Transcript: Diagnosing Wrist Pain for New Nurse Practitioners

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Liz Rohr:
Hey there, it's Liz Rohr from Real World NP, and you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients. So this week's video, I want to talk about wrist pain, the overarching general approach to diagnosing wrist pain so that you aren't missing anything. So I also made a video in doing an interview with a physical therapist last week, so definitely check that out if you haven't already. I've also made a video called Orthopedic Hacks. I will link to both of those down below. But it generally brings on a lot of pearls that we talked about both on the interview and in the orthopedic hacks video. But the first thing that I do when it comes to wrist pain and primary care, I'm not an orthopedic MP, I also want to give that disclaimer, I am in primary care and we see this a lot.

So this is my general approach. So the first thing you want to do is, number one, is this acute or is it chronic? So did it just happen or happen a couple of days ago, or has it been greater than three months? And of course there's room for the sub-acute people as well. That's about 14 days to 30 days-ish before it starts turning into a chronic injury. And the important thing there is that, actually, with a lot of acute injuries or acute pain, there are more potentially concerning red flag diagnoses associated with that. I'm not talking about that in this video, because for the most part, patients and primary care are coming with chronic risk pain. And so in those cases, just user resources and be very cautious for the wrist pain patients that are acute. The next question is, is this a traumatic injury or is it not traumatic?


Traumatic meaning that they have some sort of fall? So you might see in documentation something called foosh, F-O-O-S-H, a fall on outstretched hand. I'm doing it if you're watching on video. And that is really important to know the mechanism of injury. If they fell like that, if they were in a motor vehicle accident, that's really important information. Not only did they have an injury that started before the pain, but also what was the mechanism of injury, because that really helps inform what else is going on. For the most part, in primary care, I am seeing chronic non-traumatic injuries or non-traumatic wrist pain rather. The third thing is, do they have any systemic symptoms? Is there any risk for a rheumatologic condition or infectious process? You really want to think about that as your main third triage thing to think about when it comes to somebody with wrist pain in primary care.


So after you've triaged, the next part is the physical assessment. You want to think about the general approach to musculoskeletal exams, but also specific special tests. And actually before I jump into that, well actually maybe as part of that. So the first thing you want to do is look at the wrist. Even if you're not that comfortable with the various bones and ligaments and tendons and muscles and all of that stuff, you can still give safe care to a patient if you're following the general approach to care, which I'm going to talk about in a second. You want to start by looking at the wrist itself. So you're looking for any redness or signs of erythema. Again, considering that there are varying skin tones of patients and the underlying erythema may appear differently. Is there any swelling? Is there any pain on palpation and where is that?


Is it a more localized pain versus a diffuse pain? And a little pearl of practice there is that it's more likely to be a bony or ligamentous injury with a very point specific pain versus more diffuse pain tends to be a little bit more on the side of being a nerve related pain. So that's important. That ties back into triage. You're trying to get to the bottom of the general picture. Are we talking about a bony ligament, muscular injury? Are we talking about a nerve related injury or nerve related problem? Or are we thinking about more of a systemic related issue? And then from there, you want to assess strength. I always have, and I'm on video, but you holding your two fingers and then the patient grabbing and squeezing as hard as they can, so it doesn't hurt your hand when they do that.


And you're assessing that from a scale from one to five out of five for strength. You're also assessing range of motion the best you can. We are not physical therapists, likely if you're watching this, you're not an orthopedic NP. And so you might not necessarily be able to speak to the degrees of flexion or extension or et cetera, et cetera. And that's not typically our role in primary care anyway. But generally speaking, where's the range of motion? What is happening and where are patients getting limited? What is actually limiting them? Are they limited by pain? Are they not able to do their activities of daily life? What is contributing here? The next thing you want to think about is the special tests. There's a couple of different special tests. One is the Phalen's and Tinel's test. So Phalen's test is, and again, if you're watching the on video, holding your hands in hyperflexion, so that it's the dorsum of the hand to dorsum of the hand and you're holding it together for about 30 seconds, and seeing if there's any pain or numbness or tingling.


And that's assessing the carpal tunnel, for any carpal tunnel syndrome. And the sensitivity and specificity there is not a hundred percent, as with most tests, it's around 68 to 73% sensitivity and specificity. I should have written those down, but that's approximately where it is. The next one is the Tinel's test. And so again, if you're watching on video, you can see, but if you're listening, it's right at the base of the palm where the wrist meets the palm, and then palpating right over the carpal tunnel basically to elicit any sort of nerve pain or numbness or tingling as well. And similarly, sensitivity and specificity around the same, so not a hundred percent. The next one to consider, and that I recommend doing, is a test for De Quervain's tenosynovitis. So again, if you're watching, you can see this, but if you're listening, I'll describe it.


My thumb is going in the middle of my palm and I'm wrapping the rest of my fingers around, and then I'm pulling my hand down so that it's putting tension over the radial side of my arm. And so that pulling will elicit pain up into the forearm and almost all the way up to the elbow if that is a positive test for De Quervain's tenosynovitis. And I believe the sensitivity and specificity is around the same, but those are all repetitive motion type of overuse injuries for carpal tunnel as well as De Quervain's. Couple other things to add. The triage based approach will really help you in a lot of ways, especially if it's chronic and not traumatic. De Quervain's, carpal tunnel syndrome, there's arthritis, there's a couple of more rare zebra diagnoses. But one of the nice things about orthopedics, and maybe orthopedic people are going to hate me for saying this, but there's a general pathway, the orthopedic hacks video, I talk about this as well, but it's basically there's four main steps when it comes to orthopedic related things.


So if we've determined this as an orthopedic injury or overuse or problem versus a nerve problem versus a systemic problem, the main general steps are nonsteroidal anti-inflammatories medications, if that works for that patient's according to their comorbidities. The next one is physical therapy. The next step is injections, and the next step is surgery. That's typically the general broad categories of intervention that orthopedics will generally offer, orthopedic musculoskeletal injuries. And so, the nice thing is, even if you're not necessarily super familiar with the zebra diagnoses that can go with wrist pains, that are the chronic non-traumatic wrist pains, you can send them to physical therapy. And if you haven't watched the physical therapy interview that I did last week, again, please do so, but we touched on this a little bit, is that even though they have different diagnoses from a medical standpoint, the interventions might be similar.


So that's a little pearl of practice there. And I guess when it comes to the assessment, I didn't talk about imaging yet. So when there's acute injuries, especially when there's acute injuries, but if there's chronic pain that is related to a previous injury, you may want to consider doing plain radiography for those patients just to start, to see if there are any bony specific injuries. And so I can write in the description down below, but it's usually a PA, lateral and oblique view, I believe. But anyway, don't quote me on this video, I'll have it for real in the description down below this video. Usually I want to consider that kind of imaging. For chronic pain you don't necessarily need imaging, it's really dependent on the history and your assessment. So if it's really classically coming up as carpal tunnel, you don't necessarily need an x-ray for that.


You can do a clinical diagnosis using your assessment and then determine if they need bracing versus they need physical therapy assessment to help you clarify the diagnosis. And then one other pearl practice is that I always recommend, and generally speaking medicine recommends, if there is a joint problem we're looking at the joint below and the joint above. So you're looking at the finger joints as well as the elbow to see if there's any referred pain from either location.

So that is the quick overview of assessing wrist pain in primary care. Please let me know what questions you have. How about this video or future videos? If you haven't grabbed the ultimate resource guide for the new NP, head over to realworldnp.com/guide. You'll get these videos sent straight to your inbox every week with notes from me, patient stories and bonuses that I really just don't share anywhere else. Thank you so very much for watching. Hang in there and I'll see you soon.