WRIST AND HAND JOINT PAIN
Wrist and hand joints are very important joints in our day to day functional activities due to its incredible dexterity and precision of function which range from pinching, typing, grabbing, holding, writing, driving to playing sport. Wrist joint is a complex joint that bridges the hand to the forearm and composed of numerous small bones working in tandem to provide functionality and flexibility.
The multiple joints and structure of the hand and wrist allows it to compound movements which surpasses movements of any single joint in the body and allows a wide range of activity. The wrist must be extremely mobile to give our hands a full range of motion. At the same time, the wrist must provide the strength for heavy gripping.
To treat wrist and hand joint pain successfully we need to understand the anatomy and physiology of this complex joint.
ANATOMY OF WRIST AND HAND JOINT
The anatomy of the wrist and hand is complex because of the presence of many different functional joints.
IMPORTANT STRUCTURES OF THE WRIST AND HAND JOINT
BONES AND JOINTS: There are 15-bones that form connections from the end of the forearm bones to the hand.
The distal Radioulnar joint is the joint between the convex head of the ulna and concave ulnar notch of the radius bone.
The Wrist joint consists of two rows of carpal bones. The proximal (first) row contains (from radius to ulnar) the scaphoid, lunate, triquetral and pisiform bones, the distal or second row consists of trapezius, trapezoid, capitate and hamate.
The wrist joint complexes are:
The radiocarpal joint is the joint between distal part of the radius and articular disc of the proximal row of carpal bones. The joint moves along two axes: anterior posterior for ulnar and radial deviation, and transverse for flexion and extension.
The intercarpal joint is the joint between the proximal and distal rows of carpal bones. It function is to augment the mobility of the carpal bones and thus allow the greater mobility of the wrist.
The carpometacarpal joint is the joints between the distal row of carpal bones and the second to fifth metacarpal bones. This joint is rarely mobile, except for the joint with fifth metacarpal, which permit slight movement in palmar direction to allow opposition of the fifth finger.
The trapezium-fist metacarpal joint is the joint between the articular surface of trapezium and first metacarpal bone. It allows movement in two directions: abduction-adduction and opposition-reposition.
The metacarpophalangeal joints are the joint between metacarpal and phalange bone. The metacarpophalangeal joint of the thumb is different from the other fingers. It is a hinge joint and allows only flexion movement. The metacarpophalangeal joint of the second to fifth fingers is a ball and socket joint. It allows flexion and extension and abduction and adduction with the index finger having the greatest mobility.
The interphalangeal joints are the hinge joint between the phalanges. It allows only flexion and the range of flexion increases form the index to little finger which allows a fist to be made.
LIGAMENTS AND TENDONS
Ligaments are the soft tissue structures that connect bones to bones. The ligaments around a joint usually combine to form a joint capsule. A joint capsule is a watertight sac that surrounds a joint and contains lubricating fluid called synovial fluid. In the wrist, the eight carpal bones are surrounded and supported by the joint capsule.
COLLATERAL LIGAMENTS: These ligaments connect the forearm to the wrist, one on each side of the wrist. The one on the ulnar bone is called ulnar collateral ligament. It is originate from ulnar styloid (the bump at the side of little finger) and has two parts that connect to two carpal bones in the proximal row, namely, triquetrum and pisiform bone. This ulnar ligament adds support to small disc of cartilage where ulnar meets the 2-carpal bones. This disc of cartilage is called triangular fibrocartilage complex. The ulnar ligament stabilizes the triangular fibrocartilage complex and keeps the wrist from bending too far toward the thumb. The other one on the radial bone is called radial collateral ligament is at the thumb side. It’s between the outer radial styloid process and scaphoid bone. The radial collateral ligament prevents the wrist from bending too far to the side toward the little finger.
TRANSVERSE CARPAL LIGAMENT: This is a thick band of tissue that crosses the front of the wrist. This band of tissue keeps the flexor tendon from bowing outward when curl the fingers, thumb and wrist.
DORSAL LIGAMENTS: These ligaments are comparatively thin. They are reinforced by the floor and septa of the fibrous tunnels for the six dorsal compartments and have a ‘Z-shaped’ configuration. The pattern and shape of these ligaments is important for the treatment with deep friction which should be diagonal to the direction of the fibers.
PALMAR LIGAMENTS: A complex system of ligaments joints the different carpal bones to the radius and ulna on the palmar aspect of the wrist. These ligaments are taut during wrist extension.
Radial deviation is about 15° in movement; ulnar deviation is about 45°, when the wrist is kept at neutral position between flexion and extension (between bend forward and backward). Flexion and extension both have movement of about 85°, with wrist in the neutral position between radial and ulnar deviation. The movement depends on the individual body frame and flexibility.
MUSCLE AND TENDONS
Tendons connect the muscles to bone. The tendons that cross the wrist begin as muscles from forearm. Those tendons that cross the palm side of the wrist are called the flexor tendons. They curl the fingers, thumb and bend the wrist. These tendons run beneath the transverse carpal ligament. These flexor tendons are enclosed by the carpal tunnel and the tunnel of Guyon. Within the carpal tunnel are found: the median nerve; the tendon of the flexor carpi radialis and the flexor pollicis longus, in separate sheath; and the superficial and deep flexor of the digits, within a common tendon sheath.
The tendons that cross over the back of the wrist are called extensor tendons. Extensor tendons run through a series of tunnels, called compartments and there six compartments. These compartments are lined with slick substance called tenosynovium, which prevents friction when the extensor tendons glide inside the compartment. The extensor tendons bend the fingers, thumb and wrist backward.
Intrinsic Muscles:These are the muscles inside the hand
The thernar muscles:These include the abductor pollicis brevis, opponens pollicis, and flexor pollicis brevis with its superficial and deep head and the adductor pollicis with its transverse and oblique head. These help move the thumb and let touch the tips of each finger on the same hand, called opposition.
The hypothenar muscles: Are the abductor digiti minim, flexor digits minimi brevis and opponens digiti.
The lumbrical muscle:there four Lumbrical muscles. They originate at the radial aspect (thumb area) of the tendons of the deep flexor digitorium muscle and insert at the dorsal aponeurosis of the finger and the joint capsules of the metacarpophalangeal joints. They bend the metacarpophalangeal joints and bend backward the interphalangeal joint.
Palmar interossei: the three palmar interossei muscles close the fingers towards the middle finger, bend forward the metacarpophalangeal joint and bend backward the interphalangeal joint of the fingers.
The dorsal interossei: there four dorsal interossei. They originate from the sides of the five metacarpal bones, each having two heads, each in the side of the two adjacent metacarpal bones. They course towards the proximal phalanges, where they attach into the extensor aponeurosis of the fingers. The first dorsal interosseus goes to the radial aspect of the index finger, the second dorsal interosseus goes to the radial aspect of the middle finger, and the third dorsal interosseus goes to the ulnar aspect of the middle finger, the fourth dorsal interosseus goes to the ulnar aspect of the fourth finger. The dorsal interossei abduct (open) the fingers away from the middle finger. They also flex (bend forward) the metacarpophalangeal joints and extend (bend backward) the interphalangeal joints.
The palmar aponeurosis: The palmar aponeurosis of the hands is a continuation of transverse ligament of the carpus (flexor retinaculum) and consists of transverse and longitudinal fibers. The latter are part of the tendon sheaths of the flexor tendons (deep transverse metacarpal ligaments) and also connect to the capsules of the metacarpophalangeal joints. The aponeurosis is also connected to the deep fascia of the hand, which is attached to its skeleton. Together with the ligaments, septa, and fasciae, the palmar aponeurosis forms a functional unit. It protects the skin of the soft tissue of the mid-hand by fixes the skin of the palm to the metacarpal bones during a strong grip.
The three most important nerves of the wrist and hand begin together at the shoulder and cross the wrist. These nerves are: median, ulnar and radial nerves. They carry signal from brain to the muscle that move the arm, hand, finger and thumb. The nerve also carry signal back to the brain about sensations such as touch, pain, tactile stimulation, positional senses and temperature. The median nerve is most commonly affected in the carpal tunnel, whereas the ulnar nerve is compresses in the region of Guyon’s tunnel. Lesions of the radial nerve at the wrist are less common.
The radial nerve runs along the thumb side of the forearm. At the elbow, the radial nerve divides into the posterior interoseous nerve (deep motor branch), which supply the extensor muscle of the wrist and finger, and the superficial radial nerve (a superficial sensory branch) which lies under the brachioradialis muscle. It wraps around the end of the radius bone toward the back of the hand. It gives sensation to the back of the hand from thumb to the third finger. It also goes to the back of the thumb and just beyond the main knuckle of the back surface of the ring and middle fingers.
Median nerve: This nerve crosses the front part of the elbow. Its motor branches supply the pronator teres, flexor carpi radialis, Palmaris longus, and flexor digitorium superficialis muscles in proximal forearm. The median gives off the interoseous branch that supply the flexor pollicis longus, flexor digitorum profundus to the index and long fingers, and the pronator quadratus muscle after passing between the head of the pronator teres muscle. About 4 centimeter to the wrist median nerve gives off it palmar cutaneous branch that supply the skin over the central part of the heel of the wrist; this area is spared from sensory changes of in carpal tunnel syndrome. The median nerve then enter the hand through the carpal tunnel, between the tendon of flexor pollicis longus and flexor digitorum superficialis, where it is subject to compression. Distal to the transverse ligament (flexor retinaculum), the nerve divides into 2-branches. A short motor branch goes to the thenar eminence, where it supplies the abductor pollicis brevis and opponens pollicis muscles, and sometimes the flexor pollicis brevis and the first and second Lumbrical muscles. The sensory palmar digital branches supply the palmar surface and the dorsal aspect of the distal phalanges of the thumb, the second and third fingers and the radial half of the fourth finger.
Ulnar nerve: This nerve crosses posterior to the medial humeral epicondyle in the cubital tunnel. It gives off 2-moter branches in the forearm to supply the flexor carpi ulnaris and flexor digitorum profundus muscles to the ring and small fingers. Proximal to the wrist, it gives off the palmar cutaneous branches, which supply the proximal skin over the ulnar side of the palm as it travels across the palmar aspect of the forearm and wrist, outside the tunnel of the Guyon. The dorsal cutaneous branch supplies the ulnar side of the dorsum of the hand, the dorsal aspect of the fifth finger and the ulnar half of the fourth finger. The ulnar nerve, together with the ulnar artery, passes between the pisiform and the hook of the hamate through the tunnel of Guyon. After passing through the canal/tunnel, it divides into a mainly sensory superficial terminal branch, which supplies the distal ulnar border of the palm of the hand and the palmar surfaces of the fifth and ulnar half of the fourth finger and deep terminal branch, which is entirely motor and supplies nearly all the small muscles of the hand.
Traveling along with the nerves is the large vessels that supply the hand with blood. The brachial artery divides at the elbow into radial and ulnar branches. The largest artery is the radial artery that travels across the front of the wrist, closest to the thumb. The radial artery is where the pulse is taken in the wrist. The ulnar artery runs next to the ulnar nerve through Guyon’s canal. The ulnar and radial arteries arch together to form the superficial palmar arch within the palm of the hand, supplying the front of the hand and fingers. Other arteries travel across the back of the wrist to supply the back of the hand and finger.
CAUSES OF THE HAND AND WRIST PAIN
- Connective tissue disorder- A) inflammation B) Over use of the tendon C) Progressive fibrosis of the palmar aponeurosis, digital fascia and natatory ligament.
- Traumatic hand disorder- A) tendon sprain/strain B) tendon tear C) breaking bone D) ligament strain/sprain.
- Nerve injuries.
- Muscle injury.
- Repetitive movement of the hand and fingers.
WRIST AND HAND PAIN DIAGNOSES
May include but not limited to the following diagnoses.
- Tendinitis is aseptic inflammation of tendon.
- Tenosynovitis is an inflammation of synovial lined tendon sheaths.
- Stenosing tenosynovitis (trigger finger) is a condition in which inflamed tendon sheaths become thicken and fibrosed (dry).
- De Quervain syndrome: This is inflammation of the synovial sheaths of the abductor pollicis longus and extensor pollicis brevis tendon in the first extensor compartment. Swelling within this enclosed space restricts tendon gliding.
- Dupuytren Disease: This is a progressive fibrosis of the palmar aponeurosis, natatory ligament (within web spaces), and digital fascia. It manifests as either a cellular nodule in the adipose tissue containing myofibroblast or collagenous cords in the aponeurosis.
- Carpal tunnel Syndrome: This is a condition where the median nerve being compresses in the carpal tunnel between the flexor compartment tendons.
- Ulnar tunnel Syndrome: This is a condition where ulnar nerve is injured in the Guyon canal/tunnel. The origin of ulnar tunnel syndrome may include an ulnar artery aneurysm or thrombosis, carpal ganglia, hamate fracture, blunt trauma, or compression. The syndrome produces isolated or combined sensory and motor symptoms, depending on the area of compression. Symptoms may include acute or insidious onset of pain, paresthesia, or anesthesia. Weakness may result in the ulnar-innervated intrinsic muscles, affecting grip and key pinch. Weakness contributes to claw-hand posture, in which the metacarpal joints hyperextend and interphalangeal joints flex. Wastage of the intrinsic muscle is usually the evident.
- Distal Radioulnar joint dislocation.
- Sprains and Dislocations.
Physical treatment (conservative treatment) depends on the proper understanding of the wrist and hand joint anatomy as was outlined or discussed above. Therefore, successful treatment of this complex joint of the wrist and hand requires understanding of mechanism of the injury and disease that is causing the pain and disabilities.
To successfully treat hand and wrist joint, therapist needs to perform a thorough evaluation which should include patient’s history, physical status, functional capability of the patient and tests and measurement
Patient history should include: which hand is your dominant, your occupation, chief complaint, is onset acute, chronic or insidious. If is acute, the patient should describe the mechanism of injury. If the onset is insidious, does patient knows the cause.
Physical status of the patient include inspection for skin dryness and movement, palpation for blood supply , movement and muscle strength of neck, shoulder, elbow, wrist and hand joint.
Functional capability of the patient is about the functions that patient can perform, and how he or she performs the functions and functional limitations.
Patient’s posture in relation to the affected arm, need to also be considered, in order to find the cause of the condition and the origin of the symptom.
If the condition is post-surgical, surgical note need to be review in order to know what the surgeon did and what are around the region.
Test and measurements should include integrity of the ligaments, joint alignment, muscles action, blood supply, and nerve functions.
All these will give the therapist good impression of the cause of the symptoms and the location in order to execute proper plans of care with wright treatment procedures. Therapist need to explain evaluation findings and, treatment procedures which should include the benefits and the risks of the treatment to the patient.
Treatment procedures may include the following:
Contrast bath: This is application of the ice and warm in succession to reduce inflammation and edema.
Myofascial release to release restricted fascia to increase circulation, reduce edema, aid healing, increase range of motion, increase neurovascular bundle motility and reduce pain in order to improve the functional ability level.
Therapeutic exercises which may be in form of stretching or strengthening depend on evaluation findings. Stretching will relax restricted fascia, increase muscle glide, increase range of motion, increase circulation and reduce pain or stiffness in order to improve functions. Strengthening exercise can be passive, active/assistive, active and resistive movement. Resistive exercise can be prescribe as 45% of 1RM to increase muscular endurance, 55% of 1RM for endurance and strength, 75% of 1RM for strength and 100% of 1RM is for muscular power. In performing any exercise, posture is very important because exercise with wrong/ bad posture can cause harm than good.
Soft tissue mobilization to release restricted fascia, increase neuromuscular bundle motility, increase circulation, increase muscle fiber glide and reduce pain.
Ultrasound may also be used in pulse or continuous mode depends on whether you want thermal effect which is use for pain control of the non-thermal effect for edema control, and healing. Frequency of 1MHz is use when the tissue is deep and 3MHz is use when the tissue is superficial.
Neuromuscular Re-education can be used to improve hand and fingers muscle coordination.
Laser therapy can also be used to control pain but the cause of the pain still need to be treated for lasting outcome.
Parafinbath can be used as adjunct to other treatment for moist heat to reduce pain.
Before I end this write up, I will like to clear some confusion about which therapist treat shoulder, arm elbow, wrist and hand, is it Occupational or Physical therapist? Both therapists can treat this area of the body. (Physical Therapists scope of practice).
Raifu Olorunfemi, PT., MS.
Central Florida Therapist & Rehabilitative Group, Inc.