Causes
1. Soft Tissue Disorders: - Tendon disorders, ligament sprains, Dupuytren's Contacture, Ganglions |
2. Joint Disease |
3. Bone Disorders - Osteochondritis of the lunate |
4. Nerve Entrapments - Median, ulnar Nerve, Bowler's Thumb |
Referred Pain, Vascular Causes |
DeQuervain's Tenosynovitis
- Involves repetitive strain of the adductor pollicis longus and extensor pollicis brevis |
- Women between 30 and 50yo |
- Associated with: RA, Psoriatic Arthritis, Trauma, Pregnancy |
Hx
- Insidious Wrist pain (radial side + 1st metacarpal sharp pain) |
Pain can radiate up wrist and forearm |
Worse with thumb and wrist movements |
Better with rest, heat or cold |
Exam
Minor swelling over distal radius |
Tenderness over involved tendons |
AROM + RROM of wrist and thumb extension painful - pt describes it as "squeaky" |
Pain worse with grasping, abduction of the thumb and ulnar deviation |
RROM WNL or weakness due to pain |
+ve Finkelsteins (pain on lateral wrist) |
DDx
RA or OA |
Cx radiculopathy (C5,C6) |
Intersection Syndrome |
CTS, Ganglion Cyst |
Scaphoid fracture |
Keinbock's disease |
Management
Resting and avoiding triggering cause |
Ice @ Radial styloid |
Ultrasound with hydrocortisine gel |
Buddy taping of thumb to base of first finger |
Chronic cases - stretching exercises into the palm - sets of 20 , held for 5 seconds |
Electrical stimulation along tensons |
NSAIDs advice |
Refer to GP - Corticosteroid injection if not responding |
Dorsal Wrist Syndrome
- Mild injury to the scapholunate ligament , dorsal wrist ganglion |
Exam
- Tenderness over the dorsal aspect of the wrist in the region of the scapholunate joint |
- Pain on passive extension of the wrist |
- Pain on finger extension test |
- Clunking on Watson's test |
- No physical findings of rotary subluxation of the scaphoid , absence of abnormality on wrist x-ray |
Management
- Steroid injection into the wrist , if that fails, consider surgery |
Dupuytren's contracture
- Hypertrophic nodular fibroplasia of the palmar fascia |
- Flexion deformity of MCP and PIP |
- Affects more white males at 60-70 yo |
- 4th and 5th digit most affected |
- Hereditary, chronic alcoholism, epilepsy and diabetes |
Management
- Passive stretching of flexor tendons after massage |
- Surgery for advanced cases |
Gamekeeper's Thumb AKA Skier's thumb
- Sprain/ rupture of UCL of MCP joint of the thumb |
- Valgus force on abducted 1st MCP/ FOOSH |
Hx: Pain over UCL of 1st MCP joint (starts immediately, pt hears snapping/popping)
Valgus trauma , pt describes it as I jammed my thumb/my thumb got bent back
Weakness in punch grip strength. Rupture = unable to pinch at all! |
Exam
Swelling + bruising over ulnar aspect of MCP joint |
TTP over UCL, soft mass = retracted, ruptured UCL , hard mass = avulsion, MFTP over forearm + thumb muscles |
AROM + PROM shows hyperextension/hyperabduction, RROM weak due to pain |
Median/radial nerve involvement possible |
+ve valgus stress test |
+ Empty end feel/excessive motion = Grade III sprain |
DDx
- MCP Joint dislocation |
- Phalangeal f# |
- Congenital 1st MCP hypermobility |
- Torn RCL of thumb (rare) |
Management
4-6 weeks of thumb spica cast immobilisation |
Refer to GP/A&E |
Ganglion
- Fluid filled benign lump that comes from tendon shealth/joint capsule |
- Usually on the dorsum of the hand |
Hx: Painless mass on wrist - can be painful
Usually insidious but can be caused by minor/major trauma
If painful, pain usually comes and goes - comes on with excessive wrist use
Can limit ROM/decrease grip strength
Cyst can impinge on neurological structures |
Exam: Visible mass on wrist
TTP, soft + rigid
Joint cysts = larger + soft
Tendon cysts = smaller and hard
+Ve Finger extension test
Allen's test if pressing on vascular structures |
DDx: Infection (red, swollen, painful)
Tenosynovitis
Sarcoma
Lunate/carpal dislocation
Lipoma
RA |
Management: PRICE, Aspiration (if causing symptoms), NSAIDs |
Consider US |
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