Hand and Wrist Normal function of the hand and wrist is obviously of great importance. A cursory review of this area is included in the Upper Extremity Examination. What follows is a of commonly occurring pain syndromes and pathologic processes involving this region. 1. Carpal Tunnel Syndrome Presentation and Anatomy The median nerve travels through a narrow space when it crosses the wrist en route to the hand. Occasionally, this space becomes inadequate to accommodate the nerve, placing it under increased pressure. The precise reason why this occurs is not clear. Patients usually report some combination of the following * Numbness and tingling (ie neuropathic pain symptoms) in the distribution of the median nerve (thumb, index, middle and lateral � of ring finger) * Symptoms are often worse at night, presumably due to tendency to flex wrist during sleep. Flexing puts additional pressure on the nerve. * Patients will often try to shake out their hands in an effort to reduce pain and increase blood flow (based on the patients assumption that decreased perfusion caused the symptoms). * With increased severity, pain can be present at all times during the day. * In severe cases, there may be loss of motor strength of the thumb (see below). Examination * The hand and wrist usually appear normal * Pain may some times be reproducible by tapping over the nerve (Tinnels sign). It may also occasionally be reproducible if the wrist is held in forced flexion x 1 minute (Phelans sign). Neither of these signs is particularly sensitive. Examination * The hand and wrist usually appear normal * Pain may some times be reproducible by tapping over the nerve (Tinnels sign). It may also occasionally be reproducible if the wrist is held in forced flexion x 1 minute (Phelans sign). Neither of these signs is particularly sensitive. In advanced carpal tunnel, there may be atrophy of the thenar eminence (due to denervation of the muscle as well as disuse atrophy) and associated decrease in motor strength. The Abductor Pollicis Brevis (APB) muscle receives sole innervation from the median nerve. Function can be tested by providing resistance to abduction up and away from the plane of the palm. Prolonged compression will lead to impaired 2 point discrimination on sensory testing. That is, the patient cant discern whether being touched with one object or 2 when separated by 5mm (can check using a bent paper clip). Ganglion Cyst Presentation and Anatomy Idiopathic, spontaneous protrusion of joint fluid outside of the articular space. The cyst is painless and usually located on the dorsal aspect of the wrist. Dupuytrens Contracture Presentation and Anatomy Thickening of the palmar fascia, which is usually painless and develops slowly over time. If pronounced, it may prevent the hand from being able to fully open. Heberdens Nodes Presentation and Anatomy Bony excresences that cause deformity at the DIP joints of the fingers. Occurs slowly over time and is associated with Osteoarthritis. May affect many joints or only a few, though not usually symmetric. Similar protrusions at the PIP joints are called Bouchards nodes. Trigger Finger Presentation and Anatomy Flexor tendons connect muscles proximal to the wrist to the fingers. When the muscles shorten, they pull on the tendons, causing the fingers to flex. Occasionally, nodules/irregularities develop along the tendons, which then interfere with their smooth movement thru pulleys on the palm. Patients note difficulty flexing and extending the affected finger and lack of smooth movement. This is associated with a sensation of sudden freeing of the tendon (triggering) when the irregularity slips through the pulley. Tenosynovitis of the Thumb (DeQuervains type) Presentation and Anatomy Repetitive abduction and adduction of the thumb can irritat