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.
Table 64.2Lateral tennis elbow: typical clinical profile |Favorite Table|Download (.pdf) Table 64.2 Lateral tennis elbow: typical clinical profile
|Age ||40–60 years |
|Occupation ||Carpenter, bricklayer, cleaner, gardener, dentist, violinist |
|Sport ||Tennis, squash |
|Symptoms ||Pain at outer elbow, referred down back of forearm |
| ||Rest pain and night pain (severe cases) |
| ||Pain in the elbow during gripping hand movements (e.g. turning on taps, turning door handles, picking up objects with grasping action, carrying buckets, pouring tea, shaking hands) |
|Signs ||No visible swelling |
| ||Localised tenderness over lateral epicondyle, anteriorly |
| ||Pain on passive stretching wrist |
| ||Pain on resisted extension wrist and third finger |
| ||Normal elbow movement |
|Course ||6 to 24 months |
|Management || |
rest from offending activity
RICE* and oral NSAIDs if acute
exercises—stretching and strengthening
| || |
Additional (if refractory):
On examination the elbow looks normal, and flexion and extension are painless.
There are three important positive physical signs:
localised tenderness to palpation over the anterior aspect of the lateral epicondyle
pain on passive stretching at the wrist with the elbow held in extension and the forearm prone (see FIG. 64.3)
pain on resisted extension of the wrist with the elbow held in extension and the forearm prone (see FIG. 64.4)
Lateral tennis elbow test: reproducing pain on passive stretching at the wrist
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.
The wringing exercise. Chronic tennis elbow can be cured by a simple wringing exercise using a small hand towel.9
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.
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.
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.
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.
Lateral tennis elbow: the dumbbell exercise with the palm facing down
Tennis elbow stretching exercise: the hand and wrist are rhythmically rotated inwards until the painful point is reduced
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 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.
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.
Carpal tunnel syndrome (median nerve compression syndrome
Table 64.3Carpal tunnel syndrome: causes or associations |Favorite Table|Download (.pdf) Table 64.3 Carpal tunnel syndrome: causes or associations
Consider cervical nerve root pressure
Granulomatous disorders (TB, etc.)
Occupational: repetitive work with flexed wrists
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.
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.
Carpal tunnel syndrome: Tinel sign
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
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.
Injection technique for carpal tunnel syndrome: between the palmaris longus and ulnar artery
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.
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.
Injection site for trigger finger
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.
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.
Dupuytren contracture showing flexion contractures of the fourth and fifth digits and a palmar cord
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.
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)
Triad of diagnostic signs
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.
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.
Method of tendon sheath injection
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.
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 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.
Intersection syndrome: pain is present over the intersection of tendons
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.
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.
Mallet finger with swan-neck deformity following rupture of the extensor tendon to the distal phalanx
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.
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).
Mallet finger: position of finger after application of tapes
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).
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.
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).
Raynaud phenomenon: symptoms and colour changes of fingers with cold
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)
Chilblains—itchy, patchy discolouration without pallor
Diffusely cold mottled hands—recover quickly on warming
Exclude underlying causes with appropriate tests.
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.
Vasodilators (during cold weather)15
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
amlodipine 5–20 mg (o) once daily
nifedipine SR 30–60 mg (o) once daily
diltiazem SR 180–240 mg (o) once daily
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.
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.
Throbbing, burning pain, worse at night
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 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.
Typical sites of arthritic conditions and osteochondritis in the hand
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 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.
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 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.
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.)
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
‘Cracked’ hands and fingers
Wear protective work gloves: cotton-lined PVC gloves.
Use soap substitutes (e.g. Cetaphil lotion, Dove).