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Symptom sorter – hand and wrist pain

The GP overview

This may be the presenting problem but just as often it is a ‘while I’m here’ symptom. The differential diagnosis is quite wide but ‘arthritis’ is often uppermost in the patient’s mind. A brief history and focused examination should provide the correct diagnosis quite rapidly in most cases.

Differential diagnosis

Common

– Osteoarthritis (especially the carpometacarpal joint of the thumb and the distal interphalangeal joints of the fingers)

– Carpal tunnel syndrome

– Trauma (e.g. sprain, scaphoid fracture)

– Rheumatoid (or other inflammatory) arthritis

– Tenosynovitis

Occasional

– Ganglion

– Gout

– Raynaud’s disease or syndrome

– Infection (e.g. paronychia, pulp space)

– Work-related upper limb disorder (WRULD)

– Trigger thumb or finger

– Other nerve entrapment, e.g. ulnar nerve, cervical root pain

– Complex regional pain syndrome

Rare

– Infected eczema (common, but rarely presents with pain)

– Writer’s cramp

– Peripheral neuropathy

– Dupuytren’s contracture (usually painless)

– Diabetic arthropathy

– Osteomyelitis

– Kienböck’s disease (avascular necrosis of the lunate)

Ready reckoner

 OACarpal tunnelTraumaRATenosynovitis
Symmetrical joint swellingNoNoNoYesNo
Abrupt onsetPossibleNoYesNoPossible
ParaesthesiaeNoYesNoNoNo
Worse at nightNoPossibleNoPossibleNo
Tendon tenderNoNoPossibleNoYes

Possible investigations

– LIKELY: none.

– POSSIBLE: X-ray, FBC, ESR/CRP, rheumatoid factor, uric acid.

– SMALL PRINT: blood screen for underlying causes in peripheral neuropathy or Raynaud’s syndrome, if clinically indicated.

– X-ray: may show a fracture in trauma, joint erosions in RA, the typical features of OA, and sclerosis or collapse of the lunate in Kienböck’s disease.

– FBC: Hb may be reduced in inflammatory arthritis; WCC raised in infection.

– ESR/CRP: raised in infective and inflammatory conditions.

– Rheumatoid factor: may support a clinical diagnosis of RA.

– Uric acid: an elevated level (post episode) supports a diagnosis of gout.

Top tips

– OA of the fingers can be relatively abrupt in onset and inflammatory in appearance compared with OA at other sites.

– Explore the patient’s occupation – this will provide valuable information regarding the possible cause and effect of the problem.

– Simply asking the patient to point to the site of the pain can help distinguish two of the most commonly confused differentials: OA of the carpometacarpal joint of the thumb and de Quervain’s tenosynovitis. In the former the pain is relatively localised to the base of the thumb; in the latter the discomfort – and certainly the tenderness – is more diffuse.

– Pain from a ganglion can precede the appearance of the ganglion itself – or the ganglion may be fairly subtle, only appearing on wrist flexion.

– Remember that RA is a clinical diagnosis – don’t rely on blood tests. Early referral minimises the risk of long-term joint damage.

– If in doubt over tenderness in the anatomical snuff box after a fall on the outstretched hand, refer for A&E assessment – a missed scaphoid fracture can cause long-term problems.

– Do not underestimate pulp space infection – this can cause serious complications such as osteomyelitis or bacterial tenosynovitis. It may need IV antibiotics or incision and drainage.

– Thenar wasting suggests significant compression in carpal tunnel syndrome – refer.

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