Hand and Wrist Pain

Painful conditions of the tendons and tendon sheaths of the hand and wrist are often related to repetitive or unaccustomed activities. The resultant edema, inflammation, and fibrosis of the structures interfere with the normal function of the tendon as it moves within the sheath.

De Quervain Tenosynovitis and Flexor Tenosynovitis

De Quervain tenosynovitis affects the abductor pollicis longus and extensor pollicis brevis. Typical symptoms are pain over the radial aspect of the wrist during activities and tenderness that is usually found over the affected tendons proximal to the level of the carpometacarpal joint of the thumb. Pain is reproduced by stretching the tendons with the thumb inside a closed fist (i.e., the Finkelstein maneuver). Flexor tenosynovitis, or trigger finger, is caused by involvement of the flexor tendons of the digits, usually at the level of the metacarpophalangeal joint. Patients complain of locking of the affected digit in a flexed position, often with a sudden painful release on extension. Treatment of de Quervain tenosynovitis and flexor tenosynovitis may require rest, local heat, immobilization with a splint, or local infiltration with glucocorticoids. Surgical release is rarely required.

Carpal Tunnel Syndrome

Carpal tunnel syndrome is caused by compression of the median nerve at the wrist as it courses with the flexor tendons[38] [see Figure 2] and [see 11:II Diseases of the Peripheral Nervous System]. Entrapment is usually associated with flexor tenosynovitis related to overuse or trauma. In addition, an association has been observed with medical conditions such as diabetes mellitus, rheumatoid arthritis, pregnancy, and hypothyroidism, as well as with rare conditions, such as amyloidosis, acromegaly, and localized infection. Carpal tunnel syndrome is relatively common in the general population. A recent study found that 14% of the general population have symptoms suggestive of carpal tunnel syndrome; such symptoms were confirmed by clinical examination and electophysiologic studies in 2% to 3% of the patients studied.[39] In addition, 18% of asymptomatic people were found to have electrophysiologic evidence of median nerve entrapment. Carpal tunnel syndrome is more common in persons with occupations that require repetitive wrist movements, awkward wrist positions, or the use of vibrating tools or great force. Patients report numbness, tingling, and pain over the palmar radial aspect of the hand; these symptoms are often worse at night or after use. Reproduction of paresthesia with maximal wrist flexion (i.e., the Phalen test) or tapping over the volar aspect of the wrist (i.e., the Tinel sign) are often considered to be helpful clinical findings. However, a recent review of published studies suggests that the pattern of pain and findings of decreased sensation and weakness of thumb abduction are the most reliable diagnostic findings.[40] Because of the uncertainties in the reliability of diagnostic findings, electrodiagnostic testing is usually necessary to confirm a diagnosis, particularly when surgical intervention is considered.

Figure 2. Carpal Tunnel Syndrome. Carpal tunnel syndrome involves the entrapment of the median nerve in the canal that encloses the nerve and several flexor tendons and that is formed by bones of the wrist and the transverse carpal ligament. Traumatic thickening of the flexor tendon sheaths can compress the median nerve.

Conservative treatment measures include use of NSAIDs and placement of a wrist splint in a neutral position. Local injection of glucocorticoids affords short-term relief in most patients, but long-term improvement is less predictable.[41] Surgical decompression by sectioning of the volar carpal ligament results in excellent outcome in 67% to 80% of patients; it is indicated in patients whose conditions respond poorly to conservative therapy, patients with chronic or recurrent symptoms, or patients with weakness or atrophy of the thenar muscles. In a recent study, patients with poor upper extremity function, patients who used alcohol, or patients with worse mental health status were less likely to have good results from surgical therapy.[42]

Dupuytren Contracture

Dupuytren contracture is a fibrosing condition of the palmar and digital fascia that results in thickening and puckering of the palmar skin with subcutaneous nodules and often in flexion contracture of the underlying digit. Dupuytren contracture may be associated with other fibrosing syndromes, with an autosomal dominant inheritance pattern, and possibly with liver disease, epilepsy, and alcoholism. Although spontaneous improvement may be seen, surgical intervention to improve function may be useful in individual cases.

Stiff-Hand Syndrome

The stiff-hand syndrome, resembling scleroderma, is characterized by thickening of the skin and subcutaneous tissues and generalized limitation of hand and wrist motion. This condition is seen almost exclusively in young patients with long-standing insulin-dependent diabetes mellitus.[43]

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