Injuries or pain in the hand and wrist are common in the workplace, particularly in occupations that involve a forceful and repetitive pinching or finger loading. Careful assessment of symptoms and a focused physical examination are necessary to make the proper diagnosis since the symptoms can often be vague and difficult to reproduce.
1. Nonspecific Forearm, Wrist, or Hand Pain
Workers sometimes present to the occupational medicine clinic with nonlocalizing aches or pains in the distal upper extremities or symptoms that change in quality and location with time. Approximately half of these have a normal physical examination. These patients may have an early preclinical condition that has yet to declare itself with no localizing symptoms or physical findings. These patients can be rewarding or frustrating to manage depending on the approach to treatment.
One approach is to treat these as somatizations and try to identify and address underlying psychological or psychosocial factors that may be triggering symptoms. This approach should be considered if the symptom location and quality change with time and there is no apparent aggravation by specific tasks or biomechanical activities. Psychosocial factors at work can be explored by enquiring about relationships with coworkers and supervisors; concerns of job loss; the patient's pattern of wellbeing and energy level through the workweek; etc. Talking through constructive approaches to difficult work or home life may be very useful. A poor sleep pattern may also suggest psychosocial factors. The poor sleep pattern and symptoms respond well to daily exercises as simple as nondirected walks. Or they may respond to low-dose pm tricyclic antidepressants or other mood altering medications. These patients may benefit from a referral to a therapist.
Another approach is to try to identify the specific tasks and biomechanical activities at work or home that aggravate the symptoms. This approach is most useful if the symptom location does not change over time and the patient can identify specific aggravating activities. The physician should consider the ergonomic risk factors that might affect tissues in the location of the symptoms. For example, pain in the elbow region may be due to the repeated forceful pinching or gripping; sustained wrist extension; or contact stress at the elbow. For pain at the wrist, consider sustained wrist extension or ulnar deviation; sustained forearm pronation; repeated wrist motion; or contact stress on the volar surface of the wrist. Interventions should be proposed that directly address the aggravating activities. For example, some computer users are symptomatic using a conventional keyboard or mouse because their symptoms are aggravated by forearm pronation. They may respond well to a split keyboard and an asymmetrical mouse. The patient should be warned that their symptoms may take several weeks to resolve after the intervention is implemented. A number of workplace intervention studies have demonstrated a benefit of symptom reduction following the introduction of new tools or changes in work practices that address ergonomic risk factors.
In general, physicians should avoid using the terms repetitive strain injury or cumulative trauma disorder as a diagnosis but should instead identify the specific disorder or disorders, when possible. If there are no localizing physical examination findings, it is appropriate to use “hand pain” or “elbow pain.” Effective treatments and prognoses are different between the specific disorders and the use of generic terms can cloud effective management.
Ganglion cysts are the most common soft tissue tumor of the hand. These mucin-filled cystic lesions occur most often in the second to fourth decades. They can be asymptomatic or produce pain with direct pressure or during certain wrist motions. Patients seek care when they change size or become symptomatic.
Ganglion cysts can be associated with a joint capsule or tendon sheath. They are most commonly found over the dorsum of the wrist but can also occur on the volar side. They are well circumscribed and feel fluid filled. If they are large enough, then they can be transilluminated with a small penlight. When they occur in the hand, they are typically found on the volar surface and may present as a small, round, “BB-like” firm mass near the base of the digits.
Other types of soft tissue masses should be considered, particularly if the mass feels more solid than cystic.
Imaging & Diagnostic Studies
The diagnosis can be made clinically. Radiographs can be useful if the mass feels bony or calcified in nature. The diagnosis can also be confirmed with an MRI, CT scan, or ultrasound if the physical examination is inconclusive.
A few workplace studies link ganglion cysts to work involving repeated wrist motions, but the evidence is limited.
Asymptomatic lesions can be observed and will occasionally resolve on their own, particularly if they are small and have been present for less than a year. Avoiding weight-bearing with wrist extension can help decrease pain associated with dorsal wrist ganglia. Aspiration can be performed in the clinic although recurrence rates after aspiration has been reported to be 50–70%. Use of a large bore needle (eg, 18 gauge) to puncture the cyst walls may decrease recurrence. Injection with steroid has been shown to have an increased incidence of skin depigmentation and subcutaneous fat atrophy. Surgical excision can be performed for symptomatic ganglia that do not respond to conservative treatment.
3. De Quervain Tenosynovitis (First Dorsal Wrist Extensor Compartment Tenosynovitis)
De Quervain tenosynovitis involves the first dorsal compartment of the wrist. The involved tendons include the abductor pollicis longus and the extensor pollicis brevis. The onset is usually associated with overuse of the thumb and wrist particularly with radial deviation, as in repetitive hammering, lifting, or pipetting. The tenosynovial lining will show low-grade inflammation.
Patients in new, hand intensive job activities or those who engage in repetitive lifting may complain of pain in an ill-defined area along the radial side of the base of the thumb, occasionally extending as far distally as the interphalangeal joint. This condition is also seen in new or nursing mothers. There is usually very localized tenderness over the radial side of the distal radius and swelling may be present. When the patient grasps the fully flexed thumb into the palm and then ulnar deviates the hand at the wrist, exquisite pain develops and reproduces the patient's complaint (Finkelstein test)(Figure 9–5).
Finkelstein test. With the thumb clasped in the palm as shown, the wrist is deviated toward the ulna, producing pain over the first dorsal extensor compartment.
Chronic nonunion of the scaphoid bone occasionally produces similar symptoms. Pain associated with osteoarthritis of the first carpometacarpal joint, which occurs in approximately 25% of white women older than 55 years of age, may mimic De Quervain tenosynovitis, which occurs in younger patients.
Imaging & Diagnostic studies
This is primarily a clinical diagnosis and there are no specific radiographic findings. However, radiographs of the wrist can rule out carpometacarpal osteoarthritis and nonunion of the scaphoid bone.
Patients are instructed to lift with the palm facing upwards (full supination) rather than with the palm down, and avoid using the thumb. Tools can be modified to reduce repeated forceful thumb flexion especially with the wrist in a nonneutral posture. The thumb that strikes the spacebar on a keyboard, usually the right, may be at risk.
The first line of treatment can be activity modification including lifting with the palm in supination, avoiding repetitive lifting and thumb abduction, and use of a thumb spica splint to immobilize the thumb. NSAIDs can be helpful for pain management.
Steroid injection is often successful at curing this condition. Injection is generally performed with a combination of local anesthetic and steroid given into the tendon sheath over the area of the radial styloid with a single injection using a 25-gauge needle. Every attempt should be made to place the injection within the sheath and avoid subcutaneous injection of steroid that can cause skin depigmentation and fat atrophy. Only 1–2 cc of total fluid will fit into the tendon sheath.
In patients who do not respond to local injection, surgical decompression of the common extensor sheath by incision may be necessary. Patients who have certain anatomic variations, such as a separate subsheath for the extensor pollicis brevis tendon or multiple slips of the abductor pollicis longus, may be less likely to respond to injection. Unfortunately, there is no reliable way of distinguishing these patients clinically or radiologically.
4. Other Extensor Tendinopathies of the Wrist
Tendonitis can occur at five other specific sites on the extensor side of the wrist (Figure 9–6). The common sites are intersection syndrome (ECR, third compartment), extensor digitorum communis (EDC, fourth compartment), and extensor carpi ulnaris (ECU, sixth compartment). Intersection syndrome (ECR travels beneath muscles of APL and EPB) and fourth extensor compartment tenosynovitis (EDC) can occur with repeated or sustained wrist extension or other overuse, such as with excessive typing or mousing. ECU tendonitis occurs after a twisting injury and presents as vague or deep pain over the ulnar side of the wrist. EDC synovitis with swelling and fluid is unusual outside the setting of inflammatory or crystalline arthropathy, and patients with these findings should be evaluated for these conditions.
Extensor tendon entrapment sites: First is De Quervain tenosynovitis (ABL and EPB), second is ECR insertion on carpal bones, third is intersection syndrome (ECR travels below ABL and EPB muscles), fourth is EDC, and sixth is ECU.
It is useful to localize the tendonitis to the specific compartment. There may be very localized tenderness or pain with resisted loading of the tendon/muscle. Patients with tendonitis over the ECU tendon have ulnar-sided wrist pain that can often extend from the insertion point over the base of the fifth metacarpal bone, over the distal ulna, and into the distal forearm. The pain is often worse with resisted wrist extension and ulnar deviation. Similarly, tendonitis of the ECR tendons creates pain at the second and third metacarpal that also can extend into the forearm. Pain with this condition tends to be worse with resisted wrist extension and radial deviation. Intersection syndrome occurs at the distal forearm where the muscle bellies of the tendons the first dorsal compartment cross over the radial wrist extensors, causing compression in this area.
ECU tendonitis must be distinguished from a tear of the triangular fibrocartilage complex. ECR tendonitis can be confused with De Quervain or scaphoid fractures or nonunions as well as radiocarpal arthritis.
Imaging & Diagnostic studies
Tendonitis is primarily a clinical diagnosis. However, MRI studies will sometimes show fluid or inflammatory changes around the affected tendon.
Reduction of duration of forceful gripping and repeated wrist motion may prevent these conditions for hand intensive work. For computer users, ergonomic modifications can reduce wrist extension with keyboard and mouse use.
The primary treatments include activity modifications, wrist splints, NSAIDs, and, if indicated, ergonomic evaluation of work tasks and tools. Corticosteriod injections can be done but should be limited in number to prevent the risk of tendon rupture. Surgery is only indicated in very rare instances of refractory pain.
5. Trigger Digit (Stenosing Tenosynovitis)
Stenosing tenosynovitis of the flexor tendon to a finger or of the flexor pollicis longus to the thumb may produce pain when the digit or thumb is forcibly flexed or extended. Motion of the proximal interphalangeal (PIP) joint of the finger or the interphalangeal (IP) joint of the thumb produces the symptoms, which is a painful snap. This causes the joint to collapse suddenly much like a trigger.
The cause of the tenosynovitis may be repetitive finger flexion. It is also associated with systemic diseases such as diabetes, thyroid dysfunction, and rheumatoid arthritis. The patient's work history may reveal a cause of the disorder; however, most cases are idiopathic.
Triggering is usually reproducible on examination but can often only be noticed if the finger is actively rather than passively flexed. In the early stages, patients may present with pain over the A1 pulley only and no triggering. Sometimes a nodule can be palpated at the A1 pulley (near the MCP joint) with passive flexion of the PIP joint. In the later stages, the digit may become “locked” in extension (or more rarely in flexion) such that the motion is so limited the triggering cannot be reproduced.
Traumatic injuries to the hand can cause pain in similar areas.
Imaging & Diagnostic Studies
Imaging studies are not needed to make this diagnosis and are usually normal.
Avoidance of repetitive digit flexion against a load and good diabetic control can help prevent triggering.
At the early stages, splinting in extension at night can help. However, injection of a combination of steroid and local anesthetic (1–2 cc total volume) into the area of the synovial sheath around the A1 pulley is often curative. Patients not responding to injection or developing recurrent symptoms may require surgical release of the tendon sheath.
6. Carpal Tunnel Syndrome
Carpal tunnel syndrome is an entrapment or pressure neuropathy of the median nerve as it passes through the carpal tunnel volar to the nine flexor tendons. The canal boundaries are the rigid transverse carpal ligament on the volar side and the carpal bones on the dorsal side.
Carpal tunnel syndrome affects workers of any age but is more common in women. Pregnancy, increasing age, and obesity increase the risk. Symptoms may appear after an injury, such as a direct blow to the dorsiflexed wrist or an injury associated with a Colles fracture. Rheumatoid arthritis, which causes inflammation in the sheath surrounding the flexor tendons, is one example of a space-occupying lesion that produces the encroachment. Rare hypothyroid patients with myxomatous tissue in this area are at risk for bilateral symptoms. While the cause of the syndrome is unknown in many cases, repeated or sustained forceful gripping or repetitive wrist and finger movements involved in work have been associated with carpal tunnel syndrome. There continues to be controversy about the association between carpal tunnel and the use of a keyboard or computer mouse. Patients with carpal tunnel syndrome may find that keyboarding, especially with the wrist in extension or forearms in full pronation, exacerbates their symptoms.
In the absence of an acute injury, patients can develop paresthesias in the median nerve distribution gradually and spontaneously (volar surface of the thumb, index, and long fingers as well as the radial half of the ring finger). With progression of the syndrome, patients may be awakened at night with pain, tingling, burning, or numbness in this area of the hand. Characteristically, patients tend to stand up and massage the area or shake the wrist and fingers. Symptoms may also occur with driving or sustained gripping. Further progression may lead to hand weakness. Untreated carpal tunnel syndrome with progressively worsening symptoms may result in permanent damage to the median nerve with consequent persistent skin sensory deficit and thenar motor atrophy and weakness.
When patients are seen early, there is no evidence of thenar atrophy, and sensation (2-point discrimination at 4 mm) remains intact. Patients who hold their wrists maximally flexed for 60 seconds (Phalen sign) may develop symptoms or direct pressure with the thumb over the carpal tunnel area can also recreate symptoms (carpal compression test)(Figure 9–7A). Tapping with a reflex hammer at the volar wrist may recreate shooting pains into the tips of the digits (Tinel sign). There may be diminished abductor pollicis brevis strength (Figure 9–7B). The diagnosis is confirmed by median nerve electrodiagnostic studies (nerve conduction studies and EMG).
A. Carpal compression test—wrists are flexed to 45 degrees and examiner's thumbs press over carpal tunnel for 30 seconds; B. Strength testing of APB (median nerve innervated)—patients are instructed to raise up the tip of thumbs against examiner's thumbs.
Pain in the median nerve distribution with entrapment at the carpal tunnel should be distinguished from median nerve compression occurring proximally. Occasionally, cervical radiculopathy (C5, C6, C7) or pronator teres syndrome may resemble this condition, but neurologic examination should distinguish between these.
Imaging & Diagnostic Studies
Imaging studies are not needed to make this diagnosis. Nerve electrodiagnostic studies are helpful in both confirming the diagnosis and estimating the severity of nerve dysfunction. The nerve conduction study should be temperature adjusted.
Avoidance of repeated or sustained forceful gripping or repetitive wrist and finger movements, prolonged wrist flexion or extension, or direct pressure on the carpal tunnel can help prevent symptoms. There are many examples of tools or jigs that allow work to be performed with less forceful pinch or grip. Some examples are the use of anti-torque bars on inline screwdrivers; tool clutch adjustment to minimally effective torque; tools with lower force switches; and tool balancers that support the weight of the tool. Tools that reduce sustained posture extremes such as split keyboards or those that reduce extreme pronation such as asymmetrical computer mice may also be useful.
Underlying conditions, such as rheumatoid arthritis or hypothyroidism, causing carpal tunnel should be treated. In the absence of signs of neuropathy, patients are instructed in reducing provocative or repetitive activities. Wrist splints holding the wrist in neutral are effective in alleviating symptoms. Splinting consistently at night for a period of 4–6 weeks can be curative in the early stages. Carpal tunnel syndrome associated with pregnancy usually responds to splinting and the symptoms resolve after delivery. For patients not responding to rest and splinting, injections of cortisone into the carpal tunnel (with care to avoid injection into the median nerve) can be beneficial. Patients who fail to respond to the preceding measures or whose symptoms recur may require carpal tunnel release surgery, endoscopically or open. When patients present with signs of nerve injury, constant numbness, loss of sensibility, or thenar atrophy, early surgery is preferred. Surgery is well documented to be beneficial when performed on patients with confirmed carpal tunnel, therefore the diagnosis should be confirmed by electrodiagnostic studies before surgery is undertaken.
7. Ulnar Neuropathy at Wrist, Hypothenar Hammer Syndrome
Ulnar neuropathy at the wrist can be caused by a space-occupying lesion in the area of Guyon canal. Patients have loss of sensation over the ulnar hand and weakness of the hypothenar, interosseous muscles, and even “clawing” of the hand. Hypothenar hammer syndrome is a vascular injury of the ulnar artery that occurs with compression or repetitive “hammering” using the hypothenar eminence. The superficial palmar branch of the ulnar artery lies in close proximity to the hamate and repetitive trauma can cause occlusion of the branch resulting in diminished arterial flow to the second through fifth digits.
Callousing over the hypothenar eminence may be present. With ulnar neuropathy at the wrist, the patient may have diminished sensation of the small finger and ulnar border of the ring finger. At later stages, atrophy of the hypothenar muscles and the interosseous muscles can develop as well as clawing of the hand. Patients with hypothenar hammer syndrome present with signs of ischemia such as cold sensitivity, decreased capillary refill, discoloration, or tip necrosis. The Allen test may be useful to evaluate ulnar artery blood flow.
Systemic causes of neuropathy, cubital tunnel syndrome, T1 radiculopathy, and Reynaud syndrome should all be considered on the differential diagnosis.
Imaging & Diagnostic Studies
MRI or CT scan is often helpful to identify an occult lesion in Guyon canal or elsewhere over the ulnar nerve. Neurodiagnostic studies can also be used to determine the area of compression and degree of dysfunction. Arteriography is very useful in confirming the diagnosis of hypothernar hammer syndrome.
Repetitive hammering with the hypothenar eminence of the hand should be avoided. Sheet metal workers should use a rubber mallet.
Ulnar neuropathy at the wrist due to an occult mass needs to be surgically treated to relieve the symptoms. Release of Guyon tunnel can also be done in the absence of a mass. The treatment of hypothenar hammer syndrome is more controversial. Avoidance of smoking, keeping the digits warm, and calcium channel blockers may be helpful. Often there is enough redundancy in the hand vasculature that conservative treatment can be used until the collateral circulation becomes more robust. However, surgical interventions such as embolization or resection of the thrombosed segment with or without vein grafting are sometimes needed.
8. Hand Arm Vibration Syndrome
Hand arm vibration syndrome (HAVS) involves both neurologic and vascular signs and symptoms associated with the use of electric and pneumatic vibrating hand tools. Tools, such as chain saws, chipping hammers, riveting guns, blowers, grass trimmers, grinders, sanders, and rock drills may have high levels of handle vibration and their use over months or years may lead to HAVS. Because most vibration from small power tools is absorbed by the fingers and palm, clinical pathology is usually confined to the distal upper extremity. Modern chain saws and many vibrating commercial tools have reduced handle vibration compared to earlier models. However, limited tool maintenance or the use of worn or imbalanced cutting heads will generate higher exposure risk. The clinical expression of HAVS occurs most commonly with outside work performed in colder climates. However, the underlying pathology is caused by the tool signature not cold temperature.
The classic presentation, which is the basis for tool standards, is cold-provoked blanching of the fingers, thus the term vibration white fingers (VWF) or occupational Raynaud phenomenon. At lower exposures, neurologic symptoms predominate. These symptoms usually begin as problems of hand coordination and fine manipulation. Progression includes intermittent numbness, tingling, and pain (see Stockholm Workshop Scales for severity assessment). Hand and arm pain and hand paresthesias are relatively common in hand tool users, and may be related to nerve compression or chronic soft tissue injury. Accordingly, differentiation of exposures and precise diagnosis of the medical condition are essential. At earlier stages, vascular signs and symptoms can be stabilized and reversed if vibration exposure is minimized or stopped. Because neurologic symptoms may involve either mechanoreceptors or trunk nerves, the prognosis is more variable. The most severe cases that involve skin trophic changes and gangrene are rarely seen. Their presence requires more extensive investigation for a major comoribidity, such as a collagen vascular disease or obstructive arterial disease. The examination should include skin perfusion evaluation, digit sensory testing where available, such as with monofilaments or 2-point discrimination, and provocative maneuvers for distal nerve compression, as in the carpal tunnel syndrome (CTS).
Raynaud disease and entrapment neuropathies, such as CTS and thoracic outlet syndrome should be considered. CTS and digital nerve pathologies are more complex because vibratory exposure is likely to be complicated by intrinsic risks and biodynamic workplace factors. In addition, because VWF is a vasospastic disorder, routine noninvasive vascular imaging will usually be normal. Thoracic outlet syndrome (TOS) can be a confounding diagnosis because of its independent effects on large arteries and the brachial plexus. However, vascular expressions of TOS are unusual and can be visualized by Doppler, angiography, MRA, or multidetector CT.
Imaging & Diagnostic Studies
Sensory function can be evaluated with the vibration and thermal perception threshold tests (VPT and TPT), but these types of quantitative sensory tests (QSTs) have limited availability. Nerve conduction studies may be useful for evaluating digital nerve function and to rule out or rule in a component of CTS. The value of using finger systolic blood pressure or laser Doppler to evaluate vasospasm, under conditions of cold provocation, has a long established acceptance, but application is highly specialized. Routine noninvasive vascular tests are not useful, unless an obstructive pathology is under consideration.
Use of power tools with lower levels of handle displacement (mm) or acceleration (m/s2) can reduce the incidence and even prevent HAVS. The handle vibration level of vibrating hand tools should be available from the manufacture and compared to national (ANSI; EU) and international (ISO) standards. Exposure can also be reduced by reducing the minutes of tool use per day to below thresholds set by national and international standards. Monitoring of exposure duration and symptoms is especially important for tools with high levels of handle vibration. Vibration exposure levels can also be reduced with jigs or tool balancers that support the tool and isolate the vibration from the worker or reduce the grip force required to use the tool. The use of antivibration gloves or tape wrapped around tool handles can effectively reduce vibration exposure levels at higher frequencies. However, their utility under different working conditions, patterns of tool use, and grip force characteristics remains undetermined. Smoking cessation is highly beneficial because it reduces arterial vasospasm.
Treatment involves minimizing exposure to vibrating hand tools. If carpal tunnel syndrome is also present, carpal tunnel surgery may be useful.
Wrist sprains are common and usually involve a fall onto an outstretched hand with stretching of the dorsal wrist capsule or high-force loads such as occurs when a high-torque drill binds and twists the hand and forearm. The patient presents with pain and swelling over the dorsal wrist.
Patients will have dorsal wrist pain over the radiocarpal joint and may have swelling and ecchymosis in this area as well.
Fractures of the radius or carpus must be ruled out. Any patient with tenderness in the anatomic snuffbox should be assumed to have an occult scaphoid fracture and treated accordingly. Patients may also have a tear of the scapho-lunate (SL) ligament.
Imaging & Diagnostic Studies
Imaging studies including a PA, lateral, and oblique of the wrist can be used to rule out fracture. Patients with snuffbox tenderness should be further evaluated with a scaphoid view. Clenched-fist views of the wrist can be helpful to evaluate for widening of the scapho-lunate joint, which suggests injury to the SL ligament. An MRI can be obtained to look for a ligament injury or occult fracture.
Safe work practices to prevent falls and use of wrist guards during high-risk sporting activities can help prevent these common injuries. High-torque hand tools such as drills should have the clutch or torque limiter engaged. High-torque drills should be used with two hands instead of one.
Rest, wrist splinting, and NSAIDs are the mainstay of treatment for wrist sprains.
10. Ulnar Collateral Ligament Injury of the Thumb (Skier's or Gamekeeper's Thumb)
Forcible radial deviation of the thumb can cause partial or complete disruption of the ulnar collateral ligament with or without fracture. This condition can be seen in skiers when the thumb is injured forcibly against the ski pole. Scottish gamekeepers were thought to develop chronic attenuation of the same ligament by breaking the necks of ducks and other game by gripping the neck with both hands and rotating the forearms. Splinting can be used for stable injuries or nondisplaced avulsion fractures. Open surgical repair should not be delayed when there is a question of instability.
Rupture of the ulnar collateral ligament will cause pain and tenderness over the ulnar border of the thumb metacarpophalangeal (MP or MCP) joint (the three joints of the thumb are CMC [carpometacarpal], MCP, and IP). The ligament sometimes retracts proximal to the insertion of the adductor pollicis insertion and a lump (known as a Stener lesion) can be felt in this area. The thumb MCP joint should be evaluated for stability by gentle radial deviation in full extension and 30 degrees of flexion. Increased laxity or a “soft” endpoint in both positions when compared to the normal side suggests a complete tear.
Fractures in the area as well as simple sprains of the MCP joint and radial collateral ligament injuries are on the differential.
Imaging & Diagnostic Studies
Radiographs of the thumb can be used to diagnose avulsion injuries. MRI can be helpful for differentiating full from partial tears if the examination is equivocal.
Avoidance of repetitive forced radial deviation can prevent chronic attenuation of the ligament.
Partial tears or nondisplaced avulsion injuries can be treated with thumb spica casting for 6 weeks. Compliant patients can be treated with a hand-based thumb spica splint to include the MCP joint, but they must be cautioned to wear this full-time except for skin care and avoid any thumb radial deviation when the splint is off. Full-thickness tears with instability or those with a Stener lesion are treated with surgical repair or reconstruction.
The triangular fibrocartilage complex (TFCC) consists of ulnocarpal ligaments, the subsheath of the extensor carpi ulnaris tendon, the radioulnar ligaments, and a central fibrocartilagenous disk similar to the meniscus in the knee. The TFCC provides stability at the distal radioulnar joint (DRUJ). It can be torn from a fall onto an outstretched hand or other causes of high-force wrist loading.
Patients with an acute tear will have pain over the ulnar portion of the wrist. It can be vague and is often described as “deep” in this area. They will be tender just distal to the ulnar head. Passive ulnar deviation of the wrist may worsen their pain. The DRUJ may be unstable and should be tested by stabilization of the radius with one hand and moving the distal ulna dorsally and volarly with the other and checking for laxity. The joint should be checked with the forearm in full pronation, neutral, and full supination and compared to the other side. Rotation of the wrist may produce a painful catch or clunk.
A TFCC tear can be difficult to differentiate from ECU tendonitis. Patients with ECU tendonitis will be tender at the ECU insertion at the base of the fifth metacarpal and may have radiating pain up the forearm, whereas the pain is more localized with a TFCC tear. Mechanical symptoms such as a painful catch or clunk in certain positions are more suggestive of a TFCC tear.
Imaging & Diagnostic Studies
Radiographs of the wrist may show an ulnar styloid avulsion; however, most of these injuries are not thought to be associated with TFCC tears. 3T MRI images or MR/arthrogram can be useful in the diagnosis of TFCC tears.
Fall prevention is important in preventing TFCC tears, as is the use of wrist splints in high-risk sporting activities. Patients with an “ulnar positive” wrist where the ulna is longer than the radius may be more prone to a central chronic TFCC tears.
Chronic central tears can often be treated conservatively with rest, ice, and splinting. Acute tears without DRUJ instability can also be treated conservatively but may require casting for 4–8 weeks until the symptoms improve. Tears associated with mechanical symptoms or DRUJ instability are often treated with arthroscopic surgery, as are other types of tears that fail conservative treatment.
Kienböck disease is avascular necrosis (AVN) of the lunate. The condition is often idiopathic but can be associated with other conditions causing AVN such as chronic steroid use. It may be bilateral. A similar condition can occur in the scaphoid and is called Preiser disease. AVN of both carpal bones has been associated with very high levels of exposure to vibrating or percussing hand tools but the evidence is not strong.
Patients will have wrist pain centered over the lunate but it may be vague in nature. They may also have swelling and synovitis of the wrist. Stiffness with wrist flexion and extension may be present.
Wrist sprains, scaphoid nonunions, and osteoarthritis of the wrist all have similar presentation. Kienböck tends to present in young men.
Imaging & Diagnostic Studies
PA, lateral, and oblique views of the wrist are needed to make the diagnosis and stage the disease. Typical findings include sclerosis of the lunate, lunate collapse or loss of lunate height, lunate fragmentation, and eventually degenerative changes in the radiocarpal and midcarpal joints. Stage 1 Kienböck is diagnosed on MRI only where T1 images will show decreased vascularity of the lunate. The disease occasionally occurs bilaterally and radiographs of the opposite side should also be performed.
This condition is generally considered idiopathic but there may be an association with high levels of exposure to vibrating or percussing hand tools.
Treatment depends on stage of the disease. Patients at the earlier stages of the disease and those with open physes can be treated with casting or splinting and can show revascularization of the lunate over 1–2 years. Patients with significant lunate collapse are often treated surgically. Those who are radial positive (radius longer than the ulna) can be treated with radial shortening or other “joint leveling procedures.” Revascularization procedures can also be done. Once degenerative changes have begun in the wrist, salvage procedures including proximal row carpectomy or partial or total wrist arthrodesis may be needed.
13. Dupuytren Contracture
Dupuytren contracture is thickening of the palmar fascia, which is the layer of tissue between the skin and the underlying tendon sheath. It typically begins as a small nodule or nodules that can grow over time to form cords. These cords eventually lead to contracture of the digit at the proximal interphalangeal and metacarpophalangeal joints. This condition is more common over the ulnar digits. It is often seen in individuals of Northern European descent, is more common in males, and has a hereditary predisposition.
At the early stages, subcutaneous, nonmobile nodules can be felt at the palm. At later stages, palpable subcutaneous cords can be felt and may extend into the digits and cause puckering of the overlying skin. Patients may have relatively fixed contractures of the MP and PIP joints and an inability to lay the hand flat on a table.
Other causes of contracture, such as joint sprains, missed fractures, and tendon injuries, should be considered. Other masses of the hand such as ganglion cysts or nerve sheath tumors can have a similar appearance to Dupuytren nodules.
Imaging & Diagnostic Studies
No imaging is needed to make the diagnosis. Radiographs of the involved digits may be helpful in assessing underlying arthritis. MRI imaging can be useful in differentiating Dupuytren nodules from other types of masses.
The disease is thought to be primarily genetic in nature although there are some studies that suggest as association with alcohol abuse, smoking, and very high levels of physical exposure (vibration and force) during the working life.
Patients who are asymptomatic can be observed. However, when the contractures reach around 30 degrees, patients may have some functional deficits. Splinting and therapy have not been shown to be particularly effective. Collagenase injections have recently been introduced into the market for this condition and thus far have acceptable midterm results. Surgical options include needle fasciotomy or open partial fasciectomy, with the open procedure remaining the gold standard.
14. Osteoarthritis of the Fingers or Wrist
Osteoarthritis of the first carpometacarpal (CMC) joint occurs in about 25% of women older than 55 years of age. Osteoarthritis of the DIP and PIP joints is also extremely common with advancing age, affecting nearly 100% of women older than the age of 80. Osteoarthritis of the fingers and wrist has been linked to stereotypical loading of the hand with tasks performed in the same way over 10–20 years.
Although the condition is frequently asymptomatic, some patients are aware of pain at the base of the thumb when grasping, such as when unscrewing large glass jars, and there may be a clinical deformity of “squaring” or a “shoulder sign” with subluxation of the base of the thumb at the CMC joint. In addition, there may be crepitus with pressure over the CMC joint. Patients may also have a positive grind test with reproduction of pain with axially loading of the thumb metacarpal onto the trapezium. The fingers may show bone spurs or synovitis at the DIP or PIP joints and patients often have limited flexion or extension at these joints.
The differential diagnosis of thumb CMC arthritis includes De Quervain tenosynovitis (discussed earlier) in which the tenderness and swelling are more proximal.
Imaging & Diagnostic Studies
Plain-film radiographs will demonstrate osteoarthritic changes in the joint.
Smoking has been shown to increase cartilage degeneration. For jobs that involve repeating the same hand activities many times an hour, job rotation to other tasks involving other types of hand motions may reduce the risk.
Most patients will respond to instructions to avoid repetitive painful activities such as extreme positions of thumb abduction. Wearing an orthosis to immobilize the thumb can minimize symptoms. For the digits, avoidance of repetitive gripping can help.
Anti-inflammatory drugs are helpful for patients who experience pain at night. Steroid injection can be done into the thumb CMC joint. The DIP and PIP joints are often so small that they can be difficult to inject with a steroid. Patients refractory to conservative treatment may benefit from surgery. At the thumb CMC joint, surgery usually consists of resection arthroplasty (removal of the trapezium) with or without ligament reconstruction and/or tendon interposition. Arthritis at the DIP and PIP joints is usually treated with arthrodesis, although arthroplasty at the PIP joint can be performed for limited indications.
Scaphoid fractures typically occur from a fall on the outstretched hand. In elderly patients with osteoporosis, the same mechanism of injury may produce a Colles (distal radius) fracture. Any patient with an acute fall and snuffbox tenderness should be treated as if they have a scaphoid fracture since early diagnosis and immobilization play a key role in healing of these fractures. Scaphoid fractures that go on to nonunion almost invariably result in degenerative changes at the wrist.
Patients will have tenderness over the anatomic snuffbox or volarly over the distal pole of the scaphoid. They may also have swelling, ecchymosis, and limited range of motion.
Fractures of the radial styloid, De Quervain's tenosynovitis, and CMC arthritis can cause pain in the same area.
Imaging & Diagnostic Studies
PA, lateral, oblique views of the wrist as well as a scaphoid view should be obtained if a scaphoid fracture is suspected. Often the fracture is only visible on one of these three views. Nondisplaced scaphoid fractures are often not apparent on initial plain radiographs and may require repeat radiographs 1–2 weeks later or advanced imaging such as an MRI or CT scan.
Any patient in whom a fracture is clinically suspected should be immediately immobilized with a thumb spica splint or cast until radiographs can be repeated in 1–2 weeks or advanced imaging obtained. A scaphoid fracture that is nondisplaced can be treated in a short arm thumb spica cast. Immobilization is continued until fracture union is seen radiographically, usually at least 12 weeks. The restrictions imposed by cast immobilization can be partially avoided by percutaneous screw fixation of the scaphoid. For displaced fractures, open reduction and internal fixation usually are indicated. Symptoms from a scaphoid nonunion may occur long after the original injury. Surgical treatment with bone grafting is necessary to repair a scaphoid nonunion.
Mallet fingers are injuries to the extensor tendon of the finger near the DIP joint. They typically occur after a high velocity load to the end of the digit, such as when a ball hits the end of the finger leading to a stretch or rupture of the extensor tendon.
Pain at the DIP joint with inability to actively extend the DIP joint is the usual presentation (Figure 9–8). Fractures may or may not be present.
Mallet finger. Patient is asked to extend the fingers and is unable to extend the injured DIP joint.
Imaging & Diagnostic Studies
A lateral view of the phalanges can identify fractures and will determine if the joint is subluxated.
Most injuries do well with conservative treatment even if they are several months old. The DIP joint is splinted in extension full-time with a Mallet splint for 6–8 weeks. The splint allows time for the tendon to recover; if the finger is flexed during this time the splint period may have to be restarted. In the case of a fracture with joint subluxation, surgical pinning may be indicated.
17. Phalangeal & Metacarpal Fractures
Fractures of the phalanges and metacarpals can occur after falls, a direct blow (such as punching a wall), or a twisting injury.
Pain, swelling, ecchymosis, decreased range of motion, and deformity are common with these fractures. Patients should be carefully assessed for malrotation. In a normal hand, gentle flexion of the digits into the palm should result in no digital overlap and all the tips of the fingers should point to the area of the scaphoid. Fractures of the metacarpals or phalanges can result in loss of this normal “cascade” of the tips of the fingers, or malrotation, with overlap or scissoring onto the neighboring digits or deviation of the border digits away from the palm.
Sprains, soft tissue contusions, and dislocations can have similar presentations and are readily distinguishable on radiographs.
Imaging & Diagnostic Studies
PA, oblique, and lateral views of the hand should be taken to diagnose metacarpal fractures. Fractures of the phalanges are better visualized on dedicated views of the involved finger.
Treatment can vary depending on the displacement and type of fracture. Simple avulsion fractures can be treated with splinting or buddy-taping for pain. Nondisplaced metacarpal fractures or metacarpal fractures without malrotation or extensor lag can be treated with splinting or casting for 4–6 weeks. Phalangeal fractures treated conservatively are usually not immobilized for longer than 3–4 weeks because of the risk of permanent stiffness. Splinting or casting should be in the intrinsic plus position with the IPs extended and the MPs flexed 60–90 degrees, and should include the joint above and below the injury as well as the bordering digit(s). Fractures with malrotation, significant displacement, an unstable fracture pattern, significant shortening, joint involvement, or multiple fractures in the same hand are often treated surgically with closed reduction and pinning or open reduction and internal fixation.
18. Radius or Ulnar Fractures
Fractures of the ulnar or radius usually result from a fall or trauma. In young patients, the trauma is usually fairly high energy. In osteoporotic patients it is often a fall from standing.
Patients present with pain, swelling, ecchymosis, and deformity of the forearm or wrist. The skin should be carefully checked for any breaks that may indicate an open fracture. A careful neurovascular examination should also be performed.
Sprains and soft tissue injuries can have a similar presentation.
Imaging & Diagnostic Studies
PA and lateral views of the forearm or PA, lateral, and oblique views of the wrist should be obtained depending on the site of injury.
Osteoporotic patients should be carefully treated and monitored to prevent these types of injuries. Forearm guards may be used in high-risk sporting activities such as martial arts.
Almost all fractures of the radial shaft are treated surgically in adults. Isolated ulnar fractures can be treated with casting or splinting depending on location, displacement, and age of the patient. Distal radius fractures are treated with either casting or surgery again depending on the age of the patient, activity level, displacement of the fracture, and intra-articular involvement.