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Overview and Evaluation of Hand Disorders
Common hand disorders include a variety of deformities, ganglia, infections, Kienböck disease, nerve compression syndromes, noninfectious tenosynovitis, and osteoarthritis. Complex regional pain syndrome (reflex sympathetic dystrophy) is Complex Regional Pain Syndrome (CRPS), and hand injuries are discussed in Fractures, Dislocations, and Sprains.
Deformities can result from generalized disorders (eg, arthritis) or dislocations, fractures, and other localized disorders. Most nontraumatic localized disorders can be diagnosed by physical examination. Once a hand deformity becomes firmly established, it cannot be significantly altered by splinting, exercise, or other nonsurgical treatment.
Common bacterial hand infections include paronychia (see Acute Paronychia), infected bite wounds, felon, palm abscess, and infectious flexor tenosynovitis. Herpetic whitlow is a viral hand infection. Infections often begin with constant, intense, throbbing pain and are usually diagnosed by physical examination. X-rays are taken in some infections (eg, bite wounds, infectious flexor tenosynovitis) to detect occult foreign bodies but may not detect small or radiolucent objects.
Treatment involves surgical measures and antibiotics. The increased incidence of community-acquired and nosocomial methicillin-resistant Staphylococcus aureus (MRSA) should be taken into consideration. Uncomplicated MRSA infections are best treated with incision and drainage. If there is a high incidence of MRSA and the infection is severe, hospitalization and vancomycin or daptomycin (for IV therapy) are recommended, as is consultation with an infectious disease specialist. For outpatients, trimethoprim/sulfamethoxazole, clindamycin, doxycycline, or linezolid (for oral therapy) can be given. Once culture and sensitivity results rule out MRSA, nafcillin, cloxacillin, dicloxacillin, or a 1st- or 2nd-generation cephalosporin can be given.
Common nerve compression syndromes include carpal tunnel syndrome, cubital tunnel syndrome, and radial tunnel syndrome. Compression of nerves often causes paresthesias; these paresthesias can often be reproduced by tapping the compressed nerve, usually with the examiner’s fingertip (Tinel sign). Suspected nerve compression can be confirmed by testing nerve conduction velocity and distal latencies, which accurately measure motor and sensory nerve conduction. Initial treatment is usually conservative, but surgical decompression may be necessary if conservative measures fail or if there are significant motor or sensory deficits.
(See also Tendinitis and Tenosynovitis.)
Although the digital flexor tendons and extensor pollicis brevis are commonly affected, tenosynovitis may involve any of the tendons in or around the hand.
History and physical examination findings are often diagnostic in hand disorders.
The history should include information about the trauma or other events that may be associated with symptoms. The presence and duration of deformity and difficulty with motion are noted. The presence, duration, severity, and factors that exacerbate or relieve pain are elicited. Associated symptoms, such as fever, swelling, rashes, Raynaud syndrome (see Raynaud Syndrome), paresthesias, and weakness, are also recorded.
Examination should include inspection for redness, swelling, or deformity and palpation for tenderness. Active range of motion should be tested for any possible tendon injury. Passive range of motion can detect the presence of fixed deformities and assess whether specific motions aggravate pain. Sensation may be tested by 2-point discrimination, using 2 ends of a paper clip. Motor function testing involves muscles innervated by the radial, median, and ulnar nerves. Vascular examination should include evaluation of capillary refill, radial and ulnar pulses, and the Allen test (see Arterial Blood Gas Sampling). Stress testing is helpful when specific ligament injuries are suspected (eg, ulnar collateral ligament in gamekeeper’s thumb—see Ulnar Collateral Ligament Sprains). Provocative testing can aid in the diagnosis of tenosynovitis and nerve compression syndromes.
Laboratory testing can aid the diagnosis of inflammatory arthropathies (eg, RA) but otherwise has a limited role. Plain x-rays and MRI are helpful for detecting injuries, arthritis, and Kienböck disease or to rule out hidden foreign bodies that could be sources of infections. MRI and ultrasonography can help assess tendon structure and integrity and detect deep abscesses. High-resolution ultrasonography allows imaging in real-time motion and is especially helpful for evaluating tendons and synovitis. Nerve conduction testing can help diagnose nerve compression syndromes. Bone scan is an alternative to MRI for the diagnosis of occult fractures and can aid the diagnosis of complex regional pain syndrome.
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