Wrist pain

Wrist pain or discomfort is common, and usually presents as painful movements, swelling (diffuse or localised), or changes in sensation associated with wrist movement.

Anatomy

The wrist is made up of eight bones arranged in two rows, a joint capsule, and various tendons covered by a special band, the flexor retinaculum. The arrangement of the bones is such that a small tunnel is formed, which houses the median nerve as it passes to the hand, an artery and some tendons.

Possible causes and their symptoms

The possible causes of wrist pain are related to the anatomy, that is, problems of the bones, tendons and ligaments, nerves, joints and blood supply. Some systemic diseases, like rheumatoid arthritis, can also affect the wrist joint. Wrist problems are more common in the elderly.

A careful history and examination will usually give a diagnosis, though some investigations may be needed. Important information includes the patient’s occupation and lifestyle, the onset and site of the pain, which movements make it worse, location of any swelling, grip strength, and history or signs of other underlying disease.

Predisposing risk factors include pregnancy, age, some types of sport and any repetitive work.
Some common causes of wrist pain are:

• Soft tissue injuries – ligament sprains or tears, cartilage damage and tendonitis are common in sportsmen. Repetitive strain injury is also common in, for example typists, assembly line workers, or professional sportsmen like golfers. Pain, swelling and limitation of movement are found.
• Bone injuries are quite obvious – fractures are usually painful, have accompanying bruising and swelling, limitation of movement and the wrist may even look crooked.
• Carpal tunnel syndrome. Here the median nerve becomes trapped as it passes through the tunnel formed by the arrangement of the wrist bones. Wrist pain plus abnormal sensation in the fingers are characteristic, and can be induced by positioning the hands in a certain way. This syndrome may be triggered during pregnancy.
• Osteoarthritis commonly affects the wrist, especially in older females.
• Rheumatoid arthritis may affect many joints at once, including the wrist, where it usually affects both wrists simultaneously.
• Ganglion is a swelling due to overproduction of joint fluid caused by chronic irritation. Around 90 percent of ganglia appear on the back of the hand, mostly near the thumb.
• Kienböck’s disease refers to death of part of a wrist bone (the lunate bone), usually following repetitive minor injuries or an undiagnosed acute injury. Pain and weakness are prominent in this condition.
• Other conditions can cause wrist pain, such as:
• auto-immune conditions (SLE, scleroderma),
• leukaemia,
• Paget's disease of bone,
• Gout,
• Diabetes,
• infections of the joint, and
• De Quervain's tenosynovitis

Diagnostic investigations
Diagnosis can usually be made after taking a history and conducting a careful examination of the patient.

X-rays are helpful in showing bone problems such as fractures, and may also show signs of joint abnormalities or Kienböck’s disease. Non-bony problems may best by shown by CT or MRI scans, and some cases may need an arthroscopy to look inside the joint.

Full blood count (FBC) and immunological studies may be needed in suspected cases of auto-immune diseases (rheumatoid arthritis or SLE, for instance), or infections. In rare cases, a swollen joint may have some of the fluid sampled for testing.

Grip strength measurement (dynamometry), nerve conduction studies and electromyograms may also be needed.

Treatment

Structural problems such as fractures or ligament injuries are usually managed by an orthopaedic or hand surgeon. Treatment may include immobilising the joint with a cast, or open surgery to remove small pieces of damaged tissue and/or screw fixation or bone grafting.

Carpal tunnel requires surgery.

Soft-tissue problems may need painkillers and anti-inflammatory drugs, including cortisone, which may be injected into the joint.

Outcome


Results are generally good if the correct diagnosis is made and all underlying causes managed.

Complications
These are often related to delay in diagnosis, or complications of surgery. Medical treatment may fail to relieve the pain, stiffness and limitation of movement. Surgery may be complicated by poor wound healing, infection, nerve or vascular damage, or bone death. Arthritis may persist after either medical or surgical treatment.

Prevention


Awareness of repetitive strain injury, especially in the workplace, is encouraged; and sportsmen are advised to wear protective gear. Patients are encouraged to avoid fractures by attending to healthy bone strength (including adequate intake of calcium and vitamin D) and by taking sensible precautions to avoid home accidents (like installing handrails on stairs, making sure there are no loose rugs, providing good lighting and so on).

(Dr AG Hall)