#339 Hand and Wrist Pain with Dr. Ted Parks

June 6, 2022 | By Paul Williams

Video

A wrist strained episode?

Join us as Curbsiders favorite Dr. Ted Parks gives us a hand with the diagnosis and management of common causes of hand and wrist pain.

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Credits

• Writer and Producer: Paul Williams, MD
• Infographic and Cover Art: Paul Williams, MD
• Hosts: Paul Williams MD and Molly Heublein, MD
• Editor: Emi Okamoto, MD (written materials)
• Guest: Ted Parks, MD

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Show Segments 

• Intro, disclaimer, guest bio
• Guest one-liner
• Anatomy review: the thumb is the short one
• Pathophysiology of De Quervain’s tenosynovitis
• Physical examination for thumb pain
• Management of DeQuervain’s and CMC arthritis
• Pathophysiology of trigger finger
• Management of trigger finger
• Pathophysiology of carpal tunnel syndrome
• Physical examination for carpal tunnel syndrome
• Carpal tunnel syndrome management
• Outro

Hand and Wrist Pain Pearls

1. Pain at the base of the thumb may represent carpometacarpal (CMC) arthritis or De Quervain’s tenosynovitis
2. The Finkelstein test is sensitive and specific for identifying De Quervain’s tenosynovitis, while the CMC grind test may help identify CMC arthritis
3. 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
4. De Quervain’s is also managed with NSAIDs and immobilization–if there is no improvement, cortisone injection can be considered
5. Trigger finger can be identified by the characteristic catching and “triggering” of the finger with extension
6. 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
7. Carpal tunnel syndrome is caused by compressive changes and impairment of axonal microvascular circulation 
8. Carpal tunnel syndrome is initially managed by nocturnal bracing of the wrist
9. 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
• Phalen’s and Tinel’s tests can be done, but are not very good (D’Arcy and McGee, 2000)
  • Tinel’s test involves tapping over the carpal tunnel to reproduce symptoms
  • Phalen’s test has the patient placing the back or their hands against each other, with their elbows in the wing position for 30-60 seconds
    • This creates a “kink” in the carpal tunnel that recreates symptoms
  • Thenar wasting in a younger patient indicates chronic denervation
    • If present, symptoms may not be reversible

Management

• Typically begins with nocturnal bracing of the affected wrist for several weeks
  • Patients often sleep with their wrists bent, which worsens symptoms overall
• Cortisone injections can be diagnostic and therapeutic if conservative measures do not help sufficiently
  • If there is no relief with cortisone, reconsider the diagnosis or refer for electromyography
  • If there is relief and subsequent return of pain, this may be a patient who would do well with surgery
• Surgery consists of an incision in the palm, and the transverse carpal ligament is divided
  • The gap between the two stumps of the ligament fills with blood, which hardens into scar tissue
  • This increases the volume of the carpal tunnel, which allows for accommodation of the relevant structures

Links

1. Practical Office Orthopedics by Edward (Ted) Parks, MD

Goal

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…  

1. Efficiently diagnose and manage carpometacarpal arthritis
2. Diagnose and appropriately manage De Quervain’s tenosynovitis
3. Identify trigger finger in the outpatient setting
4. Describe the underlying pathophysiology of carpal tunnel syndrome
5. Effectively perform initial management of carpal tunnel syndrome
6. 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.