Arm and hand pain (excluding fractures)

Probability diagnosis

Dysfunction of the cervical spine (lower)

Disorders of the shoulder

Medial or lateral epicondylitis

Overuse tendonopathy of the wrist

Carpal tunnel syndrome

Osteoarthritis of the thumb and DIP joints

Serious disorders not to be missed

Cardiovascular:

• angina (referred)

• myocardial infarction

• axillary vein thrombosis

• arm claudication (left arm)

Infection:

• septic arthritis (shoulder/elbow)

• osteomyelitis

• infections of tendon sheath and fascial spaces of hand

• sporotrichosis (‘gardener’s arm’)

Neoplasia/cancer:

• Pancoast tumour

• bone tumours (rare)

Pitfalls (often missed)

Entrapment neuropathies (e.g. median nerve, ulnar nerve)

Pulled elbow (children)

Foreign body (e.g. elbow)

Rarities:

• polymyalgia rheumatica (for arm pain)

• complex regional pain syndrome I

• thoracic outlet syndrome

• erythromelalgia

• Kienböck disorder

Masquerades checklist

Depression

Diabetes

Spinal dysfunction

Is the patient trying to tell me something?

Highly likely, especially with the so-called RSI syndromes.

Key history

Include an analysis of the pain and a history of trauma, particularly unaccustomed activity. In children ask about pulling the child up by the arms or a fall on an outstretched arm. Ask for relationship of pain to any sleep disturbance.

Key examination

Inspect the arm as a whole with both arms free of clothing and compare both sides. It may be necessary to examine a variety of joints including the cervical spine, shoulder, elbow, wrist and various joints of the hand.

Key investigations

• FBE

• ESR/CRP

• Consider ECG, nerve conduction studies, plain X-ray according to rule ‘if in doubt, X-ray and compare both sides’, ultrasound for soft tissue injuries (e.g. tendonopathy)

Diagnostic tips

The working rule for arm pain causing sleep disturbance:

• thoracic outlet: patient cannot fall asleep

• carpal tunnel syndrome: wake in middle of night then settles

• cervical spondylosis: wakes patient with pain that persists.

Always keep regional pain syndrome in mind for persistent burning pain in hand following injury, trivial or severe.