Diagnosis of Hand conditions

Hand conditions Diagnosis: Book Excerpts

• Differential Diagnosis - Hand and Foot Rashes
• Differential Diagnosis - Wrist & Hand Pain/Swelling
• Differential Diagnosis - Hand & Foot Rashes
• Approach to the Diagnosis - EXTREMITY, HAND, AND FOOT DEFORMITIES
• Approach to the Diagnosis - HAND AND FINGER PAIN
• Differential Overview - Wrist/Hand Pain
• Approach to the Diagnosis - EXTREMITY, HAND, AND FOOT DEFORMITIES
• Approach to the Diagnosis - HAND AND FINGER PAIN

Diagnostic Tests for Hand conditions: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Hand conditions.

Hand and Foot Rashes: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Dyshidrotic eczema (pompholyx)
  –Very common idiopathic skin disease
  –Affects one or both hands and/or feet in the thenar eminence, palms and/or soles, and sides of fingers and toes
  –Causes itching, scaling, and erythema, and minute vesicles and painful fissures
  –Usually chronic and intermittent, and often exquisitely pruritic

• Irritant or allergic hand eczema
  –Very common
  –Difficult to distinguish from dyshidrosis because both are vesicular and very itchy
  –Flares occur during work/hobbies, with improvement on vacation when away from the irritant or allergen
• Tinea manus (hand) and tinea pedis (foot)
  –Presents as itchy, diffuse, light scale, and/or maceration; prominent on palmar, plantar (moccasin distribution), and interdigital surfaces
  –Erythema is rarely present
  –Often “two hands and one foot” or “two feet and one hand” are affected
• Scabies
  –Presents as short (a few millimeters), linear burrows and vesicles on the hands and feet (web spaces), belt region, and/or intertriginous spaces
  –Intensely pruritic, especially at night
  –Often many members of the household unit affected
  –Definitive diagnosis made by visualizing the scabies mite in a skin scraping

• Psoriasis
  –Often affects the hands and/or feet
  –Well-demarcated, erythematous plaques
  with adherent scale, or can present as a focal or diffuse pustular eruption
  –Look for associated nail dystrophy or other skin involvement

• Pityriasis rubra pilaris
  –Well-demarcated bright salmon or red plaques on the palms or soles

• Keratoderma
  –Focal or diffuse thickening of the skin of the palms or soles

Workup and Diagnosis

• History and physical examination
  –Note chronic exposure to chemicals or potential irritants at work or in hobbies
  –Any family history of psoriasis or allergy/atopy
  –Look closely for the presence of small, clear “water blisters” under the skin that may indicate pompholyx
  –Examine nails for evidence of coexisting onychomycosis (very common in cases of tinea pedis and manus, and a nidus for frequent reinfection), “oil spots,” or nail pitting (may suggest psoriasis)
  –Examine joints for arthritis (psoriasis/Reiter's), eyes (Reiter's), and genitalia (psoriasis/Reiter's)

• KOH preparation from scale scraped from the palms, soles, or between the toes to determine presence of branching hyphae of tinea or scabies mites
• Culture any intact pustules
• Consider performing a patch test to rule out allergic contact dermatitis
• A punch biopsy may be helpful to distinguish psoriasis or PRP from the other common eczematous diseases of the hands and feet
• Fungal culture of nail clipping if onycholysis (nail thickening) present
• Dermatology referral is often indicated in resistant cases

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Wrist & Hand Pain/Swelling: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Carpal tunnel syndrome
  –Most common cause of significant wrist discomfort and morbidity
  –Associated with repetitive use activities (e.g., typing)
  –Pain and numbness symptoms result from entrapment of the median nerve under the transverse ligament
• Overuse injury
• Osteoarthritis
• Tenosynovitis (DeQuervain's) of the radial wrist
  –Results from inflammation of the tendon sheaths of the extensor pollicis brevis and abductor pollis longus
  • Ganglion cysts
    –Common growths of tendons and ligaments in the wrist area occurring on both the dorsal and ventral surface
    –They are compressible, round, often tender, and mobile
  • Trauma
    –The most common mechanism of injury is a fall on the outstretched hand
    –The most commonly fractured carpal bone is the scaphoid
    –Other mechanisms include direct blows, crush injuries, fall on an angulated wrist, and severe twisting motions
  • Fibromyalgia
  • Compartment syndrome
  • Chest or shoulder masses, resulting in compression of lymphatic or venous systems
  • Venous thrombosis of the subclavian or distal veins
  • Flaccid paralysis following a CVA
  • Angioedema secondary to hymenoptera sting
  • Rheumatologic disease
  • Peripheral neuropathy
  • Insect or animal bite/sting
  • Infection (e.g., staphylococcus aureus, streptococci)

  Workup and Diagnosis

  • History and physical examination of the hand, wrist, elbow, and shoulder
    –Tinel's sign is positive if pain is elicited by tapping the anterior wrist
    –Phalen's sign is positive if wrist flexion for >30 seconds elicits pain or numbness
  • Lab investigation is usually unnecessary, but may include rheumatoid factor, ANA, ESR, CBC, uric acid, TSH, β-hCG (pregnancy test)
• Standard X-rays include PA, lateral, and oblique views
• EMG and nerve conduction studies are indicated if carpal tunnel syndrome or other neuropathy is suspected
• Arthrocentesis with crystal analysis may be indicated if warmth and redness are noted in the wrist and MCP joints
• Bone scan may be necessary to evaluate for avascular necrosis, occult fracture, or bone infection
• Rarely, CT or MRI is indicated
• Shoulder/chest CT may be indicated to evaluate for masses resulting in nerve entrapment or vascular compromise

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Hand & Foot Rashes: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Infectious

• Enterovirus infection (hand-foot-and-mouth disease, Coxsakie virus, other nonpolio enteroviruses)
• Kawasaki disease (one of the five criteria)
• Scabies
• Tinea
• Candidal skin infection
• Ricketsial rash: Rocky Mountain spotted fever (RMSF), murine typhus
• Mononucleosis (EBV)
• Measles: Atypical forms start on hands/feet
• Scarlet fever, post-streptococcal infection desquamation rash
• Infectious endocarditis: Janeway lesions, Osler nodules
• Spirochete infection: Secondary syphilis, Lyme disease (acrodermatitis chronica atrophicans)
• Congenital toxoplasmosis
• Rat-bite fever (Streptobacillus moniliformis, Spirillum minus)
  Immune-mediated
  • Urticaria: Hands and feet involved in 85% of the cases
  • Juvenile rheumatoid arthritis
  • Systemic lupus erythematosus
  • Raynaud phenomenon (acrocyanosis)
  • Acute graft-vs-host disease
    Skin disorders
  • Atopic dermatitis (infantile)
  • Dyshydrotic eczema, pompholyx
  • Chronic allergic contact dermatitis
  • Psoriasis
  • Lichen simplex
  • Papillon-Lefèvre syndrome
  • Olmsted syndrome
  • Acrodermatitis enteropathica (zinc deficiency) can be presenting sign of cystic fibrosis
  • Toxic shock syndrome: Desquamation during the recovery phase; major criteria for staphyloccocal TSS
  • Drugs: Ampicillin, especially in patients with infectious mononucleosis
  • Chronic liver disease: Cirrhosis, hepatoma
  • Metabolic disease: Gangliosidosis
  • Malignancy: Acute leukemia, lymphoma

  Workup and Diagnosis

  • History
    –Season of onset (can be a clue for various infectious etiologies)
    –Patient's age
    –Presence of fever, pruritus (typical of urticaria)
    –Tick/rat/bat bites (e.g., rat bite fever or Lyme disease)
    –Travel (to endemic areas for Lyme, RMSF)
    –Sick contacts
    –Contact allergen
  • Physical exam
    –Rash pattern and distribution, desquamation (interdigital, periungal), edema, involvement of other areas of the body
    –Other signs and symptoms associated (oral lesions, URI symptoms, arthritis, genital chancre)
    –Verify criteria for disease such as Kawasaki, Lyme, juvenile rheumatoid arthritis
  • Labs
    –CBC, ESR/CRP
    –Serologic testing for RMSF, Lyme, syphilis, toxoplasmosis, SLE
    –Throat swabs and stool culture for enterovirus serotype (no therapeutic significance)
    –KOH prep for hyphae
  • ECG, echocardiography, and cardiology consult if Kawasaki disease or endocarditis is suspected

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

EXTREMITY, HAND, AND FOOT DEFORMITIES: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

It is usually a simple matter to decide whether the deformity is due to neurologic disease or to joint or bone disease. An x-ray film of the hands or feet may be useful in acromegaly and many congenital disorders. Referral to an orthopedic or neurologic specialist is usually indicated if bone or neurologic involvement is probable. An arthritis workup can be done (see page 343) if joint disease is the cause of the deformity.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

HAND AND FINGER PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

In diagnosis, most of these conditions will be obvious on inspection. The difficulty arises when the hand looks normal. Then one must check for the following:

1. Carpal tunnel syndrome by tapping the volar aspect of the wrist (Tinel sign)
2. Brachial plexus neuralgia and scalenus anticus syndrome by Adson tests
3. Causalgia by stellate ganglion block to see if pain is relieved
4. Cervical spine disease by a roentgenogram, possibly a myelogram or MRI, and nerve blocks of the various roots. Referral to a neurologist is often necessary. In early rheumatoid arthritis, the joints may be normal on inspection but pain and stiffness of the hands and fingers in the morning is an excellent clue.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Wrist/Hand Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

Phenomena

❑ Wrist sprain

❑ Paronychia

❑ Ganglion cyst

❑ Carpal tunnel syndrome

❑ Ulnar neuropathy

❑ Trigger finger

❑ Mallet finger

❑ Digital ganglion

❑ Dupuytren contracture

❑ De Quervain tenosynovitis

❑ Colle fracture

❑ Navicular fracture

❑ Metacarpal fracture

❑ Felon

❑ Bennet fracture

❑ Smith fracture

❑ Flexor tendon rupture

❑ Reflex sympathetic dystrophy

❑ Lunate dislocation

Hands in Arthritis

❑ Osteoarthritis

❑ Rheumatoid arthritis

❑ Gout

❑ Systemic lupus erythematosus

❑ Psoriatic arthritis

❑ Scleroderma

❑ Gonococcal arthritis

Diagnostic Approach

Pain, swelling, and fusiform enlargement of multiple hand joints is characteristic of inflammatory arthritis. Involvement of the DIP joints is seen with psoriatic arthritis, and of the PIP and MCP joints with rheumatoid arthritis. Osteoarthritis involves both the PIP and DIP joints, but the swelling is more bony than soft tissue.

With infection, swelling is most prominent in the dorsum of the hand regardless of the original location.

Grip strength can be compared grossly by simultaneously gripping the examiner’s fingers using both hands, or quantitatively by gripping a tightly rolled, slightly inflated blood pressure cuff.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

EXTREMITY, HAND, AND FOOT DEFORMITIES: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

It is usually a simple matter to decide whether the deformity is due to neurologic disease or to joint or bone disease. An x-ray film of the hands or feet may be useful in acromegaly and many congenital disorders. Referral to an orthopedic or neurologic specialist is usually indicated if bone or neurologic involvement is probable. An arthritis workup can be done if joint disease is the cause of the deformity.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

HAND AND FINGER PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

In diagnosis, most of these conditions will be obvious on inspection. The difficulty arises when the hand looks normal. Then one must check for the following:

1. Carpal tunnel syndrome by tapping the volar aspect of the wrist (Tinel sign)
2. Brachial plexus neuralgia and scalenus anticus syndrome by Adson tests
3. Causalgia by stellate ganglion block to see if pain is relieved
4. Cervical spine disease by a roentgenogram, possibly a myelogram or magnetic resonance imaging (MRI), and nerve blocks of the various roots. Referral to a neurologist is often necessary. In early RA, the joints may be normal on inspection, but pain and stiffness of the hands and fingers in the morning is an excellent clue.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

 » Next page: Signs of Hand conditions

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