By J. Pinnello, M.D.
The wrist is a complex joint that connects the hand to the forearm. It contains eight bones and their associated ligaments as well as the surrounding tendons and nerves that support the function of the hand and fingers. A wide variety of wrist conditions and injuries can produce wrist pain.
Injuries to the wrist commonly occur when one falls on an outstretched hand. Obvious deformity does not necessarily accompany severe wrist injuries and it is not true that “if you can move it, it must not be broken”. Therefore, acute wrist pain from such a fall or from other trauma should be evaluated promptly by a health care provider as in many instances the injury may be worse than initially thought. In addition to careful examination, X-rays or other tests may be ordered to assess the extent of damage to the wrist. Splinting, casting or even surgery may be necessary depending on the severity of the injury.
But beyond significant traumatic injuries, there are many other causes of wrist pain. Wrist discomfort may be mild and may or may not slowly worsen with time. One may notice symptoms with certain positions or activities or only during certain times of the day or night. Initially, many people try basic treatment on their own by avoiding those activities that produce symptoms, by using basic pain medications, or even by splinting the wrist. But if these proprietary measures don’t successfully resolve the symptoms, a visit to the doctor is probably in order. There are any number of problems that can produce pain, swelling, stiffness or other symptoms at the wrist. Among the most common are ganglion cysts and various types of tendonitis
A ganglion (GANG-lee-on) cyst is a firm, fluid-filled lump that is typically found on either the back side or the palm side of the wrist. A small amount of fluid exists in the wrist to help lubricate the various bones as they rub against each other. A weak spot in the lining of the wrist joint may allow that fluid to push or balloon out into the adjacent tissues, thus creating the ganglion. Ganglion cysts usually appear in young to middle age adults, they appear more commonly in women and they may or may not be associated with an injury. Ganglions can range in size from a pea to a large grape. Sometimes they grow in size and sometimes they can actually shrink, only to grow again later. They typically will not spread and they have no potential to become cancerous. Ganglion cysts can be painful or painless. They may cause stiffness or limited motion at the wrist and if a ganglion puts pressure on an adjacent nerve it can cause numbness or tingling in part of the hand. Ultimately, many people do not like the cosmetic appearance, especially if the cyst
Many ganglions can shrink and some may resolve pontaneously. Therefore, initially observation should be the first line of treatment. Aspiration, or removing fluid with a needle, is another non-surgical treatment. The skin is numbed and a needle is used to pop the cyst and withdraw the fluid. Usually clear, jelly-like fluid is withdrawn. This minor procedure can help confirm the diagnosis and minimize the symptoms. Unfortunately, recurrence of the cyst occurs in up to 50 percent following aspiration.
The most reliable method of treating a ganglion cyst is by surgical excision. The cyst and its connection to the underlying joint are removed. This is done on an outpatient basis and can be done under a regional (arm numbed) or general anesthetic. The risks are low and the chance of recurrence is very low. Full recovery is expected in a few weeks.
De Quervain’s Tenosynovitis
De Quervain’s tenosynovitis or “Washer Woman’s Sprain” is painful inflammation on the thumb side of the wrist. This condition was named after a Swiss surgeon, Fritz de Quervain, who wrote about it in 1895.
The underlying cause is irritation or inflammation (-itis) of the tendons (cordlike fibers that attach muscle to bone) that control some of the movements of the thumb. Repetitive motions, overuse or mild trauma are all likely causes, but frequently, the cause is unknown. Women are eight to ten times more likely to experience this than men. Most commonly de Quervain’s tenosynovitis affects those between the ages of 30 to 50.
The most common symptom is pain on the thumb side of the wrist. In particular, one may notice more discomfort with pinching, grasping, or twisting of the wrist, such as may occur when unscrewing the lid of a jar or lifting an infant. The thumb may also snap or catch and there is often localized swelling on the thumb side of the wrist.
A Dr. Finkelstein described a test that, if positive, virtually confirms the presence of de Quervain’s tenosynovitis. First you tuck your thumb in your palm and make a fist. Then you move your wrist towards your small finger, like when hammering a nail. If this causes significant pain along the thumb side of the wrist then it is highly likely that you have de Quervain’s teneoynovitis.
Non-surgical treatment for de Quervain’s includes antiinflammatory medications like aspirin, ibuprofen, Aleve or others. In addition, a wrist and thumb splint may be beneficial. To decrease the inflammation, some patients benefit from a cortisone injection around the tendon.
Surgery is indicated only when de Quervain’s tenosynovitis is long-standing or unresponsive to non-surgical treatment. Surgery is an outpatient procedure that can be performed under local, regional or general anesthetic. The sheath that covers the tendon is released to allow the tendons to move more easily and this in turn, relieves the inflammation. Recovery from surgery is quick and risks are low.
In summary, the wrist is a complex joint and there are many possible causes of wrist pain or other wrist symptoms. While ganglion cysts and de Quervain’s tenosynovitis are two of the more common non-traumatic causes of wrist pain, there are certainly many other problems that can occur. An orthopedic surgeon, who is a specialist in the diagnosis and treatment of conditions affecting muscles, bones and joints, is best qualified to make the appropriate diagnosis and undertake the proper treatment so that you can return to normal activities without symptoms as quickly as possible.
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