Wrist and hand pain

# Overview
The wrist contains eight carpal bones. These bones are aligned by a sequence of ligaments and cartilaginous connective tissue. Though pain and numbness is a frequent presentation, carpal tunnel syndrome is the most common diagnosis.

# Diagnosis

## Physical Examination

### Extremities
- Tinel's sign
- Positive when pain occurs if anterior wrist is tapped.
- Phalen's sign
- Positive if flexing the wrist for more than 30 seconds causes pain or numbness

## Laboratory Findings
- Typically unnecessary though some tests may include:
- Rheumatoid factor
- ANA
- ESR
- CBC
- Uric acid
- TSH
- Pregnancy test

## X Ray
- PA
- Lateral
- Oblique

## MRI and CT
- Rarely used
- May be needed to diagnose masses causing nerve problems or compromise of the vascular system

## Other Imaging Findings
- Bone scan may be needed to asess potential avascular necrosis, occult fracture or infections of the bone.

## Other Diagnostic Studies
- If carpal tunnel syndrome or other neuropathy is suspected, EMG and nerve conduction studies should be performed.
- If warmth and redness are present in wrist and MCP joints, Arthrocentisis with crystal analysis may be necessary

# Differential Diagnosis of Causes of Wrist and hand pain
Causes include;  
- Carpal Tunnel Syndrome
- Most frequent cause of wrist discomfort and morbidity
- Linked to repetative activities
- For example: writing, typing, etc.
- Symptoms are a consequence of the mendian nerve becoming trapped beneath the transverse ligament cause pain and numbness.
- Injury due to overuse
- Osteoarthritis
- Tenosynovitis or DeQuervain's of the radial wrist
- Caused by the inflammation in the tendon sheaths of the extensor pollicis brevis and abductor pollis longus
- Ganglion cysts
- Growths common to the wrist area taking place on the dorsal and ventral surfaces.
- These cysts are round, tender to touch and movable.
- Trauma
- Falling on the wrist is the most common method of injury
- The scaphoid bone is the most commonly injured
- Other means of trauma include:
- direct hit
- crush
- fall when wrist is in a vulnerable position
- twisted wrist
- Fibromyalgia
- Keinbock's Disease
- Compartment Syndrome
- Compression of the lymphatic system or venous system due to chest or shoulder masses
- Venous thrombosis in subclavian veins and distal veins
- Paralysis (flaccid) after CVA
- Quinke's disease resultant of hymenoptera sting
- Rhumatologic disease
- Insect sting/bite
- Infections

# Treatment
- Carpal Tunnel Syndrome
- Corticosteroid injection makes progress in more than half of patients
- Tenosynovitis
- Corticosteroid injection alongside the tendon sheaths

## Acute Pharmacotherapies
- Carpal Tunnel Syndrome
- NSAIDs reduce inflammation
- Stings
- Antihistamines and steroids

# Surgery and Device Based Therapy

## Indications for Surgery
- Ganglion cysts
- require a minimally invasive prcedure that includes draining fluid from the cyst and injecting a steroid.
- Surgery to remove Ganglion cysts is occasionally required
- Carpal Tunnel Syndrome
- Surgery is potentially needed to remove the pressure from the nerve area and remove the transverse ligament from beneath the median nerve

## Device Based Therapy
- Carpal Tunnel Syndrome
- cock-up splints relieve pressure and strain during repetative activities
- Tenosynovitis
- Thumb spica splint
- Fracture
- Casting and X-ray in 7-9 days in order to avert complications of occult fractures