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| __NOTOC__ | | __NOTOC__ |
| {{SI}} | | {{Musculoskeletal problems of the wrist and hand}} |
| | '''For patient information, click [[Musculoskeletal problems of the wrist and hand (patient information)|here]]''' |
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| {{CMG}} | | {{CMG}} |
| == 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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|
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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 overview|Overview]]== |
| * '''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 anatomy|Anatomy]]== |
| * '''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 historical perspective|Historical Perspective]]== |
| == 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 classification|Classification]]== |
| * '''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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|
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| === Stiffness === | | ==[[Musculoskeletal problems of the wrist and hand pathophysiology|Pathophysiology]]== |
| * '''[[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 causes|Causes]]== |
| * '''[[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 differential diagnosis|Differentiating Musculoskeletal problems of the wrist and hand from other Diseases]]== |
| === 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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|
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| === Specific Maneuvers === | | ==[[Musculoskeletal problems of the wrist and hand epidemiology and demographics|Epidemiology and Demographics]]== |
| * '''Palpation of the Radiocarpal Joint Line'''
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| *:*:* 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 === | | ==[[Musculoskeletal problems of the wrist and hand risk factors|Risk Factors]]== |
| * 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 === | | ==[[Musculoskeletal problems of the wrist and hand natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| * 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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|
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| === Nerve Conduction Studies === | | ==Diagnosis== |
| * Indicated if suspected median nerve compression
| | [[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 x ray|X Ray]] | [[Musculoskeletal problems of the wrist and hand CT|CT]] | [[Musculoskeletal problems of the wrist and hand MRI|MRI]] | [[Musculoskeletal problems of the wrist and hand ultrasound|Ultrasound]] | [[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]] |
| * 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]] |
|
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| ----
| | == Case Studies == |
| | [[Musculoskeletal problems of the wrist and hand case study one|Case #1]] |
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| {{WikiDoc Sources}} | | {{WikiDoc Sources}} |
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| [[Category:Disease]] | | [[Category:Disease]] |
| [[Category:Musculoskeletal Disease]] | | [[Category:Musculoskeletal Disease]] |
| [[Category:Primary care]]
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