 |
|
WRIST
& HAND PAIN |
Correct
diagnosis of wrist and/or hand pain is sometimes difficult due to the
fact that there are a large number of anatomic structures in a small
space. Hand and/or wrist pain is a common complaint and a structured
history and examination will help to narrow the differential diagnosis
to a manageable level. |
| DIFFERENTIAL
DIAGNOSIS: |
 |
Trauma
(lacerations, fractures, etc.) |
|
Tendinitis
(wrist/finger extensors, flexors, deQuervain’s tenosynovitis,
etc.) |
|
Sprain (ligamentous
injuries) |
|
Peripheral
nerve entrapment (median nerve, ulnar nerve) |
|
Arthritic
conditions |
|
Osteochondritis
(avascular necrosis) |
|
Complex
Regional Pain Syndrome (CRPS) (RSD, Causalgia) |
|
|
Pain related to
trauma, helps to narrow the list of possible diagnosis. Burning pain
with changes in color and temperature several days, following minor
injury may indicate CRPS. |
HISTORY: |
- History of
injury? How? When?
- Where is
the pain located?
- When did
the pain start? Was it gradual or sudden?
- Describe
the pain (sharp, stabbing, burning, dull ache). Is it constant or
intermittent? Is there numbness or tingling? When?
- Is there
swelling, change in color and temperature?
- Is there
noise during movement?
|
| CLINICAL
FINDINGS: |
- Deformity
(arthritic, atrophic)
- Swelling,
discoloration
- Tenderness
- Loss of
strength, motion or sensation
- Crepitation
(noise during movement or palpation)
- Fractures
TESTS: |
|
Physical
tests (Tinel’s sign, Phalen’s sign, Finkelstein’s test) |
|
X-ray
(plain radiographs may be most useful) |
|
Bone scan |
|
MRI |
|
Electromylogram
and/or nerve conduction velocity studies |
|
Aspiration |
|
Arthrography |
|
CBC,
Sedimentation rate, Rheumatoid factor, antinuclear antibody test |
|
| MANAGEMENT: |
Trauma
- Nonsteroidal
anti-inflammatory drugs for pain
- Corticosteroid
injections or orally
- Tetanus
toxoid for penetrating wounds
- Surgical
intervention
|
Tendonitis
tenosynovitis
- Pain
medications
- Cortisone
injection into sheath
- Immobilization
- Surgical
decompression
|
Arthritis
- NSAID’s
- Oral
steroids
- Physical
Therapy
|
Infections
- Early
recognition
- Appropriate
antibiotic therapy
- Incision
and drainage
- Elevation
and local heat application
|
Vascular
Impairment (secondary to trauma, infection, or occlusive disease)
- Stop
smoking
- Reassurance
and advice
- Avoid cold
weather, handling iced objects and wear warm cloths and gloves
during cold weather
- Sympathetic
blocks
- Drugs to
increase arterial circulation
- Sympathectomy
may be required
|
Complex
Regional Pain Syndrome (CRPS)
- Sympathetic
blocks (stellate ganglion, Bier block)
- Anticonvulsant
medication (gabapentin, etc.)
- Tricyclic
antidepressants (amitriptyline, etc.)
- Physical
Therapy
- Pain
medications (NSAID’s)
|
Other
therapy
- Diet
(adequate vitamin D and calcium, multiple vitamins and minerals,
Vitamins C and E)
- Activity
(physical and occupational therapy) restrict painful activity
- Patient
education retraining
- Rehabilitation
(stretching and strengthening)
- Follow-up
|
Author: Robert V. Plehn, M.D., DABA, FACA
Medical Director, DoctorsForPain.com |
