WRIST AND HAND CONDITIONS
Wrist joint arthritis
The wrist joint is most commonly affected by rheumatoid or traumatic arthritis (as in a fall on the outstretched hand) and less commonly by osteoarthritis. The patient will feel pain on moving the wrist upwards and downwards and may be unable to reach the extremes of movement. The joint may be swollen and tender according to the amount of inflammation present.
Physiotherapy can help with treatment that includes soft tissue massage and mobilisations, without provoking the pain, to prevent the joint from stiffening. Ice and electrotherapy may be used with advice to avoid aggravating activities, especially heavy lifting. It is important to keep the joint moving and exercise will be given with the advice to move the wrist within the pain free range of movement.
Rheumatoid arthritis in the wrist responds well to an anti-inflammatory injection of steroid.
Thumb joint (Trapeziofirst-metacarpal joint)
The joint is mainly affected by osteoarthritis and the condition is common in middle-aged women. It’s usually as a result of overuse; especially with the thumb in the stretched back position. X-ray confirms the diagnosis as well as squeezing the joint surfaces together. The patient complains of pain and tenderness at the base of the thumb and on using the thumb for writing, gripping, unscrewing jars etc.
Physiotherapy can help by using a specific massage technique called frictions across the front of the joint and by stretching the joint by pulling on the thumb itself. Patients can be shown how to do that at home too. Ice and electrotherapy may be used, with advice on how to avoid aggravating activities. The joint can also be injected with steroid that reduces the inflammation and pain within the joint.
The finger joints can become swollen and painful as a result of trauma (traumatic arthritis e.g. wicket keeping) or rheumatoid or osteoarthritis. The affected joints become stiff and pain is provoked at either end of their range of movement. Fracture should be eliminated if suspected, although treatment for finger fracture is usually by strapping the affected finger to its neighbour. It is always wise to seek an orthopaedic opinion for adolescents if fracture is suspected, to prevent deformity and loss of normal function in the hand.
Physiotherapy can help by applying soft tissue massage and encouraging movement in the finger joint to prevent stiffness. Ice, exercises in warm water and electrotherapy may be used with advice on progressively using the joint without aggravating the pain and swelling.
Subluxed carpal bone
There are several small bones at the base of the hand that together are called the carpus – and each individual bone is a carpal bone. That part of the wrist needs to be nice and loose to allow the hand to function and occasionally one of the bones just slightly moves out of place, i.e. becomes subluxed. It is usually the bone in the middle of the carpus, known as the capitate, that subluxes and it appears as a bump at the back of the wrist with the hand in the dropped position. It can happen after a sudden jolt on the outstretched hand such as in gymnastics or landing against the wall whilst playing squash.
The patient will complain of discomfort at the back of the wrist which will increase on stretching the hand downwards, with a painful block to the movement on bending the wrist upwards.
Physiotherapy can help by applying a specific technique that stretches the carpus to allow more room for the bones to move, before applying a quick thrust to the bone to put it back into place. The technique is not painful and the result can be immediate. Ultrasound and specific massage to the ligaments that support the bone in place can be applied if the area remains sore but this usually settles in a few days without further treatment.
Occasionally, if the joint has been out of place for several weeks or months, mobilisations may be needed to gain more movement before the technique can be applied. The problem may recur several times but usually settles after a year or two in all.
Collateral ligaments at the wrist
Ligaments are strong ‘elastic bands’ that attach a bone to a bone to stabilise a joint. The collateral ligaments at the wrist lie on either side of the wrist and act as a restraint to sideways movements. The ligaments can be sprained by suddenly overstretching the joint, as in falling onto the hand. Or they may become painful with repetitive overuse in occupational activities or hobbies. The patient will complain of a specific point of tenderness on one side of the wrist and stretching the ligament into the opposite direction will also be painful.
Physiotherapy can help by applying a specific massage technique called frictions across the tender point on the ligament. Ice and electrotherapy may also be used with advice to avoid aggravating activities, if possible, until the pain settles. An injection of steroid may be given if the symptoms persist.
Carpal tunnel syndrome
The median nerve runs through a tunnel at the base of the hand where it can become compressed, producing pins and needles and pain in the palm at the thumb, the index and ring fingers. It can be especially troublesome at night. There are several conditions that can lead to a reduction of the space and compression of the nerve, including tenosynovitis, trauma and diabetes.
The condition usually responds well to injection with steroid which, being an anti-inflammatory drug will help to reduce swelling in the tunnel and reduce compression on the nerve. Physiotherapy can also help with treatment including local electrotherapy, usually ultrasound, and techniques to mobilise the nerve that can also be given as a home exercise. If pregnancy is the cause of the problem, when an injection is not suitable, the above treatment can be applied and the symptoms usually settle in the post-natal period.
Fibrocartilage tears and meniscal lesions at the wrist.
A small cartilage ‘disc’ sits in the joint between the hand and the forearm bone on the little finger side. It can be prone to tears and occasional displacements that can arise from trauma, such as a fall on the outstretched hand, or repetitive overloading of the joint, as in racquet sports for instance. Problems arising from the disc are relatively rare but it may cause pain and clicking on the little finger side of the wrist.
Physiotherapy may help by stretching the joint whilst applying circular flicking movements. If the symptoms do not settle quickly the patient can be referred for arthroscopy (key hole surgery) and have the fragment removed.
Trigger finger or thumb
A ‘snapping’ sensation with a catching pain may be felt in the hand on bending and straightening a finger or the thumb. The tendon that makes the finger or thumb bend runs through a ‘pulley’ that can become thickened and lead to the problem.
Trauma to the hand or repetitive strain can lead to the problem that is best treated with a local injection of steroid that will reduce the thickening and restore smooth gliding of the tendon. Physiotherapy with ultrasound and mobilising techniques can be tried if injection is not appropriate.
De Quervain’s tenosynovitis
The tendons that pull the thumb backwards and outwards from the hand run in a sheath as they cross the wrist and with overuse the sheath may become inflamed, known as tenosynovitis. The patient will complain of pain on using the thumb which is important in all hand movements, especially those requiring precision as in writing etc. Holding the thumb across the palm will also produce pain as the tendons are stretched through the inflamed sheath.
Physiotherapy can help by applying a specific massage technique called frictions across the painful area, with advice to modify activities as far as possible to avoid aggravating the condition. Ice and electrotherapy, usually ultrasound, can be used. A thumb brace can splint the thumb to avoid excessive movement but these aren’t always effective and the pressure of the brace against the area can be uncomfortable. An injection of anti-inflammatory steroid into the sheath can cure the condition although more than one injection may be needed to achieve full recovery.
Oarsman’s wrist (intersection syndrome)
The muscles that move the thumb backwards and outwards are attached to the forearm bones and their tendons wind round the thumb side of the lower forearm to attach to bones in the thumb. At that point they cross over the two tendons that straighten the index finger and middle fingers, making a point of potential friction as the structures exert tension in different directions. This can produce tenosynovitis at the wrist or, more commonly at the point where the muscle attaches to its tendon (musculotendinous junction). It usually comes on with overuse of the thumb and wrist, as used in the rowing action (thus ‘oarsman’s wrist) or with unaccustomed and excessive use of scissors.
Patients will complain of pain in the lower forearm when moving the thumb and on stretching the thumb across the palm with the wrist bent downwards. There may also be a creaking or squeaking sensation on the thumb side of the forearm as the thumb is moved, known as crepitus.
Physiotherapy can help by applying a specific massage technique called frictions gently across the painful site with advice on resting from the aggravating activity. Ice and electrotherapy, usually ultrasound, can be used to relieve pain and to promote recovery.
Finger tenosynovitis and tendinopathy
The finger tendons may be affected by overuse or trauma at two main points: where the tendon attaches to the bone in the hand (teno-osseous site) or where the tendons are in sheath as they cross the wrist (tenosynovitis). The patient will complain of pain when the relevant finger is used, either at the tendon’s attachment to the bone or where the tendons cross the wrist. With tenosynovitis the pain will also be noticed when the tendon is being stretched into the opposite direction.
Physiotherapy can help by applying a specific massage technique called frictions across the tender part of the tendon with advice on relative rest to avoid aggravating the problem. Ice and electrotherapy, usually ultrasound, can be used to relieve pain and to promote recovery. If symptoms do not settle an injection of anti-inflammatory steroid can be given either into the area of attachment or between the sheath and the tendon in tenosynovitis.
Interosseous muscle lesions
The muscles between the bones in the hand are called the interosseous muscles and they work to spread and bring the fingers back together. Occasionally they can become painful after sudden unaccustomed use of the hand or general overuse, when the patient will complain of a vague ache in the back of the hand that is made worse by repeated gripping.
Physiotherapy can help by applying a specific massage technique called frictions up and down against the bone at the tender site. Ultrasound can also be useful to relieve pain and promote recovery.
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