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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.

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