How to manage De Quervain’s, carpal tunnel syndrome, CMC OA and trigger finger
Before we discuss the common problems that affect the wrist and hand, let’s first discover the anatomy. The wrist joint is made up of the joints between the radius, ulna and carpal bones. It is surrounded by a joint capsule and many strong ligaments on all sides. In the hand the carpal bones meet with the metacarpals, and the metacarpals with the phalanges to form the fingers and thumb. The remaining anatomy is made up of tendons, muscles and nerves. For an assessment of a hand or wrist injury book a shoulder and upper limb appointment for assessment and ultrasound scan.
On the palmar side of the wrist termed the volar wrist we have the carpal tunnel – a fibro-osseus tunnel that houses the flexor policis longus (FPL), flexor digitorum superficialis (FDS) and profundis (FDP), and the median nerve which supplies sensation and power to the thumb side half of the hand. Outside the carpal tunnel we have the flexor carpi radialis (FCR), flexor carpi ulnaris (FCU) and Guyon’s canal which house the ulna artery and nerve. The ulna nerve supplies sensation to the little finger side of the hand and strength for the muscles of the hand and some of the muscles of the thumb.
Ref: European Society of MusculoSkeletal Radiology: Musculoskeletal Ultrasound Technical Guidelines III. Wrist.
What is Carpal tunnel syndrome?
This is compression of the median nerve where it runs through the carpal tunnel. The median nerve supplies sensation to the thumb, index finger, middle finger and half of the ring finger. People with carpal tunnel syndrome will often report tingling and numbness in this part of the hand. It also supplies motor power to the adductor pollicis brevis and patients will report an inability to do up buttons, put earrings in or make a pincer grip. It is sometimes caused by thickening of the finger tendons in people who a lot of typing for example, the nerve can also become thickened taking up space in the tunnel and compressing the nerve further.
How do you diagnose carpal tunnel syndrome?
Other than symptoms nerve compression will be tender at the site of the compression, your therapist may compress the carpal tunnel with the index finger for 20—30 seconds and it may start to give your symptoms. Phalen’s test may be positive, and sensation of the fingers may be different (index finger compared to ring finger). We can also ultrasound scan the nerve and see if it is compressed and thickened.
Treatment for carpal tunnel syndrome?
The first port of call will be to reduce the activities that seem to aggravate the problem and splint the wrist at night with a straight wrist. This may need to be done for several weeks to allow the nerve to recover.
Ultrasound guided steroid injection for carpal tunnel syndrome
In those who have intermittent symptoms an ultrasound guided steroid injection delivered around the nerve may help to reduce symptoms. We would normally inject the ulna side of the palmaris longus. In those who have constant symptoms an ultrasound guided steroid injection is less likely to help and may require surgery. A carpal tunnel release increases the volume of the carpal tunnel by 12% and can settle persistent symptoms.
On the back side of the wrist, termed the dorsum of the wrist, there are 6 compartments that house the main tendons. These are termed extensor compartments.
- Extensor compartment 1: this houses abductor policis longus (APL) and extensor policis brevis (EPB) – tendons that go to the thumb.
- Extensor compartment 2: this houses extensor carpi radialis longus (ECRL), and brevis (ECRB)
- Extensor compartment 3: extensor policis longus (EPL) – another tendon that goes to the thumb.
- Extensor compartment 4: extensor indices (EI) and extensor digitorum comunis (EDC) – to the index finger and all finger respectively
- Extensor compartment 5: extensor digiti minimi (EDM) – to the little finger
- Extensor compartment 6: extensor carpi ulnaris (ECU)
Ref: European Society of MusculoSkeletal Radiology: Musculoskeletal Ultrasound Technical Guidelines III. Wrist
Most pathology occurs in EC1 and EC6 on this side of the wrist.
What is De Quervain’s tenosynovitis?
This is quite a common condition causing pain at the base of thumb, especially in new mums that are constantly lifting a growing baby. It sometimes gets termed mummy thumb for this reason, or it can also be termed tech thumb as people can develop this problem from lots of texting with the thumbs. This is a tenosynovitis (tendon swelling) of the first extensor compartment (EC1 – housing APL and EPB) just as the tendons pass over the radial styloid and scaphoid. The tendons pass under a thickened piece of tissue called a retinaculum that helps to keep the tendons in place and act as a pulley to direct their angle of force. In De Quervain’s syndrome two things can happen – first the tendons themselves can become thicker and irritated much like in other tendinopathies, and secondly the retinaculum can also thicken causing a rubbing of the tendon as it moves back and forth. This irritates the tenson and causes the swelling and pain.
How do you diagnose De Quervain’s tenosynovitis?
There are some simple tests that your therapist can do to assess and diagnose De Quervain’s tenosynovitis. First it will look slightly swollen over the tendon and there will be less movement in the affected thumb which is also painful. A stretch on the tendon called Finklestein’s test will be painful as will resisted movements of the thumb. We can also ultrasound scan the tendons to see if they are thickened, if the retinaculum is thickened and whether there is inflammation in the area.
Treatment for De Quervain’s tenosynovitis
The first line of treatment is to try to stop doing the things that aggravate the thumb, such as change the way you are texting or using your devices or change your work duties. This is more difficult to do if you have a new baby and here you would wear a wrist splint to off load the tendons. You should also wear a thumb splint at night to rest the tendons in a comfortable position. Next you should start some thumb strengthening exercises guided by your physiotherapist. It might also be worthwhile trying some anti-inflammatories if you are not breast feeding.
Ultrasound guided steroid injections for De Quervain’s tenosynovitis
If rest, anti-inflammatories, splinting and exercises are not resolving the issue you might need a steroid injection. At Wandsworth Physiotherapy we use ultrasound guided steroid injections to treat De Quervain’s tenosynovitis. We can view the tendon nicely and the injection can be deposited into the tendon sheath which reduces some of the risks of superficial injections such as skin depigmentation and fat atrophy.
What is trigger finger?
Trigger finger is caused by a thickening of the flexor tendons that we were introduced to earlier – either FPL, FDS or FDP where they pass under a pulley called the A1 pulley at the base of the finger or thumb above the metacarpal joint. This thickened nodule in the flexor tendon catches as it passes under the A1 pulley causing the pain and locking of the finger.
How do you diagnose trigger finger?
This is very much a clinical diagnosis of catching and clicking of the affected finger over the MCP joint. We can also ultrasound scan the hand and see the thickened tendon as it passes back and forth under the A1 pulley.
Treatment for trigger finger
As with many conditions in the wrist and hand splinting is a good option to allow the tendon to rest and recover and perhaps go back to its normal shape and size. Strengthening exercises for the fingers is also warranted. If the finger locks and requires a forced to unlock – this requires an A1 pulley surgical release.
Ultrasound guided steroid injection for trigger finger
As with the other conditions in the wrist and the hand mild to moderate trigger finger symptoms can be managed quite well with an ultrasound guided steroid injection. The ultrasound guidance allows us to place the needle tip directly into the tendon sheath and deposit the steroid.
What is base of the thumb arthritis?
The base of the thumb is also known as the CMC joint. It is made up of the trapezium (one of the carpal bones) and the first metacarpal. This is perhaps the most worn joint in the body, far more so than the hip and the knee and is susceptible to arthritis. The joint between the scaphoid, trapezium and trapezoid bones in the wrist known as the STT joint is also vulnerable to arthritic injury and can lead to base of the thumb pain.
How do you diagnose base of the thumb arthritis?
Symptoms include pain at the base of the thumb and there may be or weakness with a pinch grip. As with other forms of arthritis the joints may feel stiff and sore first thing in the morning and take 30 minutes to loosen up and they may ache more when it’s cold. An x-ray will help to diagnose the condition and we can also see joint wear and swelling on ultrasound.
Treatment for base of the thumb arthritis?
Thumbs splints are useful for symptom relief for some patients as are anti-inflammatory medications. Sometimes surgery is required.
Ultrasound guided steroid injections for base of the thumb arthritis
Ultrasound guided injections have been shown to useful in alleviating symptoms in some people and it may be worth trying this before surgery. We can visualise the CMC and STT joints quite well on ultrasound making sure the medication is delivered where it is required.
