Visualize the anatomy when a patient presents with pain in the hand or fingers (Table 31). The skin may show contact dermatitis, fungal infection, furuncle, cellulitis, or traumatic lesion. An insignificant wound may be infected; if there are streaks going up the arm, lymphangitis has complicated the picture. Herpes zoster rarely occurs in this area. Underneath the skin, the many tendon sheaths and fascial pockets are inviting sites for infection following a minor wound, but the swelling is obvious. One space particularly well known, the pulp space at the tip of the finger (usually the index finger), may develop a felon. A paronychial infection that involves the nail is very painful. A hematoma under the nail is perhaps even more painful.
The arteries of the hand may go into intermittent painful spasms in the Raynaud phenomenon, which occurs for example in macroglobulinemia, menopause, and rheumatoid arthritis (RA). It also occurs in a primary form called Raynaud disease. This is an extremely painful condition associated with cold, blue hands (intermittently) and gangrene (ultimately). The collagen diseases and Buerger disease may cause a vasculitis of the arteries and the Raynaud phenomenon. Finally, peripheral arterial emboli may occur here, but they are more frequent in the lower extremities. Surprisingly, the veins of the hand do not frequently develop thrombophlebitis, except in the hospitalized patient on frequent intravenous therapy. This may not be unusual when one realizes that varicose veins are uncommon in the upper extremities. Buerger disease also may involve the veins of the hand. The tendons are sometimes trapped in their sheaths and cause pain. De Quervain stenosing tenosynovitis of the extensor pollucis tendon is a common form. The muscles of the hands are not commonly involved in myositis but are frequently traumatized and contused, particularly in contact sports. Trapping of the median nerve in the carpal tunnel is a well-known cause of pain in the hand and fingers, particularly in the thumb, index, and middle fingers. Sensory changes involve these and the medial half of the ring finger; there may be significant atrophy of the thenar eminence with the Tinel sign. The Phalen test is usually positive also. Remember that the ulnar nerve may be trapped also, causing pain in the little finger and associated sensory changes. The carpal tunnel syndrome may be caused by multiple myeloma, amyloidosis, acromegaly, RA, menopause, and a host of other conditions. Symptoms similar to those of the carpal tunnel syndrome may come from high up the peripheral nerve tract. Compression of the brachial plexus by a cervical rib, a scalenus anticus muscle, or the clavicle (so-called costoclavicular compression syndrome) may be the culprit. Chronic bursitis or arthritis of the shoulder may ultimately lead to a causalgia, as will a peripheral nerve injury, and create pain in the hand and fingers. The frozen shoulder following pneumonia, myocardial infarctions, and other chest conditions can do the same. The brachial plexus may also be involved by Pancoast tumors. At a third site, compression of the cervical nerve roots by a herniated disc, cervical spondylosis, TB, and primary and metastatic tumors may be the cause of hand and/or finger pain. Cord conditions like syringomyelia and brainstem involvement of the thalamus by embolism or thrombosis may occasionally cause pain in the hand, but in the latter condition, there is usually an accompanying leg pain.
HEADACHE—EXTRACRANIAL AND CRANIAL
V I N D Vascular Inflammatory Neoplasm Degenerative and Deficiency Skin Herpes zoster Abscess (scalp) Superficial Arteries Migraine Superficial Nerves Occipital neuralgia Skull Tuberculosis Osteomyelitis Osteomas Metastatic carcinoma Multiple myeloma Temporomandibular joint Cervical Spine Tuberculosis Cord tumor Metastasis Osteoarthritis Sinuses Sinusitis Sinus tumor or polyp Eyes Uveitis Retinitis Scleritis Orbital tumor Ears Otitis media Mastoiditis Petrositis Acoustic neuroma Cholesteatoma Teeth Abscess Dental caries Nose Rhinitis Mucormycosis Schmincke tumor
In the deepest penetration of our dissection of the hand we encounter the most common structures that cause hand pain, the bones and joints. The bones may be fractured, dislocated, or contused or the joints may be sprained, but if the joints are painful, arthritis is the most likely cause. This may be RA, osteoarthritis, gout, or gonococcal arthritis. More rarely, it is associated with psoriatic arthritis, lupus erythematosus, and other systemic diseases.
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:
CASE PRESENTATION #38 A 33-year-old Filipino female secretary complained of pain, numbness, and tingling in both hands for several months. asfasd
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8 
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