7 Wrist Problems EDWARD J. S HAHADY Wrist problems and complaints are another group of common and frus- trating musculoskeletal issues in primary health care. Wrist injuries can be intimidating because of the complex anatomy and concern for potential long-term disability. Overcoming the fear and frustration of caring for wrist injury becomes possible with a few simple organizational steps: 1. Step 1 is to realize that 95 % of patients seen in the office with wrist- complaints can be classified into three categories and six to seven problems. 2. Step 2 is to take a focused history that segments the categories into acute trauma, overuse trauma, and medical disease. You now have a manageable list (Table 7.1) to begin further investigation. 3. Step 3 is to perform a focused thorough wrist examination. With a focused history and a thorough wrist examination you most likely now have the diagnosis. Your knowledge of the usual history and examination associated with the most common problems has facilitated the diagnostic process. 4. Step 4 is ordering confirmatory studies if needed (many times they are not). 5. Step 5 is to start treatment. (This may include appropriate consultation.) Five percent of the time the diagnosis will not be so obvious. However, not being one of the 95% is usually obvious. That is when additional studies and/or a consultation becomes necessary. Rare or not so frequent problems are usually the ones that receive the most press. How often do you hear the words “I got burned once” mentioned about a rare problem that was missed in the primary care setting. Having a good working knowledge of the characteristics of common problems pro- vides an excellent background to help recognize the uncommon. The uncom- mon is easy to recognize once you know the common. Be driven by the search for the common rather than the expensive intimidating search for the rare birds. 118 7. Wrist Problems 119 TABLE 7.1. Classification of common wrist problems. Overuse trauma ● Carpal tunnel syndrome ● De Quervain’s tenosynovitis ● Other tendonitis Acute trauma ● Fractured scaphoid bone of the wrist ● Scapholunate ligament rupture ● Wrist sprain Medical problems ● Arthritis associated with other diseases like rheumatoid arthritis 1. Focused History The first question is whether the onset of the problem was acute. Did it just start or has it been present for a prolonged period of time? The next question would depend on the answer to the first. If the onset is acute, then ask about a fall, especially one that involved breaking the fall with the outstretched hand (a common mechanism in wrist injury). If the onset is not acute, ask about occupations, hobbies, or sports that involve repeated wrist movement like computer use, painting, and throwing sports. A recent change in occupation or intensity of activity is also important. Ask about any chronic disease. Wrist pain can accompany collagen vascular diseases like rheumatoid arthritis. 2. Focused Physical Examination Begin by asking the patient to go through four motions without your help. This examination establishes a marker for severity of the injury and a base- line to assess degree of recovery. The four wrist motions are ulnar deviation (Figure 7.1); radial deviation (Figure 7.2); wrist extension (Figure 7.3); and wrist flexion (Figure 7.4). It is important to start every examination by defining range of motion (ROM) and noting any difference between one wrist and another. Use a goniometer to precisely assess degrees of motion. The remaining examina- tion will be dictated by the focused history. 3. Case 3.1. History A 33-year-old female secretary presents to your office with right wrist pain for the past 6 months. It was relieved by taking a few ibuprofen tablets but now the pain is persistent and makes it difficult for her to type. She also notes 120 E.J. Shahady 30 degrees FIGURE 7.1. Ulnar deviation; 30° is normal. 20 degrees FIGURE 7.2. Radial deviation; 20° is normal. 7. Wrist Problems 121 FIGURE 7.3. Wrist extension; normal is up to 80°. FIGURE 7.4. Wrist flexion; normal is up to 80°. 122 E.J. Shahady some weakness when she grasps objects and occasionally she drops her cof- fee cup. She is frustrated by her inability to open jars or twist off lids. She feels like she is an old woman before her time. She reports no falls and she has no other complaints. Her general health is excellent. She is a power walker and takes no medications. 3.2. Thinking Process The lack of a fall or other acute trauma makes the diagnosis listed under acute trauma less likely. Still perform the examination maneuvers to assess for trauma as some patients forget the fall that occurred some time ago. Probably this examination will be negative for acute trauma. Medical causes are also unlikely, as she has no history of chronic disease that suggests this. If this is the first sign of a systemic chronic disease, it will soon become obvi- ous by a lack of response to your treatment and appearance of other symp- toms of that disease. This makes an overuse syndrome most likely. Additional questions and the wrist examination that will focus on overuse syndromes should make the diagnosis. Carpal tunnel syndrome is a possibility and it has a characteristic history. These patients usually have occupations that require prolonged or repeated wrist flexion. They also usually complain that the pain is located on the palm of the hand in the thenar area (thumb side). The pain may radiate the elbow. Numbness and tingling in that area of the palm are usually present. The pain may radiate up to the elbow and it is aggravated by wrist flexion and exten- sion. These patients may also awaken at night with pain and numbness because the wrist falls into flexion with sleep. Grasping objects is painful and they may report dropping cups and glasses. This patient is a secretary and she spends 6 h a day with computer data entry. Her pain is in the thenar area and is accompanied by numbness and tingling. She awakens in the morning feeling like she needs to rub or shake her hand to “get the circulation back.” The diagnosis of carpal tunnel syn- drome is most likely. The physical examination should be preformed to con- firm this diagnosis and to rule out the other possibilities. Carpal tunnel syndrome is a compression neuropathy of the median nerve. The physical examination will focus on assessing the sensory and motor func- tions of that nerve. First observe the palm of the hand and compare the thenar area of the injured hand to the noninjured hand to look for atrophy. Next, tap over the median nerve at the wrist (Figure 7.5). A positive test (Tinel’s sign) is the production of tingling on the palmer surface of the thumb, index finger, and a portion of the middle finger. Test the strength of the thenar muscles by assessing the ability of the thumb to move toward the little finger against resistance (Figure 7.6). Placing the wrists together in maximum flexion (Phalen’s test) for 45 s or less will cause numbness or aching. (Figure 7.7). De Quervain’s tenosynovitis is an inflammation of the tendon sheaths of the abductor pollicis longus and the extensor pollicis brevis at the first dorsal 7. Wrist Problems 123 FIGURE 7.5. Median nerve percussion (Tinel’s test). FIGURE 7.6. Thenar muscle strength test. 124 E.J. Shahady FIGURE 7.7. Phalen’s test. compartment over the radial styloid. These tendons form the floor of the anatomic snuffbox of the wrist (Figure 7.8). Palpate the tendons over the radial styloid and at the floor of the snuffbox for pain and tenderness. Perform Finkelstein’s test (Figure 7.9) by asking the patient to ulnar-deviate the wrist with the thumb flexed and abducted into the palm places tension on the ten- dons and their sheaths. The examiner may have to provide an additional force to complete the test. Reproduction of the pain clinches the diagnosis. Examination of the snuffbox to evaluate the scaphoid (Figure 7.10) is important to rule out a subtle fracture that has been overlooked from past trauma. How to do this examination will be explained when scaphoid frac- tures are discussed in Section 7 (Scaphoid Fractures). This patient had positive Phalen’s and Tinel’s signs. She had no thenar atro- phy and thumb opposition was not weak. Her Finkelstein’s test is negative and there is no tenderness over the radial styloid (Figure 7.8). This history and phys- ical examination makes the diagnosis of carpal tunnel syndrome most likely. 3.3. Additional Studies No further studies are needed at this time unless a scaphoid fracture is sus- pected. Nerve conduction studies are helpful if the diagnosis is not clear or surgery is a therapeutic consideration. 7. Wrist Problems 125 Radial Styloid Snuff Box Extensor Pollicis Brevis Abductor Pollicis Longus FIGURE 7.8. Anatomic snuffbox area. FIGURE 7.9. Finkelstein’s test. 126 E.J. Shahady FIGURE 7.10. Examination of the snuffbox for scaphoid fracture. 3.4. Treatment for Carpal Tunnel Syndrome Most cases will respond to conservative measures. First, identify and decrease the offending activity that is causing the problem. Workstation modifications to decrease wrist flexion can be very beneficial. Examples include adjusting keyboard height and supports for the wrist and forearm. Intermittent breaks from typing every few hours decreases fatigue. If none of these measures work, consider a change in occupation or sport technique. Writing a note to the patient’s employer, coach, or teacher explaining how these changes will increase productivity helps patients obtain the cooperation of their superiors.