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Probability diagnosis

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Dysfunction of the cervical spine (lower)

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Disorders of the shoulder

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Medial or lateral epicondylitis

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Overuse tendonopathy of the wrist

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Carpal tunnel syndrome

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Osteoarthritis of the thumb and DIP joints

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Serious disorders not to be missed

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Cardiovascular:

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  • angina (referred)

  • myocardial infarction

  • axillary vein thrombosis

  • arm claudication (left arm)

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Infection:

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  • septic arthritis (shoulder/elbow)

  • osteomyelitis

  • infections of tendon sheath and fascial spaces of hand

  • sporotrichosis (‘gardener’s arm’)

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Neoplasia/cancer:

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  • Pancoast tumour

  • bone tumours (rare)

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Pitfalls (often missed)

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Entrapment neuropathies (e.g. median nerve, ulnar nerve)

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Pulled elbow (children)

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Foreign body (e.g. elbow)

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Rarities:

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  • polymyalgia rheumatica (for arm pain)

  • complex regional pain syndrome I

  • thoracic outlet syndrome

  • erythromelalgia

  • Kienböck disorder

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Masquerades checklist

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Depression

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Diabetes

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Spinal dysfunction

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Is the patient trying to tell me something?

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Highly likely, especially with the so-called RSI syndromes.

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Key history

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Include an analysis of the pain and a history of trauma, particularly unaccustomed activity. In children ask about pulling the child up by the arms or a fall on an outstretched arm. Ask for relationship of pain to any sleep disturbance.

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Key examination

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Inspect the arm as a whole with both arms free of clothing and compare both sides. It may be necessary to examine a variety of joints including the cervical spine, shoulder, elbow, wrist and various joints of the hand.

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Key investigations

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  • FBE

  • ESR/CRP

  • Consider ECG, nerve conduction studies, plain X-ray according to rule ‘if in doubt, X-ray and compare both sides’, ultrasound for soft tissue injuries (e.g. tendonopathy)

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Diagnostic tips

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The working rule for arm pain causing sleep disturbance:

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  • thoracic outlet: patient cannot fall asleep

  • carpal tunnel syndrome: wake in middle of night then settles

  • cervical spondylosis: wakes patient with pain that persists.

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Always keep regional pain syndrome in mind for persistent burning pain in hand following injury, trivial or severe.

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