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Chapter 64

### Introduction

A pain in the hand is worth a look at the neck. By heck don't forget the neck!

Orthopaedic surgeon to students 1965

Pain in the arm and hand is a common problem in general practice, tending to affect the middle aged and elderly in particular.

### Overview of causes of a painful arm and hand

Like pain in the shoulder, pain originating from the cervical spine and shoulder disorders can extend down the arm. While pain from disorders of the shoulder joint (because of its C5 innervation) does not usually extend below the elbow, radiculopathies originating in the cervical spine can transmit to distal parts of the arm (see FIG. 64.4, later in this chapter).

Important causes are illustrated in FIGURE 64.1. Myocardial ischaemia must be considered, especially for pain experienced down the inner left arm.

###### FIGURE 64.1

Important causes of arm pain (excluding trauma and arthritis)

Soft tissue disorders of the elbow are extremely common, especially tennis elbow. Two types of tennis elbow are identifiable: ‘backhand’ tennis elbow, or lateral epicondylitis, and ‘forehand’ tennis elbow, or medial epicondylitis, which is known also as golfer's or pitcher's elbow.

Other significant elbow disorders include inflammatory disorders of the elbow joint, such as rheumatoid arthritis, osteoarthritis and olecranon bursitis, which may follow recurrent trauma, gout, rheumatoid arthritis or infection.

Another important group of disorders are the various regional pain syndromes around the wrists, including the common de Quervain tenosynovitis (affecting the tendons of extensor pollicis brevis and abductor pollicis longus) and to a lesser extent the extensor tendons to the fingers. Pain from these overuse syndromes can be referred in a retrograde manner into the forearm.

A fascinating and poorly understood syndrome is that related to dysfunction of the upper four vertebral segments of the thoracic spine, which can cause referred pain in the arm that does not correspond to the dermatomes. This syndrome is often confused with the more common regional pain disorders such as tenosynovitis and tennis elbow.

The various causes of the painful arm can be considered with the diagnostic strategy model (see Table 64.1).

Table 64.1

Pain in the arm and hand: diagnostic strategy model

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