Hand and Wrist Pain

This may be the presenting problem but just as often it is a ‘while I’m here’ symptom. The differential diagnosis is quite wide but ‘arthritis’ is often uppermost in the patient’s mind. A brief history and focused examination should provide the correct diagnosis quite rapidly in most cases.

Published: 2nd August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • Osteoarthritis (Especially the Carpometacarpal Joint of the Thumb and the Distal Interphalangeal Joints of the Fingers)
  • Carpal Tunnel Syndrome
  • Trauma (e.g. Sprain, Scaphoid Fracture)
  • Rheumatoid (or Other Inflammatory) Arthritis
  • Tenosynovitis

Occasional Diagnoses

  • Ganglion
  • Gout
  • Raynaud’s Disease or Syndrome
  • Infection (e.g. Paronychia, Pulp Space)
  • Work-Related Upper Limb Disorder (WRULD)
  • Trigger Thumb or Finger
  • Other Nerve Entrapment, e.g. Ulnar Nerve, Cervical Root Pain
  • Complex Regional Pain Syndrome

Rare Diagnoses

  • Infected Eczema (Common, but Rarely Presents with Pain)
  • Writer’s Cramp
  • Peripheral Neuropathy
  • Dupuytren’s Contracture (Usually Painless)
  • Diabetic Arthropathy
  • Osteomyelitis
  • Kienböck’s Disease (Avascular Necrosis of the Lunate)

Ready reckoner

Key distinguishing features of the most common diagnoses

OACarpal TunnelTraumaRATenosynovitis
Symmetrical Joint SwellingNoNoNoYesNo
Abrupt OnsetPossibleNoYesNoPossible
Worse at NightNoPossibleNoPossibleNo
Tendon TenderNoNoPossibleNoYes

Possible investigations

Likely: None.

Possible: X-ray, FBC, ESR/CRP, rheumatoid factor/anti-CCP antibodies, uric acid.

Small Print: Blood screen for underlying causes in peripheral neuropathy or Raynaud’s syndrome, if clinically indicated.

  • X-ray: May show a fracture in trauma, joint erosions in RA, the typical features of OA, and sclerosis or collapse of the lunate in Kienböck’s disease.
  • FBC: Hb may be reduced in inflammatory arthritis; WCC raised in infection.
  • ESR/CRP: Raised in infective and inflammatory conditions.
  • Rheumatoid factor: May support a clinical diagnosis of RA (consider anti-CCP antibodies if negative).
  • Uric acid: An elevated level (post episode) supports a diagnosis of gout.
  • Blood screen: If investigating possible peripheral neuropathy or Raynaud’s syndrome

Top Tips

  • OA of the fingers can be relatively abrupt in onset and inflammatory in appearance compared with OA at other sites.
  • Explore the patient’s occupation – this will provide valuable information regarding the possible cause and effect of the problem.
  • Simply asking the patient to point to the site of the pain can help distinguish two of the most commonly confused differentials: OA of the carpometacarpal joint of the thumb and de Quervain’s tenosynovitis. In the former the pain is relatively localised to the base of the thumb; in the latter the discomfort – and certainly the tenderness – is more diffuse.
  • Pain from a ganglion can precede the appearance of the ganglion itself – or the ganglion may be fairly subtle, only appearing on wrist flexion.

Red Flags

  • Remember that RA is a clinical diagnosis – don’t rely on blood tests. Early referral minimises the risk of long-term joint damage.
  • If in doubt over tenderness in the anatomical snuff box after a fall on the outstretched hand, refer for A&E assessment – a missed scaphoid fracture can cause long-term problems.
  • Do not underestimate pulp space infection – this can cause serious complications such as osteomyelitis or bacterial tenosynovitis. It may need IV antibiotics or incision and drainage.
  • Thenar wasting suggests significant compression in carpal tunnel syndrome – refer.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.