Provider Practice Essentials registered nurse continuing education

Common, Non-Emergent Hand and Wrist Conditions-Part 2

Kelsey Bates, APRN

Hand and wrist conditions of the non-emergent variety are common. Let’s pick up where we left off from our last post, and talk about some more. Pain in the thumb and wrist can be due to repetitive stress, and also direct trauma. Having a good understanding of the common things that can cause pain is important. Here we will discuss two common conditions – deQuervain tenosynovitis and Ganglion cysts.

de Quervain tenosynovitis

Non-Emergent Hand and Wrist Conditions

Subjective

Pain and swelling at the wrist on the thumb side. Movement of the thumb or making a fist makes the pain worse. Often times a triggering phenomenon, creaking or crepitus of the area is present with thumb movement. The most common cause is a repetitive stress injury of the thumb.

Other potential culprits could be gout, rheumatoid arthritis, diabetes mellitus, vibration exposure (power tools, jack hammer) and the postpartum period due to an altered hormone state and repetitive ulnar deviation of the wrist from lifting the baby.

Objective

Swelling and pain with palpation over the abductor pollicis longus and extensor pollicis brevis tendons at the first dorsal compartment of the wrist. Flexing and extending the thumb can cause crepitus. Pain at the first dorsal extensor compartment with the Finkelstein’s test. This is a hallmark test for all hand and wrist conditions

Imaging is usually not necessary because the diagnosis can be made from the subjective information and physical exam. However, lateral and PA radiographs should be considered to rule out a bony abnormality or fracture that could be part of the problem.

Differential diagnosis

  • Carpometacarpal arthritis of the thumb
  • Tendon sheath nodule
  • Ganglion cyst,
  • Tendon rupture
  • Flexor carpi radialis tendinitis
  • Fracture
  • Wrist osteoarthritis
  • Superficial radial neuritis

Plan

  • Forearm based thumb spica splint for two weeks
  • NSAIDs and ice massage as needed
  • Physical therapy after initial two weeks in splint, if no improvement

Consider corticosteroid injection into the tendon sheath if splinting fails to improve tenosynovitis. While steroids are often helpful with reducing the inflammation there is risk of atrophy and loss of pigmentation to the injected area. If the tendon sheath is unresponsive to all of the above-mentioned treatments, then a surgical referral is necessary.

Ganglion cyst of the wrist and hand/finger

Non-Emergent Hand and Wrist Conditions

Subjective

A lump that can be on the dorsal or volar surface of the wrist, palm side base of the finger (flexor tendon sheath cyst) or dorsum of the finger below the nail bed. In some cases, the lump is a cosmetic issue only. In other cases, the lump can also cause pain and the patient may experience numbness, tingling or weakness if the median or ulnar nerve are impacted. Ganglion cysts typically appear in 15 to 40 year old individuals. This is one of the more unsightly hand and wrist conditions. The cyst will vary in size.

Increased activity to the area will usually cause the size of the ganglia to increase. Finger ganglion cysts can also cause furrowing of the fingernail due to the pressure of the cyst on the nail matrix. Patients with a finger ganglion cyst (many times a mucoid cyst) may report the cyst breaking open, draining a clear, jellylike fluid, healing and then the cyst reappearing.

Objective

  • Smooth fluid filled mass to the dorsum or volar radial wrist, at the flexor tendon sheath or dorsal side of the finger above the DIP joint
  • More prominent with flexion and extension.
  • Ganglia that are on the radial aspect of the wrist may pulsate due to being close to or attached to the radial artery.
  • Cyst can be tender to palpation.
  • Typically, transillumination is present due to being fluid filled (keep in mind a solid mass will not transilluminate).

Radiographs of the affected area should be obtained to rule out any bony pathology. Wrist radiographs include PA and lateral. Hand radiographs include PA, lateral and oblique. Finger radiographs include PA and lateral views.

Differential diagnosis

  • Arthritis
  • Soft tissue or bone tumor
  • Arterial aneurysm
  • Lipoma
  • Intraosseous ganglion
  • Kienbock disease, stage 1
  • Dupuytren disease

Plan

For the wrist, immobilization is helpful to some degree but it is typically not a permanent solution. While it may be uncomfortable for the patient to wear an immobilizer wrist brace it can decrease the size of the ganglion, likewise decreasing the symptoms. Aspiration of the cyst can lead to a resolution but there is an 85%-90% reoccurrence of the cyst. GREAT caution should be taken when aspirating a volar wrist ganglion due to the proximity of the radial artery. Surgical excision is an option with a 10%-15% chance of reoccurrence of the cyst.

Tendon sheath ganglion cyst treatment consists of a needle rupture immediately followed by a massage to disperse the contents of the cyst. Caution should be taken with this procedure due to the proximity of the neurovascular bundle. Surgical excision is an option, as well.

For the finger, due to a high risk of infection, aspiration/rupture is not recommended. With these specific cysts being prone to rupturing on their own, there can be a risk of infection. The first choice of antibiotic to treat with is a first-generation cephalosporin. Make sure the patient is up to date on their tetanus immunization. If needed refer to a hand specialist for further management.

If the ganglion cyst is not causing the patient any discomfort and it’s only a cosmetic issue, educate the patient on their options. Let them know it is fine to just observe and often times the cyst will resolve on its own.

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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