Hand and wrist overuse injuries:
De Quervain's and CTS

EUGENE HONG, MD, Associate Professor of Sports Medicine and Family Medicine; and Chief, Division of Primary Care Sports Medicine, Drexel University College of Medicine, Philadelphia, Pa.

Among the most common overuse injuries of the hand and wrist are de Quervain's tenosynovitis and carpal tunnel syndrome. Here is a review of these conditions, as well as a brief look at managing stress fractures of the upper extremities.

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Overuse injuries of the hand and wrist can affect any of the constituent bones, tendons, ligaments, nerves, cartilage, or so the list of possible conditions to consider is lengthy. A partial enumeration of injuries includes intersection syndrome, extensor carpi ulnaris tendinitis, trigger finger, scapholunate ligament sprain, triangular fibrocartilage complex injury, gymnast's wrist of the radius, Kienböck's disease of the lunate, and scaphoid or hamate fractures. This article discusses de Quervain's tenosynovitis and carpal tunnel syndrome (CTS), 2 of the most common hand/ wrist overuse conditions seen in primary care practice. It concludes with some brief reminders on evaluating and managing stress fractures of the upper extremities.

As with other overuse injuries, a careful history and physical examination, supported by selective imaging and testing, can help identify the underlying pathophysiology. The goals of treatment are restoring, maximizing, and preserving function of the affected site. Consider referral when symptoms are persistent despite appropriate initial treatment, if the diagnosis is unclear, or if there is physician or patient discomfort with the clinical course.

De Quervain's tenosynovitis

This tenosynovitis of the thumb's abductor pollicis longus and the extensor pollicis brevis (the 2 tendons that make up the first of 6 dorsal compartments) was first described in 1895. The condition arises with repetitive activity requiring a forceful grasp with ulnar deviation or repetitive thumb use. Patients localize pain at the radial side of the wrist and thumb, and the symptoms can extend proximally. Paresthesia distally or associated conditions like CTS or trigger finger are common.

Pain is reproduced with resisted thumb extension and abduction. A positive response to Finkelstein's test is pathognomic for de Quervain's disease: reproduced pain with passive ulnar deviation of a closed fist (see Figure 1). Maximal tenderness is usually around the radial styloid. Distinguish between snuff-box tenderness (which is tenderness of the scaphoid bone) and tendon tenderness; note that the 2 tendons affected by de Quervain's tenosynovitis form the radial border of the anatomic snuff-box. Careful examination can differentiate between de Quervain's tenosynovitis and a possible old or missed scaphoid injury. If there is a trauma history (a fall on an outstretched arm, for example) with tenderness on the distal radius, plain radiographs should be considered.

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Treatment includes NSAIDs, ice, rest, and immobilization with a wrist splint with a thumb spica. If the splint is not dispensed at the office, it is important to see the splint at the follow-up visit: Even when "thumb spica" is specified on the prescription, I have often seen patients given a simple wrist splint, with the thumb moving freely—and the patient reporting no improvement in symptoms. For injection, give 0.5 mL of betamethasone sodium phosphate (Celestone) and 0.5 mL of 0.5% bupivacaine (Sensorcaine) with a 25-gauge needle; inject along the tendon sheath at the point of maximal tenderness (see Table 1).

 

TABLE 1 Corticosteroid injection for de Quervain's tenosynovitis and carpal tunnel syndrome
Diagnosis	Site of injection (needle size)	Dosage*
De Quervain's tenosynovitis	Point of maximal tenderness, usually just distal to radius (25 gauge 1 inch)	0.5 mL/0.5 mL
Carpal tunnel syndrome	Under carpal ligament (25 gauge 1.5 inch)	0.5 mL/0.5 mL
*Betamethasone sodium phosphate injectable (6 mg/mL)/0.5% bupivacaine. An alternative to betamethasone injectable is triamcinolone acetonide injectable, another long-acting corticosteroid. Note that 40 mg of triamcinolone injectable (40 mg/mL) is equivalent to 8 mg of betamethasone for injection.

Carpal tunnel syndrome

The carpal tunnel is defined by carpal bones on 3 sides and the carpal ligament, extending from the pisiform and hamate ulnarly to the scaphoid and trapezium radially. It is only slightly larger than its contents (9 flexor tendons and the median nerve). Any process that increases the pressure can result in CTS: repetitive overuse, diabetes, thyroid disease, amyloidosis, rheumatoid arthritis, and pregnancy. Up to 25% of patients may also have concurrent ulnar neuropathy, de Quervain's tenosynovitis, trigger finger, or degenerative joint disease of the thumb. CTS may affect about 1% of the population of the United States.

Patients complain of numbness and/or pain in the wrist and hand, extending classically in the median distribution of thumb, index, middle finger, and radial side of the ring finger. Pain may sometimes radiate to the elbow and above. Night pain that wakes patients from sleep is common; ask whether the patient gets up at night and shakes the hand in an attempt to relieve the symptoms. Motor signs, thenar wasting, and thumb weakness are late findings that indicate worse disease.

A positive Tinel's or Phalen's sign is consistent with CTS, although positive predictive values are only 0.55 and 0.48, respectively.¹ Applying pressure over the carpal ligament, thus increasing pressure inside the tunnel, is uncomfortable for the patient. Compare the result of the examination with that on the other side.

Radiographs are not routinely needed; however, consider them if there is a trauma history, recent or remote, since an unknown fracture may contribute to decreased carpal tunnel volume. If the diagnosis is uncertain, consider electromyelography (EMG) with nerve conduction velocity testing. This testing can be fairly uncomfortable for patients, so order it only when the results may affect management decisions, such as referring someone for surgical intervention. The sensitivity of EMG ranges from 49% to 84%, but the specificity can be as high as 95%.¹

Initial management consists of splinting in a wrist splint, used night and day, with a course of NSAIDs and ice 3 to 4 times a day for at least 2 weeks. I find corticosteroid injections to be helpful not only diagnostically but also therapeutically. A colleague who is a hand surgeon does not believe in such injections, since he considers CTS to be a progressive condition for which surgical cure should not be delayed. I have found that the benefits of 1 injection, with other appropriate management, can last a year or longer. In general, use no more than 2 or 3 injections a year. If symptoms are persistent and/or progressive, or thenar weakness or atrophy is present, consider surgical referral.

When injections are performed properly and with care, the risk is minuscule. To landmark the injection, stay to the ulnar side of the palmaris longus to avoid the median nerve. To locate the palmaris longus, have the patient oppose the thumb and little finger and palmar-flex the wrist—the palmaris will become prominent in the middle of the volar wrist. Pierce the skin between the second and third volar wrist crease, and at a 30-degree angle, to enter the carpal tunnel, with the needle tip aimed toward the middle finger (for the medication, dosage, and needle size, see Table 1). Occasionally, you will feel backward pressure on the syringe plunger as you encounter the increased pressure of the carpal tunnel (see Figure 2).

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Stress fractures

In a medical misnomer not involving any true fractures, stress fracture refers to a repetitive injury to a bone that exceeds the bone's ability to repair itself. A biopsy of the affected site would reveal local edema and microhemorrhage. Although stress fracture occurs more frequently in the weight-bearing lower extremities, up to 3% of all stress fractures affect the upper extremities. Suspect stress fracture when a patient has focal bony tenderness on examination, especially if the patient is an athlete involved in throwing, racquet sports, or gymnastics.

Initially, the patient may note pain only during activity, but it then progresses to persistent pain despite rest. Increasing age, a lower baseline fitness level, and poor equipment or mechanics all can be part of the overuse history. Significant findings on examination are localized tenderness, erythema, edema, and periosteum thickening.

Plain x-ray films may not reveal bony changes for 4 to 6 weeks. Triple-phase bone scan with single photon emission CT (SPECT) has been the gold standard for diagnosis, though MRI is being used increasingly.²

The treatment for stress fractures is rest. Restrict the patient from the inciting activity, and prevent further injury to the bone. Recovery time depends on the location and extent of injury, but it often ranges from 6 to 12 weeks. Pain-free cross training is allowed. When treating a female patient with stress fracture, be on the lookout for the female athlete triad comprising stress fracture, eating disorder, and amenorrhea. This condition requires a more comprehensive, multidisciplinary approach to management than is usually found in most primary care practices.

Also see the article by Dr Hong, "Managing overuse injuries of the shoulder and elbow," Patient Care, November 2003, page 34. Available at: http://www.patientcareonline.com .

PRODUCED BY PETER D'EPIRO

REFERENCES

1. Verdon ME. Overuse syndromes of the hand and wrist. Prim Care. 1996;23:305-319.

2. Bruker P. Stress fractures of the upper limb. Sports Med. 1998;26:415-424.

SUGGESTED READING

Hanlon DP, Luellen JR. Intersection syndrome: a case report and review of the literature. J Emerg Med. 1999;17;969-971.

Nguyen D, McCue FC, Urch SE. Evaluation of the injured wrist on the field and in the office. Clin Sports Med. 1998;17;421-432.

Rettig AC. Wrist and hand overuse syndromes. Clin Sports Med. 2001;20:591-611.

Wright SA, Liggett N. Nerve conduction studies as a routine diagnostic aid in carpal tunnel syndrome. Rheumatology. 2003;42:602-603.

 

Hand and wrist overuse injuries: De Quervain's and CTS. Patient Care December 2003;37:14-21.