Family medicine
Wrist Pain
Wrist pain is a common musculoskeletal complaint arising from injury, overuse, or systemic conditions affecting the bones, joints, tendons, ligaments, or nerves of the wrist.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | De Quervain's tenosynovitis [1][2] | Middle-aged women; pain at radial styloid aggravated by thumb motion; +ve Finkelstein's test | 「你郁拇指嗰陣痛唔痛？」→ Finkelstein's test positive |
| Carpal tunnel syndrome (CTS) | Night numbness/tingling in median nerve distribution (thumb–middle finger); +ve Tinel's/Phalen's | 「夜晚瞓覺有冇手指痺醒？邊幾隻指頭？」 | |
| Wrist sprain / overuse tendinopathy | History of minor trauma or repetitive strain; tender but no deformity; no red flags | 「最近有冇扭親或者做多咗運動？」 | |
| Ganglion cyst | Visible/palpable non-tender lump, usually dorsal wrist; transilluminates | 「隻手腕有冇生咗粒嘢？」→ Palpable cystic swelling | |
| Serious Not To Miss | Scaphoid fracture | FOOSH (fall on outstretched hand); anatomical snuffbox tenderness | 「有冇跌親用手掌撐住？」→ 按解剖鼻煙壺位有冇痛 |
| Septic arthritis | Acute hot, red, swollen joint + fever; cannot move; risk factors (DM, IVDU, immunosuppression) | 「隻手腕有冇紅、腫、熱？有冇發燒？」 | |
| Distal radius fracture (Colles'/Smith's) | Clear trauma, deformity ("dinner fork"), swelling, unable to move | 「跌親之後有冇變形？」 | |
| Malignancy (bone tumour) | Constant night pain, weight loss, no trauma | 「夜晚痛唔痛？有冇瘦咗？」 | |
| Pitfalls | 1st CMCJ osteoarthritis [2] | Base-of-thumb pain; Grind test positive (push & rotate thumb at CMC joint) | 「揸嘢、開樽蓋痛唔痛？」→ Grind test |
| TFCC injury (ulnar-sided) | Ulnar-sided wrist pain; positive ulnar fovea sign / press test | 「痛喺尾指嗰邊？扭手腕痛唔痛？」 | |
| Kienbock's disease (lunate AVN) | Progressive dorsal wrist pain in young adult; reduced grip | 「手腕背面痛？揸嘢冇力？」→ X-ray: lunate sclerosis | |
| Masquerades | Cervical radiculopathy (C6/C7) | Neck pain with radiation to wrist/hand; dermatomal numbness; Spurling's +ve | 「你條頸有冇痛？轉頭嗰陣手有冇痺？」 |
| Hypothyroidism (→ CTS) | Fatigue, weight gain, cold intolerance; CTS as presenting feature | 「你有冇成日攰、怕凍、肥咗？」 | |
| Diabetes (→ CTS / trigger finger) | Polyuria, polydipsia; DM ↑ risk of CTS and tenosynovitis | 「有冇口渴、夜尿多？」 | |
| Depression (somatic pain) | Low mood, anhedonia, sleep disturbance, pain without clear organic cause | 「你心情點？瞓得好唔好？」 | |
| Trying to Tell Me Something? | Anxiety about RA / cancer | FHx or friend diagnosed with RA; fear of disability | 「你擔唔擔心係類風濕或者其他嚴重嘢？」 |
| Work/family stress | New parent unable to hold baby; typing-dependent job at risk | 「返工或者屋企壓力大唔大？」 | |
| Domestic violence | Injury pattern inconsistent with story; reluctant to explain | Observe for inconsistencies; ask gently in private |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好！我係X醫生，今日由我同你傾。你隻手腕唔舒服係咪？可唔可以同我講吓點樣唔舒服？」("Hi, I'm Dr X. Your wrist is uncomfortable? Can you tell me about it?") | Patient-centred opening, open question, sets interpersonal tone |
| 0:30–2:00 | HPI: symptom analysis – site, onset, character, radiation, associations, timing, exacerbating/relieving, severity | 「痛咗幾耐？邊隻手？乜嘢情況會痛啲？休息之後會好啲嗎？朝早起身有冇僵硬？」 | Systematic symptom capture; morning stiffness duration discriminates inflammatory vs mechanical |
| 2:00–3:00 | Red flags + targeted systems review – trauma, swelling, locking, numbness/tingling, weakness, fever, weight loss, skin rash | 「有冇撞親？有冇痺、冇力？有冇發燒或者出疹？其他關節有冇痛？」 | Rules out fracture, septic arthritis, CTS, RA, connective tissue disease |
| 3:00–3:30 | PMH, Drug Hx, Allergy, FHx | 「你有冇長期病？食緊咩藥？有冇藥物敏感？屋企人有冇類風濕或者痛風？」 | Screens for gout, RA FHx, OA, drug side-effects |
| 3:30–4:30 | Social Hx + Occupation + Functional impact + ICE | 「你做咩工作？平時要唔要成日用手腕做嘢？影唔影響你返工或者湊BB？你自己覺得係咩原因？最擔心嘅係咩？你希望我今日幫到你啲咩？」 | Scores heavily on ICE & functional impact; uncovers hidden agenda (e.g. new mother worried about holding baby, office worker worried about typing) |
| 4:30–5:15 | Physical exam offer / key sign | 「我想檢查吓你隻手腕，可以嗎？我會做幾個測試。」→ Perform Finkelstein's test, palpate anatomical snuffbox, Tinel's/Phalen's, assess grip | Demonstrates focused exam; the key physical sign(s) score marks |
| 5:15–5:45 | Summarise, empathy, signpost plan | 「聽落你隻手腕痛咗X星期，做嘢嗰陣痛啲，影響到你湊BB/返工。我明白你好擔心…」 | Shows active listening & empathy |
| 5:45–6:00 | Safety-net + close | 「如果隻手腕突然腫晒、發燒、或者手指痺到冇感覺，就要即刻返嚟睇。有冇嘢想問？」 | Safety-net statement; avoids abrupt ending |
How to uncover the hidden agenda:
"Why today?" 「點解揀今日嚟睇？」– The patient may present with wrist pain but the real reason is fear of rheumatoid arthritis (FHx), inability to care for newborn, anxiety about cancer, or work disability. The ICE questions at 3:30–4:30 are critical. Listen for cues like "my mother had RA" or "I can't hold my baby".
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Site | Which wrist? Which part – thumb side, pinky side, dorsal, volar? | 「邊隻手？痛喺邊個位置——拇指嗰邊定尾指嗰邊？手背定手掌嗰面？」 | Radial = de Quervain's/scaphoid; ulnar = TFCC; dorsal = ganglion; volar = CTS | De Quervain's, scaphoid fracture, TFCC injury, CTS |
| Onset | Sudden or gradual? Any injury? | 「係突然痛定係慢慢開始？有冇撞親跌親？」 | Acute trauma → fracture; insidious → overuse/inflammatory | Distal radius fracture, scaphoid fracture, tendinopathy |
| Character | Dull ache, sharp, burning, tingling? | 「係痠痛、刺痛、定係痺痺哋？」 | Tingling/burning → neuropathic (CTS); aching → mechanical/inflammatory | CTS, neuropathy |
| Radiation | Does pain go to fingers or forearm? | 「痛有冇伸上手臂或者落手指？」 | Radiation to thumb/index/middle → CTS; to forearm → referred | CTS, cervical radiculopathy |
| Aggravating | Worse with gripping, thumb use, typing, at night? | 「扭毛巾、揸嘢、打字會唔會痛啲？夜晚瞓覺有冇痺醒？」 | Thumb motion aggravates → de Quervain's [1]; night waking/numbness → CTS | De Quervain's, CTS |
| Morning stiffness | Morning stiffness? How long? | 「朝早起身有冇僵硬？大概幾耐先鬆返？」 | > 1 hr → inflammatory (RA); < 30 min → OA/mechanical | RA, other inflammatory arthritis |
| Swelling | Any swelling or lump? | 「有冇腫起嚟或者生咗粒嘢？」 | Visible lump → ganglion; diffuse swelling → synovitis | Ganglion cyst, RA, septic arthritis |
| Other joints | Any other joints painful? | 「其他關節有冇痛？手指、膊頭、膝頭？」 | Polyarthritis → RA, SLE, psoriatic arthritis | RA, connective tissue disease |
| Numbness/weakness | Numbness or weakness in fingers? Dropping things? | 「手指有冇痺、冇力？有冇成日跌嘢？」 | Median nerve distribution → CTS | CTS |
| Red flags | Fever, redness, unable to move, recent infection? | 「有冇發燒？隻手腕有冇紅晒？郁唔郁到？近排有冇病過？」 | Hot, red, swollen joint + fever → septic arthritis (emergency) | Septic arthritis, osteomyelitis |
| Skin | Any rash, psoriasis patches, nail changes? | 「皮膚有冇出疹？指甲有冇變？」 | Psoriatic plaques/nail pitting → psoriatic arthritis | Psoriatic arthritis |
| PMH | Diabetes, thyroid, RA, gout, pregnancy? | 「你有冇糖尿、甲狀腺問題、痛風？有冇懷孕？」 | DM/hypothyroid/pregnancy → CTS risk; gout → crystal arthropathy | CTS, gout, CPPD |
| Drug Hx | NSAIDs tried? Steroids? Fluoroquinolones? | 「有冇食止痛藥？食咗有冇好啲？」 | Response to NSAIDs; fluoroquinolones → tendinopathy | Drug-related tendinopathy |
| Allergy | Drug allergies? | 「有冇藥物敏感？」 | Safety for prescribing | — |
| FHx | Family history of RA, gout, autoimmune? | 「屋企人有冇類風濕、痛風、或者免疫病？」 | Strong FHx RA → patient concern about RA | RA, autoimmune |
| Occupation | Keyboard work, manual labour, repetitive hand use? | 「你做咩工作？要唔要成日用手腕做重複動作？」 | Repetitive activities e.g. keyboarding, assembly line work, lifting newborn babies → de Quervain's [1] | De Quervain's, CTS, overuse tendinopathy |
| Functional impact | Can you work, cook, hold baby, write? | 「影唔影響你返工、煮飯、湊BB？」 | Functional limitation = biopsychosocial problem | — |
| ICE – Idea | What do you think is causing this? | 「你自己覺得係咩問題？」 | Uncovers health beliefs | — |
| ICE – Concern | What worries you most? | 「你最擔心嘅係咩？」 | Hidden fear (cancer, RA, disability) | — |
| ICE – Expectation | What were you hoping for today? | 「你今日最希望我點幫你？」 | X-ray? Referral? Sick leave? Pain relief? | — |
Case Report Form Answer Builder
Template: "Wrist pain for [duration], [side], [location], [onset], aggravated by [activity], associated with [swelling/numbness/morning stiffness]. No trauma / history of FOOSH. Occupation: [e.g. keyboard worker / new mother]. No fever, no rash, no other joint involvement."
Key points to capture:
- Duration, laterality, exact site (radial/ulnar/dorsal/volar)
- Onset (acute vs insidious), trauma history
- Aggravating/relieving factors (thumb use, gripping, night symptoms)
- Morning stiffness and duration
- Associated symptoms (numbness, swelling, weakness, other joints)
- Functional impact (work, ADLs, childcare)
- Red flags asked and excluded
| Likely RFC | How to Phrase |
|---|---|
| Pain interfering with work/childcare | "Wrist pain affecting ability to perform work duties / care for newborn" |
| Fear of serious diagnosis | "Concern that wrist pain may be rheumatoid arthritis" |
| Seeking investigation | "Wants X-ray to exclude fracture" |
| Wants treatment | "Seeking pain relief to continue daily activities" |
Tip: The main RFC is NOT "wrist pain" — it's why the patient came today. Listen for the turning point: "I can't hold my baby", "My mother had RA", "My boss says I need a sick note."
| Component | Likely Content | Example Wording |
|---|---|---|
| Idea | Thinks it's from overuse / "RSI" / arthritis | "Patient thinks wrist pain is caused by repetitive computer use at work" |
| Concern | Worried about RA, permanent damage, unable to work | "Patient is worried this could be rheumatoid arthritis because her mother was diagnosed with RA" |
| Expectation | Wants X-ray, pain medication, referral, sick leave | "Patient hopes to get an X-ray and pain medication today" |
De Quervain's tenosynovitis — if the patient is a middle-aged woman with radial-sided wrist pain aggravated by thumb motion and repetitive hand activities (e.g. lifting newborn, keyboarding), and Finkelstein's test is positive. [1][2]
Minimum supporting evidence:
- Radial-sided wrist pain
- Aggravated by thumb use / gripping
- Positive Finkelstein's test
- Relevant occupation / repetitive activity
Alternative most likely: If history suggests nocturnal numbness in median nerve distribution → CTS. If history suggests post-trauma + snuffbox tenderness → Scaphoid fracture. Adapt based on the stem given.
| DDx | One Key Discriminator |
|---|---|
| Carpal tunnel syndrome | Nocturnal numbness/tingling in thumb, index, middle finger; positive Phalen's/Tinel's |
| 1st CMCJ osteoarthritis | Pain at base of thumb with gripping; positive Grind test; age > 50; bony enlargement |
| Scaphoid fracture | History of FOOSH; anatomical snuffbox tenderness; may have normal initial X-ray |
| Type | Problem |
|---|---|
| Biological | Wrist pain causing functional limitation (reduced grip strength, unable to lift objects) |
| Psychological | Anxiety about having a serious/chronic condition (e.g. RA), fear of disability |
| Social/Functional | Unable to perform work duties (typing/manual tasks) OR unable to care for newborn; may need sick leave; financial impact |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| De Quervain's tenosynovitis | Positive Finkelstein's test [1][2] | Patient makes a fist with thumb tucked inside fingers; examiner ulnar-deviates the wrist → acute pain at radial styloid along EPB/APL tendons [2] | Pathognomonic for 1st extensor compartment tenosynovitis; reproduces the patient's pain |
| Carpal tunnel syndrome | Positive Phalen's test (or Tinel's sign) | Patient holds wrists in maximum flexion for 60 seconds → tingling in median nerve distribution; OR tap over carpal tunnel at wrist crease | Compression/tapping reproduces median nerve symptoms |
| 1st CMCJ OA | Positive Grind test [2] | Axially load and rotate the thumb metacarpal against the trapezium → pain and crepitus | Confirms articular pathology at 1st CMCJ specifically |
| Scaphoid fracture | Anatomical snuffbox tenderness | Palpate the anatomical snuffbox (between EPL and EPB tendons) with wrist in ulnar deviation → point tenderness | High sensitivity for scaphoid fracture; if positive, treat as fracture even if X-ray initially normal |
| Septic arthritis | Hot, swollen, erythematous joint with severely restricted ROM | Inspect and palpate the wrist; attempt passive ROM → extreme pain and guarding; check temperature | Joint that is acutely hot, red, swollen with fever = septic arthritis until proven otherwise → urgent referral |
| RA (wrist involvement) | Boggy synovial thickening at wrist + MCP/PIP involvement | Palpate for soft, warm, boggy swelling over the wrist; check for symmetrical MCP/PIP synovitis | Symmetric small joint synovitis with wrist involvement + morning stiffness > 1 hr = highly suggestive of RA [3] |
Exam Discriminators and Traps
Top Traps That Lose Marks
- Forgetting to ask about trauma — a scaphoid fracture after FOOSH can present as "just wrist pain" with a normal X-ray. Always ask about falls.
- Not asking about nocturnal symptoms — CTS classically wakes patients at night with tingling. Missing this = missing CTS.
- Confusing De Quervain's with 1st CMCJ OA — both cause radial-sided pain. Use Finkelstein's test (De Quervain's) vs Grind test (CMCJ OA) to discriminate [2].
- Writing "wrist pain" as the main reason for consultation — the RFC must capture why today and the patient's underlying concern/need.
- Not screening for inflammatory arthritis — always ask about morning stiffness duration, other joint involvement, and systemic symptoms (fatigue, weight loss).
- Forgetting ICE or doing it superficially — ICE is heavily weighted. Use specific phrases, not just "any concerns?"
- Missing the hidden agenda — the patient may fear RA because of a family member, or need sick leave but is embarrassed to ask.
| Red Flag | Possible Diagnosis | Action |
|---|---|---|
| Hot, red, swollen joint + fever | Septic arthritis | Same-day A&E referral for joint aspiration |
| FOOSH + snuffbox tenderness (even normal X-ray) | Scaphoid fracture | Thumb spica splint + repeat X-ray/MRI in 10–14 days |
| Significant deformity after trauma | Distal radius fracture | A&E referral for reduction |
| Progressive night pain + weight loss + no trauma | Bone malignancy | Urgent X-ray + ortho/oncology referral |
| Rapid-onset polyarthritis + systemic symptoms | RA / connective tissue disease | Urgent rheumatology referral + bloods (RF, anti-CCP, ESR/CRP) |
For probable De Quervain's: "Avoid repetitive thumb/wrist movements, use a thumb spica splint, trial of topical/oral NSAIDs. If no improvement in 4–6 weeks, consider corticosteroid injection. Return if worsening, new numbness, or fever."
「如果痛嚴重咗、手指開始痺、或者發燒，要即刻返嚟睇。」
High Yield Summary
What to ASK:
- Site (radial vs ulnar vs dorsal), onset (trauma?), aggravating factors (thumb use? night symptoms?), morning stiffness duration, other joints, numbness, occupation/repetitive activities, ICE (especially concerns about RA/cancer)
What to WRITE on the Case Report Form:
- Chief complaint with duration, side, and functional impact
- RFC = the real reason they came today (not just "wrist pain")
- ICE with specific patient wording
- Most likely Dx: De Quervain's tenosynovitis (if radial-side, thumb-aggravated, repetitive use) — supported by positive Finkelstein's test
- DDx: CTS (night numbness, Phalen's), 1st CMCJ OA (Grind test), scaphoid fracture (FOOSH, snuffbox tenderness)
- Biopsychosocial: biological pain/function, psychological worry, social/work impact
What NOT to MISS:
- Septic arthritis (hot joint + fever → A&E)
- Scaphoid fracture (FOOSH + snuffbox tenderness → even if X-ray normal)
- CTS (nocturnal tingling → median nerve)
- Hidden agenda (fear of RA, inability to care for baby, work pressure)
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: Upper Limb Painful Conditions_Dr. Margaret Woon Man FOK_1. Overuse conditions.pdf (pp. 26) — De Quervain's clinical features: middle-aged women, repetitive activities, pain/swelling in wrist aggravated by thumb motion [2] Senior notes: Maksim Surgery Notes.pdf (p. 245) — De Quervain's tenosynovitis: Finkelstein's test, DDx with 1st CMCJ OA (Grind test), Wartenberg's syndrome, intersection syndrome [3] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (pp. 1674–1678) — RA clinical manifestation: wrist involvement, morning stiffness > 1 hour, carpal tunnel syndrome in RA, joint distribution
Weight Loss (unintentional)
Unintentional weight loss is a clinically significant involuntary decrease in body weight, typically defined as a loss of more than 5% of baseline body weight over 6 to 12 months, often indicating an underlying medical, psychiatric, or nutritional disorder.
Overview
General surgery notes organised by history taking, presenting complaints, examination, and system-based topics.