Rheuma CARE

Approach to hand
and wrist pain

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Concepts to learn
1. Anatomy of hand and wrist
2. Common problems of hand and wrist pain
3. Examination
4. Investigations

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Anatomy
1. Hand bones

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Wrist Bones
First row
1. Hamate
2. Capitate
3. Trapezoid
4. Trapezium
Second row
5. Pisiform
6. Triquetrum
7. Lunate
8. Scaphoid

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Wrist and hand joints

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Tendons

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Nerves

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Regions of hand
 History

S Skin and nail

Site S

P Pattern
Onset O

Characteristics C S Severity

Radiation R
E Exacerbating and
relieving features

Associated features A
T Timing

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S (Site): Be specific about the location of the pain. Is it in your fingers, palm, wrist, or all over? Is it in one hand or both?

O (Onset): When did the pain start? Was there a specific event or injury that triggered it, or did it develop gradually over time?

C (Character): Is it pain. Is there numbness, weakness

R (Radiation): Does the pain radiate to any other areas, such as your forearm, elbow, or shoulder?

A (Associated symptoms): Is there EMS? How long does it last? Is there swelling, redness, difficulty gripping objects.

T (Timing): Is the pain intermittent or persistent? Is there a time of day when it's worse (e.g., morning stiffness)?

E (Exacerbating and relieving factors): What makes the pain worse? What seems to improve it (rest, ice, pain medication)?

S (Severity): Is there difficulty in making fist, gripping objects. If its acute pain, rate the pain on a scale of 1 (mild) to 10 (worst ).

P (Pattern): Is it affecting both hands or single hand. Is it migratory or persistent.

S (Skin and nail changes): Is there any skin or nail changes

 Rule out the following first

Previous treatment
Sprain

Fracture Falls

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 Examination
• Look

Nail fold Nail pitting Onycholysis

capillary loss
 Dactylitis

Synovitis

RS3PE (remitting seronegative symmetric

Complex Regional Pain Syndrome synovitis with pitting oedema)
 Deformities

Z deformity
Swan neck

Heberden node
Boutonniere
deformity

Bouchard node
Ulnar deviation
Rheumatoid nodules Ganglion

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Gottron’s papules

Sclerodactyly

Calcinosis cutis

Raynaud's Phenomena

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Examination

Tenderness (TJC) and synovitis (SJC)

• Palpate DIP ,PIP ,MCP , CMC ,Wrist
• MCP squeeze

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 Examination
Range of motion
 Hand ROM- Ask the patient to make a fist. They should be able to
bury their fingernails in the palm of their hand.

 Wrist ROM- range of motion in your wrist by asking you to move

your hand up and down (flexion and extension), side to side (radial
and ulnar deviation), and in a circular motion.

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Phalen’s test for median nerve compression within the carpal tunnel

1. Raise arm to shoulder level

2. Bring dorsum of hands together in midline
3. Hold wrist in forced flexion for 30-60 secs

Positive test Tingling and numbness over median nerve distribution

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Finkelstein’s test for De Quervain’s tenosynovitis

1. Flex thumb across palm and wrap the fingers around the thumb
2. Passively deviates the wrist in an ulnar direction

Pain indicates positive test

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Power grip

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Investigations
•Radiographs
•Ultrasonography

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 Inflammatory arthritis

Rheumatoid Arthritis (RA)

• Symmetrical involvement: This is a hallmark feature of RA.
• Small joints- mainly the PIP ,MCP joints . The DIP joints usually spared in RA
• Spindle-shaped swelling
• Wrist involvement: Distal radioulnar joint
• Tendon involvement: Tenosynovitis
• Deforming arthritis -Swan-neck deformity (hyperextension of PIP joint with flexion of DIP joint) ,
boutonniere deformity (flexion of PIP joint with hyperextension of DIP joint). MCP joint deformities include
ulnar drift, volar subluxation, and flexion deformities. Wrist ankylosis deformity

Spindle-shaped swelling

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 Inflammatory arthritis

Psoriatic Arthritis (PSA)

• Asymmetrical involvement:
• Distal interphalangeal (DIP) joint involvement: A distinguishing feature of PsA
• Sausage-like swelling
• Nail involvement
• Wrist involvement: less common in PsA compared to RA
• Deforming arthritis –Gull wing deforming ,saw tooth ,pencil in cup , opera glass hand deformity

Dactylitis

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 Inflammatory arthritis

Connective tissue disorders

• Hand and wrist involvement is usually less severe and inflammatory compared to RA and PSA
• Does not follow a specific pattern of joint involvement
• Can cause swelling of tendon sheaths
• Non-Deforming arthritis
• Other features – Rashes, Raynaud’s ,Sclerodactaly

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Pseudogout

 Sudden wrist inflammation in an older patient may be due to

calcium pyrophosphate arthritis (pseudogout).
 Marked swelling and inflammation are observed the joint feels hot
 Usually seen in wrist ,ankle and knee

Chondrocalcinosis in wrist

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Raynaud’s phenomena

• Raynaud's phenomenon causes fingers and toes to experience episodes of reduced blood flow in
response to cold or emotional stress.

• During an attack, the affected areas typically turn white, then blue, and finally red as blood flow
returns

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Osteoarthritis

1. Erosive OA
• Heberden’ s nodes (DIP joints)
• Bouchard nodes (PIP joints)
2. CMC osteoarthritis

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De Quervain’s tenosynovitis

Significant radial-sided wrist pain with focal swelling and tenderness proximal to the radial styloid over these tendons.

Demonstration of the Finkelstein test.

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TRIGGER FINGER (STENOSING DIGITAL TENOSYNOVITIS)

• Flexor tendon gets stuck or catches within its sheath, causing a popping or snapping sensation when you try to bend or
straighten your finger.
• The thickening of the tendon sheath or the A1 pulley itself can narrow the space for the tendon to glide smoothly.
• In some cases, a small nodule might form on the tendon, further hindering its movement within the A1 pulley\
• A sensation of your finger catching or locking in a bent position is the classic symptom,

Demonstration of the Finkelstein test.

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Dupuytren’s contracture
• Thickening of the palmar fascia (fibrous tissue layer in the palm).
• Genetic predisposition and diabetes are risk factors.
• Develops gradually over months or years.
• Presents with painless thickening and nodule formation in the palm.
• Gradual contracture (bending) of one or more fingers towards the palm, making it difficult to
straighten them completely.
• In severe cases, the finger might become permanently bent

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Carpel Tunnel Syndrome

• A condition that causes numbness, tingling, and pain in the hand and forearm
• The median nerve, which runs along the carpal tunnel in your wrist, gets compressed.

Burning or tingling sensations or numbness (or both) over the volar aspect of the radial three digits. Pain at
night and difficulty sleeping. Difficulty holding objects. May report weakness while holding phone, glass.

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 Treatment
Non-surgical treatment options include
 Anti inflammatory drugs
 Immunosuppressive drugs.
 Avoidance of repetitive activity
 Splinting with active physical therapy
 Hand occupational therapist

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Conditions that respond to local steroid therapy
 Tenosynovitis, e.g. De Quervain’s.
 Tendon nodules and ganglia.
 Flexor tenosynovitis (and trigger finger).
 Dupuytren’s contracture.
 Carpal tunnel syndrome.
 Synovitis: radiocarpal and radioulnar at the wrist, MCPJs and PIPJs, first carpometacarpal.

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Surgical options for the hand and wrist may include:
 Synovectomy of joints and/or tendons (RA).
 Ulna styloidectomy and wrist synovectomy (RA).
 Tendon repair and transfer operations (RA).
 Dupuytren’s release/fasciectomy.
 Carpal tunnel release.

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 Common causes of hand and wrist disorders
Articular

 Arthritis of the wrist, MCP, PIP, or DIP

 Trauma, Hypermobility, and sprain

 RA (wrist, MCP, PIP joints)

 PSA (Wrist, MCP, PIP, DIP joints, dactylitis)

 Osteoarthritis (first CMC, PIP - Bouchard's Nodes: and DIP joints- Heberden nodes)

 Deformities (Swan neck ,boutonniere ,Z shaped ,Ulnar drift, Wrist ankylosis)

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Periarticular
•Tenosynovitis
1. De Quervain’s tenosynovitis
2. Distal flexor stenosing tenosynovitis (trigger finger or thumb)
•Dupuytren’s contracture
•Ganglia, subcutaneous nodules, tophi
•Pigmented villonodular tenosynovitis (giant cell tumor of the tendon sheath)

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Neurologic
 Median nerve entrapment (carpal tunnel or at pronator teres)
 Brachial plexopathy
 Cervical nerve root irritation
 Complex regional pain syndrome

Referred pain.
 Fibromyalgia

Skin changes
 Scleroderma- Raynaud’s, sclerodactyly, telangiectasia, ischemic digital ulcers, -, pitting of the skin, nail fold abnormalities,
periungual erythema
 Small- or large vessel Vasculitis- With digital ischemia, ischemic ulcers,
 Takayasu arthrit
 PSA-psoriatic skin and nail lesions
 MTX nodules

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Thank you

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