Common, Non-Emergent Hand and Wrist Conditions (Part 1)

Kelsey Bates, APRN

Hand and wrist issues are not something to take lightly. We use our hands for SO many things on a consistent basis. Two of the most common, non-emergent hand and wrist conditions that cause dysfunction are osteoarthritis and carpal tunnel syndrome. Imagine you are sitting down to chart on patients and a few minutes in to typing your thumb and pointer finger start to go numb. How frustrating and distracting would that be? I find it helpful when reviewing a diagnosis to imagine myself in the patients position to get a better understanding and appreciation of the issue. Likewise, learning from our patient’s outcomes can give us better results.

Now let’s jump into a review of carpal tunnel syndrome and OA of the hand.

Carpal Tunnel Syndrome

Subjective

• Numbness, tingling and pain that radiates from the radial portion of the wrist and hand into the thumb, index finger, third finger and also the radial half of the fourth finger.
• Pain can also radiate into the forearm and sometimes up to the shoulder.
• Symptoms can also be worse at night. Repetitive or stationary movements with the wrist flexed or extended can also make the symptoms worse (ex. prolonged computer work, writing, cell phone use, driving, reading). Dropping items and difficulty opening jars are common complaints in addition to the discomfort.

Objective

• Orthopedic test: positive median nerve compression test, Tinels and Phalens.
  • Potentially thenar atrophy can also be present, there will be decreased strength with thumb opposition against resistance and visible muscle loss in the thenar eminence. Difficulty distinguishing two-point discrimination (4 mm or less is considered abnormal).
    
• Diagnostics are not always needed but if treatment is not working then diagnostics can be useful.
• An EMG/NCS is considered a “confirmatory test” but don’t use the results as the foundation for a diagnosis. Studies have shown that 5-10% of individuals with carpal tunnel syndrome also have normal EMG/NCS results, on the flip side, some individuals have no s/s of carpal tunnel syndrome and they have abnormal electrophysiologic testing.
• If ROM in the wrist is limited consider also getting a wrist radiograph.
• Cervical imaging to rule out cervical or thoracic causes.
• If there is a potential for cardiometabolic issues to be the culprit then consider lab testing (glucose, HgbA1c, thyroid panel).
• Common to see with pregnancy, 40-60 yo women, mass in the carpal tunnel area, diabetes mellitus, thyroid dysfunction, gout, trauma and tenosynovitis.

Differential Diagnosis

• Cervical radiculopathy
• Thoracic outlet syndrome
• CMC OA
• Wrist OA
• Diabetic neuropathy
• Hypothyroidism
• Flexor carpi radialis tenosynovitis
• Volar radial ganglion
• Median nerve compression at the elbow

Plan

• Neutral position wrist splints (3-4 weeks) at night specifically, as we tend to “curl up” when we sleep.
  • The splints can be worn during the day if the patient can function with them on. Ice and heat as needed.
• Work modifications such as, keyboard or forearm supports and avoiding holding the wrist in a flexed position for prolonged periods of time.
• Potentially order an ergonomic work station assessment if the patient’s own modifications are not helping.
• NSAIDs are also helpful for a short period of time, not long term.
• Referral to a hand therapist to also assist with specific strengthening exercises/stretches.
• Consider a corticosteroid injection into the carpal canal.
• If the patient has done all of the above-mentioned treatments for 3 months and improvement has not been made a referral to a hand surgeon may also be in order.

Osteoarthritis of the hand

Subjective

• Stiffness and discomfort at the distal interphalangeal (DIP), proximal interphalangeal (PIP) and/or thumb carpometacarpal (CMC) joints.
• Pain with palpation over the joints. If at the base of the thumb, pinching and gripping motions will also cause pain to the area and can radiate into the wrist and forearm.
• Eventually the patient can develop weakness and joint instability in the affected area.
• Common non-emergent hand and wrist condition

Objective

• Heberden node (bony nodule at the DIP joints)
• Bouchard node (bony nodule at the PIP joints)
• At first the nodes can be painful but overtime the pain resolves.
• If OA is at the CMC joint, a grind test is also usually positive.
• Radiographs (PA, oblique and lateral) of the painful area are also useful in visualizing degeneration of the joint and potentially subluxation (misalignment).

Differential diagnosis

• Sprain/strain
• Tenosynovitis
• Fracture
• Carpal tunnel syndrome (for CMC OA)

Plan

• Splinting for 2-3 weeks for the area to rest.
• NSAIDs for a short period of time, not long term.
• Referral to a hand therapist to assist with hand splints and also specific exercises/stretches.
• Home paraffin treatments.
• Topical rub-in creams.
• Corticosteroid injection.
• If no improvement with these non-invasive treatments, then referral to a hand specialist and possible surgical consult.

References

American Academy of Orthopaedic Surgeons. (2016). Hand and wrist. In J. E. Adams & M. C. Hubbard (Eds.), Essentials of musculoskeletal care (5th ed.), (423-547). American Academy of Orthopaedic Surgeons.

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