Wrist Pain

Ulnar Nerve Compression | Carpal Tunnel Syndrome | De Quervain's Tenosynovitis | References

Ulnar Nerve Compression

Definition: Ulnar nerve compression, also known as ulnar neuropathy, occurs when the ulnar nerve is compressed, usually at the wrist (Guyon's canal) or elbow (cubital tunnel), leading to pain, numbness, and weakness in the hand.

Aetiology: Causes include prolonged pressure on the elbow or wrist, trauma, repetitive movements, or anatomical abnormalities. Ulnar nerve compression at the wrist is often due to activities that involve prolonged or repeated wrist flexion and pressure on the hypothenar eminence.

Pathophysiology: Compression of the ulnar nerve at the wrist can lead to impaired nerve conduction, resulting in sensory and motor deficits in the areas supplied by the ulnar nerve, including the little finger, ring finger, and intrinsic hand muscles.

Risk Factors: Occupations or activities involving repetitive wrist or elbow movements, prolonged elbow flexion, and previous elbow or wrist injuries.

Signs and Symptoms:

• Numbness and tingling in the ring and little fingers.
• Weakness in the hand, particularly in the grip and fine motor tasks.
• Pain in the forearm or hand, which may worsen with prolonged elbow flexion or wrist pressure.
• Muscle wasting in the hypothenar eminence and intrinsic hand muscles in severe cases.

Investigations:

• Clinical Diagnosis: Based on history and physical examination, including Tinel's sign over Guyon's canal and Froment's sign for ulnar nerve function.
• Nerve Conduction Studies (NCS) and Electromyography (EMG): Useful for confirming the diagnosis and assessing the severity of nerve compression.
• Imaging: Ultrasound or MRI may be used to assess for structural causes of compression, such as ganglion cysts or anatomical abnormalities.

Management:

• Primary Care: Activity modification to reduce pressure on the ulnar nerve, use of wrist splints, NSAIDs for pain relief, and referral to physiotherapy for exercises to improve strength and flexibility.
• Specialist Care: Corticosteroid injections may be considered in some cases. Surgical decompression (ulnar nerve release) may be required for severe or refractory cases.

Carpal Tunnel Syndrome

Definition: Carpal Tunnel Syndrome (CTS) is a condition caused by compression of the median nerve as it passes through the carpal tunnel in the wrist, leading to pain, numbness, and weakness in the hand.

Aetiology: The condition can be caused by repetitive hand movements, wrist injuries, or conditions that increase pressure within the carpal tunnel, such as pregnancy, diabetes, or rheumatoid arthritis.

Pathophysiology: Compression of the median nerve within the carpal tunnel leads to impaired nerve function, resulting in sensory and motor symptoms in the areas supplied by the median nerve, particularly the thumb, index, middle, and radial half of the ring finger.

Risk Factors: Repetitive hand and wrist movements, pregnancy, obesity, diabetes, hypothyroidism, and rheumatoid arthritis.

Signs and Symptoms:

• Numbness and tingling in the thumb, index, middle, and radial half of the ring finger, particularly at night.
• Weakness in the hand, particularly in grip strength and thumb opposition.
• Pain in the wrist and hand that may radiate up the arm.
• Positive Phalen's test (pain or tingling with wrist flexion) and Tinel's sign (tingling with percussion over the carpal tunnel).
• In severe cases, atrophy of the thenar muscles.

Investigations:

• Clinical Diagnosis: Based on history and physical examination, including Phalen's and Tinel's tests.
• Nerve Conduction Studies (NCS) and Electromyography (EMG): Useful for confirming the diagnosis and assessing the severity of nerve compression.
• Ultrasound: May be used to assess the size of the median nerve and the presence of any structural abnormalities contributing to compression.

Management:

• Primary Care: Activity modification to avoid repetitive wrist movements, wrist splinting (particularly at night), NSAIDs for pain relief, and referral to physiotherapy for exercises to improve wrist and hand function.
• Specialist Care: Corticosteroid injections may be used for temporary relief. Surgical decompression (carpal tunnel release) is considered in severe cases or when conservative management fails.

De Quervain's Tenosynovitis

Definition: De Quervain's tenosynovitis is a condition characterised by inflammation of the tendons of the extensor pollicis brevis and abductor pollicis longus as they pass through the first dorsal compartment of the wrist, leading to pain and swelling on the radial side of the wrist.

Aetiology: Often caused by repetitive hand or wrist movements, particularly those involving gripping, pinching, or wringing. It is common in new mothers due to the repetitive lifting and carrying of infants.

Pathophysiology: Repetitive strain leads to inflammation and thickening of the tendon sheath, resulting in pain and restricted movement of the affected tendons.

Risk Factors: Repetitive wrist and hand movements, pregnancy, postpartum period, and occupations or activities involving frequent thumb or wrist movements.

Signs and Symptoms:

• Pain and tenderness on the radial side of the wrist, particularly over the first dorsal compartment.
• Swelling in the affected area.
• Pain that worsens with thumb movements, such as gripping or pinching.
• Positive Finkelstein's test (pain when the thumb is flexed across the palm and the wrist is ulnarly deviated).

Investigations:

• Clinical Diagnosis: Based on history and physical examination, including Finkelstein's test.
• Ultrasound: May be used to confirm the diagnosis and assess the extent of tendon involvement.

Management:

• Primary Care: Activity modification to avoid repetitive thumb and wrist movements, use of a thumb spica splint, NSAIDs for pain relief, and referral to physiotherapy for tendon gliding exercises.
• Specialist Care: Corticosteroid injections may be considered for persistent symptoms. Surgical release of the first dorsal compartment is an option for severe or refractory cases.

References

1. NHS (2024) Wrist Pain: Ulnar Nerve Compression, Carpal Tunnel Syndrome, and De Quervain's Tenosynovitis. Available at: https://www.nhs.uk/conditions/wrist-pain/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Carpal Tunnel Syndrome and Other Wrist Pain Syndromes. Available at: https://cks.nice.org.uk/topics/carpal-tunnel-syndrome/ (Accessed: 24 June 2024).
3. British Medical Journal (2024) Diagnosis and Management of Ulnar Nerve Compression and Other Wrist Disorders. Available at: https://www.bmj.com/content/350/bmj.h4500 (Accessed: 24 June 2024).
4. American Academy of Orthopaedic Surgeons (2024) De Quervain's Tenosynovitis and Other Wrist Conditions. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/de-quervains-tenosynovitis/ (Accessed: 24 June 2024).

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