Musculoskeletal problems of the wrist and hand medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Management

Acute Trauma

• Assess ligamentous, vascular, neurologic integrity
• X-Rays

  • If fracture suspected
  • Scaphoid views if tenderness in anatomic snuff box

• If no fracture

  • Rest, ice, splint as below; nonsteriodal anti-inflammatory drugs (NSAIDs)
  • If pain persists, repeat X-rays after 2 weeks to detect fracture not seen on initial films

Empiric Treatment for Mild-Moderate Wrist Pain with Normal ROM

• Neutral position

  • Avoidance of extremes of movement
  • Can use veclro wrist splint to immobilize in neutral position

• Restriction of repetitive gripping/grasping and exposure to vibration
• Restriction of lifting to less than 10 pounds
• Ice: to dorsal surface of wrist for 15 minutes up to three times a day
• Stretching: passive stretching in flexion and extension
• If persistent symptoms (or if traumatic injury, moderate to severe pain or decreased ROM or grip strength), further evaluation +/- X-rays needed

Specific Treatment for Various Syndromes

• Radiocarpal Arthritis

  • Mild: ice and Velcro wrist immobilizer with metal stay; NSAIDs x 3-4 weeks
  • Moderate to severe: local steroid injection
  • Crystal-induced: usual treatment for gout vs. pseudogout
  • Start flexion/extension passive ROM exercises once acute symptoms controlled
  • Gripping and wrist extension toning exercises after flare resolves
  • If persistent symptoms at 3 months with loss of >50% of ROM, refer to orthopaedist

• DeQuervain’s Tenosynovitis

  • Ice to radial styloid
  • Restriction of thumb gripping/grasping

    • Buddy-tape thumb to 1st finger
    • Treat with dorsal hood splint
    • Treat with Velcro thumb spica splint

  • If persistent symptoms at 3-4 weeks, prescribe steroid injection

    • 3/8” proximal to tip of radial styloid
    • 25 gauge needle
    • Depo-Medrol 80 mg/mL, ½ mL
    • 2-3 mL anesthetic (lido)
    • May repeat at 4-6 weeks if symptoms persist

  • 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)

• CMC Arthritis

  • Rest + NSAIDs (x 3-4 weeks) + restriction of gripping/grasping

    • Oversized tools and grips
    • Overlap-taping of joint, or
    • Dorsal hood splint, or
    • Velcro thumb spica spliint

  • If symptoms persist at 3-4 weeks, prescribe steroid injection

    • 3/8” proximal to base of metacarpal bone
    • 25 gauge needle
    • Adjacent to abductor tendon in snuffbox
    • ½ mL anesthetic + ½ mL Depo-Medrol 40 mg/mL
    • Repeat at 4-6 weeks if symptoms not reduced by 50%

  • Once pain improved, passive stretching of thumb flexors/extensors

• Gamekeeper’s Thumb

  • Ice to MP joint + immobilization with overlap taping, dorsal hood splint or thumb spica splint
  • Complete rest needed for 3-6 weeks to allow ligament healing/reattachment
  • Once recovered

    • Passive ROM flexion/extension exercises of thumb
    • Isometric toning of thumb flexion (squeeze tennis ball x 5 sec, repeat 20-25 times)

• Ganglion Cyst

  • Reassurance: may resolve spontaneously
  • If persistent, aspirate cyst (note: 18 gauge needle needed; anesthetize via 25 gauge needle first)
  • Limit repetitive wrist motions; consider Velcro wrist brace
  • If recurrence after aspiration, repeat aspiration and inject Depo-Medrol 40 mg/mL
  • If further recurrences, consider ortho referral for removal, though may recur even after excision

• Carpal Tunnel Syndrome

  • Treat any underlying cause (diuretics, antiinflammatories, L-T4, etc.)
  • Reduce repetitive wrist motion: occupational adjustments
  • Velcro wrist splint at night (or day and night if severe sxs)
  • Consider referral for steroid injection or surgery if inadequate symptom improvement
  • Note: 90% respond to steroid injection; surgery may be avoidable with physical therapy (PT) + steroid injection
  • Once symptoms improved (3-4 weeks after pain resolved), passive stretching exercises for flexor tendons