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Hand and Wrist Injuries

Hand and wrist injuries are common following a fall onto an outstretched hand or in individuals involved in ball and contact sports or upper limb weight bearing sports (such as gymnastics). Patients suffering from hand and wrist pain are often seen in physiotherapy practice. Pain may be caused by local structures within or around the wrist or hand or occasionally, may be referred from other sources (such as the neck, upper back, shoulder or elbow).

One common clinical presentation is the patient suffering from sudden onset wrist pain typically as a result of a fall onto an outstretched hand, the cause of which is often torn ligaments or connective tissue around the wrist, such as a Sprained Wrist or occasionally a fracture such as a Radius Fracture or Scaphoid Fracture. In patients who experience finger trauma in ball or contact sports, a Sprained Finger or Thumb is often the result.

Gradual onset hand and wrist pain often develops as a result of overuse particularly in gripping activities such as racquet sports or manual work such as carpentry. One of the more common overuse wrist injuries is Wrist Tendonitis which involves gradual degeneration and inflammation of one or more wrist tendons. In those patients with associated neck, upper back, shoulder, elbow or forearm pain, Referred Pain (frequently from the neck, upper back, shoulder or elbow) is often the cause of symptoms. In older patients with gradual onset wrist pain associated with generalised wrist stiffness, Wrist Arthritis may be the source of symptoms. There are numerous other causes of hand and wrist pain, some of which present suddenly due to a specific incident, others which develop gradually over time.

Below are some of the more common causes of hand and wrist pain with a brief description of each condition to aid hand and wrist pain diagnosis. Conditions have been organised according to sudden or gradual onset and common or less common conditions for ease of use.

Metacarpal Fracture

A break in one of the metacarpal bones of the hand usually due to a punch, a direct blow to the back of the hand or a fall onto an outstretched hand. Associated with severe pain in the hand that may radiate into the wrist or fingers, in addition to swelling, tenderness on firmly touching the affected region of the bone, markedly reduced hand function and sometimes bony deformity.

Find out what may be causing your hand or wrist pain:

Sudden Onset Hand and Wrist Pain

Common Injuries

Sprained Wrist

Tearing of connective tissue and / or ligaments of the wrist joint typically as a result of a fall onto an outstretched hand causing the wrist to stretch excessively. Associated with pain in the wrist that may increase when firmly touching the affected region of the wrist joint, restricted wrist joint mobility and often swelling.

Sprained Finger

Tearing of connective tissue and / or ligaments holding the bones of the finger together typically following excessive stretching of the joint in one direction. Associated with pain on firmly touching the affected joint, restricted joint mobility and often swelling.

Sprained Thumb

Tearing of connective tissue and / or ligaments holding the bones of the thumb together typically following excessive stretching of the joint in one direction. Associated with pain on firmly touching the affected joint, restricted joint mobility and often swelling.

Radius Fracture

A break in the radius bone near the wrist usually due to a fall onto an outstretched hand. Associated with severe pain usually located on the thumb side of the wrist that may radiate into the thumb, hand or forearm, in addition to swelling, tenderness on firmly touching the affected region of the bone, markedly reduced wrist function and sometimes bony deformity.

Scaphoid Fracture

A break in one of the wrist bones located on the thumb side of the wrist (scaphoid) usually due to a fall onto an outstretched hand. Associated with severe pain at the time of injury that may settle to an ache, usually located on the thumb side of the wrist. Swelling, tenderness on firmly touching the affected region of the bone and markedly reduced wrist function are also present.

Phalanx Fracture

A break in one of the small bones of the finger (phalanges) usually due to a traumatic direct blow to the finger such as during ball or contact sports. Associated with severe pain in the affected finger, swelling, tenderness on firmly touching the affected region of the bone, markedly reduced finger function and sometimes bony deformity.

Wrist impingement / impaction syndromes

Pain in the wrist due to compression or pinching of structures within the wrist joint usually during a traumatic end of range wrist movement (e.g. a fall onto an outstretched hand), typically with the wrist in extension and in combination with weight bearing forces through the affected wrist (such as during gymnastics). Symptoms may increase on firmly touching the affected region of the wrist and on certain wrist movements.

TFCC Tear

Damage to cartilage tissue located on the little finger side of the wrist joint usually due to excessive compression forces often in association with twisting or side bending forces through the wrist such as a fall onto an outstretched hand, or during gymnastics, racquet sports or manual work such as using a hammer. Pain is usually located on the little finger side of the wrist and can occasionally radiate into the forearm or hand. There is usually tenderness on firmly touching the affected tissue and often swelling. Reduced grip strength may also be present. In some cases a clicking or catching sensation may be experienced during certain wrist movements.

Dislocated Finger

Tearing of connective tissue surrounding one of the finger joints with subsequent displacement and separation of the bones forming the joint so the joint surfaces are no longer situated next to each other (i.e. the finger often appears deformed). Typically occurs as a result of a traumatic impact to the finger such as during ball sports and causes severe pain in the finger, a feeling of the finger ‘popping out’, deformity of the finger joint and sometimes pins and needles or numbness.

Referred Pain

Pain referred into the wrist or hand from another source such as the neck, upper back, shoulder or elbow frequently associated with symptoms above the wrist and hand (such as in the neck, upper back, shoulder, arm, elbow or forearm). Typically associated with pain on firmly touching the region responsible for the referred pain and / or loss of movement in that region. Sometimes in association with pins and needles or numbness in the affected arm or hand.

Less Common Injuries

Hamate Fracture

A break in one of the small wrist bones located on the little finger side of the wrist usually following hitting the ground during a golf swing, swinging a tennis racquet, baseball bat or playing volleyball or due to a fall onto an outstretched hand. Associated with severe pain at the time of injury that may settle to an ache, usually located on the little finger side of the wrist / hand, on the palm side of the hand. Swelling and tenderness on firmly touching the affected bone are also typically present.

Lunate Fracture

A break in one of the small wrist bones located approximately in the middle of the wrist usually following a fall onto an outstretched hand. Associated with severe wrist pain at the time of injury that may settle to an ache and can occasionally radiate into the hand or forearm. Swelling and tenderness on firmly touching the affected bone are also typically present.

Distal Radio-Ulnar Joint Sprain

Tearing of connective tissue and / or ligaments of the joint located between the ends of the forearm bones just before the wrist typically as a result of a fall onto an outstretched hand, often in combination with twisting of the wrist and forearm. Associated with pain in the wrist that may increase when firmly touching the affected region of the joint, restricted wrist joint mobility (particularly rotation of the wrist) and often swelling.

Carpal Dislocation

Tearing of connective tissue joining adjacent small bones of the wrist with subsequent displacement and separation of the affected bones forming the joint so the joint surfaces are no longer situated next to each other. Typically occurs as a result of severe trauma such as a fall onto an outstretched hand and causes severe wrist pain, deformity of the wrist, pain on firmly touching the affected joint and sometimes pins and needles or numbness.

Kienbock’s disease

Gradual bony tissue death to one of the small bones located approximately in the middle of the wrist secondary to a loss of its blood supply. Typically occurs as a result of trauma to the wrist (such as a fall onto the outstretched hand). Usually associated with chronic pain located on the front or back of the wrist that increases on firmly touching the lunate bone and often reduced wrist range of movement. Pain may also increase during weight bearing activity through the wrist and general use of the hand. Most common in those aged in their twenties.

Finger Tendon Ruptures

Complete tearing of one or more finger tendons, typically following a traumatic incident such as a direct impact to the finger during ball or contact sports. Associated with pain and swelling in the finger that may radiate into the hand, significant weakness of the affected finger and often deformity of the finger (e.g. a bent finger) that typically cannot be straightened by using the affected finger alone. Pain may also increase on firmly touching the affected tendon at the level of the finger.

Ulnar Artery Aneurysm or Thrombosis

Damage to the ulnar artery located on the little finger side of the palm of the hand at the level of the hamate bone resulting in dilation of the artery and / or the formation of a blood clot. Typically occurs following trauma or repeated impact to this part of the hand (e.g. using this part of the hand as a hammer, or during a karate chop in martial arts). May result in pain, discolouration, numbness, coolness, pins and needles or numbness in one or more fingers and sometimes the little finger side of the palm of the hand. Occasionally, swelling or a mass on the little finger side of the palm of the hand at the level of the hamate bone may also be present.

Hand and Wrist Injuries? Get it checked and treated today! Call us at +65 6471 2744 or Email to: info@boneclinic.com.sg

Diagnosis and Management of Carpal Tunnel Syndrome

Carpal tunnel syndrome is a common cause of motor and sensory symptoms in the hand. The complications that result can lead to limitations of activities of daily living and time away from work. This article summarizes the investigation and treatment of this disorder in light of the result from recent clinical trials.

Introduction

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy and one of the most important causes of lost days at work. The incidence  is 139 per 100,000 person years for men and 506 for women.

The sex ratio varies from 2:1 in the UK to over 20:1 in South Korea. It is often present in both hands. Repetitive wrist movements, high-force hand grip and the use of vibrating tools have been associated with an increased prevalence. In many countries, CTS is recognized as a compensable occupational disease.

Anatomy and Pathophysiology

The medial cord of the brachial plexus from roots C8 and T1 from the motor supply of the median nerve while sensory fibres from the lateral aspect of the hand run in the lateral cord, from roots C5, C6 and C7. The terminal branches of the median nerve supply the thenar muscles (abductor pollicis brevis, flexor pollicis brevis, opponens pollicis) and the lateral two lumbricals. A number of anomalies are found in normal individuals at all levels of the nerve, e.g. the median and musculocutaneous nerve may be fused, the ulnar may supply all the thenar muscles and the median may supply the intrinsic muscles. These variations need to be considered during electrophysiological assessment. The floor and sides of the carpal tunnel are formed by the eight carpal bones. The tranverse carpal ligament forms the roof; it is attached to the hook of hamate and pisiform on the ulnar side and the scaphoid and trapezium on the radial side.

CTS is a sonsequence of compression of the median nerve within the carpal tunnel resulting in mechanical compression and local ischaemia. A rise in intracarpal canal pressure leads to reduced epineural blood flow and intrafascicular oedema. Histological examination of synovial biopsies shows a marked increase in fibroblast density, collagen fibre size and vascular proliferation compared with controls, changes that are similar to those seen after injury to other tissues. With time, changes in the myelin sheath and axonal injury are evident on nerve conduction testing. Over its long course, the median nerve becomes susceptible to compression at sites other than the carpal tunnel. In the pronator syndrome, the nerve is compressed by the pronator teres muscle, causing numbness in the hand and forearm tenderness. A proximal branch of the median nerve, the anterior interosseus nerve, may be compressed, producing weakness confined to the flexor pollicis longus, flexor digitorum profundus and pronator quadratus but without sensory loss.

Carpal Tunnel Syndrome

 Diagnosis

The clinical features in patients with electrophysiologically confirmed CTS are variable, but numbness over the lateral aspect of the hand is a typical feature of the syndrome, which may be more obvious during sustained grip, such as while reading a newspaper or driving. Initial symptoms may be intermittent but become more sustained as disease progresses. Awakening from sleep or symptoms upon awakening are common complaints. The majority of cases are idiopathic, but CTS is associated with conditions such as diabetes mellitus, renal dialysis, rheumatoid arthritis, thyroid dys-function, pregnancy and use of oral contraception.

Most CTS patients present with these classical symptoms but clinicians should be aware of atypical presenting feature.

A self-administered hand diagram has been devised to classify the level of centainty of the diagnosis into classic, probable, possible and unlikely; however, it was found to be unhelpful in the Asian population. Individuals with a high body mass index (BMI) of >29 are 2.5times more likely to develop CTS thatn those with a BMI <20.

Summary

For patients with CTS associated with other medical conditions such as hypothyroidism, treatment of the underlying disorder alone may resolve hand symptoms. Advise on avoiding activities that would exacerbate the disease should be given. Carpal Tunnel decompression is recommended at the outset for patients who have clinical or electrophysiological evidence of severe CTS and in those with symptoms of acute onset (e.g. post-traumatic). Splinting with or without steroid injection would be the first line treatment for patients with mild to moderate CTS, in view of the fact that a minority  would respond with first line treatment. Carpal tunnel release can be subsequently offered to those who do not respond to splinting and anti-inflammatory injection and to those who relapse. Failure to respond to carpal tunnel release is unusual; reasons include initial misdiagnosis, incomplete division of the flexor retinaculum, iatrogenic nerve branch injury and perineural fibrosis. Re-examination of the diagnosis and surgical re-exploration should be considered in these cases.