Wrist and Hand Pain
A 62-year-old woman presents with pain in her hands. She has stiffness for 45 minutes in the morning and pain with activities. How do you progress?
A careful history is invaluable in diagnosis. Of course this is not always possible in an exam situation. It is important to define where she has her hand pain. Is it in the wrists or is it in the fingers? Similarly the character of the pain is important. Nerve compression syndromes often give a burning or shooting quality to the pain whereas arthritis usually gives an ache in the joint. The duration of symptoms is important. Many rheumatological problems develop over a period of months and often years. However, there are rheumatological problems that can develop overnight such as gout.
As with other joint problems it is important to know if other joints are involved rather than just the joint or joints that the patient complains about. A careful history will often unveil a more diffuse problem than was previously suspected. The pattern of this joint involvement will often point to a diagnosis. For instance, ninety percent of patients with rheumatoid arthritis will have synovitis that affects the metacarpophalangeal (MCP) or wrist joints in a symmetrical pattern.
After taking a history, the clinician should have formulated a differential diagnosis.
The clinical examination then helps differentiate between these diagnoses. To begin the examination of the hands and wrists the patient must be properly positioned. The hands and wrists must be exposed to at least the elbow. Placing a patient’s hands on a pillow is ideal.
Table: Common causes of wrist, thumb and finger pain.
Much can be gathered from careful observation. In fact, a diagnosis can often be reached before even touching the patient! Look first at the hands in general. Look for swelling. Swelling can be difficult to detect. It can be confined to one joint or many joints or can be due to tenosynovitis (inflammation of tendon sheaths). It often involves subcutaneous tissues around the joint. Swelling can be quite diffuse such as in the RS3PE syndrome (Remitting Symmetrical Seronegative Synovitis with Peripheral Oedema) or quite localized such as in synovitis or tenosynovitis. Look for muscle wasting, which can be easily seen on the dorsum of the hand (interossei muscles), thenar and hypothenar eminences. Look for dilated veins due to increased blood flow that occurs with inflammation. Look for subcutaneous nodules (table of causes).
Look at the shape of the hands. Look for ulnar deviation of the fingers. This is due to an erosive arthropathy of the MCP joints that results in ligament destruction hence deviation of the fingers. Look for the classic changes of rheumatoid arthritis – Boutonnière deformity, swan neck deformity and Z-deformity of the thumb (diagram). There maybe an inability to straighten the fingers. This maybe due to joint disease but can be due to tightening of the skin seen in scleroderma or contracture of the palmar aponeurosis (Dupuytren’s contracture).
Now look carefully at the fingernails. There are five nail changes associated with psoriasis – pitting (more than 20 pits per nail are pathological), ridging, onycholysis, colour changes and hyperkeratosis. Look also for vasculitic changes such as splinter haemorrhages. The periungal region may also have dilated veins. Capillaroscopy is the best method for detecting these. This requires a capilloscope and is beyond what is expected in a routine examination. The pattern of the dilatation is associated with various connective tissue diseases.
Ask the patient to turn her hands over. Carefully look for telangiectasia especially in the fingers. Telangiectasias are usually only 1-2mm in diameter and are due to dilatation of capillaries and venules. Telangiectasia can be found in CREST syndrome (an acronym for calcinosis, Raynaud’s phenomenon, oesophageal dysmotility, sclerodactyly and telangiectasia). Calcinosis can be seen often on the pulps of the fingers. However, calcinosis can occur anywhere. They are usually small hard white lesions and can be tender. Sclerodactyly is the end result of skin tightening and gives the fingers a tapered appearance. Raynaud’s phenomenon and oesophageal dysmotility are usually found on history. Occasionally one will see Raynaud’s phenomenon occurring particularly in the colder months. Classically this begins with the fingers becoming pale or white due to vascular spasm. There is often pain associated with the spasm. The fingers then become cyanotic or blue. Finally as the spasm resolves they become flushed or red. With severe Raynaud’s phenomenon the fingertips become ischaemic and form ulcers. The ulcers can be of variable severity. They can be infected, markedly ischaemic or healing. If the ulcers do heal they usually leave a hardened scar like region on the fingertip.
Subcutaneous calcinosis can sometimes be difficult to distinguish from gouty tophi. Tophi are often much larger and less in number than subcutaneous calcinosis. They also occur in close proximity to a joint. Occasionally chalk like material (tophus) will exude from the lesion.
Finally it is time to palpate the joints. Each joint must be individually palpated. The clinician needs to know if there is inflammation in the joint. The cardinal signs of inflammation (and hence synovitis) are colour (erythema), rubor (hot), pain, dolour (swelling) and functio laesa (loss of function). Therefore, the joint is palpated to detect swelling (bony or soft), warmth, synovial thickening, an effusion and tenderness. At the same time the joint can be moved through its range of motion to detect limitations in function.
Begin at the distal interphalangeal (DIP) joints. Palpate the DIP joint with your two thumbs and two index fingers on opposite sides of the joint (diagram). Feels for swelling - bony swelling is hard and non-tender. These lesions are Heberden’s nodes and are due osteoarthritis. There is joint space narrowing and osteophyte formation with a subsequent decrease in range of motion. Boggy swelling with tenderness suggests synovitis. Synovitis of the DIP joints is most often due to psoriatic arthritis but can be seen in other forms of inflammatory synovitis.
Move onto the proximal interphalangeal (PIP) joints. The joints can be examined in the same way as the DIP joints. Bony non-tender swelling of the PIP joints are known as Bouchard nodes and are again due to joint space narrowing and osteophyte formation. Boggy swelling and tenderness suggests synovitis. It can be difficult to detect an effusion. Gently squeeze your thumbs together whilst feeling the joint with your index fingers. If there is an effusion one will feel a bulge of fluid and the joint margins will become indistinct. Gently move the joint through its range of motion. Osteoarthritis and synovitis will result in a decreased range of motion.
Examine the metacarpophalangeal (MCP) joints next. This time palpate the joint using your 2 thumbs with the palm of the patient’s hand in your fingers (diagram). Feel for synovitis. Again this can be difficult to detect and needs to be done carefully. Notice if the is a loss of definition between the metacarpal heads due to periarticular swelling. Check for limitation in movement by asking the patient to make a fist. With significant joint disease the patient will be unable to tuck their fingers into the palm of their hand. Note any “triggering” of the fingers. This is due to a small nodule getting trapped with in the tendon sheath. The patient can flex the finger but cannot extend them without excessive force or assisting the finger with the other hand. It can be a complication of tenosynovitis or rheumatoid arthritis. As a measure of how much limitation there is, the distance between the middle fingertip and the palm of the hand can be measured. This can then be used as an objective measure of disease progression.
The thumb needs special attention. Tenosynovitis commonly involves the thumb and is usually caused by overuse. The abductor pollicis longus and the extensor pollicis brevis sheaths become inflamed resulting in pain made worse by movement. Swelling can be detected over the radial styloid. To check for this ask the patient to place their thumb in the palm of their hand (on the same side). Gently move the wrist in an ulnar direction. This will cause pain along the line of the tendons. (Specificity?)This is known as de Quervain’s tenosynovitis. (why?) Osteoarthritis of the first carpometacarpal (metacarpotrapezium) joint and scapho-trapezium joint can also give pain with this manoeuvre. If these joints are tender to palpation the pain is probably due to osteoarthritis.
The wrist is a complex joint that is difficult to thoroughly examine. It is an ellipsoid joint with the distal radius and triangular fibrocartilage (attached to the distal ulna) and the proximal end and the scaphoid, lunate and triquetrum at the distal end. It has a broad range of movement (80-90° flexion, 70-80° dorsiflexion, 40-50° ulnar deviation and 15-20° radial deviation) yet maintains it’s stability.
Initially palpate the wrist joint with the palm down. Palpate the wrist joint in the same manner as examining the MCP joints (use both thumbs with the fingers on the volar aspect supporting the wrist). Feel the ulnar styloid. This is often tender in rheumatoid arthritis due to a combination of synovitis and tenosynovitis. There will be swelling medial to the ulnar styloid with significant tenosynovitis. Feel the radial styloid. Then grasp both styloids with separate hands and attempt to move them in the anteroposterior plane. Pain with this movement is due to disease in the inferior radioulnar joint, which is approximately midway between the two styloid processes (diagram).
Feel for swelling in the wrist. This is best felt on the dorsum of the wrist just distal to the distal radioulnar joint. With synovitis there will be boggy swelling and tenderness. Next palpate along the joint line towards the ulnar styloid. Common causes of tenderness here are disruption of the triangular fibrocartilage, inflammation of the ulnar collateral ligament or tendonitis of the extensor carpi ulnaris tendon. Then palpate back towards the radial styloid. Localized swelling and superficial tenderness maybe due to inflammation of the extensor compartments. There are six compartments along the dorsum of the wrist. Palpate the anatomical snuffbox. Marked tenderness here suggests a fracture of the scaphoid.
Turn the wrist over. Palpate along the anterior joint line. Tendonitis of the flexor carpi radialis and flexor carpi ulnaris will result in focal tenderness at their respective insertion sites. Test the range of movement of the wrist with passive then active movement. The best way to test passive movement is to ask the patient to place the palms of their hands together and then the dorsum of their hands together (diagram). Test active movement by asking the patient to extend their wrist and hold it that position. The examiner then pushes against the extended hand. Similarly test for active flexion by asking the patient to hold the wrist flexed whilst the examiner tries to straighten the wrist.
Finally test for carpal tunnel and ulnar tunnel syndromes. Whilst doing this the examiner will also be testing function in the hand. Carpal tunnel syndrome is due to compression of the median nerve in the carpal tunnel at the wrist. Ulnar tunnel syndrome is due to compression of the ulnar nerve in the ulnar tunnel at the wrist. Be aware that the ulnar nerve can also be compressed at the elbow. Look for wasting of the thenar and hypothenar eminences. Test for paraesthesia. Pinprick sensation will be reduced on the anterior aspect of the thumb, index, middle and the lateral aspect of the ring fingers in carpal tunnel syndrome. In ulnar nerve compression the fifth and medial aspect of the ring finger will have decreased pinprick sensation. Test for weakness. Test the strength of the pincer grip between the thumb and index finger. Then test the pincer grip between thumb and fifth finger. Tap over the median nerve. A positive Tinel’s sign will cause shooting pains into the fingertips. Then compress the median nerve at the wrist by holding your index finger over the median nerve and flexing the wrist. A positive Phalen’s sign will cause pain in the distribution of the median nerve.