Chapter 64: Pain in the arm and hand

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

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.

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).

Probability diagnosis

The commonest causes of arm pain are referred pain and radiculopathies caused by disorders of the cervical spine, the tennis elbows (lateral and, to a lesser extent, medial epicondylitis), carpal tunnel syndrome (CTS) and regional pain syndromes caused by inflammation of the tendons around the wrist and thumb.

Disorders of the shoulder, particularly supraspinatus tendonitis, should be considered if the pain is present in the C5 dermatome distribution. Pain in the hand is commonly caused by osteoarthritis of the carpometacarpal joint of the thumb and the distal interphalangeal (DIP) joints, and also by CTS.

Serious disorders not to be missed

Like any other presenting problem, it is vital not to overlook malignant disease or severe infection. In the case of the arm, possible malignant disease includes tumours in bones, lymphoma involving axillary glands and Pancoast tumour, which may cause severe arm pain before any signs are evident.

Neoplastic tumours of the hand are uncommon and usually benign. Benign tumours include giant cell tumour of the tendon sheath, pigmented villonodular synovitis, neurilemmoma and neurofibroma. Malignant tumours are exceptionally rare but can include synovioma and rhabdomyosarcoma.

In addition, myocardial ischaemia, especially infarction in the case of pain of sudden onset, should be considered for left arm pain.

Sepsis can involve joints, the olecranon bursa and the deeper compartments of the hand, the latter leading to serious sequelae if not rapidly diagnosed and treated.

Subclavian or axillary vein thrombosis, known as ‘effort thrombosis’, causes swelling in the arm with pain high in the axilla. It is seen in people working constantly above their head, such as painters and basketballers. It is an emergency requiring antithrombotic therapy.

Pitfalls

Such conditions may include entrapment syndromes for peripheral nerves. If in doubt the patient should be referred for electromyography. Variations of peripheral nerve entrapments include the pronator syndrome (compression of the median nerve by the pronator teres or a fibrous band near the origin of the deep flexor muscles) and ulnar nerve entrapment at the elbow in the cubital fossa and, rarely, in the Guyon canal in the wrist.

Lesions of the nerve roots comprising the brachial plexus can also cause arm pain, especially in the C5 and C6 distribution. These can be detected by the brachial plexus tension tests.

Rarer causes of arm pain

These include polymyalgia rheumatica, although the pain typically involves the shoulder girdle, regional pain syndrome (Sudeck atrophy) and the thoracic outlet syndromes.

The thoracic outlet syndromes include problems arising from compression or intermittent obstruction of the neurovascular bundle supplying the upper extremity, for example, cervical rib syndrome, costoclavicular syndrome, scalenus anterior and medius syndrome, ‘effort thrombosis’ of axillary and subclavian veins and the subclavian steal syndrome.

The commonest cause of the thoracic outlet syndrome is sagging musculature related to ageing, obesity, and heavy breasts and arms, aptly described by Swift and Nichols as ‘the droopy shoulder syndrome’.¹

Cervical ribs are relatively common and may or may not contribute to the thoracic outlet syndrome. Often the cause is a functional change in the thoracic outlet due to the ‘droopy shoulder syndrome’ with no significant anatomical fault.²

Arm claudication is also rare. It can occur with arterial obstruction due to occlusion of the proximal left subclavian artery or the innominate artery. Exercise of the arm may be associated with central nervous system symptoms as well as claudication.

Seven masquerades checklist

Of the seven primary masquerades, spinal dysfunction and depression are those most likely to be associated with arm pain. Nerve root pain arising from entrapment in intervertebral foramina of the cervical spine or from a disc prolapse frequently leads to pain and/or paraesthesia in the arm.

Although diabetic neuropathy primarily manifests in the lower limbs it may be associated with neuropathies in the hands, including erythromelalgia (redness and burning related to heat). Hypothyroidism may cause a CTS.

Psychogenic considerations

The hand can be regarded as a highly emotive ‘organ’ that is frequently used to give outward expression to inner feelings. These can range from grossly disturbed psychiatric behaviour, manifested as a hysterical conversion disorder by a non-functioning hand, to occupational neuroses such as repetition strain injury (RSI) and malingering.³ Experienced occupational physicians and surgeons³ find the hand and arm a source of functional disability most often as a result of industrial injury. Of great concern are the various so-called RSI disorders, which in some people may be a means of work avoidance or a ‘ticket’ for compensation or both.

History

The painful arm represents a real diagnostic challenge, so the history is very relevant.

It is common for arm pain to cause sleep disturbances and three causes are cervical disorders, CTS and the thoracic outlet syndrome. The working rule is:

• thoracic outlet syndrome—patients cannot fall asleep

• CTS—patients wake in the middle of the night

• cervical spondylosis—wakes the patient with pain and stiffness that persists well into the day⁴

The history should include an analysis of the pain and a history of trauma, particularly unaccustomed activity. In children evidence should be obtained about the nature of any injury, especially pulling the child up by the arms or a fall on an outstretched hand, which can cause potentially serious fractures around the elbow.

Examination

As part of the physical examination of the painful arm it may be necessary to examine a variety of joints, including the cervical spine (CHAPTER 62), shoulder (CHAPTER 63), elbow, wrist and the various joints of the hand. The arms should be inspected as a whole and it is very important to have both arms free of clothing and compare both sides.

Elbow joint

Inspection (from anterior, lateral and posterior aspects). Hold elbow in an anatomical position to measure the carrying angle of forearm—elbow fully extended, forearm supinated (palm facing forwards) normal 5–15° (greater in females). Note any swellings:

• olecranon bursitis (bursa over olecranon)

• nodules:

  • – RA (subcutaneous border ulna)

  • – gout

  • – SLE (rare) and rheumatic fever (very rare)

  • – granulomas (e.g. sarcoidosis)

Examine it from the back to assess the triangle made by the olecranon and epicondyle.

Palpation. Perform with patient supine and elbow held in approximately 70° flexion. Palpate bony landmarks and soft tissue. Note especially any tenderness over lateral epicondyle (tennis elbow) and medial epicondyle (golfer’s elbow).

Movement (test active and passive). Hinge joint:

• extension—flexion (0° to 150°):

  • – the arc for daily living is 30–130°

  • – limitation of extension is an early sign of synovitis

• pronation—supination (rotation):

  • – occurs at radiohumeral joint

  • – test in two positions: 90° flexion (held to side of body) + at full extension

  • – supination 85° plus

  • – pronation 75° plus

    Resisted movements

• Painful resisted flexion at wrist = medial epicondylitis

• Painful resisted extension at wrist = lateral epicondylitis

Wrist joint

Follow the usual rules: look, feel, move, test function, measure, look elsewhere and X-ray. Note swellings or deformities, including the ‘anatomical snuff box’ and distal end of radius. Feel for heat, tenderness and swelling, especially over the radial aspect of the wrist.

Movements. With elbow fixed at 90° and held into the waist:

1. compare dorsiflexion and palmar flexion on both sides (normal range extension 70–80° flexion 80–90°)

2. compare ulnar deviation (normal to 45°) and radial deviation (20°)

3. compare pronation and supination (normal to 90° for both)

Neurological examination

Test sensation, motor power and reflexes where indicated.

Summary of tests for motor power:

• C5—test resisted movement deltoid

• C6—test resisted movement biceps

• C7—test resisted movement triceps

• C8—test resisted EPL and FDL

• T1—test resisted interossei

Sensory patterns are presented in FIGURE 62.4 (CHAPTER 62).

Investigations

Pain in the arm and hand can be difficult to diagnose but the rule to follow is: ‘If in doubt, X-ray and compare both sides’. This applies particularly to elbow injuries in children. The presence of a foreign body in the hand or arm also requires consideration.

Investigations to consider include:

• blood film and WCC

• ESR

• ECG

• imaging

  • – plain X-rays e.g. cervical spinal

  • – ultrasound

  • – arthrograms (shoulder, elbow, wrist)

  • – CT or MRI scanning

  • – technetium bone scan

• nerve conduction studies

• electromyography

Note: Modern sophisticated ultrasound examination is becoming a vital diagnostic modality for soft tissue disorders such as tendonopathy.

The main concerns with children are the effects of trauma, especially around the elbow. Considerable awareness of potential problems and skilful management are required with children’s elbow fractures. Foreign bodies in the arm also have to be considered.

Pulled elbow

This typically occurs in children under 8 years of age, usually at 2–5 years, when an adult applies sudden traction to the child’s extended and pronated arm (see FIG. 64.2a): the head of the radius can be pulled distally through the annular radioulnar ligament (see FIG. 64.2b).⁵

Symptoms and signs

• The crying child refuses to use the arm.

• The arm is limp by the side or supported in the child’s lap.

• The elbow is flexed slightly (any flexion will be strenuously resisted).

• The forearm is pronated or held in mid-position.

• The arm is tender around the elbow (without bruising or deformity).

Note: An X-ray is not usually necessary.

Treatment

1. Gain the child’s confidence.

2. The child stands facing the doctor with the parent holding the non-affected arm.

3. Place one hand around the child’s elbow to give support, pressing the thumb over the head of the radius.

4. With the other hand, firmly and smoothly flex the elbow and suddenly and firmly twist the forearm into full supination (see FIG. 64.2c). A faint click (which will be painful) will be heard. After a few minutes the child will settle and resume full pain-free movement. Warn parents that recurrences are possible up to 6 years.

An easier method for the child is to very gently alternate pronation and supination through a small arc as you flex the elbow.

Note: Spontaneous resolution can occur eventually. Place the arm in a sling if necessary. If you cannot get the child’s cooperation, send them home in a ‘high’ sling.

Fractures and avulsion injuries around the elbow joint, which are a major problem in children, are discussed in more detail in CHAPTER 133.⁶

Elderly patients are more likely to be affected by problems such as referred pain, radiculopathy or myelopathy from cervical spondylosis, tumours, polymyalgia rheumatica, entrapment neuropathies such as CTS and ulnar nerve entrapment. The latter can be related to trauma, such as Colles fractures. In addition the elderly are more prone to suffer from the thoracic outlet syndrome as previously described under ‘Pitfalls’. Osteoarthritis of the hand and tenosynovitis, such as trigger thumb or finger, are more common with advancing age.

Tennis elbow is caused by overuse or overload of the muscles of the forearm, especially in the middle aged. Two types of epicondylar tendonopathies are identifiable: ‘backhand’ tennis elbow, or lateral epicondylitis, and ‘forehand’ tennis elbow, or medial epicondylitis, which is also known as golfer’s or pitcher’s elbow. ‘Backhand’ tennis elbow, which will be termed lateral tennis elbow, is the common classic variety. It is an overload injury caused by excessive strain on the extensor muscles of the forearm resulting from wrist extension. Both conditions are generally self-limiting, but symptoms can persist for up to 2 years, or even much longer.

Lateral tennis elbow (lateral epicondylitis)

The patient who presents with this common and refractory problem is usually middle aged and only about one in 20 plays tennis. A typical clinical profile is presented in TABLE 64.2.

Signs

On examination the elbow looks normal, and flexion and extension are painless.

There are three important positive physical signs:

1. localised tenderness to palpation over the anterior aspect of the lateral epicondyle

2. pain on passive stretching at the wrist with the elbow held in extension and the forearm prone (see FIG. 64.3)

3. pain on resisted extension of the wrist with the elbow held in extension and the forearm prone (see FIG. 64.4)

Management

Although there are myriad treatments, the cornerstones of therapy are rest from the offending activity and exercises to strengthen the extensors of the wrist. The application of ice may help relieve discomfort of acute pain. Three systematic reviews have found little evidence for efficacy of any one specific intervention but short-term use of NSAIDs and progressive strengthening and stretching exercises were better than placebo.⁷ A trial of oral NSAIDs or topical NSAID applied four times a day may be worthwhile.⁸

Stretching and strengthening exercises for the forearm muscles represent the best management for tennis elbow. Three options are presented.

1. The wringing exercise. Chronic tennis elbow can be cured by a simple wringing exercise using a small hand towel.⁹

   Method

   • Roll up the hand towel.

   • With the arm extended, grasp the towel with the affected side placed in neutral.

   • Then exert maximum wring pressure: first flexing the wrist for 10 seconds, then extending the wrist for 10 seconds.

     This is an isometric ‘hold’ contraction.

     This exercise should be performed only twice a day, initially for 10 seconds in each direction. After each week increase the time by 5 seconds in each twisting direction until 60 seconds is reached (week 11). This level is maintained indefinitely.

     Note: Despite severe initial pain, the patient must persist, using as much force as possible. Review at 6 weeks to check progress and method.

2. Weights exercise. The muscles are strengthened by the use of hand-held weights or dumbbells. A suitable starting weight is 0.5 kg, building up gradually (increasing by 0.5 kg) to 5 kg, depending on the patient.

   Method

   • To perform this exercise the patient sits in a chair beside a table.

   • The arm is rested on the table so that the wrist extends over the edge.

   • The weight is grasped with the palm facing downwards (see FIG. 64.5).

   • The weight is slowly raised and lowered by flexing and extending the wrist.

   • The flexion/extension wrist movement is repeated 10 times, with a rest for 1 minute, and the program is repeated twice.

3. The pronating exercise.¹⁰ A suitable stretching exercise is to rhythmically rotate the hand and wrist inwards with the elbow extended and the forearm pronated (see FIG. 64.6). Another proven exercise program is that outlined by Nirschl¹¹ and this can be provided by referral to a physiotherapist familiar with the program.

The injection of 1 mL of a long-acting corticosteroid and 1 mL of local anaesthetic should be reserved for those severe cases when pain restricts simple daily activities, and not used initially for those patients with only intermittent pain.

A Netherlands study showed that corticosteroid injections are the best short-term treatment for tennis elbow. Over the longer term, physiotherapy offers better results than injection but is on a par with a wait and see approach.¹²

Severe and refractory cases can be referred for surgery but this is rarely indicated and there is no evidence to date on its efficacy. The usual procedure is the stripping of the common extensor origin combined with debridement of any granulation tissue.³ Other treatments include glyceryl trinitrate patches and autologous blood injections.

Medial tennis elbow (medial epicondylitis)

In ‘forehand’ tennis elbow, or golfer’s elbow, the lesion is the common flexor tendon at the medial epicondyle. The pain is felt on the inner side of the elbow and does not radiate far. The main signs are localised tenderness to palpation and pain on resisted flexion of the wrist.

In tennis players it is caused by stroking the ball with a bent forearm action or using a lot of top spin, rather than stroking the ball with the arm extended.

The treatment is similar to that for lateral epicondylitis except that in a dumbbell exercise program the palm must face upwards.

After-care and prevention (lateral and medial epicondylitis)

Tennis/sport should be resumed gradually. Players recovering from tennis elbow should start quietly with a warm-up period and obtain advice on style, including smooth stroke play. During a game they should avoid elbow bending and ‘wristy’ shots. A change to a good-quality racket (wooden or graphite frame) with a medium-sized head and suitable grip size may be appropriate.¹¹ The patient should be advised not to use a tightly strung, heavy racket or heavy tennis balls. It may be worthwhile to advise the use of a non-stretch band or brace situated about 7.5 cm below the elbow.

Olecranon bursitis

Olecranon bursitis presents as a swelling localised to the bursa (which has a synovial membrane) over the olecranon process. The condition may be caused by trauma, arthritic conditions (rheumatoid arthritis and gout) or infection.

Traumatic bursitis may be caused by a direct injury to the elbow or by chronic friction and pressure as occurs in miners (beat elbow), truck drivers or carpet layers. Acute olecranon bursitis with redness and warmth can occur in rheumatoid arthritis, gout, pseudogout, haemorrhage and infection (sepsis). Septic bursitis must be considered where the problem is acute or subacute in onset, and hence aspiration of the bursa contents with appropriate laboratory examination is necessary (smear, Gram stain, culture and crystal examination). Treatment depends on the cause.

Simple aspiration/injection technique

Chronic recurrent traumatic olecranon bursitis with a synovial effusion may require surgery but most cases can resolve with partial aspiration of the fluid and then injection of corticosteroid through the same needle. Sepsis must be ruled out.

Overuse syndromes of forearm muscles⁸

Pain is often experienced in the belly of a muscle, such as the flexors and extensors, following unaccustomed use of the wrists and elbows. There is pain on contraction and stretching of the muscles and tenderness on palpation. This problem can be limiting for a significant period. Early treatment includes relative rest, ice packs, analgesics (paracetamol) and gradual return to activity. Referral for physiotherapy to supervise rehabilitation is important.

Carpal tunnel syndrome

Patients with CTS complain of ‘pins and needles’ affecting the pulps of the thumb, and index, middle and half of the ring finger (see FIG. 64.7). They usually notice these symptoms after, rather than during, rapid use of the hands. They may also complain of pain, which may even radiate proximally as far as the shoulder, from the volar aspect of the wrist. Causes or associations of CTS are presented in TABLE 64.3.

The pathognomonic symptom

Patients complain of awakening from their sleep at night with ‘pins and needles’ affecting the fingers. They get out of bed, shake their hands, the ‘pins and needles’ subside and they return to sleep. In severe cases, the patient may awaken two or three times a night and go through the same routine.

Work-related CTS

CTS is seen in many work situations requiring rapid finger and wrist motion under load, such as meat workers and process workers. A type of flexor tenosynovitis develops and thus nerve compression in the tight tunnel. It is advisable to arrange confirmatory investigations by nerve conduction studies and electromyography for this work-induced overuse disorder. This testing is also indicated where the diagnosis is uncertain or if the condition persists and numbness or weakness develops.

Diagnosis (simple clinical tests)

In the physical examination a couple of simple tests can assist with confirming the diagnosis. These are the Tinel test and Phalen test. However, they are ‘soft’ signs with a relatively low sensitivity and specificity.¹⁴

• Hold the wrist in a neutral or flexed position and tap over the median nerve at the flexor surface of the wrist. This should be over the retinaculum just lateral to the palmaris longus tendon (if present) and the tendons of flexor digitorum superficialis (see FIG. 64.8).

• A positive Tinel sign produces a tingling sensation (usually without pain) in the distribution of the median nerve.

• The patient approximates the dorsum of both hands, one to the other, with wrists maximally flexed and fingers pointing downwards.

• This position is held for 60 seconds.

• A positive test reproduces tingling and numbness along the distribution of the median nerve.

The test that has the highest specificity of all basic clinical tests is two point discrimination, but it has low sensitivity for CTS.¹⁴

Treatment

The treatment is determined by the severity. For mild cases simple rest and splinting (particularly at night) is sufficient. Carpal tunnel injection with 1 mL of corticosteroid is frequently of diagnostic as well as therapeutic value (see FIG. 64.9). Ultrasound therapy has been used with some success. Surgical release (flexor retinaculotomy) is necessary for patients with sensory or motor deficits and those with recalcitrant CTS.

Systematic evidence-based reviews indicate the benefit of short-term oral corticosteroids⁷ and local corticosteroid injection (short-term). NSAIDs, diuretics and wrist splinting are unlikely to be beneficial. Avoid use of diuretics.

In reference to surgery, one review found similar clinical outcomes between open carpal tunnel release and endoscopic release but the latter had more complications.⁷

Trigger finger/thumb (flexor tenosynovitis)

In the fingers the common work-induced condition is stenosing flexor tenosynovitis, also known as trigger thumb and finger. Trigger finger or thumb has a reported lifetime risk of 2.6% in the population and is more common in the fifth and sixth decades of life.¹⁵ It is associated with type 1 diabetes, rheumatoid arthritis, gout, hypothyroidism and amyloidosis. It is caused by the same mechanism as de Quervain stenosing tenosynovitis. In middle age these tendons, which are rapidly and constantly being flexed and extended, can undergo attrition wear and tear, and fibrillate and fragment; this causes swelling, oedema and painful inflammation and the formation of a nodule on the tendon that triggers back and forth across the thick, sharp edge of the ‘pulley’ (of the fibrosseous tunnel in the finger) (see FIG. 64.10).

These patients may present with a finger locked in the palm of the hand; the finger can only be extended passively (manually) with the other hand. It is easily diagnosed by triggering. If the pulp of the finger is placed over the ‘pulley’ crepitus can be felt and tenderness elicited. The thumb and fourth (ring) finger are commonly affected, at the level of the metacarpal head.

Treatment

Oral NSAIDs (with care) may provide pain relief.¹⁵ Although surgery is simple and effective, treatment by injection is often very successful. The injection is made under the tendon sheath adjacent to but not into the tendon or its nodular swelling (A1 pulley). The approach can be proximal, distal or lateral to the nodule. Controlled trials report a success rate of up to 70%.¹⁵

• The patient sits facing the doctor with the palm of the affected hand facing upwards.

• Draw 1 mL of long-acting corticosteroid solution into a syringe and attach a 25 gauge needle for the injection.

• Insert the needle at an angle distal to the nodule and direct it proximally within the tendon sheath (see FIG. 64.11). This requires tension on the skin with free fingers.

• By palpating the tendon sheath, you can (usually) feel when the fluid has entered the tendon sheath.

• Inject 0.5–1 mL of the solution, withdraw the needle and ask the patient to exercise the fingers for 1 minute.

Improvement usually occurs after 48 hours and may be permanent. The injection can be repeated after 3 weeks if the triggering is not completely relieved. If triggering recurs, surgery is indicated. This involves division of the thickened tendon sheath only.

Dupuytren contracture

Also referred to as ‘Viking disease’, this contracture, which causes discomfort and dysfunction rather than pain, is fibrous hyperplasia of the palmar fascia leading to nodular formation and contracture over the fourth and fifth fingers in particular (see FIG. 64.12). It occurs in about 10% of males over 65 years. The cause is unknown, but there is an AD genetic predisposition. It is associated with smoking, alcoholism, liver cirrhosis, COPD, diabetes, epilepsy and heavy manual labour. If the palmar nodule is growing rapidly, injection of corticosteroids or collagenase (e.g. Xiaflex) into the cord or nodule may be beneficial, but collagenase carries a risk of tendon rupture. Surgical intervention is indicated for a significant flexion deformity.

De Quervain tenosynovitis (washerwoman’s sprain)

At the wrist, a not uncommon, work-induced condition is de Quervain stenosing tenosynovitis of the first dorsal extensor compartment tendons (extensor pollicis brevis and abductor pollicis longus), which pass along the radial border of the wrist to the base of the thumb. It is usually seen when the patient is required to engage in rapid, repetitious movements of the thumb and the wrist, especially for the first time, and thus is common in assembly line workers, such as staple gun operators.

Clinical features

• Typical age 40–50 years

• Pain at and proximal to wrist on radial border

• Pain during pinch grasping

• Pain on thumb and wrist movement

• Dull ache or severe pain (acute flare-up)

• Can be disabling with inability to use hand (e.g. writing)

• Tenderness with possible crepitations on palpation over and just proximal to radial styloid

• Firm tender localised swelling in area of radial styloid (may be mistaken for exostosis)

• Positive Finkelstein sign (the pathognomonic test)

• The patient folds the thumb into the palm with the fingers of the involved hand folded over the thumb, thus making a fist.

• Move (adduct) the wrist in an ulnar direction (towards the little finger) to stretch the involved tendons as you stabilise the forearm with the other hand (see FIG. 64.13).

• A positive test is indicated by reproduction of or increased pain.

Treatment

• Rest and avoid the causative stresses and strains on the thumb abductors.

• Use a custom-made splint that involves the thumb and immobilises the wrist.

• Consider trial of oral or topical NSAIDs four times a day for 14–21 days.

• Local long-acting corticosteroid injection can relieve and may even cure the problem but care should be taken to inject the suspension within the tendon sheath rather than into the tendon.

• Surgical release is required for chronic cases.

• Identify and mark the most tender site of the tendon and the line of the tendon. Identify and avoid the radial artery.

• Thoroughly cleanse the skin with an antiseptic such as povidone-iodine 10% solution.

• Insert the tip of the needle (23 gauge) about 1 cm distal to the point of maximal tenderness (see FIG. 64.14).

• Advance the needle almost parallel to the skin along the line of the tendon.

• Inject about 0.5 mL of the corticosteroid suspension within the tendon sheath. If the needle is in the sheath very little resistance to the plunger should be felt, and the injection causes the tendon sheath to billow out.

Tendonopathy

After excluding CTS, trigger thumb/finger, de Quervain tenosynovitis, rheumatoid and related disease, tendonitis is uncommon in the hand.¹⁶ Tendonitis may occur in other extensor compartments of the wrist and hand with unusual repetitive stressful actions, such as power drills jamming, and in conveyor quality control where an object is picked up with the forearm prone, supinating to examine it and pronating to replace it.

Treatment is rest from the provoking activity, splintage and tendon sheath injection with long-acting corticosteroid in a manner similar to that described for de Quervain tenosynovitis.

Intersection syndrome¹⁷

Intersection syndrome is caused by a bursitis that develops at the site where the extensor pollicis brevis and abductor pollicis longus tendons cross over the extensor carpi radialis tendons (see FIG. 64.15). The bursitis is due to friction at the crossing point or due to tenosynovitis of the extensor tendons. On palpation tenderness is found dorsally on the radial side with swelling and crepitus. Treatment is based on relative rest, a trial of NSAIDs and an injection of local anaesthetic and corticosteroid into the bursa.

Post-traumatic chronic wrist pain¹⁰

Patients often present with persistent wrist pain following trauma, such as a fracture, sprain to the wrist or even a seemingly mild strain, such as falling down with the wrist flexed into the hand. An undiagnosed fracture, ischaemic necrosis or unstable ligamentous injury including a triangular fibrocartilage tear should be investigated by radiology or referral where appropriate. Look for a scapholunate ligament tear (which causes wrist instability) with tenderness 2 cm distal to the tubercle on the radial side of the lunate. For persistent tenderness an injection of corticosteroid and local anaesthetic into the tender site is advisable.⁸ Imaging including MRI can be helpful but if in doubt about the diagnosis refer to a hand and wrist surgeon.

Ulnar collateral ligaments injury (‘gamekeeper’s thumb’)¹⁷

A special injury is gamekeeper’s thumb (also known as skier’s thumb) in which there is ligamentous disruption of the metacarpophalangeal joint with or without an avulsion fracture at the base of the proximal phalanx at the point of ligamentous attachment (Bennett fracture). This injury is caused by the thumb being forced into abduction and hyperextension by the ski pole as the skier pitches into the snow. Pinch grip is often affected.

Diagnosis is made by X-ray with stress views of the thumb. Incomplete tears are immobilised in a scaphoid type of plaster for 3 weeks, while complete tears (Stener lesions) and avulsion fractures should be referred for surgical repair.

Mallet finger

A mallet finger is a common sports injury caused by the ball (football, cricket ball or baseball) unexpectedly hitting the fingertip and forcing the finger to flex. Such a forced hyperflexion injury to the distal phalanx can rupture or avulse the extensor insertion into its dorsal base. The characteristic swan-neck deformity (see FIG. 64.16) is due to retraction of the lateral bands and hyperextension of the proximal interphalangeal joint.

The 45° guideline

Without treatment, the eventual disability will be minimal if the extensor lag at the distal joint is less than 45°; a greater lag will result in functional difficulty and cosmetic deformity.

Treatment

Maintain hyperextension of the distal interphalangeal joint for 6 weeks, leaving the proximal interphalangeal joint free to flex. This can be managed with non-stretched adhesive tape (see FIG. 64.17).

Ischaemic necrosis

Ischaemic necrosis, particularly of the scaphoid, can occur following failure to recognise a fracture. Tenderness in the ‘anatomical snuff box’ following trauma should be treated as a scaphoid until repeated X-rays prove negative. In children, chronic pain in the region of the lunate suggests avascular necrosis—Kienböck disease, presenting with dorsal wrist pain (see later in this chapter).

Ganglia¹⁵

About 60–70% of these common soft tissue tumours occur on the dorsal aspect of the wrist. The vast majority arise from the dorsal scapholunate ligament. Pain can result from compression on an adjacent nerve or joint space. If the diagnosis is uncertain, an ultrasound scan (or even an MRI) may pinpoint the tumour. See CHAPTER 124 for treatment.

Neurovascular disorders of the hand

Painful vascular disorders, which are more likely to occur in women in cold weather, include Raynaud phenomenon, erythromelalgia, chilblains and acute blue finger syndrome. Acrocyanosis is not a painful condition.

Raynaud phenomenon

The basic feature of Raynaud phenomenon, which is a vasospastic disorder, is sequential discolouration of the digits from pallor to cyanosis to rubor upon exposure to cold and other factors (a useful mnemonic is WBR, namely white → blue → red) (see FIG. 64.18). The rubor is a reactive hyperaemia when fingers become red and tender. Associated symptoms are pain, tingling and numbness. It is possible to get loss of tissue pulp at the ends of the fingers and subsequent necrotic ulcers. The benign form is the commonest, but may indicate an evolving connective tissue disorder. It is highly significant if it extends to the MCP joints (see CHAPTER 32).

Causes

• Raynaud syndrome (idiopathic)

• Occupational trauma (vibrating machinery)

• Connective tissue disorders (e.g. rheumatoid arthritis, SLE, systemic sclerosis, CREST, polyarteritis nodosa)

• Arterial disease (e.g. Buerger disease)

• Haematological disorders (e.g. polycythaemia, cold agglutinin disease, leukaemia)

• Drugs (e.g. beta blockers, sympathomimetic drugs with receptor activity, ergotamine, nasal decongestants)

• Smoking

• Cold, wet weather

• Stress or emotional upset

Differential diagnoses

• Chilblains—itchy, patchy discolouration without pallor

• Diffusely cold mottled hands—recover quickly on warming

Investigations

Exclude underlying causes with appropriate tests.

Treatment¹⁵

• In an attack, it is best to warm the extremities gradually.

• Total body protection from cold—wear layered clothing to prevent heat loss.

• Use an electric blanket at night, as required.

• Use mittens, fleece-lined gloves and thick woollen socks.

• Gloves or mittens should be worn when handling cold surfaces and objects, such as frozen food.

• Avoid smoking.

• Consider sympathectomy.

• topical glyceryl trinitrate 2% ointment—applied to the base of the affected fingers 2–4 times daily or applied over the radial artery or dorsum of the hand

• or

• amlodipine 5–20 mg (o) once daily

• or

• nifedipine SR 30–60 mg (o) once daily

• or

• diltiazem SR 180–240 mg (o) once daily

Erythromelalgia (erythermalgia)

This condition is characterised by erythema (redness), a burning sensation and swelling of the hands (and feet) after exposure to heat and exercise. It may be primary or secondary to a disease such as diabetes, haematological disorders¹³ (e.g. polycythaemia rubra vera) and connective tissue disease. Treatment of primary erythromelalgia includes trials of aspirin, phenoxybenzamine (Dibenyline), methysergide or sympathectomy.

Acute blue finger syndrome in women

This unusual syndrome involves the sudden onset of pain and cyanosis of the ventral aspect of the digit initially, and then the entire digit. It lasts 2–3 days and the attacks recur one or more times per year. No abnormalities are found on physical or on laboratory examination.

The cause is probably spontaneous rupture of a vein at the base of the finger.

Chilblains (perniosis)

Precautions

• Think Raynaud phenomenon

• Protect from trauma and secondary infection

• Do not rub or massage injured tissues

• Do not apply heat or ice

Treatment

• Elevate affected part

• Warm gradually to room temperature

• Apply glyceryl trinitrate vasodilator spray or ointment or patch (use plastic gloves and wash hands for ointment)

• Drink rum at night

• Nifedipine SR 30 mg daily

Regional pain syndrome

The hand can be affected by complex regional pain syndrome, previously called reflex sympathetic dystrophy (RSD, also in this case Sudeck atrophy). The patient presents with severe pain, swelling and disability of the hand. It may occur spontaneously or, more usually, it follows trauma that may even be trivial. It can occur after a Colles fracture, especially with prolonged immobilisation.

Clinical features

• Throbbing, burning pain, worse at night

• Paraesthesia

• Initial: red, swollen hand; warm, dry skin

• Later: cold, cyanosed and mottled, moist skin; shiny and stiff fingers

• Wasting of small muscles

• X-rays—patchy decalcification of bone (diagnostic)

The problem eventually settles but may take years. Patients need considerable support, encouragement, basic pain relief, mobility in preference to rest and perhaps referral to a pain clinic.

Kienböck disorder

Kienböck disease is avascular necrosis of the carpal lunate bone (see FIG. 64.19), which may fragment and collapse, eventually leading to osteoarthritis of the wrist.

It presents usually in young adults over the age of 15 as insidious, progressive wrist pain and stiffness that limits grip strength and hand function. Males are affected more often than females and the right hand more than the left, indicating the relationship to trauma.

Arthritic conditions of the wrist and hand

Arthritis of the hand is an inappropriate diagnosis and specificity is required to highlight the various joints that are the targets of the specific arthritides, which include osteoarthritis, rheumatoid arthritis, spondyloarthropathies, gout, haemochromatosis and connective tissue disorders. Typical target areas in the hand are shown in FIGURE 64.19.

Osteoarthritis

Osteoarthritis commonly involves the interphalangeal joints of the fingers (especially the DIP joints)¹⁸ and the carpometacarpal (CMC) joint of the thumb. Degenerative changes produce bony swellings around the margins of the joints—Heberden nodes of the DIP joints and less commonly Bouchard nodes of the PIP joints. A patchy distribution occurs in metacarpophalangeal, intercarpal and wrist joints, usually related to trauma.

Osteoarthritis of the thumb

This is very common, especially in women. Pain is felt at the base of the thumb, and tenderness on palpation of the CMC joint is typical. Functional limitation is progressive, with weakness of the pinch grip and limited thumb excursion. Surgical correction may be required.

Rheumatoid arthritis

In rheumatoid arthritis, the DIP joints are often spared (only about 30% involved), but the metacarpophalangeal and proximal interphalangeal joints and wrist joints are generally affected symmetrically and bilaterally. Rheumatoid arthritis tends to affect the metacarpophalangeal joints of the fourth finger less commonly.

Gout

Gout may affect normal joints of the hand but is encountered more frequently in osteoarthritic hand joints (especially DIP joints) in elderly people taking diuretics. This clinical feature is known as nodular gout.

Seronegative arthropathies

A similar appearance to rheumatoid arthritis occurs, except that with psoriatic arthritis the terminal joints are often affected by swelling, giving the appearance of ‘sausage digits’. (Refer CHAPTERS 35 and 38.)

Infections of the hand

Although not encountered as frequently as in the past, serious suppurative infections of the deep fascial spaces of the hand and tendon sheath can still occur, especially with penetrating injuries and web space infection.

Infections of the hand include:

• infected wounds with superficial cellulitis or lymphangitis (Streptococcus pyogenes)

• subcutaneous tissues—nail bed (paronychia), pulp (whitlow, e.g. herpes simplex)

• erysipeloid—this is a specific infection in one finger of fishers or meat handlers, caused by Erysipelothrix insidiosa. There is a purplish erythema that gradually extends over days. It is rapidly cured by penicillin

• tendon sheath infection (suppurative tenosynovitis)—this is a dangerous and painful infection that can cause synovial adhesions with severe residual finger stiffness. The affected finger is hot and swollen and looks like a sausage

• ‘aquarium’ or ‘swimming pool’ granuloma—non-painful infection of the tendon sheath due to Mycobacterium marinum following a minor cut of the finger; doxycyclin or clarithromycin is usually effective but refer to infectious disease physician

• deep palmar fascial space infection—infection from an infected tendon sheath or web space may spread to one of the two deep palmar spaces: the medial (midpalmar) space or lateral (thenar) space

• sporotrichosis (gardener’s arm)—a chronic fungal infection from contaminated spikes of wood or rose thorns presenting as hard non-tender nodules in the skin of the hand and extending along the lymphatics of the arm. The diagnosis is confirmed by biopsy. Treat with itraconazole

Management of serious infection

• Early appropriate antibiotic treatment for infection and early surgical referral where necessary

• Antibiotics (adult doses)

  • Streptococcus pyogenes (mild to moderate cellulitis, lymphangitis)

    procaine penicillin 1.5 g IM daily, 3–7 days

    or

    phenoxymethylpenicillin 500 mg (o) 6-hourly for 10 days

    If severe, to cover both S. pyogenes and Staphylococcus aureus infection (suspected or proved)

    flucloxacillin/dicloxacillin 2 g IV 6-hourly until improved, then oral for 10 days.

‘Cracked’ hands and fingers

• Wear protective work gloves: cotton-lined PVC gloves.

• Use soap substitutes (e.g. Cetaphil lotion, Dove).

  • apply 2–5% salicylic acid and 10% liq picis carb in white soft paraffin ointment.

    or

    corticosteroid ointment: class II–III

• Disabling osteoarthritis of carpometacarpal joint for possible surgical repair

• Myelopathy (motor weakness) and persistent radiculopathy (nerve root pain and sensory changes) in the arm

• Unresolving nerve entrapment problems such as median and ulnar nerves

• Elbow injuries in children with proven or possible supracondylar fracture or avulsion epicondylar fractures

• Evidence or suspicion of suppurative infection of the tendon sheaths or deep palmar fascial spaces

• Septic arthritis and osteomyelitis

• Regional pain syndrome

• Other conditions not responding to conservative measures

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Carpal tunnel syndrome

• Olecranon bursitis

• Tennis elbow

• Trigger finger