Hand and Wrist

Here we have collated the most common conditions related to the hand and wrist. We have also included a few case vignettes to help aid your clinical understanding these conditions.

After you have worked through these we have included a brief quiz which upon completion will provide you with a nice certificate!

Case 1:

Ms Median is a 40-year-old receptionist that presents with on-going discomfort and numbness in her both her wrists, being worse in her dominant (right) hand. She describes the sensation as a tingling feeling in her thumb, index, middle and “sort of” her ring fingers.

She notices her symptoms to be worse when at work and when driving, and finds herself repeatedly having to stop what she is doing to shake her hands in an attempt to relieve the sensation.

She has a BMI of 36, married with no children, smokes 10 cigarettes a day and currently takes ramipril for hypertension and metformin for type 2 diabetes mellitus.

What is your suspected diagnosis?

Carpal Tunnel Syndrome

Risk factors:

Age over 30

High BMI
History of Rheumatoid Arthritis
Smoking
Hypertension
Pregnancy

Activities that involve repetitive wrist movements
Being female (women are at least 3 times more commonly affected

Investigations:

Tinel’s test – repeatedly tapping over the carpal tunnel area to elicit symptoms of CTS
Phalen’s test – a.k.a. the reverse prayer, placing the wrist in a sustained position of flexion to elicit CTS
Diagnosis is predominantly clinical, although electromyogram (EMG) can be performed to confirm the diagnosis, and ultrasound or MRI of the wrist can also be considered as second-line investigations if required.

Management:

Address modifiable risk factors
Wrist splint at night for at least one month
Corticosteroid injection (be aware can increases pressure in carpal tunnel worsening symptoms).
If symptoms persist, can consider Surgical decompression (although recurrence is common). Patients with bilateral CTS may experience bilateral relief of symptoms even with surgery of just one side.

Dequervian's Tenosynovitis

Inflammation of the sheath surrounding the two tendons that move the thumb:

Abductor Pollicus Longus
Extensor Pollicus Brevis

Most common in females (associated with pregnancy) and overuse (e.g. racket sports, work)

Presentation = pain and swelling at base of thumb

Diagnosis = Finkelstein’s Test – grasping thumb in fist and then bending wrist towards little finger (as pictured) considered a positive test if pain at base of thumb worsens.

Treatment = Most cases resolve with rest but there is a high recurrence rate.

rest > splinting > NSAIDs (gels) > Physio

Case 2:

Kevin Dale, 68, presents to his GP concerned about his hands. Over the previous 2 years the skin on his palms has become tighter and affected the mobility of his fingers, especially his ring finger and little finger. He reports no pain, but is frustrated nonetheless. On examination of his hands, his ring and little finger are flexed, and he struggles to straighten them out. The skin on his palms is markedly thickened. Mr Dale has no other symptoms to note but does admit to having difficulties with alcohol over many years.

What do you suspect is the diagnosis?

Duputryen's Contracture

Duputryen’s Contracture

Dupuytren’s contracture is an autosomal dominant condition causing progressive fibrosis of the palmar fascia which is painless.

The condition is caused by fibroblast proliferation and collagen deposition. Initially this begins as a puckering of the skin which worsens to permanent contractures causing finger flexion. In approximately half of patients, the condition is bilateral.

It most commonly affects males of northern European descent. It is very uncommon to develop before the age of 20 and the likelihood of development increases with age.

Risk Factors:

• Genetic susceptibility

• Caucasian ethnicity

• Male gender

• Diabetes

• Alcohol overuse

• Smoking

• Manual work

Duputryen’s is clinically diagnosed

Management:

- Can be nonsurgical or surgical.

- Collagenase injections may be used in those with a palpable cord.

- Various surgical procedures to release or remove affected fascia and potentially overlying skin may be utilised in more severe cases.

Ganglion Cysts

These are round/oval benign fluid filled lumps that can form along tendons and joints. They most commonly occur at the wrists or hands (also the ankle and feet).

They can be caused by trauma or synovial herniation.

They most commonly occur at the dorsum of the wrist.

Cane be associated with median or ulnar nerve compression.

Presentation – rarely symptomatic more of an issue of cosmesis

Cysts will transilluminate

Management – observation

- Closed rupture (external impact to pop cyst – Bible bashing do not try at home!)

- Aspiration – must be careful of the radial artery in the dorsal aspect

Osteoarthritis Features in hands

The most common site for osteoarthritis of the hands is the Distal Interphalangeal (DIP) Joints. Here can develop fibrous, bony nodules known as Herberden’s Nodes.

Fibrous, boy nodules can also develop at the Proximal Interphalangeal (PIP) Joints, known as Bouchard’s Nodes. These tend to stiffen and swell.

Osteoarthritis may occur at the base of the thumb at the First Carpometacarpal (CMC) Joint. This presents with pain at the base of the thumb.

Osteoarthritis is less common in the Metacarpophalangeal (MCP) Joints.

Rheumatoid Arthritis Features in Hands

Rheumatoid Arthritis is the most common inflammatory arthritis. It affects 3% of women and 1% of men.

These patients tend to present with morning stiffness and polyarthropathy. The hands and feet are most commonly affected. The joints are usually only affected in the later stage of the disease process.

Physical examination features include:

- Sparing of the DIP joints

- Ulnar deviation

- MCP subluxation

- Swan neck deformity

Trigger Finger

This occurs due to mechanical impingement of the ‘A1 pulley’ which prevents smooth movement of finger tendons.

It most commonly occurs in the ring and long fingers. It occurs mostly in diabetic populations and females over 50.

Symptoms include pain, clicking, catching and locking of the digit.

Management includes: splinting, NSAIDs, steroid injections, and surgical release.

QUIZ coming soon....

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