A woman attends the GP surgery complaining of pains in her hand. Five common conditions may present in this way, which are easy to distinguish and fairly easy to manage:
- Carpal tunnel syndrome
- Trigger finger/thumb
- De Quervain's syndrome
- Osteoarthritis (OA)
- Dupuytren's disease
There are four key questions to ask while taking the history, which will lead you to a targeted examination to confirm the diagnosis.
How young is the patient?
Age is all-important. Middle-aged females tend to have carpal tunnel syndrome, trigger digits and De Quervain's syndrome.
OA tends to present in the 60s, while Dupuytren's disease is common in the 60s or 70s.
Where is the pain?
The 'pointing sign' is very useful in the hand. Ask the patient to point to the site of most pain.
Pain in De Quervain's syndrome is specifically over the styloid process of the radius. Thumb OA is specifically over the base of the thumb.
Dupuytren's disease, when painful, is tender over nodules in the palm. Finger OA pain is specific in its distribution. Carpal tunnel pain is often diffuse and extends up the arm.
When does the pain occur?
Nocturnal pain is classic for carpal tunnel syndrome. Hand OA has to be very advanced to cause pain at night.
Arthritic pain in the hand tends to be use-related; finger OA hurts when a patient is grasping or lifting, thumb OA is painful when unscrewing jars, peeling potatoes, or starting the car with a key. Trigger fingers and thumbs are often more painful in the morning.
Any other symptoms?
Carpal tunnel syndrome has numbness and tingling that improves when the hand is in a dependent position.
Trigger digits exhibit clicking and, potentially, locking. OA may cause finger stiffness that is worse in the morning.
Carpal tunnel syndrome
Confirm by looking for wasting of the thenar eminence and test for sensory loss in the median nerve distribution. Perform provocative tests such as the carpal tunnel compression test and Phalen's test.
Trigger finger or thumb
Confirm by eliciting the click or triggering. There will be pain over the front of the finger or thumb. Often, you can feel the lump in the flexor tendon pressing over the front of the metacarpophalangeal joint moving when the digit is flexed.
De Quervain's syndrome
Tenderness is directly over the distal radius (styloid). There is often a swelling here. Put the thumb in the palm, close the fingers around it, hold the clenched fist and ulnar deviate the wrist - this will cause pain (Finkelstein's test).
Do this on both hands, because even on the normal hand, it is uncomfortable. Resisted extension of the thumb (resist the hitch-hiking maneuvre) also causes pain.
There is localised pain over the affected joint. Movement of the joint causes pain. Deformity may be present.
Nodules are present in the palm, which can be painful. The nodules eventually become painless cords, so Dupuytren's is regarded as a painless condition.
Treatment in primary care
Splints and anti-inflammatory drugs can be prescribed for carpal tunnel syndrome and De Quervain's syndrome.
Steroid injections can be administered for carpal tunnel syndrome, but beware of injecting into the median nerve in the centre of the wrist - always inject slightly towards the ulnar from the midline.
Trigger fingers and De Quervain's syndrome can be treated with steroid injections, which may be up to 50-60% successful. All joints in the hand can be injected, but no more than three times as there is a law of diminishing returns - subsequent injections are never as good as the first.
If symptoms persist, referral is indicated. Carpal tunnel, trigger finger and De Quervain's releases are 95% successful. Trigger fingers can be injected by the GP, with about 50% success. If this is not effective, surgery is about 95% successful.
OA is treated by the GP using the analgesic ladder, then steroid injections. When these fail, referral to a hand surgeon is indicated. Thumb OA can be treated very successfully with a trapeziectomy and finger OA is treated by joint fusion or joint replacement.
The pain in Dupuytren's disease abates with time. The only indication for surgery in this condition is finger contracture.
- Mr Field is a consultant orthopaedic hand surgeon at Gloucestershire Hospitals NHS Foundation Trust.