Hand Pain
Hand pain is a symptom arising from injury, overuse, or disease affecting the bones, joints, tendons, nerves, or soft tissues of the hand, commonly caused by conditions such as carpal tunnel syndrome, osteoarthritis, tendinitis, or trauma.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Osteoarthritis (OA) of hand | DIP (Heberden's nodes) / PIP (Bouchard's nodes); stiffness < 30 min; bony enlargement [8] | 「手指尾嗰啲關節有冇變粗？」(Are the end joints enlarged?) | ~25% |
| Carpal tunnel syndrome (CTS) | Nocturnal numbness in median nerve distribution; Tinel's/Phalen's positive | 「半夜有冇手指痺醒？係邊幾隻手指？」 | ~15% | |
| De Quervain's tenosynovitis | Pain at radial styloid; Finkelstein's test positive [2][7] | 「你揸住拇指然後向尾指方向屈手腕，痛唔痛？」(Finkelstein's) | ~10% | |
| Trigger finger | Locking/clicking of finger, palpable nodule on flexor tendon [2] | 「手指有冇卡住要用另一隻手撳先伸直？」 | ~8% | |
| Serious Not To Miss | Fracture (e.g., scaphoid) | Post-trauma; anatomical snuffbox tenderness | 「最近有冇跌親？呢度（鼻煙壺位）撳痛唔痛？」 | ~3% |
| Rheumatoid arthritis (RA) | Symmetrical MCP/PIP; morning stiffness > 1h; spares DIP [3][9] | 「兩隻手係咪一樣痛？朝早僵硬幾耐？」 | ~2% | |
| Septic arthritis | Acute hot swollen single joint + fever; needs urgent aspiration | 「隻關節有冇又紅又腫又熱？有冇發燒？」 | < 1% | |
| Malignancy (bone/soft tissue tumour) | Progressive pain, mass, night pain, weight loss | 「有冇摸到硬塊？有冇唔明原因瘦咗？」 | < 1% | |
| Pitfalls | Ganglion cyst | Visible/palpable lump on dorsal wrist, transilluminant | 「手腕有冇起咗個包？」 | ~5% |
| Gout / pseudogout | Acute monoarthritis; tophi; raised urate | 「以前有冇試過關節突然好痛好腫？有冇痛風？」 | ~3% | |
| Dupuytren's contracture | Painless flexion contracture, palpable cord in palm | 「手指係咪慢慢彎埋伸唔直？」 | ~2% | |
| Psoriatic arthritis | DIP involvement + nail pitting/onycholysis; dactylitis | 「指甲有冇凹凹哋或者甩開？」 | ~1% | |
| Masquerades | Depression | Chronic pain + poor sleep + low mood | 「心情有冇差咗？做嘢有冇冇晒動力？」 | ~10% |
| Diabetes (CTS/trigger finger) | Known DM; multiple trigger fingers; bilateral CTS [6] | 「有冇糖尿病？」 | ~5% | |
| Cervical radiculopathy (C6/C7) | Neck pain radiating to hand; dermatomal numbness; Spurling's + [1] | 「有冇頸痛？痛有冇由頸傳落手？」 | ~3% | |
| Hypothyroidism | CTS + fatigue, weight gain, constipation | 「有冇成日攰、怕凍、肥咗？」 | ~2% | |
| Trying to Tell Me Something? | Work stress / fear of disability / fear of cancer | Hidden agenda: can't work, scared of RA/cancer, family caregiving burden | 「你最擔心係咩呀？有冇嘢特別煩緊你？」 | ~10% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, open question | 「你好，我係X醫生，今日由我同你傾。請問你點稱呼呀？」「今日嚟有咩嘢唔舒服呀？」 | Friendly opening, patient-centred start, interpersonal marks |
| 0:30–1:30 | HPI: SOCRATES for hand pain | 「隻手邊度痛呀？」「痛咗幾耐？」「點樣痛法？脹痛定刺痛？」「有冇傳去其他地方？」「有咩嘢會令到佢痛啲或者好啲？」「痛嘅程度1到10分你畀幾多分？」 | Core symptom analysis; completeness of HPI |
| 1:30–2:30 | Red flags + targeted Qs | 「有冇手指麻痺、冇力？」「有冇腫起、紅、發熱？」「有冇發燒？」「有冇試過受傷？」「有冇晨早僵硬？僵幾耐？」「有冇其他關節痛？」 | Rules out serious causes; red flag marks |
| 2:30–3:30 | PMHx, DHx, FHx, SHx, Occupation | 「你以前有冇咩長期病呀？」「有冇食緊咩藥？有冇藥物敏感？」「屋企人有冇類風濕或者關節炎？」「你做咩工作㗎？平時有冇做運動或者重複嘅手部動作？」 | Biopsychosocial data; occupation is key for hand pain |
| 3:30–4:30 | ICE + hidden agenda | 「你自己覺得隻手點解會痛呀？」(Idea)「你最擔心啲咩？」(Concern)「你今日嚟最想我幫你啲咩？」(Expectation)「係咪有啲嘢特別令到你決定今日嚟睇？」(Hidden agenda) | ICE = direct mark items; hidden agenda often the real RFC |
| 4:30–5:15 | Functional impact + psych screen | 「隻手痛有冇影響你返工或者做家務？」「瞓得好唔好？心情點呀？」 | Psychosocial problems; functional impairment |
| 5:15–5:45 | Summarise + signpost | 「等我總結吓：你隻右手痛咗X個星期，主要喺XX位置，做嘢會痛啲，你最擔心XX。我講得啱唔啱？」 | Summarising + checking understanding = interpersonal marks |
| 5:45–6:00 | Close: next steps + safety net | 「我會幫你檢查吓隻手，之後再同你講下一步點做。如果隻手突然腫晒、發燒或者完全冇力，記得即刻返嚟睇。」 | Safe closure; safety-net scores marks |
Uncovering the hidden agenda: The symptom is hand pain, but the RFC may be fear of RA/cancer, inability to work, new hobby affected, or a trigger event (e.g., dropped a baby, can't hold chopsticks). Ask: 「係咩原因令你決定今日嚟睇呀？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Site | Which part of the hand hurts? | 「邊度痛呀？手指、手腕定手背？」 | Localisation guides DDx | Thumb base → OA / De Quervain's; MCP/PIP → RA; DIP → OA; wrist → CTS/fracture |
| Onset | When did it start? Sudden or gradual? | 「幾時開始痛？突然定慢慢嚟？」 | Acute → trauma/infection/gout; Chronic → OA/RA | Acute hot joint → septic arthritis/gout |
| Character | What does the pain feel like? | 「點樣痛法？脹痛、刺痛定痠痛？」 | Aching → OA; Burning/tingling → neuropathic (CTS) | Burning/numbness → CTS or neuropathy |
| Radiation | Does pain go anywhere else? | 「痛有冇傳去手臂或者頸呀？」 | Radiating to arm/neck → cervical radiculopathy | Neck → C-spine pathology [1] |
| Aggravating | What makes it worse? | 「做咩嘢會痛啲？揸嘢、扭毛巾、打字？」 | Repetitive activities → overuse (De Quervain's, trigger finger) [2] | Gripping → lateral epicondylitis; thumb motion → De Quervain's [2] |
| Morning stiffness | Any morning stiffness? How long? | 「朝早起身有冇僵硬？大概幾耐？」 | > 30 min → inflammatory arthritis; < 30 min → OA | > 1hr → RA [3] |
| Swelling/redness | Any swelling, redness, or warmth? | 「有冇腫、紅、或者覺得熱？」 | Inflammatory signs → infection/crystal/RA | Hot swollen single joint → septic arthritis / gout |
| Numbness/tingling | Any numbness or tingling in fingers? | 「手指有冇痺或者「蟻噬」嘅感覺？」 | Median nerve → CTS; ulnar → cubital tunnel | Night waking with numbness → CTS |
| Weakness | Any weakness or dropping things? | 「有冇覺得冇力、成日跌嘢？」 | Thenar wasting → CTS; intrinsic wasting → ulnar neuropathy / cervical myelopathy | Cervical myelopathy signs [4] |
| Locking/clicking | Any finger locking or clicking? | 「手指有冇卡住、要撳先伸得直？」 | Trigger finger → stenosing tenosynovitis [2] | Trigger finger |
| Colour changes | Do fingers turn white/blue in cold? | 「凍嘅時候手指有冇變白或者變藍？」 | Raynaud's phenomenon → scleroderma, SLE, primary Raynaud's [5] | Connective tissue disease |
| Skin/nails | Any skin rash or nail changes? | 「皮膚有冇出紅疹？指甲有冇變？」 | Psoriatic nail pitting → PsA; skin tightening → scleroderma | Psoriatic arthritis |
| Trauma | Any recent injury? | 「最近有冇撞親或者扭親？」 | Fracture, ligament injury | Scaphoid fracture (anatomical snuffbox tenderness) |
| PMHx | Any chronic diseases? DM, thyroid, RA? | 「有冇長期病？糖尿、甲狀腺、類風濕？」 | DM → CTS/trigger finger; hypothyroid → CTS; gout | DM neuropathy [6] |
| DHx | Any medications? | 「有冇食緊咩藥？」 | Diuretics → gout; fluoroquinolones → tendinopathy | Drug-induced |
| Allergy | Drug allergies? | 「有冇藥物敏感？」 | Safety | — |
| FHx | Family history of joint disease? | 「屋企人有冇關節炎或者類風濕？」 | RA, OA, gout have genetic component | Hereditary |
| Occupation | What is your job? Repetitive hand use? | 「你做咩工作？要唔要成日用手做重複動作？」 | Overuse conditions → De Quervain's, CTS, trigger finger [2] | Housewife/manual worker/typist |
| Hobbies | Any hobbies involving hands? | 「有冇打機、彈琴、做運動？」 | Repetitive strain | "Gamer's thumb" = De Quervain's [7] |
| Functional impact | Can you do daily tasks? Chopsticks, buttons? | 「用唔用到筷子？扣唔扣到鈕？」 | Functional limitation = social problem for CRF | Disability assessment |
| Psych screen | How is your mood? Sleep? | 「心情點呀？瞓得好唔好？」 | Chronic pain → depression/anxiety | Masquerade: depression |
Case Report Form Answer Builder
- CC: Hand pain × [duration], [laterality], [location]
- HPI high-yield points to capture:
- SOCRATES (site, onset, character, radiation, associations, timing, exacerbating/relieving, severity)
- Morning stiffness duration (inflammatory vs mechanical)
- Numbness/tingling distribution (neurological component)
- Locking/clicking (trigger finger)
- Functional limitation (chopsticks, buttons, work)
- Trauma history
- Previous episodes and treatment
- Often NOT the pain itself — look for the trigger:
- "Pain affecting work performance"
- "Worried about rheumatoid arthritis after internet search"
- "Cannot hold baby safely"
- "Dropped things and worried about something serious"
- Phrasing example: "Patient attended today because hand pain is now affecting her ability to do housework and she is worried it may be rheumatoid arthritis."
| Component | Example Wording |
|---|---|
| Idea | "Patient thinks her hand pain may be caused by arthritis / overuse from work." |
| Concern | "Patient is worried that the pain will get worse and she may lose hand function / worried about RA." |
| Expectation | "Patient hopes to get an X-ray and medication for pain relief / referral to specialist." |
Choose based on the stem. In a middle-aged woman with thumb-base/wrist pain worsened by repetitive hand use:
| If stem suggests… | Most likely Dx | Minimum supporting evidence |
|---|---|---|
| DIP/PIP bony swelling, age > 50 | Hand OA | Heberden's/Bouchard's nodes, pain worse with use, < 30 min stiffness [8] |
| Radial wrist pain, repetitive use, Finkelstein + | De Quervain's tenosynovitis | Finkelstein's test positive, pain at radial styloid [2][7] |
| Nocturnal hand numbness, median distribution | CTS | Tinel's/Phalen's positive, thenar wasting |
| Finger locking/catching | Trigger finger | Palpable nodule, snapping on extension [2] |
| Symmetrical MCP/PIP, morning stiffness > 1h | RA | Symmetrical polyarthritis, MCP/PIP, spares DIP, morning stiffness > 1h [3][9] |
| DDx | Key Discriminator |
|---|---|
| OA | Bony enlargement at DIP/PIP, < 30 min stiffness, no systemic features |
| De Quervain's | Radial styloid pain, Finkelstein's +, hx of repetitive thumb use |
| CTS | Nocturnal numbness in thumb/index/middle/radial ring finger, Tinel's/Phalen's + |
| RA | Symmetrical MCP/PIP, > 1h morning stiffness, systemic inflammation |
| Trigger finger | Locking/clicking of affected finger, palpable nodule |
| Gout | Acute monoarthritis, prior episodes, tophi, hyperuricaemia |
(Pick three that are NOT your most likely diagnosis)
| Dimension | Example |
|---|---|
| Biological | Hand pain limiting grip strength / underlying OA or inflammatory arthritis requiring investigation and treatment |
| Psychological | Anxiety about progressive joint disease / fear of disability / low mood due to chronic pain |
| Social/Functional | Unable to perform work duties (e.g., typing, cooking) / difficulty with childcare / reduced independence in ADLs |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Hand OA | Heberden's nodes (DIP) / Bouchard's nodes (PIP) [8] | Inspect and palpate DIP and PIP joints for bony swelling | Pathognomonic bony osteophytes of OA; distinguish from soft-tissue swelling of RA |
| De Quervain's | Finkelstein's test positive [2][7] | Patient makes a fist over thumb, examiner ulnar-deviates the wrist → sharp pain at radial styloid | Specific for stenosing tenosynovitis of 1st extensor compartment |
| CTS | Tinel's sign at carpal tunnel | Tap over median nerve at wrist → tingling in median nerve distribution | Suggests median nerve entrapment |
| Trigger finger | Palpable nodule + snapping on extension [2] | Palpate flexor tendon at A1 pulley (MCP level); ask patient to flex/extend finger | Nodule catches at pulley → locking |
| RA | Symmetrical MCP/PIP synovitis; ulnar deviation; swan-neck/boutonnière deformity [9] | Inspect both hands; squeeze MCP joints (MCP squeeze test → tenderness) | Symmetrical polyarthritis sparing DIP is classic RA |
| Gout | Tophi | Inspect fingers, ears, elbows for chalky deposits | Tophi are pathognomonic of chronic tophaceous gout |
| Cervical radiculopathy | Spurling's test positive [1] | Extend + laterally flex neck to affected side + axial compression → radiating pain/numbness to hand | Reproduces radicular symptoms → cervical origin |
| Septic arthritis | Hot, red, swollen single joint with restricted ROM | Inspect and palpate; attempt passive ROM (severely restricted) | Acute monoarthritis with systemic features = urgent aspiration |
Top Traps That Lose Marks
- Forgetting to ask about morning stiffness duration — this is THE discriminator between OA ( < 30 min) and RA ( > 1h). Examiners look for this.
- Missing CTS masquerading as "hand pain" — always ask about nocturnal numbness and which fingers are affected.
- Not asking about occupation/repetitive use — De Quervain's and trigger finger are occupational; this is a social-domain mark.
- Assuming hand pain = hand pathology — cervical radiculopathy refers pain to the hand. Always ask about neck symptoms.
- Forgetting ICE — ICE is a direct mark item on the CRF. Never skip it.
- Not asking about colour changes (Raynaud's) — easy miss; connective tissue diseases present with hand pain + Raynaud's.
- Writing "pain" as the RFC — the RFC is WHY the patient came TODAY, not the symptom itself.
Must-Not-Miss Red Flags → Urgent Referral
- Hot, swollen joint + fever → septic arthritis → same-day ortho referral for joint aspiration
- Acute severe hand pain + swelling in a known gout patient not responding to treatment → r/o septic arthritis
- Progressive weakness + wasting of hand muscles → cervical myelopathy / motor neuron disease → urgent neurology/ortho
- Trauma + snuffbox tenderness → scaphoid fracture (XR may be normal initially → scaphoid views, repeat XR in 2 weeks or MRI)
- New Raynaud's + skin tightening + digital ulcers → scleroderma → rheumatology referral
- Unexplained mass / night pain / weight loss → malignancy → urgent imaging and referral
Shortest safe management/safety-net line: 「如果隻手突然好腫、又紅又熱、發燒、或者手指完全冇力，要即刻返嚟急症室。」 ("If the hand suddenly becomes very swollen, red, hot, you develop fever, or completely lose strength in the fingers, come back to A&E immediately.")
Key GC lecture slide points to remember:
- De Quervain's: middle-aged women, repetitive activities, pain at radial styloid, Finkelstein's test [2]
- OA hand: Heberden's nodes (DIP), Bouchard's nodes (PIP), diminished grip and pinch strength [8]
- Trigger finger: locking/clicking, palpable nodule on flexor tendon [2]
- RA spares DIP [3]
- Cervical spine pathology can present as hand pain [1]
High Yield Summary
What to ASK: SOCRATES for hand pain; morning stiffness duration; numbness/tingling distribution; locking/clicking; colour changes; occupation + repetitive use; trauma; ICE + hidden agenda ("Why today?").
What to WRITE: CC with specific location and duration; RFC = the reason behind the visit (not just "pain"); ICE verbatim; most likely Dx with supporting sign (e.g., OA + Heberden's nodes, De Quervain's + Finkelstein's); 3 DDx each with one discriminator; biopsychosocial problems (bio: the disease; psych: anxiety/depression; social: functional/occupational impact).
What NOT to MISS: Septic arthritis (hot joint + fever → urgent); CTS masquerading as hand pain; cervical radiculopathy referring to hand; morning stiffness > 1h → RA; occupation as a cause; Raynaud's suggesting connective tissue disease.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 227. Cervical Spine Pathology.pdf [2] Lecture slides: Upper Limb Painful Conditions_Dr. Margaret Woon Man FOK.pdf (overuse conditions, clinical features, De Quervain's) [3] Lecture slides: GC 074. Multiple joint pain.pdf [4] Senior notes: Maksim Medicine Notes.pdf (p266, cervical myelopathy) [5] Senior notes: Block A - Fingers turn white and blue_ Scleroderma and MCTD, Raynaud's disease, other rheumatic diseases.pdf [6] Senior notes: Block A - Deterioration of eyesight in a diabetic patient_ diabetic complications.pdf (p7, diabetic neuropathy) [7] Senior notes: Maksim Surgery Notes.pdf (p246, De Quervain's tenosynovitis) [8] Lecture slides: Upper Limb Painful Conditions_Dr. Margaret Woon Man FOK_4. Osteoarthritis.pdf (p4, Heberden's/Bouchard's nodes) [9] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p1675–1683, RA hand examination)
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