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An aching wrist

Practical approach A patient has less control with her right hand, how can you help her?

Lisa, 51, lives locally and works as a childminder. She asks to speak to pharmacist Anna. Lisa explains that she has been experiencing problems with her right wrist. A few months ago she started minding twin boys, which meant she had to use a double pushchair. At the time, both her wrists started aching, which she put down to the weight of the boys and the pushchair. The left wrist seemed to calm down quickly; however, the right wrist still has not yet recovered.

Lisa experiences a dull aching in the hand that radiates into her forearm and sometimes even the upper arm. She has noticed that she has become increasingly clumsy with that hand, often failing to grip things and dropping them as a result. Currently she cannot use any of the pushchairs without considerable discomfort.

In the past two days, the right hand has been numb when she’s woken up. She has tried some paracetamol, but it hasn’t helped. Lisa’s only other medical condition is hypothyroidism, for which she takes levothyroxine 100mg daily.

What could be causing this discomfort?

Anna wonders if Lisa could be suffering from carpal tunnel syndrome (CTS). The carpal tunnel is an anatomical compartment of the hand. It is bounded on three sides by carpal bones, which form an arch, and on the palmar side by the transverse carpal ligament. The tunnel itself is a small gap through which the median nerve passes.

Any swelling of the tendons, ligaments or bones that surround the tunnel result in a narrowing of the gap and compression of the median nerve. This triggers symptoms in the area of the hand it covers, but also the arm and even the shoulder. Weakness and even muscle wasting may occur.

CTS is more common in women than men and often it is associated with use of heavy hand held objects. In Lisa’s case, it would appear the heavy pushchair, perhaps bumping along the road, is to blame. In addition, CTS is more common in those with diabetes and hypothyroidism. The condition can be diagnosed by a number of tests whereby movement or tapping can trigger symptoms.

What is the treatment of CTS?

Symptoms may resolve within six months, especially in younger people and those with unilateral symptoms. Many sufferers find wearing a wrist splint – which maintains the wrist at a neutral angle – helpful, especially at night when symptoms tend to be more painful. However, there is limited evidence of their efficacy. Advice should be to minimise activities that exacerbate symptoms.

There is no evidence to support the use of NSAIDs in CTS.But People do report a benefit from taking these drugs and, as long, as Lisa has no contraindications, a short trial is worth a try, although this is not supported by NICE Clinical Knowledge Summaries.

What’s next for Lisa?

Anna suggests that Lisa purchases a splint and tries some OTC ibuprofen. She advises not pushing the pushchairs until the symptoms resolve.

It is recommended that patients are referred for further investigation if symptoms do not resolve with simple measures in three months, or if symptoms are severe. The weakness in Lisa’s thumb is something to be monitored. If this persists, this may warrant earlier referral. More severe cases are often managed with local steroid injections. In very severe cases, surgery may be required.

References:

Bland JD. Carpal Tunnel Syndrome. (2007) BMJ. 18;335(7615):343-6.

NICE CKS. Carpal Tunnel Syndrome.

Page MJ, Massy-Westropp N, O'Connor D. and Pitt V. (2012) Splinting for Carpal Tunnel Syndrome (Cochrane Review).The Cochrane Library. Issue 7. John Wiley & Sons, Ltd.

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