Arm and hand pain (excluding fractures)

Question 1

Writer’s cramp

Question 2

Probability diagnosis

Answer 2

Dysfunction of the cervical spine (lower)

Disorders of the shoulder

Medial or lateral epicondylitis

Overuse tendonopathy of the wrist

Carpal tunnel syndrome

Osteoarthritis of the thumb and DIP joints

Question 3

Serious disorders not to be missed

Answer 3

Cardiovascular:

• angina (referred)
• myocardial infarction
• axillary vein thrombosis
• arm claudication (left arm)

Infection:

• septic arthritis (shoulder/elbow)
• osteomyelitis
• infections of tendon sheath and fascial spaces of hand
• sporotrichosis (‘gardener’s arm’)

Neoplasia/cancer:

• Pancoast tumour
• bone tumours (rare)

Question 4

Pitfalls (often missed)

Answer 4

Entrapment neuropathies (e.g. median nerve, ulnar nerve)

Pulled elbow (children)

Foreign body (e.g. elbow)

Rarities:

• polymyalgia rheumatica (for arm pain)
• complex regional pain syndrome I
• thoracic outlet syndrome
• erythromelalgia
• Kienböck disorder

Question 5

Masquerades checklist

Answer 5

Depression

Diabetes

Spinal dysfunction

Question 6

Is the patient trying to tell me something?

Answer 6

Highly likely, especially with the so-called RSI syndromes.

Question 7

Key history

Answer 7

Analysis of the pain

Hx of trauma, particularly unaccustomed activity.

In children ask about pulling the child up by the arms or a fall on an outstretched arm.

Ask for relationship of pain to any sleep disturbance.

Question 8

Key examination

Answer 8

Inspect the arm as a whole with both arms free of clothing and compare both sides.

It may be necessary to examine a variety of joints including the cervical spine, shoulder, elbow, wrist and various joints of the hand.

Question 9

Key investigations

Answer 9

FBE

ESR/CRP

Consider;

• ECG nerve conduction studies
• plain X-ray according to rule ‘if in doubt,
• X-ray and compare both sides’,
• ultrasound for soft tissue injuries (e.g. tendonopathy)

Question 10

Diagnostic tips

Answer 10

The working rule for arm pain causing sleep disturbance:

• thoracic outlet: pt cannot fall asleep
• carpal tunnel syndrome: wake in middle of night then settles
• cervical spondylosis: wakes pt with pain that persists.

Always keep regional pain syndrome in mind for persistent burning pain in hand following injury, trivial or severe.