Merck Manual

Please confirm that you are a health care professional

honeypot link

Overview and Evaluation of Hand Disorders

By

David R. Steinberg

, MD, Perelman School of Medicine at the University of Pennsylvania

Last full review/revision May 2020| Content last modified May 2020
Click here for Patient Education
Topic Resources

Common hand disorders include a variety of deformities, ganglia Ganglia Ganglia are cystic swellings occurring usually on the hands, especially on the dorsal aspect of the wrists. Aspiration or excision is indicated for symptomatic ganglia. (See also Overview and... read more Ganglia , infections Hand infections Common hand disorders include a variety of deformities, ganglia, infections, Kienböck disease, nerve compression syndromes, noninfectious tenosynovitis, and osteoarthritis. (See also complex... read more Hand infections , Kienböck disease Kienböck Disease Kienböck disease is avascular necrosis of the lunate bone. Symptoms include wrist pain and tenderness. Diagnosis is with imaging. Treatment is with various surgical procedures. (See also Overview... read more Kienböck Disease , nerve compression syndromes Nerve compression syndromes of the hand Common hand disorders include a variety of deformities, ganglia, infections, Kienböck disease, nerve compression syndromes, noninfectious tenosynovitis, and osteoarthritis. (See also complex... read more Nerve compression syndromes of the hand , noninfectious tenosynovitis Noninfectious tenosynovitis Common hand disorders include a variety of deformities, ganglia, infections, Kienböck disease, nerve compression syndromes, noninfectious tenosynovitis, and osteoarthritis. (See also complex... read more Noninfectious tenosynovitis , and osteoarthritis Osteoarthritis (OA) Osteoarthritis is a chronic arthropathy characterized by disruption and potential loss of joint cartilage along with other joint changes, including bone hypertrophy (osteophyte formation). Symptoms... read more Osteoarthritis (OA) . (See also complex regional pain syndrome Complex Regional Pain Syndrome (CRPS) Complex regional pain syndrome (CRPS) is chronic neuropathic pain that follows soft-tissue or bone injury (type I) or nerve injury (type II) and lasts longer and is more severe than expected... read more [reflex sympathetic dystrophy] and hand injuries Overview of Fractures A fracture is a break in a bone. Most fractures result from a single, significant force applied to normal bone. In addition to fractures, musculoskeletal injuries include Joint dislocations... read more Overview of Fractures .)

Hand deformities

Deformities of the hand can result from generalized disorders (eg, arthritis) or dislocations Finger Dislocations Most finger dislocations occur at the proximal interphalangeal (PIP) joint; they are usually caused by hyperextension and thus are usually dorsal. Finger dislocations can be dorsal, lateral... read more Finger Dislocations , fractures Fingertip Fractures Fingertip (tuft) fractures occur in the distal phalanx. The usual mechanism is a crush injury (eg, in a door jamb). (See also Overview of Fractures.) Fingertip fractures are common. They range... read more Fingertip 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.

Hand infections

Common bacterial hand infections include paronychia Acute Paronychia Paronychia is infection of the periungual tissues. Acute paronychia causes redness, warmth, and pain along the nail margin. Diagnosis is by inspection. Treatment is with antistaphylococcal antibiotics... read more Acute Paronychia , infected bite wounds Infected Bite Wounds of the Hand A small puncture wound, particularly from a human or cat bite, may involve significant injury to the tendon, joint capsule, or articular cartilage. The most common cause of human bites is a... read more , felon Felon A felon is an infection of the pulp space of the fingertip, usually with staphylococci and streptococci. (See also Overview and Evaluation of Hand Disorders.) The most common site is the distal... read more Felon , palm abscess Palm Abscess A palm abscess is a purulent infection of deep spaces in the palm, typically with staphylococci or streptococci. (See also Overview and Evaluation of Hand Disorders.) Palm abscesses can include... read more , and infectious flexor tenosynovitis Infectious Flexor Tenosynovitis Infectious flexor tenosynovitis is an acute infection within the flexor tendon sheath. Diagnosis is suggested by Kanavel signs and confirmed with x-rays. Treatment is surgical drainage and antibiotics... read more . Herpetic whitlow Herpetic Whitlow Herpetic whitlow is a cutaneous infection of the distal aspect of the finger caused by herpes simplex virus. (See also Overview and Evaluation of Hand Disorders.) Herpetic whitlow may cause... read more 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 of most hand infections involves surgical measures and antibiotics. The increased incidence of community-acquired and nosocomial methicillin-resistant Staphylococcus aureus (MRSA) should be taken into consideration (1 General references Common hand disorders include a variety of deformities, ganglia, infections, Kienböck disease, nerve compression syndromes, noninfectious tenosynovitis, and osteoarthritis. (See also complex... read more General references ). Uncomplicated MRSA infections are best treated with incision and drainage (2 General references Common hand disorders include a variety of deformities, ganglia, infections, Kienböck disease, nerve compression syndromes, noninfectious tenosynovitis, and osteoarthritis. (See also complex... read more General references ). 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. Nontuberculous mycobacterial infections should be considered in patients with more subacute inflammation, especially in those who are immunosuppressed.

Nerve compression syndromes of the hand

Common nerve compression syndromes include carpal tunnel syndrome Carpal Tunnel Syndrome Carpal tunnel syndrome is compression of the median nerve as it passes through the carpal tunnel in the wrist. Symptoms include pain and paresthesias in the median nerve distribution. Diagnosis... read more , cubital tunnel syndrome Cubital Tunnel Syndrome Cubital tunnel syndrome is compression or traction of the ulnar nerve at the elbow. Symptoms include elbow pain and paresthesias in the ulnar nerve distribution. Diagnosis is suggested by symptoms... read more Cubital Tunnel Syndrome , and radial tunnel syndrome Radial Tunnel Syndrome Radial tunnel syndrome is compression of the radial nerve in the proximal forearm. Symptoms include forearm and elbow pain. Diagnosis is clinical. Treatments include splinting and sometimes... read more . 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 Nerve conduction studies When determining whether weakness is due to a nerve, muscle, or neuromuscular junction disorder is clinically difficult, these studies can identify the affected nerves and muscles. In electromyography... read more and distal latencies, which accurately measure motor and sensory nerve conduction. Initial treatment is usually conservative (eg, rest, modified work environment, splinting, corticosteroid injection), but surgical decompression may be necessary if conservative measures fail or if there are significant motor or sensory deficits.

Noninfectious tenosynovitis

General references

  • 1. O'Malley M, Fowler J, Ilyas AM: Community-acquired methicillin-resistant Staphylococcus aureus infections of the hand: Prevalence and timeliness of treatment. J Hand Surg Am 34(3):504–508, 2009. doi: 10.1016/j.jhsa.2008.11.021.

  • 2. Chen WA, Plate JF, Li Z: Effect of setting of initial surgical drainage on outcome of finger infections. J Surg Orthop Adv 24(1):36–41, 2015.

Evaluation of Hand Disorders

History and physical examination findings are often diagnostic in hand disorders.

History

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 Raynaud Syndrome Raynaud syndrome is vasospasm of parts of the hand in response to cold or emotional stress, causing reversible discomfort and color changes (pallor, cyanosis, erythema, or a combination) in... read more Raynaud Syndrome , paresthesias, and weakness, are also recorded.

Physical examination

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 Arterial Blood Gas (ABG) Sampling Gas exchange is measured through several means, including Diffusing capacity for carbon monoxide Pulse oximetry Arterial blood gas sampling The diffusing capacity for carbon monoxide (DLCO)... read more . Stress testing Physical examination Sprains are tears in ligaments; strains are tears in muscles. Tears (ruptures) may also occur in tendons. In addition to sprains, strains, and tendon injuries, musculoskeletal injuries include... read more is helpful when specific ligament injuries are suspected (eg, ulnar collateral ligament in gamekeeper’s thumb Ulnar Collateral Ligament Sprains Ulnar collateral ligament sprains of the thumb are common and sometimes disabling. (See also Overview of Sprains and Other Soft-Tissue Injuries.) The ulnar collateral ligament connects the base... read more ). Provocative testing can aid in the diagnosis of tenosynovitis and nerve compression syndromes.

Testing

Laboratory testing can aid the diagnosis of inflammatory arthropathies (eg, rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease that primarily involves the joints. RA causes damage mediated by cytokines, chemokines, and metalloproteases. Characteristically... read more Rheumatoid Arthritis (RA) ) but otherwise has a limited role. However, synovial fluid analysis Synovial fluid examination Some musculoskeletal disorders affect primarily the joints, causing arthritis. Others affect primarily the bones (eg, fractures, Paget disease of bone, tumors), muscles or other extra-articular... read more is necessary for definitive diagnosis of crystal-induced arthritides Overview of Crystal-Induced Arthritides Arthritis can result from intra-articular deposition of crystals: Monosodium urate Calcium pyrophosphate dihydrate Basic calcium phosphate (apatite) Rarely, others such as calcium oxalate crystals read more (eg, gout Gout Gout is a disorder caused by hyperuricemia (serum urate > 6.8 mg/dL [> 0.4 mmol/L]) that results in the precipitation of monosodium urate crystals in and around joints, most often causing recurrent... read more Gout or calcium pyrophosphate arthritis Calcium Pyrophosphate Arthritis Calcium pyrophosphate arthritis involves intra-articular and/or extra-articular deposition of calcium pyrophosphate dihydrate (CPPD) crystals. Manifestations are protean and may be minimal or... read more Calcium Pyrophosphate Arthritis ) and infectious arthritis Acute Infectious Arthritis Acute infectious arthritis is a joint infection that evolves over hours or days. The infection resides in synovial or periarticular tissues and is usually bacterial—in younger adults, frequently... read more Acute Infectious Arthritis .

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.

Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
Professionals also read
Test your knowledge
Microscopic Polyangiitis
Microscopic polyangiitis (MPA) is a rare disease in which the pathogenesis is unknown. Patients with this disease present with similar findings to several other conditions such as granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA) and polyarteritis nodosa. Which of the following characteristics of polyarteritis nodosa best distinguishes it from MPA?  
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID

Also of Interest

Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
TOP