Education And Debate

ABC of Rheumatology: PAIN IN THE HAND AND WRIST

BMJ 1995; 310 doi: http://dx.doi.org/10.1136/bmj.310.6974.239 (Published 28 January 1995) Cite this as: BMJ 1995;310:239
  1. Michael Shipley

    General considerations

    Patients presenting with pain in the hand are often anxious. The hands are so important for daily activities and for communication and contact that any actual or perceived threat to their normal function is worrying. For those whose livings are made by intricate use of their hands—musicians, craft workers, keyboard operators—and for heavy labourers, the threat is often greater. More often than not, people can live with their present pain if their fear of future loss of function can be allayed.

    Causes of pain in hand and wrist

    • At all ages

    • Trauma

    • Flexor tenosynovitis

    • Trigger finger or thumb

    • Carpal tunnel syndrome

    • De Quervain's tenosynovitis

    • Ganglion

    • Dorsal tenosynovitis

    • Inflammatory arthritis

    • Raynaud's syndrome

    • Reflex sympathetic dystrophy

    • Chronic upper limb pain

    • Elderly patients

    • Nodal osteoarthritis:

      • Distal interphalangeal

      • First carpometacarpal

      • Proximal interphalangeal

      • Scaphoid fracture

      • Pseudogout

    • Gout:

      • Acute

      • Chronic tophaceous

      • Dupuytren's contracture

      • Diabetic stiff hand

    Assessment

    Patients' descriptions of their pain are important. Its quality, localisation, variability with rest or use, and the presence of any associated symptoms such as numbness or pins and needles will often be diagnostic. Trauma, sometimes unnoticed, is the most common cause of hand pain. Specific diagnoses vary slightly with age.

    Nature of pain

    Localised or diffuse

    Unilateral or bilateral

    Aching or sharp

    Present only with use

    Present constantly

    Worse at night or at rest

    Associated with sensory symptoms

    Pain in the hand and wrist may reflect a problem arising proximally; the rest of the arm and the neck should always be examined, as should the other hand. Severe pain in the hand may seem to spread up the arm to the axilla or neck. Neck pain on the same side may be primary or reflect muscle spasm, resulting from holding the arm immobile in order to protect it. Several systemic disorders—most commonly inflammatory arthritis—may present as hand pain, usually bilateral, and a full locomotor and general examination is necessary.

    Injection technique

    Hand …

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