Cookie policy notice

By continuing to use this site you agree to our cookies policy below:
Since 26 May 2011, the law now states that cookies on websites can ony be used with your specific consent. Cookies allow us to ensure that you enjoy the best browsing experience.

This site is intended for health professionals only

At the heart of general practice since 1960

Symptom sorter - hand and wrist pain

GPs Dr Keith Hopcroft and Dr Vincent Forte discuss a symptom often overlooked by patients

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.

Rate this article  (4.13 average user rating)

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Readers' comments (5)

Have your say