Pain at the base of the thumb may represent carpometacarpal (CMC) arthritis or De Quervain’s tenosynovitis
The Finkelstein test is sensitive and specific for identifying De Quervain’s tenosynovitis, while the CMC grind test may help identify CMC arthritis
Management of CMC arthritis consists of NSAIDs and immobilization using a thumb spica splint for 1-2 weeks; steroid injection can be considered if symptoms persist
De Quervain’s is also managed with NSAIDs and immobilization–if there is no improvement, cortisone injection can be considered
Trigger finger can be identified by the characteristic catching and “triggering” of the finger with extension
Trigger finger is managed by splinting the affected finger for several weeks; cortisone injections can be effective for persistent symptoms, and surgery can be performed for refractory cases
Carpal tunnel syndrome is caused by compressive changes and impairment of axonal microvascular circulation
Carpal tunnel syndrome is initially managed by nocturnal bracing of the wrist
Cortisone injection can be diagnostic and therapeutic for carpal tunnel syndrome; if they are initially effective, but the symptoms recur, surgery may be a reasonable option
Hand and Wrist Pain Notes
Initial Approach
Dr. Parks separates hand and wrist complaints as traumatic and non-traumatic
The initial goal is to rule out fracture or other worrisome pathology
Etiologies of hand and wrist pain can be divided into three broad categories:
Nerve compression (e.g., carpal tunnel syndrome)
Generally characterized by numbness and tingling
Wear and tear (e.g. osteoarthritis)
Tendonitis
Carpometacarpal arthritis
The carpometacarpal joint at the base of the thumb is especially prone to arthritis given its wide range of motion
To assess for carpometacarpal arthritis, grasp the thumb and press towards the wrist as if using a mortar and pestle
This grinds the base of the metacarpal against the trapezium
A positive test causes discomfort
This is not as good a test as the Finkelstein (see below)
Management
Can be initially managed with NSAIDs (if safe for the patient) and immobilization with a spica splint for 1-2 weeks
If splinted for too long, arthritic joints stiffen and the surrounding muscles atrophy
If pain is persistent, could consider a steroid injection in the first carpometacarpal joint
De Quervain’s tenosynovitis
The underlying pathophysiology is related to the configuration of the tendons and tendon sheaths
The tendons that operate the thumb and fingers pass through tendon sheaths in the wrist
The two tendons that operate the thumb must take a turn as they exit the tendon sheath
This underlying curve can lead to chafing against the edge of the tendon sheath, which leads to inflammation
Diagnosis can be made using the Finkelstein’s test (it should be noted that there is fiery debate over eponyms and maneuvers (Wu et al., 2018))
Dr. Parks performs the Finkelstein test by having the patient put their thumb in their palm, wrap their fingers around the thumb to make a fist, and then tilt their wrist towards their pinky
If the patient has De Quervain’s syndrome, this will usually dramatically re-create their pain
Management
Management begins with use NSAIDs for 5-10 days, if appropriate and safe for the patient
This is usually done in combination with a spica splint
Immobilization minimizes the tendon chafing and it may revert back to its usual dimensions
If pain persists and is bothersome despite this, a cortisone injection may be considered after 2 weeks minimum
This can be repeated every 3-4 months as necessary
If pain persists after injection, surgery can be considered, which involves opening up the tendon sheath
Trigger Finger
Characterized by clicking or locking of the finger or thumb
Triggering is often worse in the morning
Pathophysiology is related to inflammation of the flexor tendon as pass through hoops called “pulleys,” leading to a nodular tendinitis
With extension, these nodules get caught on the pulleys, and when it finally does pass through, there is a “clunk” known as “triggering”
Examination can be done to confirm triggering, and sometimes palpating the nodule on affected tendon can be supportive of the diagnosis
Management
Management begins with splinting of the finger, which generally is done for several weeks
The splint should remain on day and night
Cortisone injection can be done for persistent symptoms, and is effective
Surgery is rarely required, but is done by cutting the pulley to allow the tendon to move more freely
Carpal tunnel syndrome
Characterized by numbness and paresthesias in the median nerve distribution (thumb, index finger, middle finger, and radial aspect of the ring finger)
Typically symptoms are not proximal to the wrist
The underlying pathophysiology is actually driven by a vascular phenomenon (Werner and Andary, 2002)
The carpal tunnel does not have much capacity to accommodate swelling
However, compression of the tunnel leads to impairment in blood supply and subsequent ischemia
The median nerve is particularly prone to damage from this, since nerves are sensitive to even transient ischemia
The resultant nerve dysfunction leads to the symptoms of numbness, tingling, and paresthesias
Tendons are not as prone to damage from pressure or ischemia
Bracing and ergonomic changes aim at keeping the wrist straight to avoid this compression
Listeners will recognize and manage common causes of hand and wrist pain that present to primary care clinicians.
Learning objectives
After listening to this episode listeners will…
Efficiently diagnose and manage carpometacarpal arthritis
Diagnose and appropriately manage De Quervain’s tenosynovitis
Identify trigger finger in the outpatient setting
Describe the underlying pathophysiology of carpal tunnel syndrome
Effectively perform initial management of carpal tunnel syndrome
Recognize indications for steroid injection and surgical intervention for carpal tunnel syndrome
Disclosures
Dr. Parks reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Citation
Williams PN, Parks EH, Heublein M. “339 Hand and Wrist Pain with Dr. Ted Parks”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list June 6, 2022.
CME Partner
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
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