Wendy L. Halm Hand disorders may result from recreational or work-related activities or from inflammatory or degenerative disease. Acute wrist pain from fractures, contusions, strains and sprains, and instability is a common presentation. Incidence of scaphoid fracture peaks at age 15, and such fractures are infrequent in the older adult.1 Trauma or injury to the wrist may lead to the development of a ganglion cyst. Chronic wrist pain may be caused by arthritis of the hands and fingers, overuse, old injuries, or neurologic disorders. Job specialization, repetitive tasks, and workplace demographics have contributed to an increased incidence of cumulative hand and wrist injuries. Musculoskeletal-related ergonomic injuries accounted for 34% of all workplace injuries and illnesses and resulted in a median of 9 days away from work in 2012.2 These injuries, which are also known as cumulative trauma disorders, are defined as muscle, tendon, osseous, or neurologic conditions produced or exacerbated by repetitive movements.3,4 Many other factors, including sports activities, age, and various medical conditions, contribute to the development of hand and wrist pain. Acute hand and wrist injuries stemming from sports-related activities are common, including injuries to the palm from swinging a baseball bat or golf club and the classic injury to the thumb from the strap of a ski pole. Fractures of the scaphoid bone can occur during a fall onto an outstretched hand. Excessive physical activity (such as gardening or painting), may initiate or worsen existing chronic hand conditions, causing an acute pain flare. Ganglion cysts are fluid-filled sacks that can appear, disappear, and change size. Their cause is unknown. Wrist pain in the presence of systemic symptoms, such as fatigue, fever, or bilateral hand pain, suggests a systemic issue, such as Lyme disease, rheumatoid arthritis, systemic lupus erythematosus (SLE), or malignancy. Chronic wrist pain from cumulative trauma disorders usually results from repetitive microtrauma that over time affects the tendons, tendon sheaths, and connective tissues. The exact pathologic mechanism is not clearly understood.3 Carpal tunnel syndrome (CTS) is caused by compressive neuropathy of the median nerve. A bony canal bordered by the carpal bones on the radial, ulnar, and dorsal sides is roofed by the transverse carpal ligament. This canal provides a passage for the nine digital flexor tendons, the blood vessels, and the median nerve of the hand. Repetitive motion and overuse have often been thought to cause the syndrome, but recent studies may present differing conclusions. As the tendons swell, the cross-sectional area in the tunnel decreases. The resultant pressure in the small tunnel causes pressure on the median nerve. Nerve conduction is impeded, muscle strength is decreased because of the disturbance in motor fibers, and pain and paresthesia occur because of the disturbance in the sensory fibers.5 Common risk factors for development of CTS include repetitive maneuvers, obesity, pregnancy, diabetes mellitus, hypothyroidism, and female gender.4 Localized pain, numbness, tingling, weakness, and immobility are the common reasons that patients with hand or wrist disorders seek care. The symptoms may be intermittent or constant and often affect quality of life. Onset, duration, and location of all symptoms related to wrist pain should be noted. Age, sex, hand dominance, occupation, and hobbies or sports should also be documented. Past medical history should be explored for previous hand or wrist injury and any condition that might compromise nerve function, including pregnancy. Patients with a traumatic hand or wrist injury should be evaluated for fracture. Trigger finger, or stenosing tenosynovitis, is a disorder of the flexor tendons of the fingers or thumb. This condition, which may be more prevalent in patients with diabetes, gout, or rheumatoid arthritis, occurs most commonly when a nodule or thickening in the tendon catches on the edge of the A1 pulley of the finger as the tendon attempts to glide during movement.6,7 This thickening narrows the fibrous canal, which impedes tendon movement. The pulley action is impaired, causing a painful locking or triggering of the affected digit or thumb during extension. Although any digit may be affected; the middle or ring finger is most commonly involved.5 Chronic stenosing tenosynovitis (de Quervain tenosynovitis) is a condition that causes pain at the thumb base and into the distal radius.1 Women 30 to 59 years of age are more likely to have this condition.1,5 Activities requiring excessive repetitive motions (e.g., knitting) may aggravate this problem. It is also seen in new parents who frequently lift their child using wrist strength alone. Pain is noted with ulnar deviation under stress. Pouring from a pitcher or carton often reproduces pain. Dupuytren contracture, or palmar fibrosis, may be a hereditary process that initially develops as a painless nodule on the palmar fascia at the base of a digit.8 An inflammatory fibrosis subsequently expands into a bandlike cord under puckered skin and can lead to a flexion contracture. Although any finger (and both hands) may be affected, the resultant contracture most often affects the ring finger. The little finger may also be involved. The index finger is the least commonly affected digit for Dupuytren disease. CTS results from compression of the median nerve in the carpal tunnel of the wrist. Patients may have intermittent wrist pain and numbness and tingling that radiates from the palm to the thumb, index finger, middle finger, and medial aspect of the ring finger. In addition, the patient may report intermittent nocturnal paresthesia, pain and tightness at the wrist and forearm that increases with activity, and an inability to hold objects or a tendency to drop things.9 A tendency for symptoms to occur while driving, speaking on the telephone, or performing hygiene activities (brushing teeth, washing hair) may be reported. If the compression continues, the motor component of the median nerve is affected, and the ability to grasp with the thumb and index finger may be compromised.9 Arthritis is a common cause of hand and wrist pain. The trapeziometacarpal or basal joint area is a common site of osteoarthritis. Complaints include pain at the base of the thumb and weakness and pain with pinching or grasping. Arthritis in the hand can also be seen with osteoarthritis of the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints. Nodules are often seen at the DIP and PIP joints and are referred to as Heberden (DIP) and Bouchard (PIP) nodes, respectively (see Chapter 183). Rheumatoid arthritis commonly involves the metacarpophalangeal joints and the wrist in a bilateral and symmetric fashion, causing pain, inflammation, and deformity (see Chapter 221). In the case of a history of fall or other trauma, especially in the older adult, fracture is always a consideration until it is ruled out with x-ray examination. Complex anatomy and proximity of structures can make examination of the hand and wrist difficult. The physical examination should begin with inspection, noting any muscle wasting, localized swelling or masses, skin discoloration, hair loss, or deformity.7 Individual carpal bones should be palpated, passive and active range of motion should be assessed, and grip strength should be tested. Palpation of the anatomical snuff-box is necessary to exclude the possibility of scaphoid fracture. Motor function and sensory testing are also necessary. Additional provocative maneuvers and specific tests may be indicated. Physical findings seen in common causes of hand and wrist pain are described in the following paragraphs. Most cysts will be smooth and will transilluminate with light. Pain may or may not be present with palpation. Numbness, tingling, or weakness may be present if the mass is compressing the median or ulnar nerve at the wrist.6 Edema at the distal palm may be noted. The finger is fully flexed with the examiner’s finger on the metacarpophalangeal joint. The patient slowly extends the digit, and a “pop” is felt as the tendon slides back through the affected pulley. This maneuver is occasionally painful to the patient. Trigger thumb is examined in a similar manner. The patient will feel that the interphalangeal joint of the thumb is the culprit, but it is in fact the A1 pulley at the base of the thumb. Regardless of finger, there is often a palpable, tender nodule at the base of the affected digit.7
Hand and Wrist Pain
Definition and Epidemiology
Pathophysiology
Clinical Presentation
Trigger Finger
Tenosynovitis
Palmar Fibrosis
Carpal Tunnel Syndrome
Trapeziometacarpal Arthritis
Physical Examination
Ganglion Cyst
Trigger Finger
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Hand and Wrist Pain
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