Evaluation of the Painful Wrist


Wrist pain: outline of most frequent etiologies

Bone

Fractures (distal radius, scaphoid, triquetral, hook of the hamate)

Malunions (distal radius, scaphoid)

Nonunions (scaphoid, hook of the hamate, ulnar styloid)

Impingement (radiocarpal, ulnocarpal / stylocarpal impaction syndrome)

Osteonecrosis (Kienböck disease, Preiser disease)

Joint

Synovitis

Loose Bodies

Chondral lesions

Posttraumatic arthritis

Degenerative arthritis (radiocarpal, radioulnar, midcarpal, intercarpal)

Crystal arthritis (gout, pseudogout, lupus)

Inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, Reiter’s syndrome)

Ligament

Ligament tear/rupture (TFCC, SLIL, LTIL)

Instability (scapholunate, lunotriquetral, DRUJ, midcarpal, capitolunate, pisotriquetral, STT)

Tendon

Tendonitis and tenosynovitis (De Quervain’s)

Tendon tear/subluxation (ECU)

Tendon rupture

Nerve

Trauma/neuroma (superficial branch of radial or ulnar nerve)

Compression (carpal tunnel syndrome, Wartenberg syndrome, Guyon’s canal)

Peripheral neuropathy (diabetes mellitus)

Vascular

Arterial occlusion

Hypothenar hammer syndrome

Tumor

Soft Tissue (ganglion cyst, giant cell tumor, fibroma, synovial cell hemangioma)

Bone tumors (primary, metastatic)

Infection

Bacterial arthritis (staphylococco, steptococco, Lyme disease, tuberculosis, gonorrhea)

Viral arthritis

Other

Complex regional pain syndrome (CRPS)


TFCC Triangular Fibrocartilage Complex, SLIL Scapholunate Interosseous ligament, LTIL Lunotriquetral Interosseous ligament, DRUJ distal radio ulnar joint, STT Scaphotrapeziotrapezoid joint, ECU extensor carpi ulnaris





Pain


Several pain features are worth recording such as its quality (cramping, dull, aching, sharp, shooting, severe, or diffuse), frequency, duration, intensity, radiation, and movements in conjunction with the activities that may elicit pain. Nerve injury usually manifests as a sharp pain associated to a burning sensation. On the other hand, a deep, constant, boring pain mostly accompanies bone fractures. Pain from a ligamentous injury is often intermittent and elicited upon activity. In addition, location of symptoms can help guide diagnosis. The presence of localized pain may point towards ligamentous disruption, whereas nerve compression (due to carpal tunnel syndrome) is frequently associated with a more diffuse discomfort.


Predisposing Factors



Trauma


The patient should describe thoroughly any recent trauma, as its mechanism of injury may give up the diagnosis. For instance, a fall onto an outstretched hand during practice of contact sports is a common mechanism for fractures of the distal radius or scaphoid, whereas a direct palmar trauma from swinging a baseball bat or golf club could lead to a fracture of the hook of the hamate. Ligament tears may also occur, mainly at the TFCC, scapholunate and/or lunotriquetral ligaments. Depending on the kinetic energy of the trauma, these ligament injuries could either be partial or complete, isolated or associated with either distal radius fractures or scaphoid fractures. TFCC tears (with or without DRUJ instability) are often seen in gymnastic and racquet sports and may mimic extensor carpi ulnaris (ECU) pathology.

At times, trauma kinetics of a given wrist lesion remains elusive. In these situations, symptom duration may provide a temporal clue related to a vague history of trauma, while the patient refers spontaneous onset of the pain. Sometimes, the examiner faces such challenging scenario in patients with carpal bone nonunion or avascular necrosis, in whom symptoms may manifest several years after the index injury because of ongoing inflammation, leading to arthritis, swelling, pain, and loss of grip strength. The scaphoid is particularly prone to developing nonunions [5]. The latter is due to its vulnerable blood supply that can lead to complete vascular interruption of a bone fragment following wrist trauma. Idiopathic avascular necrosis generally occurs either at the lunate (Kienböck’s disease) or at the scaphoid (Preiser’s disease).


Patient Occupation or Recreational Activities


Several leisure or labor activities can affect wrist function. For example, long-standing history of typing that involves repetitive motion can trigger wrist pain, while knitting or sewing may lead to compressive neuropathy. Activities requiring forceful grasping with ulnar deviation or repetitive use of the thumb (e.g., caring for a newborn infant) can lead to De Quervain’s tenosynovitis with pain and swelling along the first extensor compartment.

Specific details regarding sport activities can be very informative about the mechanism of injury: repetitive stress versus blunt trauma. Contact sports, such as American football or rugby, may lead to blunt trauma, while noncontact sports, such as golf, tennis, field hockey involve repetitive stress of the wrist.

The presence of a painful clunking on the ulnar side of the wrist during activities that involve active ulnar deviation indicates midcarpal instability. In patients with symptoms at the ulnar side of the wrist, the examiner should to rule out DRUJ arthritis, ulnocarpal or stylocarpal impaction syndrome.


Medical History


While obtaining a thorough complete medical history, the physician should exclude the presence of systemic inflammatory disorders (lupus, rheumatoid arthritis, and degenerative arthritis), metabolic diseases (diabetes, gout, and hypothyroidism) in addition to previous surgeries. Pregnancy, hypothyroidism, and diabetes are predisposing risk factors for carpal tunnel syndrome. Rheumatoid arthritis has a tendency to involve the wrist while gouty arthritis and pseudo gout can involve the wrist joint, although more commonly they affect the lower extremities.

Patients with septic arthritis typically present with a history of constitutional symptoms or a recent infection and a poorly moveable wrist owing to severe, deep, and unrelenting pain.

Patient’s age and sex should also be considered. As example, younger patients are prone to posttraumatic carpal injuries and occult ganglion cysts, whereas older patients are susceptible to systemic diseases and degenerative processes.


Physical Examination


The physician should perform a methodical physical examination, starting with a comprehensive visual inspection of the upper extremity.

Noticeable swelling, ecchymosis, or skin changes at the level wrist can provide major clues to comprehend the mechanism of injury. Gross deformity of the wrist generally indicates an obvious pathologic process that could be due to previous fracture, dislocation, or from soft tissue and/or joint swelling. A malunited distal radius fracture is often the cause of this deformity, presenting radial deviation of the wrist, and the carpus palmary displaced on the radius. Such misalignment of the distal radius may lead to extrinsic carpal instability and wrist pain. Disruption of the distal radioulnar joint can also produce wrist deformity.

Following inspection, the physician should proceed by palpating the nonpainful areas of the wrist first and then continue to areas of maximal tenderness. This sequence is crucial because once pain/discomfort is elicited, the patient may become apprehensive, preventing further palpation. Anatomical knowledge, especially surface anatomy, can be of great help during wrist exam.

All wrist structures should be palpated and compare with the contralateral side. A systematic circumferential palpation of the wrist is performed according to patient’s history and degree of pain [6]. We routinely start on the dorso-radial corner and progress to the dorso-ulnar side and then to the palmar surface. The site of pain and tenderness suggests the presence of pathology of underlying structures; however, we should take into account the intricate three-dimensional features of the wrist structures (Table 2.2).


Table 2.2
Topographic palpation of the wrist


































































Region

Anatomic structure

Pathology

Dorso radial

Snuffbox (distal)

STT

Carpometacarpal arthritis/instability

STT arthritis

Snuffbox (middle)

Floor of the snuffbox

Scaphoid fracture/nonunion

Scaphoid Necrosis (Preiser’s disease)

Snuffbox (proximal)

Radial styloid

Radial styloid fracture

Radioscaphoid arthritis

First extensor compartment

APL/EPB

De Quervain tenosynovitis

Intersection syndrome (proximal)

Dorso central

3-4 dorsal recess

Lister tubercule

Dorsal synovitis

SLIL instability

Dorsal wrist ganglion

Kiënbock disease

Dorso ulnar

5-6 dorsal recess

LTIL

LTIL instability/arthritis

DRUJ space

DRUJ

DRUJ instability/arthritis

Ulnar head

ECU

ECU tendinosis/instability

Distal ulna

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Nov 16, 2016 | Posted by in ORTHOPEDIC | Comments Off on Evaluation of the Painful Wrist

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