Pain Management

An intrathecal pain pump is a surgically implanted drug delivery system that sends pain medication directly to the spinal cord. This unique treatment option may be recommended to selected patients of chronic pain who have not experienced adequate pain relief from conservative approaches.

The intrathecal pain pump is a small battery-powered, programmable pump which is implanted under the subcutaneous tissue of the abdomen and connected to a small catheter to deliver small doses of medication directly to the spinal fluid. The pump needs to be refilled at a regular interval usually every 1 to 3 months.

The first clinical use of an implantable intrathecal drug delivery device was in 1981 in chronic pain of malignancy.

Though the efficacy of intrathecal pain pump has been repeatedly demonstrated, the adequate evidence is still missing and there is a lack of randomized studies.

There is also a concern of tolerance and drug addiction which is feared to occur with their use.

Therefore it cannot be used in all the patients of chronic pain. It is used in patients with advanced malignancies and selected patients with chronic non-malignant pain, especially where the oral opioids are required in larger doses which might risk the side-effects.

Prerequisites for use of intrathecal pain pump are

• Failure of conservative therapies
• Surgery is not considered or cannot be done
• No active or untreated addiction
• Medical contraindications like coagulopathies, infections
• Successful trial s been completed.

Trial of Intrathecal Pumps

No intrathecal device should be implanted without first performing a trial [The trial is of the drug and the route for confirming the efficacy and not the implant itself]

The trial involves the infusion of the drug through an indwelling intrathecal or epidural catheter.

The drugs used are hydromorphone of 0.3mg/d or morphine sulfate 0.2 mg/d and the trial is done for 2-3 days.

A successful trial means a 50% improvement in pain score and improvement in function.

Intrathecal Pain Pump Placement

Under proper anesthesia and surgical precautions, a small incision is made posterior midline,  approximately 2-3 inches from the skin to the supraspinous fascia at approximately L2-3 or 3-4. The catheter is inserted into the intrathecal space. Another incision is made in the abdomen to place the pump between the skin and muscle in the right or left lower quadrant of the abdomen at or about the umbilical level.

The positioning of the catheter is checked with fluoroscopy.

After the procedure, the pump is programmed to deliver the prescribed amount of medication.

The patient is monitored after the procedure and discharged with aftercare instructions. These involve, amongst other to avoid strenuous, physical activity for 6-8 to eight weeks.

Driving and housework are not to be done for two to four weeks.

Medications

Opioids are mainly used drugs in the pain pumps. Other drugs include local anesthetics, adrenergic agonists, and other agents

The first line of treatment includes morphine or hydromorphone.

Morphine [15 mg/d], Hydromophone [10 mg/d], Bupivacaine [2-30 mg/d], Clonidine [10-1000 mg/d] are the usual doses used.

Complications of Intrathecal Pain Pump

Bleeding

• Intra-operative bleeding
  • Ineffective local hemostasis
  • Overlooked ongoing anticoagulant therapy
  • spinal tumors which can be sources of bleeding during surgery.
• Epidural hematoma
  • Due to persistent bleeding
  • Rapidly increasing back pain
  • Progresses to neurological deficits
• Post-operative superficial bleeding
• Seroma or hematoma can appear at the pump site

Catheter Issues

• Kinking
• Breakage
• Leakage

Neurologic injury

• During catheter placement
• Inflammation of the catheter tip
• Risk increases in presence of canal stenosis, arachnoiditis, or other intraspinal abnormalities

Inflammatory mass

• Expanding sterile mass or granuloma at the tip of the catheter.
• Presents
  • as new or increasing pain that worsens despite escalating doses of intrathecal opioids
  • New neurologic symptoms arise.
• MRI confirms mass
• Possibly due to the use of high concentrations of opioid, morphine specifically
• If no neurologic deficits
  • Keep medication with preservative-free saline at a minimum pump rate
  • Serial MRIs to observe the regression
  • Restart a non-offending opioid when resolved
• If neurologic deficits are present
  • Spinal cord decompression, mass removal, and catheter removal

Other complications

• Infection
• CSF leaks
• Seroma formation around the pump pocket
• Endocrinal change
  • Hypogonadotropic Hypogonadism.
  • Central hypocortisolism.
  • Decreased libido

Perioperative pain relief or postoperative pain management or postoperative analgesia deals with the treatment of pain that occurs after the surgery.

Postoperative pain can be acute that occurs immediately after the surgery or chronic that occurs and continues over a period.

This article mainly concentrates on acute postoperative pain and the term postoperative pain here means acute postoperative pain.

Optimal management of acute postoperative pain requires planning, patient and staff education, and tailoring to the type of surgery and the needs of the individual patient.

Individuals differ in their requirement for analgesia, even after identical surgical procedures and the difference could be eightfold.

Untreated pain or undertreated pain not only gives immense discomfort to the patient but also causes secondary effects of pain like pain with tachycardia, hypertension, vasoconstriction and guarding which could lead to their own list of complications.

For example, uncontrolled tachycardia in an old person could lead to myocardial ischemia and subsequent effects.

Painful abdominal and thoracic wounds restrict inspiration, leading to tachypnea, small tidal volumes, and inhibition of the patient from effective coughing and mobilization. This predisposes to the chest infection, delayed mobilization, deep venous thrombosis etc.

But on the other side, the administration of analgesics beyond the tolerance of patient could increase the risks of side and if greatly in excess, severe central effects like depressed consciousness and respiration.

Opioids were once standard drugs for postoperative analgesia. But the availability of more drugs and increased used of blocks has reduced that reliance on opioids.

Today, postoperative pain relief is multimodal including local anesthetic blocks, spinal opioids, NSAIDs along with other drugs.

A well managed postoperative pain relieves suffering and helps to achieve early mobilization. This has a greater effect on patients’ well being and also reduces the length of hospital stay.

Mechanism of Perioperative pain

Pain results from inflammation caused by tissue trauma. The trauma is caused by surgical incision and dissection or direct nerve injury as in nerve transaction/compression.

The pain is mediated by

• The release of local inflammatory mediators results in
  • Augmented sensitivity to stimuli (hyperalgesia)
  • Misperception of pain to non-noxious stimuli (allodynia)
• Sensitization of the peripheral pain receptors (primary hyperalgesia)
• Increased excitability of central nervous system neurons (secondary hyperalgesia)

Different drugs attack the pain at different sites and thus the role of multimodal anesthesia.

Assessment & Evaluation

This includes preoperative patient evaluation and planning  and includes

• A directed pain history
• Physical examination
• Pain control plan

Quantification of the pain can be done by a pain scoring system like a 10-point pain assessment scale

When Should Analgesia Start?

The pain control drugs should be given before the painful stimulus occurs as it can  prevent or substantially reduce subsequent pain or analgesic requirements [though the unequivocal evidence has not been achieved yet.]

Different Analgesic Drugs Uses in Postoperative Pain Management

Opioids

The mainstay of postoperative pain therapy in many settings is still opioids. Opioids carry their effect by binding to receptors in the central nervous system and peripheral tissues. In the immediate postoperative period, they can be given by transdermal, parenteral, neuraxial, and rectal routes.

Morphine, hydromorphone, and fentanyl are most commonly used drugs.

Butorphanol has also been used with substantial success.

Morphine is the standard choice for because it has a rapid onset of action with peak effect occurring in 1 to 2 hours. Fentanyl and hydromorphone are synthetic derivatives of morphine and are more potent, have a shorter onset of action, and shorter half-lives compared with morphine.

The most important side effect is respiratory depression that could result in hypoxia and respiratory arrest. Hence, regular monitoring of respiration and oxygen saturation is essential in patients on opioids postoperatively.

In addition, nausea, vomiting, pruritus, and reduction in bowel motility leading to ileus and constipation are also common side effects of these medications.

Once the patient is able to tolerate oral intake, oral opioids can be initiated and continued.

Intravenous Patient-Controlled Analgesia {PCA}

This involves morphine, hydromorphone, and fentanyl being administered through the PCA pump. This method of analgesia requires special equipment, which allows the patient to administer the drug as per the requirement. It gives the patient better autonomy and control over the amount of medication used. However, both patients, as well as staff setting up the equipment, require training for proper use. It provides the patient a great satisfaction as the control is with the patient.

Epidural and Spinal Analgesia

Epidural and spinal analgesia act as neuraxial regional blocks and are used extensively in thoracic, abdominal, and pelvic surgery.

In epidural analgesia, a catheter is inserted into the epidural space in the thoracic or lumbar spine and continuous infusion of local anesthetic agent along with opioids results in postoperative analgesia.

A combination of local anesthetic and opioid can be administered via a patient-controlled epidural pump too. this would lower the dose requirements for each individual drug as well as the frequency of side effects.

Insertion of epidural catheters is a specialized procedure and failure of analgesia has been reported in 27-32% cases of lumbar and thoracic analgesia respectively.

Hypotension is quite a frequent problem, necessitating administration of additional IV fluids.

Intrathecal administration of opioid and local anesthetic (0.5% bupivacaine) at induction of anesthesia results in good postoperative analgesia for up to 24 hours. Administration of intrathecal analgesia takes the same time as epidural analgesia during the anesthetic process before surgery but does not need the skilled postoperative care required for the epidural.

NSAIDs

Nonsteroidal anti-inflammatory agents (NSAIDS) form mainstay of non-opioid analgesia.

They are useful in mild to moderate levels of pain. NSAIDs act by inhibiting the enzyme cyclooxygenase (COX) thereby blocking the production of prostaglandins resulting in an anti-inflammatory response.

Ketorolac is an injectable NSAID which reduces narcotic consumption by 25 to 45%.

Ibuprofen, Diclofenac, and paracetamol are other commonly used drugs.

Acetaminophen or paracetamol’s major advantages over NSAIDs are its lack of interference with platelet function and safe administration in patients with a history of peptic ulcers or asthma. Opioid-sparing effects have been associated with paracetamol administered intravenously.

Local Anesthetics

Peripheral Nerve Blocks

The peripheral nerve blocks are effective for postoperative pain control. A nerve block is especially very useful for extremities. The drugs used are local anesthetics and long-acting like bupivacaine can provide analgesia for as long as 12 hours effectively. Lignocaine is the shorter acting drug.

In most of the cases, the peripheral nerve block is given preoperatively and is effective enough for surgical anesthesia too and in the postop period, same takes care of the postoperative pain.

Local Infiltration

This means deep infiltration of the wound edges by a long-acting anesthetic agent like bupivacaine. It is very common in colon and rectal surgeries but now increasingly being used in extremities too.

It reduces the need for other drugs for analgesia for the time it acts. Lysosomal bupivacaine is a very long acting drug and is used in local infiltration particularly.

Drugs Reducing Secondary Hyperalgesia

Ketamine

Ketamine is mainly used as the anesthetic agent. Ketamine is a noncompetitive antagonist of the NMDA receptor when used in subanaesthetic doses. Use of perioperative IV infusions of low-dose ketamine [0.1 mg/kg/hour] with results in improved analgesia and is able to spare opioid, especially in patients after major surgeries that are suffering severe pain.

Pregabalin and gabapentin

These are the alpha-2-delta ligands which were developed for the treatment of neuropathic pain but are effective in postoperative periods in reducing opioid consumption. This beneficial effect can be achieved with a single preoperative dose. In addition, the anxiolytic effect of these drugs should be taken into consideration and might be an additional beneficial factor.

Clonidine and Dexmedetomidine

These are alpha-2 agonists. These, when used in perioperative period decrease pain intensity, opioid consumption, and nausea.

Hypotension and bradycardia are dose-dependent side effects.

References

• Brennan F, Carr D B, Cousins M. Pain management: a fundamental human right. Anesth Analg. 2007;105(1):205–221.
• Kehlet H, Jensen T S, Woolf C J. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367(9522):1618–1625. 5. Kalkman C J, Visser K, Moen J, Bonsel G J, Grobbee D E, Moons K G. Preoperative prediction of severe postoperative pain. Pain. 2003;105(3):415–423.
• Abrishami A, Chan J, Chung F, Wong J. Preoperative pain sensitivity and its correlation with postoperative pain and analgesic consumption: a qualitative systematic review. Anesthesiology. 2011;114(2):445–457.
• De Oliveira G S Jr, Agarwal D, Benzon H T. Perioperative single dose ketorolac to prevent postoperative pain: a meta-analysis of randomized trials. Anesth Analg. 2012;114(2):424–433
• Haas E, Onel E, Miller H, Ragupathi M, White P F. A double-blind, randomized, active-controlled study for post-hemorrhoidectomy pain management with liposome bupivacaine, a novel local analgesic formulation. Am Surg. 2012;78(5):574–581.
• Richebé P, Beaulieu P. Perioperative pain management in the patient treated with opioids: continuing professional development. Can J Anaesth. 2009;56(12):969–981.

Myalgia is a medical term for muscle pain. It is derived from the prefix my(o)-, meaning muscle, and the suffix –algia, which refers to pain or a painful condition.

Muscle aches can be caused by diseases and disorders. It is a common complaint among adults presenting for medical care.

Nearly everyone, at some point in time, will experience muscle soreness at some point in their life. Unusual exertion, trauma, and viral infections are among the most common causes.

It is important to differentiate myalgia from myopathy (muscle disease) and myositis (muscle inflammation) though both cause muscle pain as a symptom.

Causes of Myalgia

Injury/Overuse

The most common causes of muscle pain are overuse, injury or strain. The most common cause of is tension or stress that results from an injury or excessive use of the affected muscle [as in compulsive exercise]. It causes a localized myalgia involving single or multiple muscles.

Severe or strenuous pulling activity of the ligaments can also result in pain in the muscles.

Myalgia can also be caused by diseases, disorders, medications, or as a response to a vaccination.

Rhabdomyolysis

Rhabdomyolysis is a syndrome caused by injury to skeletal muscle and involves leakage of large quantities of potentially toxic intracellular contents into plasma. It could be caused by

• Viral myositis
• Compression injury
• Drug-related
  • Fibrates
  • Statins
  • ACE inhibitors
  • Cocaine
  • Retro-viral drugs
• Severe potassium deficiency

Fibromyalgia

It is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues

Ehlers-Danlos syndrome

A connective tissue disorder characterized include overly flexible joints, elastic and bruisable skin and disorders of blood vessels.

Auto-immune disorders

Autoimmune disorders can lead to myalgia. These include

• Mixed connective tissue disease
• Systemic lupus erythematosus
• Polymyalgia rheumatica
• Polymyositis
• Dermatomyositis
• Multiple Sclerosis

Infections

Many infections can cause muscle pain including –

• Flu
• Lyme disease
• Malaria
• Toxoplasmosis
• Dengue Fever
• Hemorrhagic fever
• Muscle abscess
• Polio
• Rocky Mountain spotted fever
• Trichinosis (roundworm)
• Ebola

Metabolic Disorders

• Carnitine palmitoyltransferase II deficiency
• Conn’s syndrome
• Adrenal insufficiency
• Hyperthyroidism
• Hypothyroidism
• Diabetes
• Hypogonadism
• postorgasmic illness syndrome

Miscellaneous

Many other diseases can cause muscular pain. To name some

• Chronic fatigue syndrome
• Stickler Syndrome
• Hypokalemia
• Hypotonia (Low Muscle Tone)
• Exercise intolerance
• Mastocytosis
• Peripheral neuropathy
• Delayed onset muscle soreness
• AIDS/ HIV
• Tumor-induced osteomalacia
• Hypovitaminosis D
• Infarction

Sudden Withdrawal of certain drugs

• High-dose corticosteroids
• Opioids
• Barbiturates
• Benzodiazepines
• Caffeine
• Alcohol

Presentation of Patient with Myalgia

Pain onset is usually sudden and lingers for a few days to several weeks depending on the intensity and the cause of the pain.  Stiffness and spasm may be present especially in chronic myalgia. The pain can affect almost any part of the body including the neck, hands, legs and the back.

Depending on the region affected, additional symptoms may be present

For example, myalgia affecting the cervical region also can have the heaviness of the head accompanied by an occipital headache.

Difficulty in breathing in and breathing out may also be experienced with chest involvement in myalgia.

Irregular heartbeat is also experienced when myalgia involves the heart and is also potential for cardiac arrest.

The affected area would be tender.

Systemic symptoms like fever, vomiting, and nausea or vertigo can occur.

Chronic cases may have associated anxiety and depression.

Diagnosis

Myalgia is a symptom and may be caused by some serious underlying disorder.

Therefore underlying cause should be looked for especially if the symptoms are severe and persistent.

The diagnosis is based on medical history, physical examination and lab testing as directed by clinical course.

Treatment of Myalgia

Treatment of myalgia is of two kinds.

One is symptomatic and supportive and other one aims at the underlying condition if present.

The aim is pain relief and providing comfort to the patient.

Symptomatic and supportive treatment

This consists of rest, NSAIDs, warm or cold application, gentle massage. It is especially applicable to overuse injury muscle pains.

The rest includes resting the area of the body where the pain is.

Pain reliever drugs like NSAIDs provide relief from muscle aches.

Applying ice or heat can both relieve the pain.

When acute soreness has gone, gentle muscle stretch and massage may provide relief.

Avoidance of activity that causes pain should be done.

For chronic muscle aches,  physical therapy is helpful to increase the flexibility in sore muscles and strengthen the surrounding tissue to support the area.

Some cases may respond to anti-seizure drugs, such as pregabalin and antidepressants.

Treatment of Underlying Condition

If there is a specific condition that is resulting in muscle aches, it should be addressed. The treatment of the condition would vary from one condition to other.

For myalgia induced by the drug, stopping the particular drug would result in relief from symptoms.

Meralgia paresthetica is an entrapment neuropathy of lateral femoral cutaneous nerve resulting in pain in the outer thigh.

Lateral femoral cutaneous nerve is a sensory nerve that supplies the lateral aspect of the thigh.

Meralgia paresthetica comes from the Greek words meros (thigh) and algos (pain).

The compression of the nerve commonly due to focal entrapment of this nerve as it passes through the inguinal ligament. Rarely. It can occur due to direct trauma, stretch injury, or ischemia.

The reported incidence of meralgia paresthetica is much higher in patients with diabetes mellitus than the normal population.

No gender predilection is seen.

It may occur at any age but middle-aged people are most commonly affected.

Pathophysiology of Meralgia Paresthetica

Lateral femoral cutaneous nerve originates directly from the lumbar plexus and is formed by nerve root innervation from L2-3. The nerve runs through the pelvis along the lateral border of the psoas muscle to the lateral part of the inguinal ligament.

It passes to the thigh through a tunnel formed by the lateral attachment of the inguinal ligament and the anterior superior iliac spine. The crossover into the thigh is the most common site of entrapment.

Clinical Presentation

The main complaint of the patient is painful paresthesias and numbness of the upper lateral thigh area are the presenting symptoms.

Most cases affected on one side only. The symptoms are bilateral in up to 20% of cases.

The symptoms are aggravated by walking or standing and are relieved by sitting.

On examination, there is numbness of anterolateral thigh either in all or in parts. Some patients are found to be hyperesthetic [increased sensation]. The symptoms may be reproduced by tapping over the upper and lateral aspects of the inguinal ligament.

Extension of thigh also reproduces the symptoms. or extending the thigh posteriorly, which stretches the nerve, may reproduce or worsen the paresthesias.

Pelvic Compression Test

This is done by deep palpation of the anterior superior iliac spine. Deep palpation of anterior superior iliac spine reproduces the symptoms.

This test is considered very sensitive [93%] and specific [95%].

Causes of Meralgia Paresthetica

Following increase the risk

• Tight clothing, belts, body armor
• Pregnancy
• Obesity
• Diabetes
• Malignancy
• Iliopsoas hemorrhage

Investigations

Nerve conduction and electrodiagnostic studies are not routinely done.

The studies are contemplated when there is no identifiable risk factor, a mass lesion in retroperitoneal space or if back pain is also present.

The studies help to rule out upper lumbar radiculopathy.

Treatment of Meralgia Paresthetica

The probable cause of the condition should be addressed.  The cause if could be removed is the best form of treatment.

Most of the patients have mild symptoms which could be treated by non-operative means.

Patients should be asked to wear loose clothing and advised to lose weight if obese.

Focal nerve block at the inguinal ligament with anesthetic agent and steroids relieve the symptoms temporarily for several days to weeks.

Carbamazepine or gabapentin may help in few patients but are often ineffective.

Surgical decompression is indicated in people who are not relieved by nerve blocks.

In spite of treatment, numbness may persist for some time.

Hand pain could be due to many causes many causes, including injury and disease. Fortunately, many of those causes can be treated and the symptoms eased.

Here are some of the most common conditions that cause hand pain. But first an overview of the anatomy of hand.

Anatomy of Hand

Each hand contains 27 distinct bones that give the hand a range and precision of motion. Most of the hand muscles originate from lateral and medial epicondyles of humerus, and forearm bones.

Distal surfaces of carpal bones, articulate with the metacarpal bones and held by the palmar carpometacarpal ligaments.

Metacarpals are five in number. Each metacarpal is numbered I to V with metacarpal I connecting to the bones of the thumb, II connecting to the index finger, III connecting to the ring finger, and so on.

The distal head of the metacarpals is rounded to form a condyloid (oval) joint with the phalanges of the fingers.

There are three phalanges in each digit except for the thumbs that contain only. Phalanges that articulate with the metacarpals at the base of the digits are known as the proximal phalanges.

Muscles in the forearms flex and extend the phalanges by pulling on long tendons that run through the wrist and hand.

Dorsally, on the distal ends, phalanges bear nails.

The hand has got two surfaces, palmar surface [side of the palm] and dorsal surface.

Causes of Hand Pain

Arthritis

All type of arthritides can affect hand as well. Arthritis leads to the destruction of cartilage leading to painful joints. Most common areas affected with arthritis are base of the thumb, interphalangeal joints. Different forms of arthritis affect different regions of the hand.

Osteoarthritis is the most common type of arthritis and often affects the base of the thumb and interphalangeal joints making the joints painful and swollen.

It becomes difficult to perform manual tasks such as writing, opening jars or turning keys.

[Read more about osteoarthritis]

Rheumatoid arthritis is an autoimmune disease which can affect wrist and joints of hand as well.

Psoriatic arthritis is another form of arthritis which is associated with the disease psoriasis.

Crystal deposition diseases like gout and pseudogout may also affect the hand and cause arthropathy.

De Quervain’s Tenosynovitis

De Quervain tenosynovitis is a tenosynovitis of the tendons within the first extensor compartment at the wrist resulting in pain during thumb motion.

De Quervain syndrome is thought to be a repetitive strain injury especially in repeated postures where the thumb is held in abduction and extension to be predisposing factors. Repeated pinching, grasping, pulling or pushing have been considered at increased risk. Intensive mouse/trackball use and typing have also been implicated. Bowling, golf and fly-fishing, piano-playing, and sewing and knitting have associated.

Extensor retinaculum, over the radial styloid, makes a tunnel through which tendons of abductor pollicis longus and extensor pollicis brevis pass. When tendons thicken from acute or repetitive injury, the gliding of tendons is restrained resulting in pain.

The sheath surrounding the tendon becomes swollen and thick, and moving your thumb will be very painful.

De Quervain’s tendinitis may develop gradually or suddenly. Movements like making a fist, grasping or holding objects or turning the wrist can be difficult.

The pain results from swelling of the wrist tendons at the base of the thumb, which is caused by irritation or inflammation. Repetitive activities and overuse are often responsible for the onset of de Quervain’s.

Carpal Tunnel Syndrome

Carpal tunnel syndrome is a condition that occurs because of compression of the median nerve in the wrist and results in pain, numbness and a tingling sensation in the hand and fingers. The median nerve passes through the carpal tunnel which is a narrow space where it can get compressed.

Injuries

Hand is terminal organ of upper limb and is prone to get injured to cuts, crushes, fractures, burns, and bites.

A fracture, or a break in a bone, can cause a great deal of hand pain.

Sprain is an injury to ligament is called a sprain.

Tenosynovitis 

Tenosynovitis is pain and inflammation of the sheath that surrounds a tendon. It’s a relatively rare cause of hand pain that can affect the wrist or the fingers.

The cause is not always known. It may be brought on by a series of small injuries to the tendon, a previous injury or strain, infection, or rheumatoid arthritis.

Ganglion

A ganglion is a fluid-filled swelling that develops near a joint or a tendon. It usually appears on the dorsal side of the wrist but can be seen in tendon sheaths of thumb or fingers as well.

Size of the ganglion varies, it is a smooth, soft lump under the skin that contains thick, jelly-like fluid, called synovial fluid and often communicates with the joint of the wrist.

Most of the ganglions are painless but they can often become painful.

Trigger Finger or Thumb

Trigger thumb or finger usually occurs after middle age but can be congenital also. Both are different entities.

In congenital trigger thumb, the child is brought during early months or years because the child does not extend the involved digit and keeps it flexed.

Adult trigger thumb or finger is a condition in which a finger catches or becomes locked when you try to straighten or bend it. Women get the condition more often than men do. And trigger finger is more common in adults between ages 40 and 60.

It develops gradually. When the person forces the motion on the finger, it snaps quickly. It is a form of a stenosing tenosynovitis which usually affects the thumb or ring finger, though it can affect any finger.

Dupuytren’s Contracture

Dupuytren’s contracture is a localized formation of scar tissue beneath the skin of the palm of the hand leading to flexion of digits. Usually, it is painless but pain may occur in some cases.

Peripheral Vascular Disease

Peripheral vascular disease refers to diseases of the arteries and veins located outside the heart and. There are many types of peripheral vascular diseases and could be a cause of hand pain.

Hand infections

Hand infections can vary from minor boil to osteomyelitis. Nail bed, pulp spaces and various compartment of hand can harbor the infection. Hand infections could be caused by bacteria, viruses, or fungi.

Thoracic Outlet Syndrome

Thoracic outlet syndrome is a condition where symptoms are produced from compression of nerves or blood vessels because these get compressed in the thoracic outlet. There is radiating pain that involves the hand as well.

Diagnosis of Hand Pain

 Most of the issue are minor and hardly require investigations and work up.

In other cases, lab investigations and imaging may be required.

Lab Studies

CBC, ESR, C-reactive protein are markers of inflammation and could also suggest the presence of infection when correlated clinically. RF, anti-CCP are done in cases of suspected rheumatoid arthritis cases.

Other special investigations as required can vary from case to case.

Imaging

 Xrays are basic imaging study and are very useful in showing bony changes such as in osteomyelitis, bone tumors, fractures and dislocations.

CT is able to show bony details in greater details. MRI is useful in soft tissue involvement and is able to show lesions where x-rays could be passed as normal.

 Treatment of Hand Pain

Treatment of hand pain depends on the cause. Minor injuries and minor pains a could be managed at home with rest, fomentation and over the counter pain drugs

Following are the treatment modalities which are used in hand pain treatment. Treatments are discussed in greater details in the in-depth articles for individual disorders.

• Rest to the hand and wrist
• Anti-inflammatory or analgesic painkillers
• Drugs specific to the ailment, like anti-gout drugs or disease-modifying anti rheumatoid drugs
• Wrist splints
• Steroid injection
• Physical therapy
• Surgery