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

	OA	Carpal tunnel	Trauma	RA	Tenosynovitis
Symmetrical joint swelling	No	No	No	Yes	No
Abrupt onset	Possible	No	Yes	No	Possible
Paraesthesiae	No	Yes	No	No	No
Worse at night	No	Possible	No	Possible	No
Tendon tender	No	No	Possible	No	Yes

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.