This transcript has been edited for clarity.
Matthew F. Watto, MD: Welcome back to The Curbsiders. I'm Dr Matthew Watto, here with my great friend Dr Paul Nelson Williams and his cat, which you may or may not see in frame here. We are going to be talking about hand and wrist pain, a very common complaint in primary care.
To start off, Paul, I always get the patient with the pain in their thumb, or maybe it's in their wrist. And sometimes I'm like, is this arthritis? Is this tenosynovitis? How do we figure out the difference between those two?
Paul N. Williams, MD: Well, differently now, ever since talking with Ted Parks about how he approaches it. For musculoskeletal concerns, we're finding that the evidence supporting physical examination maneuvers is not super great. But for this one, it seems there are some good things we can do to differentiate between carpometacarpal (CMC) arthritis and de Quervain tenosynovitis, which are probably the two leading differential diagnoses for thumb pain
We can actually show this. Dr Parks talks about the Finkelstein maneuver to look for de Quervain tenosynovitis, in which you have the patient wrap their fingers around their thumb and then you just take their hand and push down. If that reproduces the pain, that's a positive Finkelstein test. That's a really good test compared with what we normally have. When looking for CMC arthritis, Dr Parks talked about taking the thumb and actually using it almost like a mortar and pestle and just kind of moving it around. You can reproduce the pain that way, which seems cruel but is also kind of fun. If you use those two simple physical examination maneuvers, you can drill down onto the two most common thumb-based concerns.
Watto: The treatment for both of these is the thumb splint to rest the area. If it's an older person, you can try topical nonsteroidal anti-inflammatory drugs (NSAIDs). You can try oral NSAIDs if it's a younger, healthier person. And then, Paul, keep the patient in that splint forever, right? I'm using my patented teaching method here.
Williams: Yes, in perpetuity. No — if I remember right, Dr Parks said at least 2 weeks, but it's not something you're going to do for forever. If it doesn't get better with some of those conservative measures, then you're moving on to the next more invasive-type things, like steroid injections or surgery.
Watto: There can be muscle wasting if they're not using the muscles, and they can lose some proprioception. It just it seems counterproductive, so you don't want to brace for too long, but brace for a short period of rest and then you can then you can take the brace off.
Trigger finger was another thing we talked about. I always thought you needed a giant splint to put on the finger, like a whole-hand glove covering the finger completely. But he told us that, actually, you can get these cute little splints that just cover the end of the finger or just cover the proximal interphalangeal joint and the distal interphalangeal joint that way. It just makes it so the person's not flexing the finger because there's actually a nodule on the tendon in this area that is getting caught on this pulley that goes across the base of the thumb. This nodule gets stuck in there, and that's what caused the triggering, so if you stop them from flexing for a while, that area can rest.
If that doesn't work, you can, you can always inject with steroids, which actually works pretty well here. He said steroids really shine for trigger finger.
Williams: This is one condition for which he really enjoys doing the surgery but has so little cause to do it because the steroids work so well.
Watto: The final thing we wanted to talk about is carpal tunnel syndrome, which we see a ton of. And Paul, you have some treatment pearls, but I just wanted to remind people that one of the common mistakes with carpal tunnel is if the patient has atypical symptoms, don't try to call everything carpal tunnel. It's typically the first two and a half fingers, including the radial side of the third digit. If it doesn't fit that distribution, then you might think it's something else.
There are certain systemic rheumatologic diseases that can cause bilateral carpal tunnel syndrome. One of them is cardiac amyloidosis. Fortunately, that's not very common, but carpal tunnel can precede cardiac amyloidosis diagnosis by several years.
If you have a patient with bilateral carpal tunnel and it's not coming from their neck, don't misdiagnose it as cervical radiculopathy. Cervical radiculopathy is much more common than cardiac amyloidosis.
Paul, what about the treatment of carpal tunnel?
Williams: This is the part I really appreciated. I will not be doing most of these treatment modalities in the office. But in terms of the way things progress, you can start with just nocturnal splinting. An over-the-counter, buy-it-at-the-drugstore, $15 carpal tunnel splint works just fine and they don't have to wear it all the time. At nighttime, patients tend to sleep with their the wrist kind of bent, which does not help their cause. A slight extension just to keep things open can be helpful and reduce symptoms markedly.
If that doesn't do the trick, steroid injections are really helpful for a couple of reasons. They can alleviate symptoms. That's great. And if they do alleviate symptoms, that tells you that you probably have the right diagnosis. If you inject steroids, but it doesn't touch the carpal tunnel at all, either you have the wrong diagnosis or that patient may not benefit from surgery because they may have such progressive disease that they aren't going to see any marked improvement. I thought that was a helpful way to evaluate how steroids are used.
Watto: And he made the point that if you see really bad muscle wasting, that patient is likely not going to do well with treatment because it's been present for too long.
We've talked about a lot here, but guess what? There was even more in the podcast. We go way in-depth, so check that out here: Hand and Wrist Pain With Dr Ted Parks. Until next time, I'm Dr Matthew Frank Watto.
Williams: Thank you and goodbye.
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Cite this: Matthew F. Watto, Paul N. Williams. Thumb, Finger, Wrist Pain? How to Evaluate Hand Symptoms - Medscape - Jan 12, 2023.
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