A 68-Year-Old Man with Chronic Wrist Pain

Abstract

Pain of the hand and wrist secondary to osteoarthritis is a common condition encountered by the pain physician. It is a non-inflammatory process which results in the destruction of cartilage of the affected joint, eventually resulting in mechanical pain and reduced strength and range of motion. Due to the progressive nature of the disease process, where early stages may be asymptomatic or tolerable, the prevalence is difficult to determine. A systematic review of 4000 radiographs found a prevalence of 5% (Watson and Ballet, J Hand Surg 9A:358–365, 1984), and a randomized cross-sectional national prevalence survey found a lifetime prevalence of 3.58% in employed individuals (Dillon et al., Am J Ind Med 42(4):318–327, 2002). The etiology of osteoarthritis of the wrist can be categorized as either traumatic, where injury to the ligaments or bones of the wrist result in altered joint loading and kinematics leading to joint degradation, or idiopathic, such as from carpal avascular necrosis (Kienbock’s disease) or congenital abnormalities of the wrist. The first approach to the diagnosis of wrist arthritis is the patient history paying special attention to hand dominance, occupational risk factors, functional requirements, and the progression of pain and any limitations in range of motion. This is then followed by a physical exam pinpointing the pain-generating joints. Radiographic imaging is essential in detecting the location and pattern of degenerative changes and therefore guiding management. Management begins with conservative measures such as immobilization with splints, the use of oral analgesics, and then progresses to more invasive interventions such as intra-articular local anesthetic/steroid injections with the goal of relieving pain and improving function. However, these techniques may only be temporary as the disease process advances requiring definitive surgical interventions, which are selected based upon the joints involved, the age of the patient, and functional requirements.