WEB EXTRA!
BY PEGGY PECK
Like many other musculoskeletal problems, most hand and wrist problems can be diagnosed by carefully considering three factors: anatomy, mechanism of injury and epidemiology, according to Edward Shahady, M.D., professor of family medicine and rural health, Florida State University College of Medicine, Tallahassee.
For example, when a 20-year-old patient presents with a "knee injury caused by a lateral blow, the diagnosis is usually medial collateral ligament damage. But when the patient is 11 or 12 years old, the most likely diagnosis is Salter-Harris fracture," Shahady said. He discussed this and other "practice pearls" Oct. 2 in an Assembly seminar, "Common Musculoskeletal Problems."
In his first case study, Shahady discussed injuries caused by a common mechanism known as a "fall on an outstretched hand." Shahady said he first tries to locate the exact source of the pain by clinical examination. "Shake the patient's hand to determine if he or she can wrap a thumb around your hand or if the thumb is held up to avoid pain," he said. Next, check for pain in the "anatomical snuff box," which is the area of the wrist just beneath the thumb. "Place your thumb in the 'snuff box' and ask the patient to rotate the hand to each side (ulnar deviation and radial deviation)," he said. If those movements increase pain, the most likely source of pain is a scaphoid injury.
Turning to anatomy, he pointed out that both dorsal and palmar views of the wrist illustrate that the scaphoid "butts directly up against the radius, so this makes sense as the site of injury." Finally, he considers epidemiology: in this case, age. "The patient is a 30-year-old. In that age group, scaphoid injury is the most likely diagnosis when the patient presents with these symptoms. But if the patient were 70 years old, the diagnosis is more likely to be injury to the humerus or the shoulder."
Treatment requires casting or splinting -- with finger immobilization -- for four to six weeks, he said.
Another common condition, de Quervain's tenosynovitis results from an injury associated with "forceful grasp coupled with ulnar deviation or repetitive use of the thumb -- the type of injury that fly fishermen, golfers or tennis players will get," he said. But also at risk are young mothers "who are constantly lifting up the baby," he said. A simple diagnostic test for this condition is Finkelstein's test: Have the patient make a fist with thumb tucked inside the fingers and then move the hand back and forth. If this causes increased pain, the most likely cause is de Quervain's, he said. He recommends treating the condition by injecting steroids plus lidocaine into the sheath surrounding the pollicis tendons.
Finally, he said the most common wrist-hand problem seen by family physicians is carpal tunnel syndrome. "With this condition, epidemiology is very important since carpal tunnel is more common in women -- especially middle-aged women -- than in men," he said. Since it is considered an overuse injury, initial treatment usually includes job modification, night splints and nonsteroidal anti-inflammatory drugs. Patients who don't respond to these measures often are good candidates for injection therapy, again with a steroid-lidocaine solution, he said.
He contended that injecting the carpal tunnel is easy with a simple trick: Have the patient flex the fingers so that they are curled into a loose fist; place the needle about 1 centimeter into the palmaris longus, keeping the needle at about a 30- to 45-degree angle; then ask the patient to open the hand and stretch the fingers. "Stretching the fingers will pull the needle into the right place," he said.
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