Diagnosis of Hand neuropathy
Hand neuropathy Diagnosis: Book Excerpts
Diagnostic Tests for Hand neuropathy: Online Medical Books
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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 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:
- Carpal tunnel syndrome by tapping the volar aspect of the wrist (Tinel sign)
- Brachial plexus neuralgia and scalenus anticus syndrome by Adson tests
- Causalgia by stellate ganglion block to see if pain is relieved
- 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
Peripheral Neuropathy:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Diabetes
❑ Alcohol
❑ Vitamin B12 deficiency
❑ Drugs
❑ Carcinomatous
❑ Lead
❑ Guillain-Barré
❑ Tabes dorsalis
❑ Syringomyelia
❑ Polyarteritis nodosa
❑ Amyloidosis
❑ Polymyositis
❑ Pellagra
❑ Arsenic
❑ Porphyria
❑ Wallenberg syndrome
❑ Thalamic lesion
❑ Brown-Sequard syndrome
Diagnostic Approach
Sensory neuropathy symptoms include positive phenomena such as tingling; pins/needles; and burning, cold, or lancinating pain. Physical findings include weakness, fasciculations, atrophy, ataxia, wide-based gait, abnormal sweating, decreased or absent deep tendon reflexes, orthostatic hypotension, hypesthesia surrounded by a zone of hyperesthesia, and vibration or position sense affected before pinprick or temperature sense.
Autonomic neuropathy symptoms include impotence, retrograde ejaculation, diaphoresis, incontinence, urinary retention, constipation, diarrhea, orthostatic dizziness, and flushing. Physical findings include delayed pupillary light response, resting tachycardia, sinus arrhythmia, and orthostatic hypotension.
Sensory loss confined to part of a limb suggests injury to a peripheral nerve, plexus, or spinal root, resulting from trauma, entrapment, or vascular insufficiency. Mononeuropathy multiplex affects multiple nerves over time (e.g., due to diabetes or vasculitis). Polyneuropathy occurs in a stocking-glove distribution starting with the longest nerves, and is due to axonal neuropathy, with a toxic or metabolic origin. Bilaterally symmetrical symptoms are found in polyneuropathy or spinal cord lesions, while unilateral involvement is seen in contralateral disease of the brainstem, thalamus, or cortex.
Injury to large myelinated nerves produces decreased light touch and proprioception with a sensation of “walking on a thick carpet” or imbalance. Injury to medium fibers causes decreased light touch and vibration sense. Injury to small unmyelinated fibers, as occurs in diabetes or amyloidosis, decreases pain and temperature sensation and produces dysesthesias. Disproportionate loss of vibration sense and proprioception compared with pain and temperature sensation occurs with diseases of the dorsal column of the spinal cord (e.g., neurosyphilis, vitamin B 12 deficiency, or multiple sclerosis) and demyelinating polyneuropathy.
Transverse cord lesions produce loss of all modalities below the level of the lesion and a band of hyperalgesia at the level of the lesion. Lateral cord compression is heralded by early sensory changes. Dorsal cord compression affects proprioception and tactile discrimination without pain or temperature loss. Pernicious anemia and tabes dorsalis preferentially affect the dorsal columns.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 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
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:
-
Carpal tunnel syndrome by tapping the volar aspect of the wrist
(Tinel sign)
- Brachial plexus neuralgia and scalenus anticus syndrome by Adson
tests
- Causalgia by stellate ganglion block to see if pain is relieved
- 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
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