PAIN IN THE HAND AND WRIST
TENOSYNOVITIS
ALL AGES
OLDR PATIENTS .
Nodal osteoarthritis .
Therapeutic ultrasound helps some people.Usually corticosteroid is injected alogside the tendon under low pressure ( not into tendon itself ) .Occasionally surgery is needed.
* CARPAL TUNNEL SYNDROME
Treatment is with a splint to hold the wrist in dorsiflexion overnight.This relieves the symptoms and is diagnostic ,used nightly for several weeks it may produce full recovery .If it does not ,a corticosteroid injection into the carpal tunnel helps in about 70% of cases ,although it may recur .Persistent symptoms or nerve damage requires nerve conduction studies and surgical decompression of the carpal tunnel.
* FIRST CARPOMETACARPAL OSTEOARTHRITHIS
Hand pain is commonly caused by injury or repetitive work-related use .When associated with pins and needles or numbness it suggests a neurological cause arising at the wrist ,elbow or neck.Pain and stiffness that are worse in the morning are due to tenosynovitis or inflammatory arthritis.The distribution of hand pain often indicates the diagnosis.
TENOSYNOVITIS
The finger flexor tendons run through a series of synovial sheath and under loops which hold them in place.Inflammation occurs with repeated or unaccustomed use ,or in inflammatory arthritis when the thickened sheaths are palpable .
Flexor tenosynovitis cause finger pain when gripping and stiffness of the fingers in the morning.Occasionally a tendon causes a trigger ,when the finger remains flexed after gripping and has to be pulled straight.A tendon nodule is palpable ,usually in the palm.
Dorsal tenosynovitis is less common except in rheumatoid arthriris.The swelling is on the back of the hand and wrist.
De Quervain's tenosynovitis causes pain and swelling around the radial styloid where the abductor policis longus tendon is held in place by a retaining band.There is local tenderness ,and the pain at the styloid is worsened by flexing the thumb into the palm.
PAIN IN THE HAND AND WRIST - CAUSES
ALL AGES
Trauma / fractures.
Tenosynovitis.
- Flexor with /without triggering.
- Dorsal.
- De Quervain's.
Carpal tunnel syndrome.
Ganglion.
Inflammatory arthritis.
Raynaud's syndrome.
Chronic regional pain .
OLDR PATIENTS .
Nodal osteoarthritis .
- DIPs ( heberden's nodes ).
- PIPs ( Bouchard's nodes ).
- First carpometacarpal joint.
Trauma - scaphoid fracture .
Pseudogout.
Gout.
- Acute.
- Tophaceous.TREATMENT
Therapeutic ultrasound helps some people.Usually corticosteroid is injected alogside the tendon under low pressure ( not into tendon itself ) .Occasionally surgery is needed.
OTHER CONDITIONS CAUSING PAIN
* CARPAL TUNNEL SYNDROME
This is due to thickened tendons or synovitis in the carpal tunnel .The history is usually typical and diagnostic with the patient waking with numbness ,tingling and pain in a median nerve distribution.The pain radiates to the forearm.The fingers feel swollen but usually are not .It is also seen during the last trimester of pregnancy.
Treatment is with a splint to hold the wrist in dorsiflexion overnight.This relieves the symptoms and is diagnostic ,used nightly for several weeks it may produce full recovery .If it does not ,a corticosteroid injection into the carpal tunnel helps in about 70% of cases ,although it may recur .Persistent symptoms or nerve damage requires nerve conduction studies and surgical decompression of the carpal tunnel.
* INFLAMMATORY ARTHRITIS
This may present with pain ,swelling and stiffness of the hands .In Rheumatoid arthritis the wrists ,proximal interphalangeal ( PIP ) joints and metacarpophalangeal (MCP ) joints are affected symmetrically.In psoriatic arthritis and Reiter's disease a finger may be swollen ( dactylitis ) or the distal interphalangeal ( DIP ) joints are affected asymmetrically.
* NODAL OSTEOARTHRITIS
This affects the DIP and less commonly PIP joints ,which are initially swollen and red.The inflammation and pain settle but bony swellings remain. There is often a strong family history and it rarely presents before 50 years of age .Reassurance and local treatment are all that is needed .
* FIRST CARPOMETACARPAL OSTEOARTHRITHIS
This causes pain at the base of the thumb when gripping or painless stiffness at the base of the thumb.
* SCAPHOID FRACTURES
These causes pain in the anatomical snuff box.They may not be seen immediately on X-ray ,Ultrasound scaphoid fractures evetually cause pain because of failed union.
* GANGLION
A ganglion is a jelly-filled ,often painless swelling caused by a partial tear of the joint capsule.The wrist is a common site.Treatment is not essential as many resolve or cause little trouble.They rarely respond to injection ,and surgical excision is possibly the best option.
DUPUYTREN'S CONTRACTURE
This is a painless palpable fibrosis of the palmar aponeurosos ,with fibroblasts invading the dermis .It causes puckering of the skin and gradual flexion of the affected fingers ,usually the ring and little fingers .It is more common in males .Caucasians ,in diabetes mellitus and in those who abuse alcohol .It is associated with Peyronie's disease of the penis - a painful inflammatory disorder of the corpora cavernosa ,leading eventually to painless fibrosis and angulation of the penis during erection .Plastic surgical release of the contracture is restricted to those with severe deformity of the fingers.
