Hand and Wrist Pain
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.
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
| OA | Carpal Tunnel | Trauma | RA | Tenosynovitis | |
|---|---|---|---|---|---|
| Symmetrical Joint Swelling | No | No | No | Yes | No |
| Abrupt Onset | Possible | No | Yes | No | Possible |
| Paraesthesiae | No | Yes | No | No | No |
| Worse at Night | No | Possible | No | Possible | No |
| Tendon Tender | No | No | Possible | No | Yes |
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.