Hand and arm pain: A pictorial guide to injections

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Applied Evidence

Hand and arm pain: A pictorial guide to injections

J Fam Pract. 2017 August;66(8):492-502

Gregory R. Waryasz, MD

Todd Borenstein, MD

Robert Tambone, MS

Joseph A. Gil, MD

Manuel DaSilva, MD

This article, with illustrative figures, will help you get to the cause of your patient’s pain and guide your administration of corticosteroid injections.

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PRACTICE RECOMMENDATIONS

› Diagnose common upper extremity conditions based on anatomic relationships. B

› Refer patients who do not respond to splinting, corticosteroid injections, or other conservative therapies to a surgeon for evaluation. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

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Primary care physicians are frequently the first to evaluate hand, wrist, and forearm pain in patients, making knowledge of the symptoms, causes, and treatment of common diagnoses in the upper extremities imperative. Primary symptoms usually include pain and/or swelling. While most tendon disorders originating in the hand and wrist are idiopathic in nature, some patients occasionally report having recently performed unusual manual activity or having experienced trauma to the area days or weeks prior. A significant portion of patients are injured as a result of chronic repetitive activities at work.¹

Most diagnoses can be made by pairing your knowledge of hand and forearm anatomy with an understanding of which tender points are indicative of which common conditions. (Care, of course, must be taken to ensure that there is no underlying infection.) Common conditions can often be treated nonsurgically with conservative treatments such as physical therapy, bracing/splinting, nonsteroidal anti-inflammatory drugs (NSAIDs), and injections of corticosteroids (eg, betamethasone, hydrocortisone, methylprednisolone, and triamcinolone) (TABLE 1^2-4) with or without the use of ultrasound. The benefits of corticosteroid injections for these conditions are well studied and documented in the literature, although physicians should always warn patients of the possible adverse effects prior to injection^3,5 (TABLE 2⁴).

To help you refine your skills, we review some of the more common hand and forearm conditions you are likely to encounter in the office and provide photos that reveal underlying anatomy so that you can administer injections without, in many cases, the need for ultrasound.

Trigger finger/thumb: New pathophysiologic findings?

Trigger finger most commonly occurs in the dominant hand. It is also more common in women, patients in their 50s, and in individuals with diabetes.⁶Trigger finger/thumb is caused by inflammation and constriction of the flexor tendon sheath, which carries the flexor tendons through the palm and into the fingers and thumb. This, in turn, causes irritation of the tendons, sometimes via the formation of tendinous nodules, which may impinge upon the sheath’s “pulley system.”

When the “pulley” is compromised. The retinacular sheath is composed of 5 annular ligaments, or pulleys, that hold the tendons of the fingers close to the bone and allow the fingers to flex properly. The A1 pulley, at the level of the metacarpal head, is the first part of the sheath and is subject to the highest force; high forces may subsequently lead to the finger becoming locked in a flexed, or trigger, position.⁶ Patients may experience pain in the distal palm at the level of the A1 pulley and clicking of the finger.⁶

Additionally . . . recent studies show discrete histologic changes in trigger finger tendons, similar to findings with Achilles tendinosis and tendinopathy.⁷ In trigger finger tendons, collagen type 1A1 and 3A1, aggrecan, and biglycan are up-regulated, while metalloproteinase inhibitor 3 (TIMP-3) and matrix metallopeptidase³ (MMP-3) are down-regulated, a situation also described in Achilles tendinosis.⁷This similarity in conditions provides new insight into the pathophysiology of the condition and may help provide future treatments.

Making the Dx: Look for swelling, check for carpal tunnel

During the examination, first look at both hands for swelling, arthropathy, or injury, and note the presence of any joint contractures. Next, examine all of the digits in flexion and extension while noting which ones are triggering, as the problem can occur in multiple digits on one hand. Then palpate the palms over the patient’s metacarpal heads, feeling for tender nodules.

Most diagnoses can be made by pairing your knowledge of hand and forearm anatomy with an understanding of which tender points are indicative of which common conditions.

Finally, examine the patient for carpal tunnel syndrome (CTS). A positive Tinel’s sign (shooting pain into the hand when the median nerve in the wrist is percussed), a positive Phalen maneuver (numbness or pain, usually within one minute of full wrist flexion), or thenar muscle wasting are highly indicative of CTS (compression of the median nerve at the transverse carpal ligament in the carpal tunnel). It is important to check for CTS when examining a patient for trigger finger because the 2 conditions frequently co-occur.⁶ (For more on CTS, see here.)