Saidala 24: Wrist pain

Introduction

Wrist pain is a common musculoskeletal complaint encountered across all age groups and clinical settings. It may arise acutely following trauma, develop insidiously due to repetitive stress, or present as part of systemic inflammatory or degenerative conditions. The wrist is a complex joint composed of eight carpal bones, the distal radius and ulna, ligaments, tendons, and critical neurovascular structures, making it particularly vulnerable to multiple pathologies.

Wrist pain not only limits functional activities such as gripping, lifting, or typing but may also indicate underlying disease processes that require prompt medical intervention. A clear understanding of its causes, diagnostic pathways, and evidence-based management—including pharmacological treatments and their dosages—is essential for clinicians.

Causes and Associated Diseases

1. Traumatic and Acute Injuries

Sprains and Strains: Caused by overstretching of ligaments or tendons due to falls, twisting, or sports-related injuries. Present with localized pain, swelling, and reduced movement.
Fractures: Common sites include the scaphoid and distal radius. Scaphoid fractures often present with tenderness in the anatomical snuffbox and may be missed on initial X-rays.
Dislocations: Carpal dislocations or perilunate dislocations are less common but severe, requiring orthopedic intervention.

2. Repetitive Stress and Overuse Disorders

Carpal Tunnel Syndrome (CTS): Median nerve compression at the carpal tunnel, leading to pain, numbness, tingling, and weakness. Symptoms are often worse at night or with repetitive hand movements.
De Quervain’s Tenosynovitis: Inflammation of the tendons at the base of the thumb, causing pain on thumb movement and a positive Finkelstein’s test.
Intersection Syndrome: Inflammation where wrist tendons intersect, typically presenting with dorsal wrist pain and swelling.

3. Arthritic and Degenerative Conditions

Osteoarthritis (OA): Degenerative changes due to age, trauma, or overuse. Pain worsens with activity and improves with rest.
Rheumatoid Arthritis (RA): Autoimmune inflammation of synovial joints, often symmetrical, causing pain, swelling, and stiffness.
Psoriatic Arthritis: Inflammatory arthritis associated with psoriasis, sometimes leading to dactylitis (“sausage digits”).
Gout and Pseudogout: Deposition of uric acid or calcium pyrophosphate crystals within the joint, leading to acute episodes of severe pain and swelling.

4. Nerve-Related Disorders

Ulnar Nerve Entrapment (Guyon’s Canal Syndrome): Compression of the ulnar nerve causing pain and numbness in the ring and little fingers.
Cervical Radiculopathy: Pain referred from cervical spine nerve root compression, often mimicking wrist pain.

5. Other Causes

Ganglion Cysts: Benign cystic swellings over the wrist joint, may cause dull aching pain or compress nearby structures.
Infections (Septic Arthritis/Cellulitis): Rapidly progressive pain, swelling, redness, and systemic features such as fever.

Pathophysiology

The underlying pathophysiology varies with etiology:

Trauma: Disruption of bone integrity, ligament stretching or tearing, and subsequent inflammatory response.
Overuse: Microtrauma to tendons or nerve compression due to swelling and repetitive stress.
Arthritis: Chronic synovial inflammation (RA, PsA), or cartilage degeneration (OA), leading to joint space narrowing and osteophyte formation.
Nerve Compression: Entrapment neuropathies reduce axonal conduction, causing neuropathic pain and functional weakness.
Infections: Bacterial invasion triggers acute synovitis with neutrophilic infiltration and cartilage destruction if untreated.

Clinical Presentation

Pain: Localized or diffuse, may be sharp, dull, burning, or throbbing.
Swelling and Redness: Suggestive of infection, inflammatory arthritis, or acute gout.
Stiffness: Especially in RA or OA.
Weakness and Numbness: Typical of nerve involvement (carpal tunnel, ulnar entrapment).
Mechanical Symptoms: Clicking, locking, or instability in ligamentous injuries or degenerative disease.

Diagnosis and Investigations

History and Examination
- Onset, duration, severity, aggravating and relieving factors.
- Occupation and repetitive activity history.
- Associated systemic features (psoriasis, gout, autoimmune disease).
Imaging
- X-rays: Useful for fractures, OA, RA erosions.
- MRI: Soft tissue evaluation (ligaments, tendons, cartilage).
- Ultrasound: Detects cysts, effusions, tendonitis, nerve compression.
Laboratory Tests
- Inflammatory Markers: ESR, CRP.
- Autoimmune Tests: Rheumatoid factor, anti-CCP (RA).
- Serum Uric Acid: For gout evaluation.
- Joint Aspiration: Synovial fluid analysis for crystals or infection.

Treatment Approaches

General Conservative Management

Rest and Immobilization: Splints or braces to support healing.
Ice/Heat Therapy: Ice for acute injuries, heat for stiffness.
Physiotherapy: Strengthening and range-of-motion exercises.
Occupational Therapy: Ergonomic modifications for repetitive stress conditions.

Pharmacological Treatment with Doses

1. Analgesics

Paracetamol (Acetaminophen): 500–1000 mg orally every 4–6 hours, maximum 4 g/day.

2. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Ibuprofen: 400–600 mg orally every 6–8 hours (max 2400 mg/day).
Diclofenac: 50 mg orally two to three times daily (max 150 mg/day).
Naproxen: 250–500 mg orally twice daily (max 1000 mg/day).
Indomethacin: 25–50 mg orally two to three times daily, particularly effective for gout.

3. Neuropathic Pain Agents (for nerve compression)

Gabapentin: Start 300 mg at night, titrate up to 900–1800 mg/day in divided doses.
Pregabalin: 75 mg twice daily, may increase to 150 mg twice daily.

4. Corticosteroids

Oral Prednisone: 5–20 mg daily for short-term control of severe inflammation in arthritis flares.
Intra-articular Triamcinolone: 10–40 mg injected directly into the joint/tendon sheath.

5. Disease-Specific Pharmacotherapy

Rheumatoid Arthritis / Psoriatic Arthritis:
- Methotrexate: 7.5–25 mg orally or subcutaneously once weekly.
- Leflunomide: 10–20 mg daily.
- Biologics (e.g., Adalimumab): 40 mg subcutaneously every 2 weeks.
Gout:
- Colchicine: 0.5 mg orally 2–3 times daily during acute attack.
- Allopurinol: 100–300 mg orally daily for uric acid reduction.
- Febuxostat: 40–80 mg orally once daily.
Septic Arthritis:
- Ceftriaxone: 1–2 g IV daily.
- Flucloxacillin: 500 mg orally four times daily for staphylococcal infections.

Surgical Management

Fractures: Open reduction and internal fixation for displaced fractures.
Carpal Tunnel Syndrome: Surgical decompression for refractory cases.
Arthritis: Wrist fusion or arthroplasty in advanced disease.
Ganglion Cyst: Surgical excision if symptomatic or recurrent.

Precautions

NSAIDs: Contraindicated in peptic ulcer disease, renal impairment, uncontrolled hypertension. Co-prescription with proton pump inhibitors (e.g., Omeprazole 20 mg daily) recommended in high-risk patients.
Corticosteroids: Risk of tendon rupture, hyperglycemia, osteoporosis. Limit frequency of intra-articular injections.
DMARDs: Require regular monitoring of blood counts and liver function.
Opioids (e.g., Tramadol 50–100 mg every 6–8 hours if needed): Reserved for severe cases; risk of dependence.

Drug Interactions

NSAIDs + Anticoagulants (Warfarin, Apixaban): Increased risk of bleeding.
NSAIDs + ACE Inhibitors/Diuretics: Risk of renal impairment (“triple whammy”).
Methotrexate + NSAIDs: Risk of bone marrow suppression and toxicity.
Colchicine + CYP3A4 inhibitors (e.g., Clarithromycin): Increased colchicine toxicity risk.
Corticosteroids + Immunosuppressants: Higher risk of infections.
Gabapentin/Pregabalin + CNS depressants (opioids, alcohol): Increased sedation and respiratory depression.

Saidala 24

الصفحات

Sunday, August 17, 2025

Wrist pain