causes of hand pain - suny upstate medical university€¦ · •“wrist extensor” tendinitis...
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Causes of Hand/Wrist Pain
Michael J Schreck, MDDivision of Hand/Upper Extremity Surgery
Assistant Professor of OrthopaedicsSUNY Upstate Medical University
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Outline
• Carpal Tunnel Syndrome
• Trigger Finger
• Tendinitis
• Arthritis
• Fractures
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Carpal Tunnel Syndrome
• Known as a “compression neuropathy”
– Nerve compression (median nerve) is what causes symptoms
• Most common compression neuropathy
• One million adults in the U.S. are diagnosed with carpal tunnel syndrome each year
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What is it?
• Compression of the median nerve, typically by the transverse carpal ligament
• Nerve compression leads to symptoms of numbness/tingling, pain, weakness/clumsiness (advanced)
– Symptoms are primarily in the thumb, index finger, long finger, and ½ of the ring finger
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Why does it occur?
• The “why” is not entirely understood
• Predisposing factors include: diabetes, hypothyroidism, excessive alcohol use, obesity, tobacco use, female sex, pregnancy, rheumatoid arthritis, repetitive motion activities
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How is it diagnosed?
• Clinical examination: symptoms reproduced by maneuvers performed by examiner –tapping on the wrist, compressing the wrist, hyperflexion of the wrist
• Nerve studies: quantify the extent of damage to the nerve fibers
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How is it treated?
• Conservative measures: steroid injection, night splints (not definitive treatments)
• Surgery: Carpal tunnel release
– Either through an incision in the palm (open) or an endoscopic technique
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Open vs Endoscopic Techniques
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Trigger Finger
• “Stenosing tenosynovitis” - tendon entrapment (stenosis)
• Mechanical impingement of the flexor tendons as they pass through a narrowed pulley (tunnel)
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• Entrapment leads to symptoms of painful catching or popping
• In severe cases, the finger will “lock” in flexion and require manipulation of the finger into extension
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Why does it occur?
• Inflammation has been cited; exact “cause” is disputed
• Predisposing factors include: female sex, age 55-60 years, diabetes, gout, kidney disease, rheumatoid arthritis
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How is it diagnosed?
• Clinical examination demonstrating pain over the A1 pulley region and or catching/locking of the finger(s) with flexion/extension
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How is it treated?
• Steroid injection (cortisone) into the A1 pulley
– Literature suggests roughly 70% success rate with steroid injection
• Splinting
– Can splint the MCP joint (first knuckle) in 15 degrees of flexion or splint the DIP joint (last knuckle) in complete extension
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• Surgery: release of the A1 pulley
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Tendinitis of the Wrist
• Continuum of stenotic conditions
– Tendons become inflamed and entrapped
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DeQuervain’s Disease
• Stenosing tenosynovitis of the first dorsal compartment – tendon entrapment
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• More common in women
• Peaks in childbearing years and perimenopausal years
• Associated with pregnancy, diabetes
• Leads to pain on the thumb-side of the wrist
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How is it diagnosed?
• Tenderness with touch over the thumb-side of the wrist, swelling
• Pain with
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How is it treated?
• Conservative measures: anti-inflammatory medications, activity modification, thumb spica splint/brace, steroid injection (cortisone)
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• Surgery: release of the inflamed tendons
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Extensor Carpi Ulnaris (ECU) Tendinitis
• “Wrist extensor” tendinitis
• One of the most common causes of tendinopathy (“diseased” tendon)
• Leads to pain on the ulnar side (small finger side) of the wrist
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• Typically occurs after a twisting injury, which is followed within 24-48 hours by pain and swelling
• Night pain is common
• Pain is increased with all motions of the wrist
– Resisted wrist extension (and ulnar deviation) particularly painful
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How is it treated?
• Conservative measures: ice, extension splinting or casting, anti-inflammatory medications, steroid injections
• Surgery: incision of the tendon sheath to release the tendon
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Flexor Carpi Radialis (FCR) Tendinitis
• “Wrist flexor” tendinitis
• Causes pain at the wrist crease
• Pain with resisted wrist flexion
• “Overuse” injury?
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• Typically affects people in 5th to 6th decade
• More common in women
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How is it treated?
• Conservative treatment (mainstay): splinting, ice, anti-inflammatory medications, cortisone injection
• Surgery: release of tendon sheath, removal of any prominent bone
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Arthritis
• Degradation of joint cartilage (surface that lines the joints)
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Thumb Base Arthritis
• Basal joint arthritis
• Extremely common
• Pain at the base of the thumb metacarpal
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• Pain with pinch, turning keys, turning a door knob, opening jars
• More common in women
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X-ray Appearance
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How is it treated?
• Conservative: splinting, anti-inflammatory medications, cortisone injections
• Surgery: either fusion (younger patients) vsremoval of arthritic bone and filling of space with tendon
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Fusion
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Bone excision, tendon interposition(Basal Joint LRTI)
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Finger Arthritis
• Diffuse pain and stiffness throughout the finger joints (knuckles)
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• Gradual “wear and tear” over the years
• Inflammatory – rheumatoid arthritis, psoriatic arthritis
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How is it treated?
• Conservative: splinting, anti-inflammatory medications, steroid injections, activity modification
• Surgery: joint fusion, joint replacement
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Fractures = Broken Bones
• Metacarpal (knuckle)
• Scaphoid (hand bone close to the wrist)
• Distal radius (wrist fracture)
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Boxer’s Fracture
• Fracture of the small finger metacarpal neck(just below the knuckle)
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• Typically treated with splinting or casting
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• If there is too much displacement/angulation, surgery is performed
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Scaphoid Fracture
• Typically caused by a fall onto the outstretched hand/wrist
• Commonly mistaken for a “wrist sprain” – pain but “x-rays are negative”
– Acute fractures can be very difficult to see on x-ray
• Pain is located in the anatomic snuff box
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How is it treated?
• In younger patients, and patients with very distal (far down) fractures, casting may be employed
• For most fractures, surgical treatment is required
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Distal Radius Fracture
• “Wrist fracture”
• One of the most common fractures of the musculoskeletal system
• Typically caused by a fall onto an outstretched hand/wrist
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X-ray appearance
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How is it treated?
• In younger patients, and in fractures without much displacement or angulation, manipulation and casting may be employed
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• If manipulation fails or there is too much displacement/angulation, surgery is required
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Questions?
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Thank You