Wrist & Hand Pain/Swelling
Wrist & Hand Pain/Swelling: Excerpt from In a Page: Signs and Symptoms
The wrist is composed of eight carpal bones that are held in alignment by a series of ligaments and cartilaginous connective tissue. Wrist pain is fairly common in primary care. Although carpal tunnel syndrome is one of the most common etiologies of wrist pain, pain and numbness in the hand is a more common presentation.
Differential Diagnosis
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Carpal tunnel syndrome
–Most common cause of significant wrist discomfort and morbidity
–Associated with repetitive use activities (e.g., typing)
–Pain and numbness symptoms result from entrapment of the median nerve under the transverse ligament
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Overuse injury
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Osteoarthritis
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Tenosynovitis (DeQuervain's) of the radial wrist
–Results from inflammation of the tendon sheaths of the extensor pollicis brevis and abductor pollis longus
- Ganglion cysts
–Common growths of tendons and ligaments in the wrist area occurring on both the dorsal and ventral surface
–They are compressible, round, often tender, and mobile
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Trauma
–The most common mechanism of injury is a fall on the outstretched hand
–The most commonly fractured carpal bone is the scaphoid
–Other mechanisms include direct blows, crush injuries, fall on an angulated wrist, and severe twisting motions
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Fibromyalgia
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Compartment syndrome
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Chest or shoulder masses, resulting in compression of lymphatic or venous systems
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Venous thrombosis of the subclavian or distal veins
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Flaccid paralysis following a CVA
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Angioedema secondary to hymenoptera sting
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Rheumatologic disease
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Peripheral neuropathy
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Insect or animal bite/sting
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Infection (e.g., staphylococcus aureus, streptococci)
Workup and Diagnosis
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History and physical examination of the hand, wrist, elbow, and shoulder
–Tinel's sign is positive if pain is elicited by tapping the anterior wrist
–Phalen's sign is positive if wrist flexion for >30 seconds elicits pain or numbness -
Lab investigation is usually unnecessary, but may include rheumatoid factor, ANA, ESR, CBC, uric acid, TSH, β-hCG (pregnancy test)
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Standard X-rays include PA, lateral, and oblique views
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EMG and nerve conduction studies are indicated if carpal tunnel syndrome or other neuropathy is suspected
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Arthrocentesis with crystal analysis may be indicated if warmth and redness are noted in the wrist and MCP joints
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Bone scan may be necessary to evaluate for avascular necrosis, occult fracture, or bone infection
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Rarely, CT or MRI is indicated
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Shoulder/chest CT may be indicated to evaluate for masses resulting in nerve entrapment or vascular compromise
Treatment
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Corticosteroid injection for carpal tunnel improves symptoms in more than half of patients; surgical intervention to release the transverse ligament and decompress the nerve entrapment may be indicated
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NSAIDs reduce inflammation and use of cock-up splints applied during activities and while sleeping reduces strain from repetitive use and reduces symptoms
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Corticosteroid injection along tendon sheaths and wearing a thumb spica splint treat tenosynovitis
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Ganglion cysts are treated by draining the thick fluid and injecting with steroid; surgical removal is occasionally necessary
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Casting of suspected fractures and repeat X-ray in 7–9 days prevents complications of occult fracture
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Antihistamines and steroids treat swelling from stings
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Treat rheumatologic and medical causes
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Biofeedback and relaxation may be beneficial in selected cases
