Hand & Wrist Pain

Definition: Disorders of the wrist and hand are a common cause of medical consultation. Pain, swelling, dysfunction, orstructural abnormalities may incite such an evaluation.

Anatomic Considerations: Sources of pain and swelling may include diarthrodial joints, tendons, tenosynovium, bone, nerve, skin, or other soft tissue structures. A detailed physical examination is required to determine whether there is articular or nonarticular (periarticular) involvement.

Cardinal Findings: It is important to note the chronology of involvement so that acute, chronic, intermittent, additive, or migratory joint involvement may be identified. Musculoskeletal disorders often manifest a distinctive pattern of joint involvement (Fig. 4). For example, RA commonly involves the proximal

Sites of hand/wrist involvement and their disease associations.

Figure 4. Sites of hand/wrist involvement and their disease associations.

interphalangeal, metacarpophalangeal, and wrist joints, whereas OA tends to involve the distal interphalangeal, proximal interphalangeal, or first carpometacarpal (base of the thumb) joints. A history of trauma should suggest the possibility of a fracture or a degenerative (OA) or overuse (CTS) condition. Patients should describe the functional limitations associated with their complaint. The medical history may disclose disorders with prominent musculoskeletal manifestations. For example, diabetics may develop flexion contractures of the fingers, the so-called syndrome of limited joint mobility.

Articular  abnormalities  often  demonstrate  obvious  clinical  findings. Bony, nodular enlargement of the distal interphalangeal (Heberden’s nodes) or proximal interphalangeal (Bouchard’s nodes) joints may suggest OA. By contrast, soft tissue swelling and effusion of the metacarpophalangeal or proximal interphalangeal joints, with or without swan-neck or boutonnière deformities, should suggest RA. Degenerative changes at the metacarpophalangeal joint may be related to OA (a rare manifestation of a common disease) or hemochromatosis (a common manifestation of a rare disease). Soft tissue abnormalities may include nodular swellings owing to ganglion cysts, rheumatoid nodules, nodules associated with MTX use, or gouty tophi. Nodular or fibrotic changes involving the flexor tendons may result in episodic “catch” or “trigger finger” when the finger is flexed and extended. Trigger fingers may be seen in both RA and OA. Thickening of the palmar fascia may result in a Dupuytren’s contracture of the fourth or fifth flexor tendons with a fixed flexion deformity of the involved digits. Tendon rupture of the fingers results in an unopposed reducible malposition or deformity away from the involved side. Thus, rupture of the extensor tendons over the dorsum of the hand (as in RA) results in the fingers being held in a position of unopposed flexion. A common cause of periarticular wrist pain is deQuervain tenosynovitis manifest as distal radial pain, with or without swelling, and a positive Finkelstein test (see Evaluation of Musculoskeletal Complaints, Table 7). Examination of the hand and wrist should also reveal the presence of cutaneous abnormalities. Common skin lesions indicating a systemic disorder may include Gottron papules over the metacarpophalangeal joints (DM), erythema or hyperpigmentation over inflamed joints (RA), periungual erythema (SLE, myositis, scleroderma, reactive arthritis, psoriatic arthritis), vasculitic lesions (digital infarcts, painful Osler’s nodes, Janeway lesions), psoriatic lesions (scaly plaques, nail pitting, onycholysis), nail abnormalities (psoriasis, Reiter ’s syndrome), sclerodactyly and distal digital pulp scars (scleroderma), and Raynaud’s phenomenon. Neurologic examination should seek muscle atrophy (from disuse or neuromuscular disease), signs of CTS (Tinel’s sign, thenar muscle wasting), and brachioradialis reflex (C5-6 innervation) and include careful sensory and motor examination of the hand and digits.

Diagnostic Testing: Testing should be guided by the results of the history and physical examination. Routine serologic testing and rheumatic screens or panels should be avoided. Nailfold capillaroscopy should be done on all patients suspected of having Raynaud’s phenomenon or sclerodactyly. Nerve conduction velocity testing may be useful in evaluating a potential neuropathy or radiculopathy. Patients with acute or chronic monarthritis may benefit from synovial fluid aspiration and analysis, and those with undiagnosed chronic monarthritis may benefit from arthrocentesis or synovial biopsy to exclude indolent infection.

Table 15: Differential Diagnosis of Wrist/Hand Pain
Periarticular
    de Quervain tenosynovitis
    Tenosynovitis (RA, gonococcal, gout)
    Trigger finger
    Dupuytren’s contracture
    Syndrome of limited joint mobility (diabetes)
Articular
    RA (PIP, MCP, wrist)
    Osteoarthritis (DIP, PIP, 1st CMC joints)
    Psoriatic arthritis (DIP, PIP, MCP joints)
    Hemochromatosis (second and third MCP joints)
Bone
    Avascular necrosis (i.e., Kienbock’s necrosis of the lunate)
    Fracture (e.g., Colles)
    Sarcoid (cystic lytic lesions)
    Periostitis (osteomyelitis, hypertrophic osteoarthropathy)
Neurologic/vascular
    Carpal tunnel syndrome
    Raynaud’s phenomenon
    Subacute bacterial endocarditis with emboli
    Digital vasculitis (RA, SLE, cholesterol emboli)
    Reflex sympathetic dystrophy
Soft tissue Ganglion
    cysts Rheumatoid
    nodules Gouty tophi
    Clubbing (hypertrophic osteoarthropathy)

Imaging: Radiographs of the hands are seldom revealing with acute presentations and may only show soft tissue swelling. Nonetheless, they should be considered if there is a history of trauma, if the condition is chronic, if there are vasomotor changes suggesting reflex sympathetic dystrophy, or if a baseline assessment is needed for a chronic osseous/articular  disorder. MRI is largely an investigative tool and should be reserved for situations in which osteonecrosis or osteomyelitis is being considered.

Therapy: Treatment is dictated by the underlying disorder.

Adapted from: RheumaKnowledgy


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