Wrist Complaints in Family Practice

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Wrist Complaints in Family Practice

• Dr. Mark Lees
• Department of Family Medicine
• University of Saskatchewan
• August, 2007

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Objectives

• More knowledge!
• Review relevant wrist anatomy
• More confidence!
• Identifying and managing common wrist disorders
• Avoid wastebasket diagnoses
• More motivation!
• To develop your own systematic approach to
  examining the wrist

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Todays Talk

• Two cases
• Review relevant anatomy and exam
• Review common pathology
• Sore tendons
• Broken bones
• Torn ligaments
• Pinched nerves
• Injection techniques (time permitting)
• Questions

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Case 1

• Mrs. B, 52 y.o day care operator
• c/o radial sided right wrist pain, 7/7 duration
• Pain is worse with lifting kids at day care, with
  thumb movement, and when she presses on her wrist
• Feels cracking sounds
• Had a slip and FOOSH on pool deck a week ago with
  wrist discomfort afterwards lasting till the next
  a.m. (settled with self prescribed margaritas q2h
  prn)
• Had been gardening a lot 3/7 ago ? symptoms worse
• Worried she might have a broken bone in her wrist

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Wrist Pain History

• Correct diagnosis in 70 of pts
• Mechanism of injury
• Regular pain history CLORIDE FPP
• Previous injuries
• Past surgery
• Other joint symptoms (esp elbow, c-spine)
• Activities (work, leisure/sport)

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Wrist Pain History

• More on MOI
• FOOSH
• Toddler
• Adolescent
• Older adult
• Direct palmar trauma
• Repetitive loading
• Distant history / vague trauma

• greenstick
• growth plate
• distal radius

• ? HOTH
• ? AVN
• ? Non-union?

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Before you even examine her

• What is in your differential?
• Scaphoid fracture
• Lunate fracture / Kienbocks disease
• Scapholunate instability
• De Quervains tenosynovitis
• Intersection syndrome
• Arthritis 1st CMC joint
• Tenosynovitis of the wrist flexor/extensor
  tendons (repetitive strain, infectious?)

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Examining the Wrist
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Range of Motion

• Flexion
• Extension
• Radial deviation
• Ulnar deviation
• Pronation
• Supination

80 degrees
70 degrees
20 degrees
30 degrees
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Inspection

• Erythema
• Swelling
• Masses
• Skin lesions
• Muscle atrophy
• Scars
• Deformities

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Palpation Hard Stuff

• Ulnar styloid process
• Radial styloid process
• Carpal bones
• Scaphoid
• Lunate
• Pisiform

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Palpation Hard Stuff

• Ulnar styloid process
• Radial styloid process
• Carpal bones
• Scaphoid
• Lunate
• Pisiform
• Hamate

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Anatomic Snuff Box

• How do you best find it?

Extensor pollicis longus

• Best position
• Thumb ? hyperextention and abduction
• Wrist ? ulnar deviation

• What defines it?

• Contents
• Scaphoid bone
• Radial artery
• Radial nerve

• What is in it?

• How do you palpate it?

Gently

• Why do we palpate it?

Abductor pollicis longus Extensor pollicis
brevis
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Where else should you palpate the scaphoid?
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Scaphoid Examination

• Scaphoid compression test (axial grind)
• Scaphoid tubercle
• Find flexor carpi radialis tendon
• Follow it to the distal palmar crease
• Use thumb to palpate just beyond crease

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• Interpretation
• Pain alone ? scapoid
• Pain clunk ? scapholunate instability
• Clunk in 36 of normal individuals ? check
  other side

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Palpation Hard Stuff

• Ulnar styloid process
• Radial styloid process
• Carpal bones
• Scaphoid
• Lunate
• Pisiform
• Hamate

• Position of function
• Find Listers (radial) tubercle
• Small hollow distal and slightly ulnar to
  Listers tubercle
• Put your index finger in the hollow
• Flex wrist

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Palpation Hard Stuff
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Why should I find the lunate anyways?

• Its a busy carpal bone
• Most frequently dislocated
• 2nd most frequently fractured
• Injured with a FOOSH

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Palpation Hard Stuff

• Carpal bones
• Scaphoid
• Lunate
• Pisiform
• HOTH

• Volar surface
• Ulnar edge
• Distal to distal wrist crease
• Nugget (mobile when wrist flexed)

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Why should I find the pisiform anyways?

• Landmark
• Guyons canal (ulnar border)
• Proximal border of the carpal tunnel
• Insertion point of FCU
• Helps to find the HOTH

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Palpation Soft Stuff

• Abductor pollicis longus
• Extensor pollicis brevis
• Extensor pollicis longus
• Path of wrist flexors
• Path of wrist extensors
• Anything swollen

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Back to our case

• Firm fusiform swelling
• Pain with thumb opposition and extension
• Palpable crepitus
• No pisiform, HOTH, scaphoid, lunate tenderness
• No pain at CMC joint with axial loading of thumb
• Upper limb strength testing and DTRs normal

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What is your diagnosis now?

• De Quervains tenosynovitis
• Co-existing OA 1st CMC joint?

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Would you like to order any investigations?
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De Quervains Tenosynovitis

• Shear microtrauma from repetitive gliding of the
  sheathed 1st dorsal compartment tendons (APL,
  EPB) over the radial styloid

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De Quervains Management

• 1st line conservative management options
• Ice
• NSAIDs (not an inflammatory condition)
• Activity modification
• Consider thumb spica splint
• 2nd line surgery (90 cure rate) (Ta, 1999)

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De Qervains Treatment The Evidence

• Systematic review (Richie, 2003)
• 459 wrists
• Injection alone ? 83 cure rate
• Injection splint ? 61 cure rate
• Splinting alone ? 14 cure rate (earlier the
  better)
• Heat, cold, diathermy, medications, rest,
  massage, splinting all not helpful (Moore, 1997)
• Cochrane review ? on going

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More Sore Tendons
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Intersection Syndrome
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ECU Tenosynovitis

• Common tendonitis (2nd only to de Quervains
  amongst athletes)
• MOI / history
• Rowing, racquet sports, non-dominant wrist of
  2-handed backhand
• Twisting injury
• Exam
• Tender along course of ECU
• Swelling about the distal ulna
• Pain often worse with finger movements
• Tx
• Splint, rest, NSAIDS, technique modification

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Wrist Flexor Tenosynovitis

• FCU gtgt FCR
• Secondary to repetitive trauma (golf, raquet
  sports)
• Pain worse with wrist flexion and resisted ulnar
  deviation
• Often tender over pisiform (sesamoid bone)

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Broken Bones
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Before we go any further
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Wrist x-ray scaphoid view
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Scaphoid Fractures

• MOI FOOSH
• Presentation often mild deep/dull radial wrist
  pain, worse with gripping
• O/E
• mild wrist swelling/bruising
• Tenderness
• Snuff box 90 sensitive, 40 specific
• Scaphoid tubercle 87 sensitive, 57 specific
• 12 both positive extremely sensitive
• Axial compression (?)

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Scaphoid Fractures

• Imaging
• Plain films
• Dont order x-ray wrist
• PA lateral scaphoid view
• Sensitivity lots of reported numbers, about 85
• If x-ray normal and clinically suspicious
• cast and f/u in 7-10 days with exam repeat
  x-ray (10-25 will now have evidence of scaphoid
  )
• Bone scintigraphy
• 3-5 days post injury
• Highly sensitive but not very specific

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Scaphoid Fractures

• Management
• Surgical referral
• Displaced gt 1 mm
• Increased scapholunate angle
• Unwilling or unable to be casted for 3/12
• Non-displaced
• Distal Short arm thumb spica cast, 1st IPJ free,
  4-6 wks
• Waist long arm thumb immobilization, 10-12 wks
• Proximal long arm thumb immobilization, 12-20
  wks
• Serial radiographs q 2/52

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Hook of the Hamate Fractures

• 2-4 carpal fractures
• Athletes with direct palmar trauma (raquet
  sports, golf, baseball)
• Often in combination with 4th-5th metacarpal
• Ulnar wrist pain
• X-ray
• Often missed by x-ray wrist
• Carpal tunnel and suppinated oblique views

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Lunate Fracture

• Acute fracture is rare
• Tenderness over the lunate (especially with a
  history of repetitive trauma) is more likely to
  be

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Lunate AVN

• Kienböck Disease
• Who
• Males 20-40, manual labourer, recreational
  activities that repetitively load the wrist
• What
• Insiduous onset wrist pain, initially only post
  activity
• Decreased flexion-extension arc, weak/painful
  grip
• Where
• Dorsal wrist, pain over lunate
• Why
• Secondary to avascular necrosis
• Etiology poorly understood (vascular supply,
  geometry, repetitive trauma)

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Torn Ligaments
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Ligamentous Injury

• Most commonly occurs between bones of the first
  carpal row
• Scaphoid ?? Lunate
• Lunate ?? Triquetrum
• Less commonly between rows (midcarpal instability)

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Scapholunate Instability

• Most common ligamentous wrist injury
• MOI / History
• Acute injury but occasionally seen with remote hx
  trauma
• Collision and contact sports
• FOOSH or jamming into another player
• If seen remote from injury wrist pain, weakness,
  giving way, clunk, snap, click
• Examination
• Acute significant wrist swelling decreased ROM
• Scaphoid tenderness (often associated )
• Positive scaphoid shift (Watsons) test

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Scapholunate Injuries

• Wide range of injuries
• Dynamic instability (normal x-ray)
• Rotatory subluxation of scaphoid
• Scapholunate dissociation
• Management
• X-ray
• stress views clenched fist, suppinated, ulnar
  dev
• Must compare with other side
• Splint, NSAIDs, refer to ortho
• Surgery possible up to 6-9 months post injury

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Lunotriquetral Injuries

• History / MOI
• Sudden axial load with wrist extension and radial
  deviation
• Fall with resultant ulnar sided wrist pain,
  weakness, giving way, click with loading
• Physical exam
• Tenderness over the lunotriquetral ligament
• Positive shear test
• X-ray usually normal
• Treatment immobilization NSAIDS

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Triangular Fibrocartilage Complex (TFCC) Injury

• TFCC
• primary stabilizer of the DRUJ and ulnar carpus
• MOI
• Acute
• FOOSH, power drills, distraction force
  (waterskiing)
• Degenerative
• Raquet sports, gymnasts, hockey players
• Complaints
• Ulnar sided wrist pain with grinding or clicking
• Exam
• Tenderness (hollow between pisiform and ulnar
  styloid)
• Supination lift test
• X-ray
• Increased ulnar variance (radial shortening)
• Associated ulnar styloid
• Widened DRUJ space
• Treatment
• Refer
• Short arm cast x 4-6 weeks

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Case 2

• The same patient in Case 1 presents 3 years
  later (55 years old)
• Complaining again of right sided wrist pain
• Radiates up into forearm and elbow
• Worse with driving and knitting and in the
  evening
• Wakes up with tingling over tips of all fingers
• Fingers swollen when symptoms at their worse
• PMHx DM

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Questions

• What is your diagnosis?
• What could it be caused by?
• How would you examine Mrs. B?
• Would you like to order any investigations?
• What treatment would you like to initiate?
• Would she improve without treatment?

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CTS Causes

• Idiopathic (most)
• Hypothyroidism
• Diabetes
• Pregnancy (usually 3rd trimester)
• RA
• Old Colles or lunate dislocation
• Chronic dialysis
• Acromegaly

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CTS Exam

• Sensory changes
• Lightly touch distal pulp of fingers
• Can patient feel a difference?
• Can you?
• 2 point discrimination (edges of pulp)
• Muscle atrophy ? thenar eminence
• Motor changes ? thumb movements/strength
• Provocative tests (Tinels sign, Phalens sign)

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CTS Exam
medicine.ucsd.edu/clinicalmed/Joints4.html
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CTS Investigations

• EMG / nerve conduction studies?
• TSH, fasting glucose
• Questionnaire (Levine, 1993)
• Sensitivity 85 (vs. 90 for NCS)
• PPV 90 (vs. 92 for NCS)
• www.myhq.com/public/s/a/saskfm/

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CTS Management

• Hyper - Conservative
• Do nothing, avoid aggrevating activities
• 1/3 resolve in 6 months (more likely if younger
  and Phalens test negative)
• Conservative
• Splints
• No conclusive evidence that they are helpful
• 24 hr splinting no better than night splinting
• Anti-inflammatories
• No evidence they are helpful
• Stop after 1 month, unlikely to provide further
  benefit

http//www.clinicalevidence.com/ceweb/conditions/m
sd/1114/1114.jsp
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CTS Management

• Semi - Conservative
• Local corticosteroid injection
• Bandolier ? appears to be beneficial, no
  difference compared to surgery at 6 and 12 months
  (Dec 06 search)
• Cochrane ? no evidence better than
  splinting/NSAIDs at 8 weeks (May 06 search)

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CTS Management

• Surgery
• Mild/moderate ? 90 complete recovery
• Severe ? 90 partial recovery, complete unlikely
• Consider earlier if predisposing condition (DM,
  wrist , etc)

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Ganglia
Please leave me alone!

• Prospective cohort study
• 155 of 233 patients referred to hand surgeon
• Mailed survey at 2 or 5 yrs
• Treatment
• Excision ? 42 recurred
• Aspirated ? 47 recurred
• Reassured ? 47 persisted

Me too!
http//www.bmj.com/cgi/content/full/328/7443/0-f
www.davidlnelson.md/Ganglion.htm
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Injecting the Wrist
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Injecting for CTS

• Syringe 5 ml
• Needle 25 gauge, 1.5 inch
• Position palm up, slight wrist extension
• Where carpal tunnel
• Landmark between PL and ulnar artery
• Angle 30 degrees, aim to 4th finger
• Depth 1-2 cm
• What 40 mg methylprednisolone (1 cc), (no
  anesthetic)
• Follow-up 2-4 weeks

www.aafp.org/afp/20030215/745.html
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Injecting for CTS

• RISKS!
• Standard injection risks
• bleeding, bruising, infection, allergy
• Trauma to
• median nerve
• ulnar artery
• Tendon weakening/rupture
• Skin pigmentation changes

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Injecting for De Quervains

• Needle 25 gauge, 5/8 inch
• Position neutral
• Where tendon sheath of the 1st doral compartment
• Landmark 3/8 inch proximal to radial styloid,
  mid-way between APL EPL
• Angle 45 degrees
• Depth flush against periosteum of radial styloid
  (3/8 -½ inch)
• What 40 mg methylprednisolone (0.5 cc)
• Follow-up 2-4 weeks

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Injecting for De Quervains

• RISKS!
• Standard injection risks
• bleeding, bruising, infection, allergy
• Trauma to the superficial radial nerve
• transient (hopefully) paresthesias 1st web space
• Skin hypopigmentation
• Tendon weakening/rupture

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• Ligament injury
• Synovium
• Radio-carpal joint

Worse with wrist flexion/extension
Dorsal Wrist Pain
Worse with finger movement

• Extensor tenosynovitis (ECR, ECU, etc.)

Localized

• Ganglion
• De Quervains

Dorsal Wrist Swelling

• Tenosynovitis
• Complex regional pain syndrome

Diffuse
Radial pain
Wrist pain grip weakness

• De Quervains

Ulnar pain

• TFCC injury
• HOTH

• CTS
• Ulnar nerve (Guyons canal)

Volar Wrist Pain Paresthesias
Wrist stiffness

• RA
• CTS

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Thank you for your attention!
References available upon request (i.e. I ran
out of time preparing this talk and didnt get a
chance to type them out)