HAND AND FINGER PAIN
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) |
Muscle and Fascia |
| |
| |
|
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 |
Retinal artery or vein occlusion |
Uveitis Retinitis Scleritis |
Orbital tumor |
|
Ears |
|
Otitis media Mastoiditis Petrositis |
Acoustic neuroma Cholesteatoma |
|
Teeth |
|
Abscess |
|
Dental caries |
| |
|
Nose |
Wegener granulomatosis |
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.
Approach to the Diagnosis
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.
Other Useful Tests
-
Arthritis panel
- Antinuclear antibody (ANA) test (lupus erythematosus)
- Electromyogram (EMG) and nerve conduction velocity (NCV) test
(carpal tunnel syndrome)
- X-ray of hand (arthritis)
- Cold response test (Raynaud phenomenon)
- Muscle biopsy (collagen disease)
- Serum protein electrophoresis (macroglobulinemia, multiple myeloma)
- Exploratory surgery
- Nail fold capillary loop dilatation and dropout (Raynaud disease)
CASE PRESENTATION #38
A 33-year-old Filipino female
secretary complained of pain, numbness, and tingling in both hands for
several months.
asfasd
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, 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: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
More About Causes of Hand swelling
» Next page: PERIORBITAL AND FACIAL EDEMA (Differential Diagnosis in Primary Care)
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:
