Musculoskeletal problems of the wrist and hand history and symptoms

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

History and Symptoms

Painful Movement

• Dorsal Wrist Pain
  • Most common complaint
  • Traumatic injury
    • Distal radial fracture
      • After fall on outstretched arm (Colles’ fracture)
      • Common in young & in elderly with osteoporosis
    • Scaphoid fracture
      • Most common bony injury
      • Tenderness in anatomic snuff box
      • Need scaphoid view +/- follow up films at 2 weeks to detect
      • Poor blood supply--risk nonunion, avascular necrosis
    • Perilunate dislocation
      • After fall on outstretched, extended wrist
      • Dorsal shift of all bones due to severe ligament injury
      • Only lunate remains articulated with radius
      • X-ray with increased interosseous scaphoid-lunate distance
    • Simple sprain
      • Injury to supporting ligaments of radiocarpal joint
    • Mild pain or stiffness
    • Normal range of motion (ROM) or <10% loss of flexion/extension
    • Resolves within 2 weeks with conservative therapy
  • Atraumatic
    • Radiocarpal arthritis
      • Unilateral usually due to prior trauma--secondary osteoarthritis (OA)
      • Uncommon site for primary OA
      • Bilateral arthritis likely due to RA or crystals
      • Wrist more common site for pseudogout than gout
      • Septic arthritis of wrist rare
      • Pain, swelling and reduced ROM of wrist
• Radial Wrist Pain and Grip Weakness
  • DeQuervain’s Tenosynovitis
    • Abductor pollicis longus and extensor pollicis (snuffbox) tendons
    • Pain worst over distal radial styloid
    • Pain worsened by activity, relieved by rest; history wrist/hand overuse
  • CMC Arthritis
    • Common, due to repetitive gripping/grasping or vibration exposure
    • Wear and tear of articular cartilage at base of thumb
    • Pain and swelling at base of thumb
  • Gamekeeper’s thumb
    • Disruption of the ulnar collateral ligament of the MP joint
    • Due to trauma (ski pole injuries) or repetitive use
    • Instability of metacarpal (MP) joint, loss of pinch/opposition function/strength
    • Pain and swelling on ulnar side of MP joint
    • Late degenerative arthritic change
  • Osteonecrosis
    • Usually involves scaphoid and lunate, history trauma in 50%
    • Reduced wrist flexion/extension, decreased grip strength
    • Most severe tenderness over anatomical snuff box
    • Can take 4-8 weeks for X-rays to show lesion; bone scan shows earlier

Dorsal Swelling

• Localized
  • Ganglion cyst
    • Painless abnormal accumulation of synovial or tenosynovial fluid
    • Due to subtle abnormalities in wrist or extensor tendon sheath
    • Overproduction of fluid irritates scar tissue and causes cyst formation
    • Small % of patients have pain due to cyst pressure on tendons/radial nerve
    • +/- Paresthesias over back of hand/fingers (pressure on superficial radial nerve)
• Diffuse
  • Extensor tenosynovitis
    • Swelling from wrist to back of hand
    • Pain aggravated by movement of fingers

Stiffness

• Rheumatoid Arthritis (RA)
  • Symmetrical joint symptoms with morning stiffness
• Carpal Tunnel Syndrome (CTS)
  • Can have stiffness as prominent feature

Sensory Changes with Wrist Use

• Carpal Tunnel Syndrome
  • Compression neuropathy of the median nerve at the carpal ligament
  • Loss of sensation at the tips of the first 3 fingers
  • Grip weakness, pain at wrist +/- radiation to fingers or forearm
  • Pain may awaken patient at night; may be relieved with wrist motion
  • Usually idiopathic
  • Can be due to reduced space in tunnel
    • Tenosynovitis / inflammatory arthritis
    • Acromegaly
    • Pregnancy (3rd trimester)
    • Hypothyroidism
    • Chronic renal failure
    • Amyloidosis
  • Can be due to increased susceptibility to pressure
    • Diabetes mellitus (DM)
    • Vasculitis
    • Hereditary neuropathy