Tuesday 12 December 2017

Dear Dr Nina: I'm worried my wrist pain will lead to crippling arthritis

Wrist pain
Wrist pain

Nina Byrnes

Our resident GP, Dr Nina Byrnes answered readers' heath queries.

Q: Two years ago I fell forward on my wrist while on holidays in Spain and injured my wrist - resulting in a lot of swelling. When I returned home a few months later I went to my GP and had an x-ray, but it didn't show anything. I was then referred to a physio who gave me exercises and after about six sessions there was still no reduction in pain. I also had an MRI which came back clear. The pain went away for a while, but it's back now. I am worried that this will get worse as I get older - as my mother is crippled with arthritis in her hands. What would you advise? I am hesitant to keep paying for physio if it doesn't work?

A: The wrist is a complex structure containing many bones tendons and ligaments. The carpal tunnel is a tube like structure located on the palm side of the wrist. Nerves and tendons pass through this onto the hand.

Injury to any part of the wrist or its structures can lead to wrist pain. Trauma is one of the most common causes of wrist pain. Falling onto an outstretched wrist most commonly leads to a fracture of the radius - which is one of the long bones of the lower arm. If the wrist flexes out, a Colle's fracture usually results - whereas it's a Smith's fracture when the wrist flexes in.

The scaphoid bone in the wrist may also be fractured. Fractures of the scaphoid don't always show themselves straight away and later x-rays or scans may be required to pick this up. Pain on pressure over the base of the thumb may suggest a scaphoid injury. If this fracture is suspected a plaster may be placed and follow up x-rays may be arranged. The blood supply to the scaphoid bone may be interrupted in missed fractures leading to a later injury called Avascular necrosis. This causes bony destruction which may result in chronic pain. Doctors will usually err on the side of caution in treating suspected scaphoid injury.

An MRI is appropriate for pain that isn't settling and it is good news that yours was clear. Pain that persists despite normal scans and physiotherapy is most likely due to chronic inflammation or repetitive strain.

Carpal tunnel syndrome commonly causes pain radiating from the palm of the hand to the middle three fingers. The pain may be described as tingling or burning. Ganglions are harmless fluid filled cysts that most commonly appear over the base of the wrist. They can cause pain if they become large or press on other structures of the wrist.

It's most likely that the pain you are experiencing is due to a chronic injury to the cartilage or chronic tendinitis. An acute injury that doesn't settle may lead to this. Repetitive use of the wrist or over-stretching of the ligament hinders healing leading to a vicious cycle of inflammation and pain. De Quervain's tenosynovitis is a chronic tendon strain that causes pain at the base of the thumb. Pain is typically worse when turning the wrist, grabbing things or making a fist. If pain is reproduced by bending your thumb across your hand, flexing the fingers over it and flexing the wrist towards your little finger (Finkelsteins test) then this is the likely cause. Scar tissue from a previous injury may be a cause.

Physiotherapy or wrist strapping and splints can help in some cases of wrist pain. If this hasn't helped an injection of the wrist joint with steroids may reduce inflammation and help improve symptoms. This needs to be done by someone trained in these procedures and you may need a specialist referral. Surgery is a last resort, but may be required in resistant cases. Osteoarthritis may set in joints that have an old injury but this tends to come on later in life and in those with a family history of the condition.It sounds like you have exhausted conservative measures of treatment and that more specialised procedures and treatment may be required.

Q: Milk and cheese tend to make my toddler quite nasally. Does this mean she could be lactose intolerant?

A. Milk is a very healthy food and it helps build bone strength, so knowing for certain whether your child has a true allergy or not is very important. It has been suggested that milk allergy is over diagnosed by parents and under diagnosed by doctors and this is probably true. The reason may lie in the fact that the symptoms of milk allergy can vary greatly from quite mild to severe or life threatening.

Symptoms of cow’s milk allergy vary greatly. They include obvious allergic symptoms such as itching, a rash, hives, tingling of the lips or mouth, runny nose, watering eyes, wheezing or shortness of breath. More subtle symptoms include irritability, abdominal pain and cramping, vomiting, loose stool, which may contain blood or food refusal. In severe allergy there may be a risk of anaphylaxis.

Cow’s milk allergy should not be confused with lactose intolerance. This is not an allergic reaction to milk. Those with lactose intolerance are missing the enzyme lactose — which normally acts in the gut to break down lactose the sugar found in milk. Lactose intolerance may cause symptoms such as abdominal pain, bloating, nausea, gas and diarrhoea but it is not an allergy and is not life threatening. Lactose intolerance can be diagnosed via a stool sample of breath test.

There is no evidence that lactose intolerance causes sinus problems.

If you feel there is a close link between dairy intake and your toddler’s nasal problems it may be worth eliminating cow’s milk for a period of eight weeks. If symptoms resolve then there may be a link. It is important to stress that calcium is an essential part of a healthy diet and so other sources will have to be found.

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