Managing wrist and hand pain
The wrist connects the forearm and the hand. It is a complex region containing many different bones and ligaments. The arrangement of the bones and ligaments allows the hand to have significant mobility while maintaining stability.
The hand also is made of several bones and ligaments which are arranged as individual digits (the fingers). The position and mobility of the first digit (thumb) is crucial to normal hand function which is essential for performance of the activities of daily living and participation in many sports.
The bones of the fingers also serve as points of origin for small muscles in the hand and points of insertion for the tendons of the muscles which flex (bend) or extend (straighten) the wrist and fingers. Important nerves and blood vessels also pass through the wrist on the way to the fingers.
There are many possible causes to consider in a person who has wrist or hand pain. The complexity of the areas means that pinpointing the exact cause of the patient’s pain is not always straightforward. A proper history must be obtained as this will contribute significantly to the physician’s ability to make a correct diagnosis.
Factors that must be considered include the patient’s past medical history, the history of a single episode or repetitive cases of trauma, and having a job or participation in a sport that requires repetitive use of the wrist and hand.
Today, we will discuss a few conditions which may lead to pain in these regions of the body:
1) Dequervain’s tenosynovitis
2) Carpometacarpal (CMC) osteoarthritis (OA)
3) Stenosing tenosynovitis (Trigger finger)
The tendons of the muscles which extend the wrist and fingers pass over the back of the wrist on the way to their insertions on the bones of the fingers. The tendons are surrounded by coverings known as synovial sheaths which help to prevent friction from the bones or ligaments in the area.
The tendons pass over the wrist in six groups called compartments. Persons who do activities involving repetitive wrist or thumb motion may get swelling of two tendons which attach to the thumb. This condition is called Dequervain’s tenosynovitis.
It causes pain in the area of the base of the thumb on the back of the wrist, along with swelling and tenderness. These symptoms can be worsened with thumb movement or ulnar deviation of the wrist (moving the hand toward the inner forearm bone).
CMC osteoarthritis refers to arthritis at the base of the thumb. This has the same causes as osteoarthritis in other areas of the body. The initial symptom is usually pain in the area when gripping objects or using the thumb forcefully.
Other symptoms include swelling, stiffness and tenderness in the area as well as decreased range of motion and grip strength. These symptoms can make it very challenging to complete activities of daily living. The base of the thumb can appear deformed as bony enlargement occurs in the late stages of the disease.
In trigger finger, the flexed (bent) finger remains stuck in a flexed position when the patient tries to extend (straighten) it. It may then extend spontaneously with a snap (like a trigger being pulled and released) or the individual may need to use the other hand to straighten it.
Repetitive trauma causes inflammation in the sheath surrounding the tendons that flex the finger. This leads to a nodule (swelling) developing in the tendon. This nodule prevents normal movement of the tendon and causes the sticking and triggering when trying to extend the finger. Apart from the triggering, there may be pain in the area of the nodule. This condition is more common in persons with diabetes.
The rehabilitation specialist has an important role to play in the management of wrist and hand pain. A thorough evaluation will suggest the cause of the pain in most patients. Where necessary, imaging such as x-rays, ultrasound or MRI will be ordered to confirm the diagnosis.
The treatment plan can be designed once the correct diagnosis has been made and will usually include occupational therapy. Pain control and education of the patient about the diagnosis are other cornerstones of management of wrist and hand conditions.
Pain control may require use of oral medications or a steroid injection into the appropriate area. A thumb spica splint will be useful in patients with Dequervain’s tenosynovitis and CMC OA. In patients who have severe injuries, fractures or conditions which are not responding to appropriate conservative treatments, referral to an orthopedic surgeon will be provided for an evaluation for surgical treatment of the disorder.
If you have severe wrist or hand pain or your pain is not resolving within a short period of time, a thorough evaluation is the first step to regaining optimal physical function.
(Dr Shane Drakes is a Specialist in Physical
Medicine &Rehabilitation and Sports Medicine.
He can be contacted at firstname.lastname@example.org)