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Wrist & Hand Pain Cheat Sheet (DRAFT) by

Wrist and hand pain + Diagnosis

This is a draft cheat sheet. It is a work in progress and is not finished yet.

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