Hand and Wrist Pain: Common Causes and Treatment by Dr Wolf
Dysfunction of the hand and wrist is one of the most common reasons people seek orthopaedic care. Carpal tunnel syndrome alone is responsible for 500,000 surgeries/year in the US at an estimated economic impact of 2 billion dollars annually. Pain, weakness, and sensory disturbances may have a variety of causes. Identifying the etiology of the problem and selecting appropriate treatment interventions is generally a straightforward process. The keys here are a good history/description of symptoms by the patient, a thorough physical exam, and appropriate diagnostic studies where indicated.
Hand pain and dysfunction usually result from nerve compression, tendonitis, or arthritis. The most common nerve compression seen in the upper extremity is carpal tunnel syndrome. In this disorder, the median nerve, which gives sensation to the thumb, index, middle, half the ring finger on the palmar side of the hand and strength to the thumb muscles, is compressed at the wrist. The median nerve passes through the carpal tunnel, a space containing the tendons which flex your fingers, at the level of the wrist. Trauma, overuse, pregnancy, or age can lead to median nerve compression and subsequent loss of grip strength, sensation, and development of pain. Symptoms are often worse at night and with activities that require gripping. While mild symptoms may be treated with bracing, physical therapy, and occasionally a cortisone injection, more severe or persistent dysfunction may indicate significant nerve damage. This should be quantitated with nerve conduction studies, which test the extent of nerve compression/conductivity, and surgery should be considered for moderate to severe nerve compression or symptoms to avoid permanent nerve damage. The surgery involves release of the transverse carpal ligament, which is the soft tissue structure compressing the nerve, and usually leads to rapid recovery and resolution of symptoms. This can be done via an endoscopic or open technique with a very small incision, with both methods providing excellent results in clinical studies. If the neurologic symptoms include loss of sensation in the small and ring fingers, the cause is usually compression of the ulnar nerve (”funny bone”) in the cubital tunnel on the inside of the elbow. Symptoms and medical work up are similar to carpal tunnel, except for the location of sensory loss and muscle weakness (small finger side of hand). Treatment is a cubital tunnel release, where the nerve is freed of soft tissue compression in the elbow, often with transposition of the nerve into a position where further compression is less likely. Results are usually very good in terms of return of strength and sensation, but may be compromised by associated factors such as diabetes, poor nutrition, smoking, and associated nerve compression in the cervical region (neck).
Tendons are the structures which connect muscles to bones. These cords slide back and forth with muscle contractions and joint movements, and are predisposed to attritional wear and inflammation, leading to pain and dysfunction. In the hand, trigger fingers and Dequervain’s syndrome are the most common tendon problems. With a trigger finger, the tendons which flex your fingers become swollen and inflamed, resulting in painful catching/triggering when fingers are flexed and extended. DeQuervains syndrome is a similar process which occurs in the extensor tendon of the thumb (tendon which straightens), causing pain in the wrist in the area of the base of the thumb, but without triggering. Initial treatment options for these problems include bracing, anti-inflammatory medication, and cortisone injection. When these options fail to cure the problem, surgical release of the pulley, a small structure which restricts the tendon movement, leads to immediate relief in most cases. This is a very minimal surgery, often through an incision less than 1 centimeter in length, with minimal down time.
Arthritis of the hand can have a variety of causes, including trauma, genetic predisposition, and inflammatory disease such as rheumatoid arthritis or gout. The articular cartilage, the white smooth covering of the bones where they join in the joints, degenerates and wears out. This causes swelling, stiffness, deformity, and pain. Arthritis can affect any joint, but is most commonly seen in the base of the thumb, where the metacarpal bone joins the trapezium on the thumb-side of the wrist. Arthritis in this area (the carpometacarpal or cmc joint) causes pain when the thumb is loaded, which occurs pretty much anytime you grip something. Nonsurgical treatment involves, once again, bracing, anti-inflammatory medication, and possibly a cortisone injection. When these fail, a cmc arthroplasty, where the degenerated trapezium bone is removed and a ligament reconstruction to stabilize the thumb is performed, has excellent results in terms of pain relief and improved function. Another common problem related to arthritis is the development of cysts. Cysts are fluid-filled masses which are connected to joints. Weakened areas of the joint allow fluid to leak out, similar to a bubble forming on a bicycle tire. In the wrist and hand these can be aspirated (decompressed with a needle/syringe) or excised surgically if symptoms warrant, but are generally not dangerous.
There are a multitude of other issues that can effect the wrist and hand, but these are the more common issues that most people encounter as they age. If you are struggling with similar problems, feel free to give me (Dr Wolf) a call at 271-6503.