A 54-year-old, right-hand dominant female presents to the Physical Medicine and Rehabilitation (PM&R) clinic with right hand and wrist pain. She describes her pain as aching. The pain began gradually about 9 months ago without preceding injury or trauma. She indicates the pain is deep in the wrist and worse in the radial aspect. The pain is aggravated by using her right hand at work. She takes an occasional ibuprofen, which seems to help temporarily.
There is intermittent tingling in the right hand and fingers; however, she is unable to specify location of paresthesia (diffuse as per patient). She denies any significant neck, shoulder, or elbow pain. She was seen by her primary care doctor who referred her to the clinic.
Past medical history: She has history of increased cholesterol for 5 years. She had menopause 1 year ago.
Social history: She works as an executive secretary, and lives with family in a house with 12 steps. She has a 23-year-old son and 21-year-old daughter.
Past surgical history: None
Allergies: No known drug allergy
Medications: Lovastatin 40 mg daily and ibuprofen 400 mg as needed
BP: 128/76 mmHg, RR: 16/min, PR: 62 per min, Temp: 97° F, Ht: 5’5″, Wt: 160 lbs, BMI: 26.6 kg/m 2
General: Well built, well nourished, in no acute distress. She is alert, oriented to person, place, and time
Extremities: No edema, skin rashes/erythema, or surgical scars. No gross deformity of upper and lower extremities.
HEENT: Normal extraocular movements, symmetric face, no ptosis, tongue midline.
Inspection: No gross muscle atrophy other than equivocal thenar eminence flattening. Equivocal shoulder sign (at first carpometacarpal joint) suggestive of first metacarpal dorsoradial subluxation.
Range of motion (ROM): Neck, shoulder, elbow are within functional limits. Full range of wrist with mild discomfort at end range of extension and radial deviation.
Motor examination: 5‒/5 right thumb abduction with pain. All other muscles (in both upper and lower extremities): 5/5 strength.
Deep tendon reflexes: 2+ in biceps, triceps, and brachioradialis bilaterally. Negative Hoffman test bilaterally.
Sensory examination: Intact to light touch and pinprick in all dermatomes of bilateral upper extremities.
Gait: Within normal limits
Provocation tests for hand and wrist
Finkelstein test: Negative
First carpometacarpal joint grind test: Pain in the joint
Watson test (scaphoid shift test): Negative
Lichtman test for midcarpal instability: Negative
Lunate-triquetral ballottement test (Reagan test): Negative
Piano key sign for radioulnar joint instability: Negative
Ulnar styloid triquetral impaction test: Negative
Labs: White blood cell (WBC): 6800 cell/mL, hemoglobin (Hg):12.0 g/dL
General Discussion: General Approach to Wrist and Hand Pain
Initial approach should focus on differentiating musculoskeletal from neuropathic pain generators. Typically, pain description, such as pins/needle, burning, “shooting,” and/or numbness indicate neuropathic pain in origin. In contrast, pain characterized as aching, deep, or sore is more representative of musculoskeletal pain. However, chronic musculoskeletal pathology can have mixed features. Musculoskeletal pathology can be further classified by location of pain and point of maximal tenderness ( Table 5.1 ). Etiologies of neuropathic pain can be further classified by the pattern of symptom distribution; diffuse (peripheral polyneuropathy) versus localized (mononeuropathy [entrapment neuropathy]) versus regional (cervical radiculopathy or brachial plexopathy). Less commonly, referred pain from proximal musculoskeletal pathology can mimic neuropathic pain generators.
|Dorsoradial||Bone||First carpometacarpal (CMC) osteoarthritis (OA): MC site for hand OA |
First metacarpophalangeal, wrist (radial-scaphoid) and scaphoid-trapezium OA
Scaphoid fracture, nonunion
|Tendons||de Quervain tenosynovitis involving first dorsal extensor compartment |
Intersection syndrome; 4–8 cm proximal to radial styloid
Extensor digitorum brevis manus syndrome (accessory muscle)
|Nerve||Superficial radial neuropathy|
|Middorsal||Bone, joint structures||Ganglion; most common (MC) from scapholunate joint |
Scapholunate ligament sprain, dissociation/instability
|Tendon||Extensor pollicis longus, extensor indicis, or extensor digitorum tendinopathy, tenosynovitis, tear |
Distal intersection syndrome (between third dorsal extensor compartment and second dorsal extensor compartment intersection distal to the Lister tubercle)
|Dorsoulnar||Bone||Arthropathy involving radioulnar joint and CMC joint (triquetrum, hamate, fourth and fifth metacarpal bone) |
Ulnar triquetral impingement
Triangular fibrous cartilage complex (TFCC) lesion
|Tendons||Extensor carpi ulnaris tendinopathy, stenosing tenosynovitis, subluxation/dislocation, tear|
|Volar radial||Bone||OA of first CMC joint. Wrist and MCP arthropathy |
|Tendons||de Quervain tenosynovitis |
Flexor carpi radialis tendinopathy
Ganglion cyst originated from flexor tendon
Linburg-Comstock syndrome (anomalous tendon slip from the flexor pollicis longus to flexor digitorum profundus [to second digit])
Trigger finger (stenosing tenosynovitis) at the A1 pulley
|Midvolar||Bone||Arthropathy involving radiocarpal, carpal and second to fourth MCP joints|
|Carpal tunnel||Carpal tunnel syndrome (often diffuse)|
|Tendon||Trigger finger |
|Volar ulnar||Bone||Radioulnar arthropathy/instability, TFCC lesion |
Pisotriquetral arthritis, ulnotriquetral impingement syndrome, fourth or fifth MCP arthropathy, hook of hamate fracture, fracture of metacarpal bone
|Tendons||Flexor carpi ulnaris tendinopathy |
Gradual onset of chronic wrist and hand pain indicates degenerative or repetitive overuse injury as the underlying mechanism for pain. In contrast, traumatic, vascular, or acute inflammatory processes occur abruptly with immediate or rapid onset. Although serious life-threatening pathologies are less common in the wrist and hand, it is important to recognize red flags, such as history of trauma/puncture and increased external compression, requiring urgent workup and treatment.
Focused physical examination of hand and wrist starts with inspection. Presence of skin lesions (erythema or rash) provides valuable information indicating inflammatory/rheumatologic, vascular, or infectious etiologies. Gross deformity of the hand and wrist suggests underlying chronic destructive pathology or muscle agonist/antagonist imbalance. Common deformities from rheumatoid arthritis (RA) include ulnar deviation of fingers and wrist, joint swelling (Bouchard node in proximal interphalangeal joint and Heberden nodes in distal interphalangeal joint), and finger deformity (Boutonniere or Swan neck deformity). Wartenberg sign (little finger abduction), ulnar claw hand, or benediction sign can be easily recognized in patients with ulnar neuropathy. In addition, it is important to evaluate proximal segments of upper extremities such as elbow, shoulder, and neck.
Significant atrophy of thenar, hypothenar, and/or intrinsic muscles indicates underlying neurologic etiologies. Lower motor neuron disease is favored over upper motor neuron disease, although mild disuse atrophy can occur in chronic painful musculoskeletal conditions. Pattern of atrophy can help the clinician develop and narrow down differential diagnoses.
Mild swelling of the hand and wrist can be easily missed, similar to mild atrophy of the hand and wrist muscles. Swelling may be present in multiple structures (joint, tendon/tenosynovium, or subcutaneous/vascular).
Passive and active ROM of the wrist, hand, and fingers should be examined. ROM of the thumb is particularly complicated, including flexion/extension, abduction/adduction, and opposition/reposition ( Fig. 5.1 ). Flexion/extension occurs in parallel to the palmar plane, abduction/adduction is perpendicular or orthogonal to the palmar plan, and opposition is the combined movement of flexion and abduction.
Systematic palpation provides important clues for local pain generators. Several bony landmarks are useful to remember. At the level of the distal wrist crease, distal pole of the scaphoid and pisiform are easily palpated. The scaphoid is located radially, and the pisiform ulnarly ( Fig. 5.2 ). At the proximal border of the first metacarpal bone, the trapezio-first metacarpal joint (often recognized as ridge of the shoulder sign) is palpable. Rotation of the tip of the thumb can be useful to identify the trapezio-first metacarpal joint with differential rotation (more rotation in the first metacarpal bone vs less mobile trapezium). Distal crease also overlaps with proximal entrance of carpal tunnel. In carpal compression test and Tinel sign, the compression site should be immediately distal to the distal wrist crease.
The pattern and the degree of weakness of muscle strength are useful for differential diagnosis. Weakness secondary to musculoskeletal pain is usually mild from extended disuse, and located around the painful structure rather than following peripheral nerve or myotomal patterns. Except for muscles in the thenar eminence, most intrinsic hand muscles are innervated by the ulnar nerve. Ulnar nerve lesion can be suspected if there is intrinsic muscle weakness, especially of power grip, such as hook and cylindric grip.
For sensory examination, understanding the difference between peripheral nerve lesions and root lesions can be useful in arriving at the differential diagnosis. Splitting of sensation in the fourth digit in peripheral nerve lesions (either median or ulnar nerve lesion) versus no splitting in C8 radiculopathy is helpful information. However, normal variation of sensory nerve distribution should be acknowledged. Examination of light touch, vibration, two-point discrimination rather than pinprick, and temperature sensation may provide more information in entrapment neuropathy, which typically involves large fibers. Bilateral symptoms with upper motor neuron complaints, such as unsteadiness or gait dysfunction, Hoffman sign, or plantar scratch reflex (Babinski sign), can be useful.
Common Differential Diagnoses for Wrist and Hand Pain
Entrapment neuropathy —carpal tunnel syndrome is the most common entrapment neuropathy, with a prevalence of about 3%. Patients present with positive sensory (tingling, paresthesia, pins/needle sensation, and/or pain) or negative sensory (numbness) symptoms in the distribution of median nerve distal to the carpal tunnel. Thenar eminence is spared because the palmar cutaneous branch courses superficial (outside) to the carpal tunnel. Symptoms are typically located in radial 3.5 fingers, with sparing of ulnar side of fourth digit. Because anatomic variation of digital nerve distribution exists, the presentation can vary.
Typically, symptoms are gradual or insidious in onset. However, with additional minor injury or trauma, some patients may report relatively abrupt onset. Symptoms are worse at night and can interfere with sleep by waking the patient. Shaking hands when symptoms occur, known as Flicker sign , often improves symptoms.
Ulnar neuropathy at the wrist (Guyon canal) is not as common as ulnar neuropathy at the elbow. Ulnar neuropathy at the wrist presents with sensory and/or motor deficits depending on the location of the lesion in Guyon canal. Because sensory symptoms are underrecognized, presentation is often delayed until significant atrophy of intrinsic hand muscles occurs.
Tendinopathy or tenosynovitis —pain from tendons and tenosynovial pathology is common in the hand and wrist, typically associated with overuse or repetitive injury. Focal, reproducible pain with exertion (resisted muscle contraction) or stretching is the hallmark physical examination finding of tendinopathy or tenosynovitis. Focal swelling of the tendon or tenosynovium may be present. The most common tendinopathy in the wrist is de Quervain disease, tendinopathy/tenosynovitis of first dorsal extensor compartment (abductor pollicis longus and extensor pollicis brevis). There is pain in the radial aspect of the wrist, in the vicinity of radial styloid process. Tendinopathy/tenosynovitis of extensor carpi ulnaris and flexor carpi ulnaris (FCU) can be suspected in the dorsal-ulnar and volar-ulnar aspect of the wrist.
Strains, sprains, and tear— localized wrist and hand pain is common following an injury of muscle/tendon (strain) or ligament (sprain). Tenderness of the injured structure can be appreciated with or without ecchymosis and/or swelling depending on the degree of injury. Typically, there are no neurologic symptoms. Ligament sprains include gamekeeper thumb, involving ulnar collateral ligament of first metacarpophalangeal joint or jammed finger involving collateral ligament in the proximal interphalangeal joint. Ligament sprain of carpal bones such as scapholunate, lunate-triquetrum ligament is often underrecognized, later developing into chronic pain and instability.
Osteoarthritis —most common location of osteoarthritis (OA) in the upper extremity is the hand, particularly in the first carpometacarpal (CMC) joint (trapezio-first metacarpal joint). The radiographic evidence of arthritis is common in middle-aged or elderly (up to 36%), and is more common in females than in males. Symptoms can be vague and confused with other commonly coexisting pain generators that present similarly, such as carpal tunnel syndrome and de Quervain disease. Pain from OA is typically intermittent during early stage of disease, becoming more constant in advanced stages. Pain is aggravated by functional activities requiring axial loading of the joint, especially smaller grip. Subtle swelling of the joint may be present, with radial-dorsal subluxation of the first metacarpal bone (shoulder sign). Stiffness accompanies pain, although not as prolonged as with RA. ROM with axial loading (CMC grind test) reproduces the pain.
Rheumatoid arthritis —affects an estimated 1% of adults. The disease is two to three times more common in females, with peak onset between 35 and 60 years. RA frequently involves multiple small joints, particularly metacarpophalangeal joints, and proximal interphalangeal joints, typically in both hands. The onset of pain is gradual, typically over weeks to months. Prolonged stiffness lasting greater than 1 hour is common. Swelling of the joint (synovitis) and tenosynovium (tenosynovitis) cause focal, multifocal, or regional swelling. In the early stages, swelling can be difficult to identify without imaging modalities, such as ultrasonography and magnetic resonance imaging (MRI). Initially, symptoms may improve with activity. Because carpal tunnel syndrome frequently coexists, owing to hyperplastic synovium and thickened transcarpal ligament, the patient may also have sensory symptoms. With prolonged inflammation of tendon/tenosynovium in RA, tear or rupture of tendons is not unusual, which can be mistaken as focal motor deficit from neurologic disorders.
Chondrocalcinosis , —the wrist is the second most common location for calcium pyrophosphate dihydrate deposition (CPPD) following the knee joint. Pseudogout is the most common form of crystal deposition disease in the wrist, often involving both wrists and hands. The onset begins between 40 and 50 years of age, typically affects elderly, and is more common in females than males. Other crystal deposition diseases such as gout and hydroxyapatite crystal deposition disease are rare in the wrist. The most common location for CPPD is triangular fibrous cartilaginous complex (TFCC), followed by scaphoid-trapezial-trapezoidal joint. It is associated with other arthropathies, such as OA, RA, and hyperparathyroidism. Typical presentation is with acute pain with swelling, but some are asymptomatic. Minor trauma may act as a trigger of symptoms. In two-thirds of patients, the condition is bilateral.
Psoriatic arthropathy —an underrecognized inflammatory arthropathy that presents with pain, deformity, redness, and swelling of the fingers (dactylitis). Deformity of fingers is not uncommon, including dactylitis and arthritis mutilans (marked bone resorption or osteolysis with telescoping digits). , Psoriatic arthropathy often accompanies spondyloarthropathy with low back pain and enthesopathy, such as insertional Achilles tendinopathy or plantar fasciitis.
Bursitis —uncommon in the wrist and hand, adventitial (acquired, not from native bursa) bursal inflammation should be included in the differential diagnosis for pain with or without focal swelling. Intersection syndrome between first dorsal extensor compartment (abductor pollicis long [APL] and extensor pollicis brevis [EPB]) and second dorsal extensor compartment (extensor carpi radialis longus [ECRL] and brevis [ECRB]) is located approximately 7 to 10 cm proximal to the radial styloid process. Less well known is distal intersection syndrome between second dorsal extensor compartment and third dorsal extensor compartment (extensor pollicis longus) found distal to Lister tubercle on the dorsum of the hand. Both conditions are aggravated by the repetitive wrist movements, specifically hammering, rowing, and racquet sports.
Undisplaced fracture and osteonecrosis —easily identifiable with severe pain, swelling, and deformity. Such fractures are managed acutely based on the degree of displacement and involvement of joint. Nondisplaced fracture or stress fracture can be missed because of false-negative initial x-ray results and lack of significant history of trauma. In patients with high-risk factors, such as osteoporosis and mineral bone disease, minor trauma or repetitive overuse can lead to fracture. Examination typically reveals discreet and subtle tenderness at the site of fracture. High level of suspicion is required for patients with risk factors. In young athletes engaged in repetitive compressive impact and torsion forces, epiphyseal injury known as gymnast wrist should also be suspected. Missed or unhealing fracture can cause osteonecrosis of carpal bones, commonly in scaphoid and lunate. In addition, avascular necrosis can also occur in carpal bones (Kienbock disease involving lunate) with insidious onset of pain, swelling, and decreased wrist ROM.
Benign and malignant tumor —rare in the hand and wrist, accounting for 6% of bony tumors or metastasis; however, tumor should be included in the differential diagnosis for patients with a history of cancer or red flags. Most tumors in the hand are benign, with giant cell tumor of the tendon sheath being the most common. Giant cell tumors are typically located in the distal radius and middle phalanx and radial three digits. Although some cases are asymptomatic, presentation is usually progressive worsening of pain, which eventually becomes constant. Pain is often worse at night or with rest. Systemic manifestation such as weight loss is uncommon.
Osteomyelitis or septic arthritis —similar to malignancy, red flags such as trauma, open/puncture/bite wound, history of acquired immunodeficiency syndrome (AIDS), intravenous drug abuse, and poorly controlled diabetes should increase suspicion for infection. With persistent wound or cellulitis, osteomyelitis or septic arthritis should be strongly considered. There is constant pain, often without any systemic symptoms. Infection may present with redness, warmth (increased temperature), and/or subtle swelling. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are frequently elevated, although white blood cell count may be normal.
Referred pain from cervical spine and elbow —typically presents with neck and elbow pain in addition to hand/wrist pain. The patient describes radiating pain from the neck down to the hand. Cervical radiculopathy (C6–C8) presents with neck pain radiating down to the forearm and distally to the fingers. C7 radiculopathy, the most common level, presents with neck pain radiating down to the hand and fingers, particularly to third digit. C6 radiculopathy radiates to the thumb and index finger, and to the ring and little finger in C8 radiculopathy. Spurling test can be specific if it reproduces radiating pain down to the hand (sensitivity 30%–60% and specificity 92%–100%). , The elbow is an underrecognized pain generator. Posterior interosseous nerve entrapment syndrome may cause deep wrist pain lacking typical sensory symptoms without elbow pain in many cases.
Other neuropathic pain —complex regional pain syndrome (CRPS) present with pain in the hand, as well as in the shoulder (shoulder-hand syndrome). CRPS may occur after nerve injury (type 2) or following minor injury, without a specific nerve injury (type 1). There is spontaneous pain, hyperalgesia/allodynia beyond the distribution of single nerve or root that is disproportionate to the inciting event. Trophic changes, such as hypertrophic nails, disturbance of hair growth, atrophic skin, edema, sudomotor abnormalities (dry, warm, erythematous extremity, cold or hyperhidrosis) may be appreciated on examination. Early recognition and aggressive management is important. Cutaneous neuropathy, such as Wartenberg syndrome from superficial radial neuropathy presents with pain, tingling, pins/needle sensation in the radial side of the wrist and hand. The pain and sensory symptoms may radiate proximally toward the elbow. Careful palpation of the lesion to trigger or reproduce the symptom (Valleix phenomenon) is a useful physical examination technique.
Absence of pain in the proximal upper extremity or neck makes referred or radiating pain less likely. Local wrist and hand pain can be divided into neuropathic, musculoskeletal, or combined.
Presence of positive sensory symptom (tingling paresthesia) in this case suggests neuropathic pain generators. Localization of the symptom into the hand and wrist makes a focal entrapment neuropathy more likely over cervical radiculopathy, brachial plexopathy, complex regional pain syndrome, or others.
Location of sensory symptoms and signs is very useful in differentiating peripheral entrapment syndrome in most cases. For example, symptoms in the palmar-radial aspect suggest carpal tunnel syndrome, ulnar side symptoms suggest ulnar neuropathy, and dorsal-radial symptoms suggest sensory radial neuropathy. As in this case, patients often have difficulty describing the exact location of sensory symptoms. In addition, there are musculoskeletal mimickers with positive sensory symptoms. Coexisting musculoskeletal pathology and focal entrapment syndrome are not uncommon.
Musculoskeletal pain generators in the radial aspect of the wrist include pathologies involving radiocarpal, scaphotrapezial, trapeziometacarpal, scaphoid-trapezium-trapezoid, scapholunate joints, ligaments, first dorsal extensor column (APL, EPB), and extensor pollicis longus.
Systematic palpation of structures is useful in delineating local pathologies. Provocative maneuvers can be applied to different structures. CMC grind test (rotation of the first metacarpal while axial loading) can reproduce pain from CMC joint while stretching by ulnar deviation can aggravate symptoms from de Quervain tenosynovitis. Resisted contraction of muscle (without joint movement) can also help to differentiate pain from joint structure or tendon/tenosynovium.
Shifting the scaphoid while pressing the distal pole of the scaphoid (pressure toward the dorsum) during radioulnar deviation of the wrist (scaphoid shift test) can reproduce the symptom mediated by scapholunate instability.
Pain reproduced by supination from pronation in an ulnarly deviated wrist is specific for ulnar triquetral impaction syndrome as the supination decreases the space between the ulnar and triquetrum.
Differential palpation can also be useful. Tenderness on the distal scaphoid tubercle at the level of distal wrist crease may suggest scaphoid bony pathology. The scaphotrapezial joint is located immediately distal to the distal pole of the scaphoid (see Fig. 5.2 ). The trapezium-first metacarpal joint is easily palpated from the proximal end of the first metacarpal, as it is located more radially and has a shape similar to the shoulder.
The pisiform is located at the ulnar side of distal wrist crease, opposite to the distal pole of scaphoid. Tenderness of the pisiform may indicate FCU enthesopathy or pisotriquetral arthropathy. Grinding of the pisiform (movement with compression) can reproduce pain on the pisiform versus worsening pain on resisted wrist flexion and ulnar deviation favoring FCU tendinopathy. Palpation of the fovea located immediately distal to the ulnar styloid process can be useful for TFCC lesion.
Paresthesia indicates the involvement of sensory nerve pathways, but often not specific in terms of size of nerve fibers. Pins/needle sensation, burning can suggest involvement of small fibers whereas loss of proprioception and light touch indicates large fiber involvement.
Electrodiagnosis (EMG) test can be particularly useful to evaluate subclinical/mild motor deficit or symptoms from large sensory fibers. In addition to localizing the lesion, EMG can characterize the lesion into axonal, demyelinating, or mixed lesions, which can guide treatment and provide severity and prognosis. In this case, an EMG test to evaluate paresthesias may be useful.
Absence of red flags, in this case, lowers the possibilities of infections or malignancy as the underlying cause although cannot be completely excluded. If there is any concern, imaging (at least x-ray), and laboratory tests should be done (ESR and CRP) to evaluate these possibilities.