CHAPTER 2 Michael Shipley University College London Hospitals, London, UK Hand or wrist pain and resultant impaired function are often the cause of great anxiety for patients. Hands give us a great deal of information about the world in which we live. They are capable of performing fine and delicate movements and are essential for work, sport, hobbies and social interaction. The wrist is a complex structure comprising three groups of joints: the radiocarpal joints, which allow flexion, extension, abduction, adduction and circumduction; the inferior radioulnar joint, which allows pronation and supination; and the intercarpal joints (Figure 2.1). Figure 2.1 The bones of the hand. CMCJ = carpometacarpal joint; DIPJ = distal interphalangeal joint; DRUJ = distal radioulnar joint; IPJ = interphalangeal joint; MCPJ = metacarpophalangeal joint; PIPJ = proximal interphalangeal joint The eight carpal bones, in two rows of four, form a bony gutter and are the base of the carpal tunnel. The flexor retinaculum, a strong fascial band, forms the palmar side of the tunnel. Running through the carpal tunnel are the deep and superficial flexor tendons, the tendons of flexor pollicis longus, flexor carpi radialis and the median nerve. The ulnar nerve lies superficial to the flexor retinaculum but deep to the transverse carpal ligament in Guyon’s canal. The extensor tendons are held in position on the extensor surface of the wrist by the extensor retinaculum. Fibrous septa divide the extensor compartment into six. All the flexor tendons are encased in a common synovial tendon sheath, which extends from a position just proximal to the wrist to the middle of the palm. Flexor pollicis longus and flexor carpi ulnaris have their own individual sheaths, as do each of the six extensor tendons. The hand bones are the metacarpals, proximal phalanges, middle phalanges, distal phalanges and sesamoid bones. A sesamoid bone lies at the base of the thumb in the tendons of flexor pollicis brevis. The first metacarpal bone of the thumb is the shortest and most mobile of the metacarpals and lies in a different plane to the others. This is important to allow opposition, i.e. pincer actions to grasp objects. The carpometacarpal and trapezoscaphoid joints are prone to osteoarthritis. Individual tendon sheaths for the deep and superficial flexor tendons start at the level of the distal transverse crease of the palm and end at the bases of the distal phalanxes. The sheath for flexor pollicis longus continues from the carpal tunnel to the distal phalanx. During flexion, five fibrous bands, or pulleys, hold the flexor sheaths in position. The second to fifth metacarpophalangeal joints flex to about 90°. Active extension is rarely more than 30°. Passive extension varies from 60° to more than 100° in people with hypermobility. The proximal and distal interphalangeal joints are hinge joints. The lumbrical and interossei muscles produce complex movements that involve extension of the interphalangeal joints and flexion at the metacarpophalangeal joints and are essential to fine hand functions, such as writing. There are many possible causes of pain in the wrist and hand (Table 2.1). Table 2.1 Causes of pain in the wrist and hand Unaccustomed or repetitive use of the fingers or inflammatory arthritis can cause flexor tenosynovitis (Figure 2.2). This is inflammation of the synovial sheath of the finger flexor tendons, which leads to volar swelling and tenderness just proximal and distal to the wrist. The flexor tendon sheaths in the palm or finger may also be affected. The hand feels stiff, painful and swollen, particularly in the morning. Rest helps. Injection is sometimes needed. Local anaesthetic helps introduce the needle alongside the tendon in the palm just proximal to the metacarpophalangeal joint. Figure 2.2 Flexor tenosynovitis Gripping and hard manual work cause palpable thickening and nodularity of the finger flexor tendons; tendon sheath synovitis may also be present. The affected fingers are stiff in the morning, when the patient also has pain in the palm and along the dorsum of the finger(s). The pain is reproduced by passive extension of the finger. This is common in rheumatoid arthritis and in dactylitis caused by seronegative arthritis. Nodular flexor tenosynovitis is more common and less responsive to treatment in patients with diabetes than in other patients. Trigger finger is caused by a nodule catching at the pulley that overlies the metacarpophalangeal joint in the palm. The patient wakens with the finger flexed and has to force it straight with a painful or painless click. Triggering also occurs after gripping. The nodule and the ‘catch’ in movement are felt in the palm. Management and injection technique – A low‐pressure injection of local anaesthetic followed by a locally acting steroid preparation alongside the tendon nodule in the palm helps (Figure 2.3) (Schubert et al., 2013). If symptoms are persistent or recurrent, surgical release is needed. Figure 2.3 Injection technique for flexor tenosynovitis and trigger finger Overuse and local injury (e.g. after opening a tight jar) are the most common causes of thumb flexor tenosynovitis and trigger thumb. Either the interphalangeal joint cannot be flexed or it sticks in flexion and snaps straight. The sesamoid bone in the flexor pollicis brevis tendon is tender on the volar surface of the thumb’s metacarpophalangeal joint. Corticosteroid injection next to the sesamoid bone at the site of maximal tenderness helps. De Quervain’s stenosing tenosynovitis affects the tendon sheath of abductor pollicis longus and extensor pollicis brevis at the radial styloid. It causes pain at or just proximal or distal to the styloid (in contrast with first carpometacarpal osteoarthritis, which causes pain at the base of the thumb). There is tenderness, and swelling and pushing the thumb into the palm while holding the wrist in ulnar deviation increases the pain. A tendon nodule may cause triggering. Management and injection technique – Rest is essential, with avoidance of thumb extension and pinching, but immobilization splints are inconvenient. Therapeutic ultrasound or local anti‐inflammatory gels help; injection of local anaesthetic, then a locally acting steroid preparation alongside the tendon under low pressure at the point of maximum tenderness rapidly relieves the pain (Figure 2.4). A second injection may be needed. Surgery is rarely necessary, unless stenosis or nodule formation develops (Peters‐Veluthamaningal et al., 2009). Figure 2.4 Injection technique for de Quervain’s tenosynovitis Inflammation of the common extensor (fourth) compartment causes well‐defined swelling that extends from the back of the hand to just proximal to the wrist. The extensor retinaculum causes a typical ‘hourglass’ shape proximal and distal to the wrist. This contrasts with wrist synovitis, which causes diffuse swelling distal to the radius and ulna. Repetitive wrist and finger movements, especially with the wrist in dorsiflexion, are the cause, and this is one of the several causes of forearm and wrist pain seen in keyboard workers and pianists. It is also common in rheumatoid arthritis. Rest helps extensor tenosynovitis, but often a corticosteroid injection into the tendon sheath is needed. Workplace reviews and wrist supports for those who use a keyboard and mouse help prevent recurrences. This is a flexion deformity affecting the distal interphalangeal joint of the finger and is due to either distal extensor tendon rupture or avulsion with a bony fragment after traumatic forced flexion of the extended fingertip. The resultant weakness is often painless and presents with an inability to actively extend the fingertip. Treatment is usually by splinting the distal interphalangeal joint in extension or, rarely, surgery. Dupuytren’s contracture (Figure 2.5) is a relatively common and painless condition associated with palpable fibrosis of the palmar aponeurosis, usually in the palm but occasionally at the base of a digit. It is more common in white people, men, heavy drinkers, smokers and patients with diabetes mellitus. The cause is unknown, but repeated trauma may be important. Fibroblast proliferation starts in the superficial fascia and invades the dermis. An early sign is skin pitting or puckering. The contraction eventually causes flexion of the digit(s), most often the ring finger of the dominant hand, but disability is often minimal. Disabling and progressive flexion is more common in the familial form. Specialist hand clinics use magnetic resonance imaging to assess the lesion. Figure 2.5 Dupuytren’s contracture The role of local corticosteroid or a new Clostridium histolyticum‐derived collagenase injection and radiotherapy in early disease is unclear, although placebo controlled studies of collagenase indicate a high success rate, but with a significant incidence of complications. Percutaneous fasciotomy or open fasciectomy are helpful but recurrence is common. No controlled studies exist. Nodular fibromatosis also affects the sole of the foot, the knuckle pads (Garrod’s pads) and the penis (Peyronie’s disease), and these conditions may co‐exist. Carpal tunnel syndrome is a peripheral nerve entrapment syndrome of the median nerve, often caused by flexor tenosynovitis or arthritis. It can occur in the third trimester of pregnancy. Repetitive use of the hand increases the risk of developing carpal tunnel syndrome but its status as a ‘work injury’ is controversial (Yagev et al., 2001). A ganglion, or very rarely amyloidosis or myxoedema, can cause carpal tunnel syndrome. Pain, tingling and numbness in a median nerve distribution (thumb, index finger, middle and radial side of ring finger) are typically present on waking or can wake the patient. The patient feels the fingers are more swollen than they look and intense aching is felt in the forearm. The symptoms may appear when the patient holds a newspaper or a car steering wheel. Permanent numbness and wasting of the thenar eminence (flexor pollicis and opponens pollicis) cause clumsiness. The patient’s description often indicates the diagnosis Tests and investigations – Tinel’s sign (tapping the median nerve in the carpal tunnel) or Phalen’s test (holding the wrist in forced dorsiflexion) may provoke symptoms. Weakness of abduction of the thumb distal phalanx with the thumb adducted towards the fifth digit is typical. The carpal tunnel and median nerve are seen on ultrasonic images, although ultrasound and MRI are not usually needed. Nerve conduction studies can confirm the diagnosis, but are often not required if the history and examination are typical. Management and injection technique – A splint worn on the wrist at night relieves or reduces the symptoms of carpal tunnel syndrome. This is diagnostic and may be curative. A corticosteroid injection into the carpal tunnel (Figure 2.6) may also be considered, as this often helps rapidly, although recurrence is common. The needle is inserted at the distal wrist skin crease, just to the ulnar side of the palmaris longus tendon, or about 0.5 cm to the ulnar side of flexor carpi radialis at an angle of 45° towards the middle finger. The local anaesthetic is injected superficially. If a small test injection of corticosteroid causes finger pain, the needle is in the nerve and needs to be repositioned. An injection often exacerbates the symptoms briefly, but it is effective and non‐toxic (Huisstede et al., 2010a). Figure 2.6 Injection technique for carpal tunnel syndrome Recurrent daytime symptoms, unrelieved by splints, warrant nerve conduction studies. Slowing of median nerve conduction at the wrist suggests demyelination due to local compression. The action potential is reduced or absent due to nerve fibre loss if the lesion is severe or prolonged. Needle electromyography is unpleasant but detects denervation. Decompression surgery should be considered for recurrent symptoms not eased by splints or injection; significant nerve damage; muscle wasting; and/or permanent numbness (Huisstede et al., 2010b). Pins and needles often increase briefly postoperatively while the nerve recovers. Recovery of sensation or strength, or both, may be limited or non‐existent if the lesion is severe and longstanding. See also https://cks.nice.org.uk/carpal‐tunnel‐syndrome. Ulnar nerve compression at the elbow can be caused by direct pressure from leaning on the elbow, stretching the nerve with the elbow in prolonged flexion at night, or holding a telephone. It causes pins and needles in an ulnar distribution (little finger and the ulnar side of the ring finger). Prolonged entrapment causes hypothenar wasting and weakness of the hand’s intrinsic muscles. The nerve is tender and sensitive at the elbow, where Tinel’s sign is positive. Nerve conduction studies are normal in around 50% of cases. Avoidance of direct pressure and prolonged elbow flexion help. Surgical anterior transposition of the nerve is occasionally needed. In some cases, the ulnar nerve is compressed in Guyon’s canal at the wrist (Townley et al., 2006). Nodal osteoarthritis most commonly involves the distal interphalangeal joints and is familial. The joint swells and becomes inflamed and painful, but the pain subsides over a few weeks or months and leaves bony swellings (Heberden’s nodes) (Figure 2.7). Most patients manage with local anti‐inflammatory gels or no treatment once they know the prognosis is good. The appearance sometimes causes distress. Occasionally, the joint becomes unstable and limits pinch gripping. Surgical fusion of the index distal interphalangeal joints or thumb interphalangeal joint in slight flexion improves grip, although this is rarely necessary. Involvement of the proximal interphalangeal joints (Bouchard’s nodes) is less common and may be mistaken for early rheumatoid arthritis (Figure 2.8). Stiffness and pain of the proximal joints impair hand function significantly. Figure 2.7 Nodal osteoarthritis (Heberden’s nodes) and first carpometacarpal osteoarthritis Figure 2.8 Nodal osteoarthritis with Bouchard’s nodes Pain at the base of the thumb in the early phase of first carpometacarpal osteoarthritis (see Figure 2.7) is disabling, but with time the joint stiffens and adducts, and pain and disability decrease. The hand becomes ‘squared’. Management is usually conservative, but a corticosteroid injection helps severe pain associated with local inflammation. Surgical replacement is rarely warranted, although the outcome is good. Some find a splint helpful (Anakwe and Middleton, 2011). The hands are often affected early in rheumatoid arthritis, with symmetrical swelling of the metacarpophalangeal joints, proximal interphalangeal joints and wrists. The feet and other joints are usually also affected. Psoriatic and other forms of seronegative arthritis are less common, are more likely to be asymmetrical, and may be associated with marked skin and tendon changes that produce a ‘sausage’ finger (dactylitis). The distal interphalangeal joints and adjacent nails may also be affected in psoriasis. Morning pain and stiffness are typical. Intra‐articular steroids are often useful adjuncts to systemic medication. Early referral to a specialist for inflammatory arthritis is recommended Sudden wrist pain in an older patient may be due to calcium pyrophosphate arthritis (pseudogout). Marked swelling and inflammation are observed – the joint feels hot and infection may need to be excluded. Chondrocalcinosis (Figure 2.9), although often asymptomatic, is usually seen in the triangular fibrocartilage of the wrist on X‐ray. The joint aspirate is turbid and contains weakly positively birefringent crystals under polarized light. Steroid injection or a short course of a non‐steroidal anti‐inflammatory drug or colchicine usually helps; regular use of non‐steroidal anti‐inflammatory drugs or colchicine can be used to manage frequent attacks. Figure 2.9 Chondrocalcinosis in wrist Acute urate gout rarely affects the hands. Tophaceous deposits in individuals with renal failure or who have been on long‐term diuretic treatment are initially painless, chalky subcutaneous deposits. The tophi can ulcerate and a few such patients also develop acute gout in the hand and elsewhere. Stiff hands are seen in 5–10% of patients with type 1 diabetes. This is more common in those with poor diabetic control and is associated with limited shoulder mobility, diabetic nephropathy and retinopathy. Patients develop waxy, tight skin and a so‐called positive prayer sign — inability to hold the fingers and palms together (Figure 2.10). However, limited joint mobility in diabetes is multifactorial, and may also be due to flexor tenosynovitis, Dupuytren’s contracture or nodal osteoarthritis. Good diabetic control is essential. Injection for symptomatic flexor tenosynovitis helps. No specific treatment exists for the skin changes. Figure 2.10 Positive prayer sign: diabetic stiff hands (also nodal osteoarthritis and flexor tenosynovitis) This disorder, which results from severe vasospasm in response to a temperature change, causes marked and typically sharply demarcated pallor of one or more digits. As circulation recovers, the digit becomes blue (cyanotic) and then bright red because of rebound hyperaemia – the ‘triphasic colour change’. Raynaud’s is more common in females than males. In young women, the condition is often a harmless nuisance, requiring warm gloves and sometimes vasodilators. Its onset for the first time in older people warrants investigation. Raynaud’s may also be part of a systemic autoimmune disorder (rheumatoid arthritis, systemic lupus erythematosus or systemic sclerosis), and it occasionally leads to necrosis. Autoimmune‐associated Raynaud’s can be extremely severe and requires specialist referral (Herrick, 2012). Vibration white finger is a compensationable industrial disease in people who use vibrating tools. It can be clinically similar to Raynaud’s but the patient’s occupational history will usually distinguish the difference Primary Raynaud’s phenomenon may resolve spontaneously. A ganglion is a cystic swelling in continuity with a joint or tendon sheath through a fault in the capsule. It is filled with clear, viscous fluid rich in hyaluronan. Ganglia are common on the dorsal wrist, are often painless and resolve spontaneously (50% at 6 years). Often, reassurance of the patient is all that is required. Wrist splints relieve the pain. Aspiration and injection are rarely effective, and surgical excision is best if the ganglion is persistent and painful. The main symptom of chronic (work‐related) upper limb disorder is pain (Box 2.1). A local cause (carpal tunnel syndrome, flexor or extensor tenosynovitis or tennis elbow) may be the initial trigger. The patient develops widespread pain that is often disproportionate to the findings but causes great distress. A prior change in work pattern may exist, and often disharmony is found at the workplace. The cause is unclear, but neurophysiological and psychosocial factors are probably involved. The phenomenon of central ‘wind‐up’ of pain seen in many chronic pain syndromes probably plays a role. It is easy for the doctor to find the problem exasperating and difficult to understand, but it is best managed non‐judgementally. Early reductions in work activities and pain control measures are important, but it is best not to ask the person to take too much time off. Advice to the employer to review work practices reduces the risk of litigation. Referral to a specialist pain clinic should be considered (Barr et al., 2004).
Pain in the Wrist and Hand
Functional anatomy
At all ages
In older patients
Tendon problems
Flexor tenosynovitis
Finger flexor tendonosis and trigger finger
De Quervain’s tenosynovitis
Extensor tenosynovitis
Mallet finger
Dupuytren’s contracture
Peripheral nerve entrapment syndromes
Carpal tunnel syndrome
Cubital tunnel syndrome
Osteoarthritis
Nodal osteoarthritis
First carpometacarpal osteoarthritis
Systemic disorders causing hand pain
Inflammatory arthritis
Acute pseudogout and chondrocalcinosis of the wrist
Acute gout and chronic tophaceous gout
Diabetic stiff hand (cheiroarthropathy – limited joint mobility syndrome)
Raynaud’s phenomenon
Other disorders
Ganglion
Chronic (work‐related) upper limb pain
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