Kokko Wrist 3/11/17. Updates in General Internal Medicine for Primary Care Wrist Pain

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1 Updates in General Internal Medicine for Primary Care 2017 Wrist Pain Kyle P. Kokko, MD, PhD Assistant Professor Hand, Wrist, and Microvascular Surgeon MUSC Department of Orthopaedics Disclosures I pulled all my pictures from Google searches I have no financial disclosures 1

2 Wrist Pain Very Common in all ages Causes Trauma Tendonitis Arthritis Cysts Common diagnosis Distal Radius Fractures Scaphoid Fractures Wrist Sprains de Quervain s tenosynovitis Basal joint arthritis Ganglion cysts Goals To help familiarize you with common causes of wrist pain To teach EASY physical exam maneuvers to help diagnose and treat common causes of wrist pain To teach EASY treatment modalities that you can do in your office To discuss when it s appropriate to treat in your office and when to refer to a hand surgeon 2

3 Trauma Any history of TRAUMA necessitates radiographs What to order? 3 VIEWS OF THE WRIST Common fractures include Distal radius fractures Scaphoid fractures Trauma What to do? IF a fracture is identified, refer to a hand surgeon IMMEDIATELY. Consider these referrals as URGENT, not emergent. These referrals should be seen within 5 days of diagnosis Place into a removable wrist splint 3

4 Common causes of wrist pain that you can treat in your office de Quervain s Tenosynovitis Basal Joint Arthritis Ganglion cysts de Quervain s Tenosynovitis Inflamed tendons within the 1 st dorsal compartment Pain with palpation of the tendons Pain elicited by Finkelstein s test Pain with resisted radial deviations 4

5 de Quervain s Tenosynovitis Pain +/- swelling Finkelstein s Test 5

6 Treatments you can provide in your office Goal Decrease inflammation within the 1 st dorsal compartment NSAIDs Splints + activity modifications Steroid injections Treatment 6

7 Wrist-based thumb spica splints Injections 7

8 What you need What you need 1 cc 1 cc mix 8

9 Injections CPT 20550, 0.75 RVUs Technique 9

10 Splint/cast + Injection Injection Splint x 3 weeks 23.5 hrs/day f/u 3 weeks for reevaluation Repeat once if necessary Better results if treated early!!! When is surgery recommended? Only after conservative measures have been exhausted What to tell your patients Outpatient surgery Takes about minutes DOES NOT require general anesthesia VERY reliable Can work on a computer the next day Can get back to ALL activities between 2-4 weeks 10

11 Surgery is performed through a cm incision Basal Joint Arthritis 11

12 Pain at the base of the thumb Pain opening jars and bottles 12

13 Turning car key or knitting Basal Joint Arthritis Most common arthritis of the wrist Most commonly degenerative Other causes Post-traumatic Inflammatory arthropathy More common in women 13

14 If tenderness to palpation? Radiographs: 3 views of the wrist Basal Joint Arthritis 14

15 Treatments you can provide in your office Goal Decrease pain and inflammation within the joint NSAIDs Splints + activity modifications Treatment 15

16 Splints When to refer to a hand surgeon? Only after conservative measures have been exhausted Give splints and NSAIDs an honest try for 2-3 months If symptoms are recalcitrant, refer to hand surgery for further evaluation in the form of injections or surgery. I don t recommend you giving injections for this unless some sort of image guided assistance is utilized (US or fluoroscopy) What to tell your patients: Injections MAY help. Surgery is VERY reliable. However, it requires a 3 month recovery that includes splints, therapy and strengthening 16

17 Ganglion Cysts Back of the wrist most common (70%) Ganglion Cysts Palm side of the wrist second most common (20%) 17

18 Ganglion cysts Pathology: Leakage of fluid out of the wrist joint or tendon sheath Most common hand mass Most often caused by trauma Typically painless Most often a cosmetic concern You don t need radiographs!!! Treatments you can provide in your office Goal decrease the size of the mass Recommend aspiration of DORSAL ganglion cysts. I DO NOT recommend aspiration of PALMAR cysts in your office. 18

19 What you need What you need 19

20 Aspiration with a needle and syringe CPT 20612, 0.70 RVUs I prefer popping the cyst with a 18 gauge needle and milking the fluid out through the needle or skin 20

21 When to refer to a hand surgeon? Palmar ganglion cysts or cysts in odd places about the hand or wrist Recurrence of previously aspirated ganglion cyst (50%) What to tell your patients: Surgery is reliable with about a 10% recurrence rate Outpatient surgery Takes about minutes DOES NOT require general anesthesia Can work on a computer the next day Can get back to ALL activities between 2-4 weeks Surgery 21

22 Acknowledgements Brad Keith, MD Kimberly Davis, MD Eric Angermeier, MD 22