Wrist/Hand Pain
Differential Overview
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.
Clinical Findings
Wrist sprain Following trauma, there is mild to moderate wrist pain and
stiffness.
Paronychia Infection, marked by redness and swelling, is confined to the base and lateral border of the nail. When infection is chronic (e.g., resulting from Candida), the epinychium is pink and glazed, and the nail is ridged.
Ganglion cyst It appears as a painless localized swelling over the volar or
dorsal/radial aspect of the wrist. Arising from the synovial lining, it will feel compressible, and may fluctuate in size with use.
Carpal tunnel syndrome Electrical pain and paresthesias in the thumb, index, middle, and radial aspect of the ring finger occur especially at night and may be relieved by shaking the wrist. Reproduction of the symptoms with Tinel sign (tapping over the volar wrist) or Phalen sign (wrist flexion for 30 to 60 seconds) is useful but does not rule out carpal tunnel syndrome when negative. Thenar atrophy may develop. Typical causes include keyboard use, pregnancy, and hypothyroidism.
Ulnar neuropathy Neuropathy presents with numbness in the ulnar aspect of the hand and weakness of the intrinsics. Typical settings include jackhammer operators and following wrist trauma.
Trigger finger The history is one of painful snapping or locking of the finger in flexion and of a tendon sheath nodule over the palmar metacarpophalangeal joint on examination. Diabetes and rheumatoid arthritis are common precipitants.
Mallet finger Look for a flexed fingertip with inability to extend the distal interphalangeal joint, resulting from traumatic rupture of the distal extensor tendon.
Digital ganglion Appearing as a firm fixed nodule in a digital joint crease, it may be confused with a sesamoid.
Dupuytren contracture A painless nodular thickening of the palmar fascia gradually develops, with a flexion contracture of the fingers, usually the fourth and fifth. Common triggers include exposure to chronic vibration trauma, as well as diabetes and alcoholism.
De Quervain tenosynovitis A combination of pain in the radial aspect of the wrist combined with grip weakness is characteristic. When the thumb is held in the palm and the wrist deviated toward the ulna (Finkelstein test), pain occurs over the anatomic snuff box. Crepitance may be felt over the radial styloid. Chronic repetitive movement of the wrist and thumb is the usual underlying cause.
Colle fracture It is produced by a fall onto an outstretched hand. Deformity is obvious, appearing as a fork profile when viewed laterally.
Navicular fracture It typically occurs after falling on an outstretched hand and should be suspected when there is tenderness over the anatomic snuff box.
Metacarpal fracture When making a fist, the knuckle prominence will be lost. There will be tenderness over the swollen area.
Felon Redness and swelling develop in the fingertip. When the pulp is indurated and has lost its resilience, pus is present.
Bennet fracture An oblique fracture through the first metacarpal results from injury to the extended thumb, and the thumb cannot be opposed.
Smith fracture It is caused by a fall with hyperflexion of the hand. The distal fragment is displaced in a volar direction, giving a “reversed fork” appearance.
Flexor tendon rupture There is a history of sudden pain in the finger while grabbing at an object, with inability to flex in isolation. The flexor digitorum profundus may be evaluated by having the patient flex the distal interphalangeal joint while holding the proximal interphalangeal joint in extension. The sublimis function is tested by holding the other fingers in extension at the metacarpophalangeal joint and looking for flexion of the proximal interphalangeal joint.
Reflex sympathetic dystrophy Burning pain, swelling, and tenderness of the hand is associated with shoulder pain. The hand may be hot or cold and the skin moist.
Lunate dislocation The lunate occupies the hollow just distal to the radius in line with the middle finger. It becomes more hollow and tender with dislocation. Carpal tunnel symptoms may occur.
Osteoarthritis It presents with a symmetrical arthritis with bony hypertrophy of the proximal interphalangeal (Bouchard) and distal interphalangeal (Heberden) joints. There can be a surprising degree of deformity and crepitance with minimal pain on motion. The carpometacarpal joint is a common location for wear from chronic use, causing pain and crepitance over the base of the thumb.
Rheumatoid arthritis Characteristic findings include symmetrical synovial swelling and bogginess of the metacarpophalangeal joints, intrinsic muscle wasting, ulnar deviation of the fingers, swan neck, and boutonnière’s deformities of the fingers, extensor nodules, and median neuropathy. When the hand is squeezed at the MCP level, multiple joints are typically painful.
Gout It occurs less commonly in the hands than elsewhere, presenting as a single intensely inflamed joint, sometimes with a waxy yellow discoloration caused by underlying uric acid crystals.
Systemic lupus erythematosus Symmetric fusiform swelling of the proximal interphalangeal and metacarpophalangeal joints, diffuse puffiness of the hands, and tenosynovitis are typical signs.
Psoriatic arthritis Foreshortened digits (“watchglass hand”) and pitting of the nails are clues; however, the former is a late finding. Psoriatic plaques are usually present, but they may be hidden in the hair, behind the ear, or in the gluteal fold.
Scleroderma The earliest sign is usually Raynaud phenomenon, followed by diffuse edema of the hands, then by bound-down skin. The digits attain a sausage configuration, and there is often atrophy of the tufts of the fingers. Cuticular telangiectasias can be observed using the ophthalmoscope.
Gonococcal arthritis It presents acutely with asymmetric oligoarthritis, fever, and pustular/necrotic skin lesions over the hands and tenosynovitis.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Hand swelling
Read excerpts from these other book chapters related to Hand swelling:
Medical Books Excerpts
- Edema
- "In A Page: Pediatric Signs and Symptoms" (2007)
- [ read ]
- Edema
- "A Pocket Manual of Differential Diagnosis" (1999)
- [ read ]
- Edema
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Edema
- "Field Guide to Bedside Diagnosis" (2007)
- [ read ]
- Edema, facial
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Edema, generalized
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Edema
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
More About Causes of Hand swelling
|
|
More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
|
|
» Next page: Pulmonary edema (Handbook of Diseases)
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
