THE CLINICAL SYNDROME

• Wrist arthritis is a common complaint that, if left untreated, can cause a significant amount of pain and suffering.

• The wrist joint is susceptible to developing arthritis as a result of a variety of conditions that share the ability to damage the joint cartilage.

• Arthritis is a degenerative joint disease.

• Patients who suffer from arthritis of the wrist typically complain of experiencing pain, swelling, and a decline in their wrist function.

• A decrease in grip strength is another finding that is common.

• Pain in the wrist joint is most often caused by osteoarthritis, which is the most common form of arthritis.

• Nevertheless, rheumatoid arthritis, posttraumatic arthritis, and psoriatic arthritis are also common causes of arthritic wrist pain.

• Because these types of arthritis affect not only the joint but also the tendons and other connective tissues that make up the functional unit, they can result in significant changes to the biomechanics of the wrist.

• These changes can have a significant impact on how the wrist functions.

SIGNS AND SYMPTOMS

• The majority of patients who visit their doctor complaining of wrist pain due to osteoarthritis or posttraumatic arthritis describe the pain as being localized around the wrist and the hand.

• The pain is made significantly worse by activity, whereas resting and applying heat offers some relief.

• The pain is consistent and has been described as an aching sensation; it may prevent one from sleeping.

• On physical examination, crepitus may be present in some patients, and some patients report that using the joint causes them to experience a grating or popping sensation.

• When rheumatoid arthritis is the underlying cause of pain and dysfunction, the metacarpophalangeal joints are frequently affected, leading to the characteristic deformity of the condition.

• Patients who suffer from arthritis of the wrist joint, in addition to experiencing pain, frequently experience a gradual reduction in functional ability.

• This is due to a decreasing wrist range of motion, which makes it difficult to perform simple everyday tasks such as using a computer keyboard, holding a coffee cup, turning a doorknob, or unscrewing a bottle cap.

TESTING

• Radiographs in their most basic form should be taken of every patient who comes in complaining of wrist pain.

• The clinical presentation of the patient may indicate the need for additional testing, which may include an evaluation of the erythrocyte sedimentation rate, a complete blood count, and testing for antinuclear antibodies.

• Imaging of the wrist using magnetic resonance and/or ultrasound is recommended if there is a suspicion of joint instability, as well as for the purpose of further characterizing the factors that contribute to pain and functional disability.

• In the event that an infection is suspected, a Gram stain and culture of the synovial fluid ought to be carried out as soon as possible, and subsequent treatment with the appropriate antibiotics ought to get underway.

DIFFERENTIAL DIAGNOSIS

• Pain in the wrist joint is most often caused by osteoarthritis, which is the most common form of arthritis.

• On the other hand, rheumatoid arthritis and posttraumatic arthritis are also frequent reasons for discomfort in the wrist.

• Arthritis-related wrist pain can also be caused by collagen vascular diseases, infections, villonodular synovitis, and Lyme disease, although these are much less common causes.

• Acute infectious arthritis is typically accompanied by significant systemic symptoms, such as fever and malaise; it should be easy to diagnose and can be treated with antibiotics.

• In most cases, collagen vascular diseases present themselves as polyarthropathy rather than as monarthropathy that is confined to the wrist joint.

• Nevertheless, the intraarticular injection technique that is described in this article is very effective at treating wrist pain that is caused by collagen vascular diseases.

TREATMENT

• The initial treatment for the pain and functional disability associated with osteoarthritis of the wrist consists of a combination of physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase-2 inhibitors.

• Both of these types of drugs are anti-inflammatory medications.

• The application of heat and cold to specific areas of the body may also be beneficial.

• It is possible that immobilizing the wrist in a neutral position using a splint will provide symptomatic relief and protect the joint from further trauma.

• Patients who do not respond to these treatment modalities may benefit from an intraarticular injection of a local anesthetic and steroid as the next logical step in the treatment process.

• In order to administer an intraarticular injection to the wrist, the patient must first be positioned in the supine position with the affected arm fully adducted at the patient's side, the elbow slightly flexed, and the palm of the hand supported by a towel that has been folded in half.

• A sterile syringe with a capacity of 5 milliliters is used to draw up a total of 1.5 milliliters of local anesthetic and 40 milligrams of methylprednisolone.

• Following the hygienic preparation of the skin that covers the dorsal joint, the location of the midcarpus proximal to the indentation of the capitate bone is determined.

• An indentation can be found just proximal to the capitate bone.

• This indentation makes it possible to easily access the wrist joint.

• A needle measuring one inch in length and twenty-five gauges in diameter is inserted in the middle of the midcarpal indentation by the clinician.

• This needle travels through the subcutaneous tissues, the joint capsule, and finally into the joint itself.

• In the event that bone is found, the needle is withdrawn into the subcutaneous tissues and then redirected higher up.

• After access has been gained to the joint space, the contents of the syringe are slowly and carefully injected.

• It ought to feel like there is very little resistance being injected.

• If there is resistance, the needle is most likely embedded in a ligament or tendon; in this case, you should move it slightly deeper into the joint space until you are able to continue the injection without encountering significant resistance.

• After the needle has been removed, a sterile pressure dressing and an ice pack are applied to the area that was just given the injection.

• Injections of platelet-rich plasma and/or stem cells have been proposed as a potential treatment for arthritis of the wrist, with the goals of reducing pain and improving functional ability.

COMPLICATIONS AND PITFALLS

• Because repetitive trauma can result in further damage to the joint, tendons, and connective tissues, it is especially important for patients suffering from inflammatory arthritis of the wrist to protect their joints.

• Joint protection is especially important for these patients.

• Infection is the most significant risk associated with intraarticular injections into the wrist joint; however, if proper aseptic procedure is followed, the risk of infection should be extremely low.

• If careful attention is paid to the anatomy that is clinically relevant, the injection technique can be performed without risk; however, the ulnar nerve is particularly vulnerable to damage at the wrist.

• After receiving an intraarticular injection into the wrist joint, approximately one quarter of patients experience a temporary increase in the level of pain they are experiencing.

• Patients should be made aware of the possibility that this will occur.