Hand and Wrist Pain

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

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
ParaesthesiaeNoYesNoNoNo
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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