What are the initial steps to manage hand and wrist pain and numbness?

Initial Management of Hand and Wrist Pain with Numbness

Begin with plain radiographs (posteroanterior, lateral, and oblique views) as your first imaging study, which can establish specific diagnoses in many cases and guide all subsequent management decisions. 1

Clinical Evaluation Framework

History Taking - Key Elements

• Duration and onset pattern: Spontaneous onset or vague/distant trauma history suggests carpal bone nonunion or avascular necrosis 2
• Numbness distribution:
  • Thumb, index, middle finger, and radial half of ring finger indicates median nerve involvement (carpal tunnel syndrome) 3, 4
  • Little finger and ulnar aspect of ring finger suggests ulnar nerve compression 3
  • Radial distribution points to radial nerve pathology 5
• Aggravating activities: Repetitive wrist extension (cycling, karate, baseball catching) increases risk of ulnar neuropathy 6
• Risk factors: Diabetes, smoking, alcohol consumption, rheumatoid arthritis, and hypothyroidism predispose to nerve entrapment 3

Physical Examination - Specific Maneuvers

• For carpal tunnel syndrome: Perform Tinel's sign (percussion over median nerve) and Phalen's test (wrist hyperflexion reproducing symptoms) 7, 3
• For De Quervain tenosynovitis: Finkelstein test with negative grind test confirms diagnosis 6
• Palpation: Localize tenderness to specific anatomic structures to narrow differential 2, 8
• Sensory testing: Document specific areas of decreased sensation corresponding to nerve distributions 3

Imaging Algorithm

Step 1: Initial Radiography (Always First)

Standard three-view radiographs (posteroanterior, lateral, oblique) are the only appropriate initial imaging study and can identify:

• Fractures (including scaphoid fractures, though conventional radiography misses up to 30%) 6
• Arthritis patterns 1
• Alignment abnormalities including ulnar variance 1
• Soft tissue mineralization and erosions 1
• Bony abnormalities causing nerve compression 5

Step 2: Advanced Imaging Based on Clinical Suspicion

If radiographs are normal or nonspecific and symptoms persist:

• For suspected carpal tunnel syndrome: Either ultrasound or MRI without IV contrast are equivalent appropriate options 1

  • Ultrasound measures median nerve cross-sectional area (increased area is diagnostic) 5
  • Ultrasound advantages: Dynamic examination capability, contralateral comparison 1

• For suspected tendon pathology (tenosynovitis, tendinopathy, tendon tears): Either ultrasound or MRI without IV contrast are equivalent appropriate options 1

  • MRI can diagnose tendinopathy, tendon tears, intersection syndrome, stenosing tenosynovitis 1, 9
  • Ultrasound is particularly useful for superficial structures and allows dynamic assessment 1

• For nonspecific chronic pain with normal radiographs: MRI without IV contrast is usually appropriate as it depicts abnormalities of bones, bone marrow, cartilage, ligaments, TFCC, synovium, tendons, and neurovascular structures 5

Conservative Management Approach

Non-Pharmacological (First-Line for All Patients)

• Ergonomic modifications: Proper workstation setup, activity pacing, use of assistive devices 9
• Splinting/orthoses: Particularly effective for carpal tunnel syndrome and thumb base involvement; advocate long-term use when beneficial 9, 3
• Exercise program: Range of motion and strengthening exercises provide symptomatic relief and functional improvement 9

Pharmacological Management

• Topical NSAIDs: First-line pharmacological treatment due to superior safety profile 9
• Oral NSAIDs (if topical insufficient): Ibuprofen 400 mg every 4-6 hours as needed (maximum 3200 mg/day), use lowest effective dose for shortest duration 10
  • Critical safety warning: Increased cardiovascular thrombotic risk (heart attack, stroke), increased GI bleeding/ulceration risk, avoid in pregnancy after 20 weeks 10
• Corticosteroid injection: For carpal tunnel syndrome when conservative measures fail 3

Common Pitfalls to Avoid

• Do not skip initial radiographs: Even when carpal tunnel syndrome seems obvious clinically, radiographs may reveal underlying arthritis or structural abnormalities affecting management 1
• Do not order MRI or CT as first imaging: No literature supports advanced imaging before plain radiographs 1
• Scaphoid fracture trap: If clinical suspicion is high despite negative initial radiographs, obtain specialized views (posteroanterior in ulnar deviation, pronated oblique) or repeat radiography in 10-14 days 6
• Bilateral symptoms: Suggest systemic etiology (diabetes, hypothyroidism, rheumatoid arthritis) rather than isolated nerve entrapment 3

When to Refer

• Neurology referral: Progressive weakness, suspected focal dystonia, or motor neuron disease signs 7
• Hand surgery referral: Severe structural abnormalities, failed conservative management after 6-8 weeks, or confirmed scaphoid fracture 7
• Rheumatology referral: Suspected inflammatory arthritis (multiple joint involvement, morning stiffness >30 minutes, elevated inflammatory markers) 7