| *:*:* Dorsal hood splint, or
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| *:*:* Velcro thumb spica spliint
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| *:* If symptoms persist at 3-4 weeks, prescribe steroid injection
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| *:*:* 3/8” proximal to base of metacarpal bone
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| *:*:* 25 gauge needle
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| *:*:* Adjacent to abductor tendon in snuffbox
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| *:*:* ½ mL anesthetic + ½ mL Depo-Medrol 40 mg/mL
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| *:*:* Repeat at 4-6 weeks if symptoms not reduced by 50%
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| *:* Once pain improved, passive stretching of thumb flexors/extensors
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| * '''Gamekeeper’s Thumb'''
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| *:* Ice to MP joint + immobilization with overlap taping, dorsal hood splint or thumb spica splint
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| *:* Complete rest needed for 3-6 weeks to allow ligament healing/reattachment
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| *:* Once recovered
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| *:*:* Passive ROM flexion/extension exercises of thumb
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| *:*:* Isometric toning of thumb flexion (squeeze tennis ball x 5 sec, repeat 20-25 times)
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| * '''Ganglion Cyst'''
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| *:* Reassurance: may resolve spontaneously
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| *:* If persistent, aspirate cyst (note: 18 gauge needle needed; anesthetize via 25 gauge needle first)
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| *:* Limit repetitive wrist motions; consider Velcro wrist brace
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| *:* If recurrence after aspiration, repeat aspiration and inject Depo-Medrol 40 mg/mL
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| *:* If further recurrences, consider ortho referral for removal, though may recur even after excision
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| * '''Carpal Tunnel Syndrome'''
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| *:* Treat any underlying cause (diuretics, antiinflammatories, L-T4, etc.)
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| *:* Reduce repetitive wrist motion: occupational adjustments
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| *:* Velcro wrist splint at night (or day and night if severe sxs)
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| *:* Consider referral for steroid injection or surgery if inadequate symptom improvement
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| *:* Note: 90% respond to steroid injection; surgery may be avoidable with physical therapy (PT) + steroid injection
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| *:* Once symptoms improved (3-4 weeks after pain resolved), passive stretching exercises for flexor tendons
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| == References == | | ==Treatment== |
| {{Reflist}}
| | [[Musculoskeletal problems of the wrist and hand medical therapy|Medical Therapy]] | [[Musculoskeletal problems of the wrist and hand surgery|Surgery]] | [[Musculoskeletal problems of the wrist and hand primary prevention|Primary Prevention]] | [[Musculoskeletal problems of the wrist and hand secondary prevention|Secondary Prevention]] | [[Musculoskeletal problems of the wrist and hand cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Musculoskeletal problems of the wrist and hand future or investigational therapies|Future or Investigational Therapies]] |
|
| |
|
| ----
| | == Case Studies == |
| | [[Musculoskeletal problems of the wrist and hand case study one|Case #1]] |
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