Hand Pain

Question 1

Differential diagnoses of Hand/ Arm Pain

Answer 1

1. Hand pain - Rheumatoid Arthtritis

Probability diagnosis
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

Serious disorders not to be missed  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)

Pitfalls (often missed) 
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

Masquerades checklist
Depression
Diabetes
Spinal dysfunction

Is the patient trying to tell me something?
Highly likely, especially with the so-called RSI syndromes.

Question 2

Hand and Arm Pain - Key History

Answer 2

Key history

Include an analysis of the pain and a history 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 3

Hand and Arm Pain - Key PE

Answer 3

Key examination

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 4

Hand and Arm Pain - Key Investigation

Answer 4

Key investigations
•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 5

Hand and Arm Pain - Diagnostic tips

Answer 5

Diagnostic tips

The working rule for arm pain causing sleep disturbance:

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

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