Painful Hand – OSCE Case | Hand Pain

Introduction
A 54-year-old woman visits her GP due to a painful hand. Work through the case to reach a diagnosis.

UK Medical Licensing Assessment (UKMLA)
This clinical case maps to the following UKMLA presentations:

Acute joint pain/stiffness

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History
Presenting complaint
“Doctor I have an awful burning sensation in my right hand.”
History of presenting complaint
What questions might you ask to find out more about the presenting complaint?
Where is the burning sensation?
“Like half of my palm and fingers towards the thumb-side”
When did this burning sensation start?
“It’s been going on for about 3 weeks now and has gradually been getting worse”
Is it always there?
“It comes on and off, but it’s been coming on more often and lasting longer recently”
Do you have any other symptoms?
“Yes, sometimes the same parts of my hand feel numb”
Does anything make it better?
“I’ve noticed that shaking my hand can relieve the feeling for a bit”
Does anything make it worse?
“When I’m using my hand for a long time the burning sensation feels worse and I can feel the numbness coming on”

Other parts of the history
What other symptoms might you want to ask her about? Which of these might be red flags?
Besides the burning sensation, have you felt pain in your hand?
“No”
Have you felt like your hand or fingers have been getting weaker recently, or have felt more clumsy than usual?
“Not really, but the numbness can make it difficult to grip things”
Have you noticed any stiffness in the joints of your fingers or wrist when moving them?
“No”
🚩 Have you noticed any changes in the appearance of your hand, like redness or deformities in its shape?
“No”
🚩 Has there been any bleeding or oozing from your hand?
“No”
🚩 Have you injured your hand or experienced physical trauma to any aspect of your hand recently?
“No”
Have you fractured any part of your hand in the past?
“No”
Do any of these symptoms apply to your other hand?
“No”
🚩 Do you have pain anywhere else, especially your neck, shoulder, arm or elbow?
“No”
Have you had an infection recently?
“No”
🚩 Do you feel weak anywhere else in your body?
“No”
🚩 Have you noticed any weight loss recently which has been unintentional?
“No”
🚩 Do you feel like you have a temperature or fever?
“No”

What other areas of the history, excluding the history of presenting complaint, might be relevant here?
Past medical history:

Type 2 diabetes – well controlled on metformin

Drug history:

Metformin
Does not take medications that could cause peripheral neuropathy

Social history:

Low alcohol intake; smoker (15 cigarettes/day)
Does not struggle with activities of daily living involving her hands
Does not perform activities that put her at risk of repetitive strain injury; does not play sports

Family history:

Mother has type 2 diabetes

Clinical examination
Which clinical examination(s) would you perform?

Examination findings
Hand and wrist musculoskeletal examination:

No scars or deformities observed
Both hands are warm on palpation – temperature not of concern
Radial and ulnar pulses are present and strong
Thenar and hypothenar eminences – no muscle wasting
Paraesthesia in the right thumb, index finger, middle finger, radial half of the ring finger and radial half of palm except for thenar eminence; left-hand sensation intact
Joint palpation – no tenderness or irregularities in any of the joints examined (including the elbow joint)
Complete range of movement in all joints bilaterally; passive and active movements are normal
Function – power grip and pincer grip intact; able to pick up, transfer and drop pen

Upper limb neurological examination:

Tone – normal
Power – 5/5 on the MRC muscle power assessment scale in both upper limbs
Reflexes – biceps, supinator and triceps reflexes are intact
Sensation – light touch, pin-prick, proprioception and vibration sensations affected in the distribution described earlier
Coordination – finger-to-nose and dysdiadochokinesia tests unremarkable

Cervical spine examination:

No scars or deformities observed; no evidence of trauma
No misalignment or tenderness on palpation of cervical spinal processes and paraspinal muscles
Active and passive movements are normal, including flexion, extension, lateral flexion and rotation

Considering the change in sensation observed on clinical examination of the right hand, which upper limb nerve(s) might be affected?
The median nerve provides sensory innervation to most of the palm towards the radial side, including the thenar eminence, thumb, index, middle finger and medial half of the ring finger, as well as the distal halves of the same digits on the dorsum.

Investigations
When might you consider the need for additional investigations? Which investigations might these be?
Given the most likely diagnosis, investigations are not necessary at this stage. Instead, initial management should be trialled first.
However, you might consider the following investigations in cases that do not respond to initial management or in those for whom further management is being considered (e.g. surgery):

Nerve conduction studies and electromyography – assess peripheral nerve integrity
Ultrasound scan – identify local structural abnormalities
MRI scan – alternative to ultrasound; also useful in identifying spinal disease

Diagnosis
What are some differential diagnoses you would consider?
Those in bold are the most likely, but a range of other potential differentials are shown using the VINDICATE acronym:

Vascular: transient ischaemic attack or stroke
Inflammatory & Infectious: carpal tunnel syndrome, De Quervain’s tenosynovitis, lateral epicondylitis (tennis elbow), proximal median neuropathy, ulnar nerve compression/entrapment
Neoplastic:
Degenerative: cervical radiculopathy, motor neurone disease
Idiopathic: carpal tunnel syndrome, proximal median neuropathy, ulnar nerve compression/entrapment
Congenital:
Autoimmune:
Traumatic: carpal tunnel syndrome, cervical radiculopathy, lateral epicondylitis (tennis elbow), proximal median neuropathy, ulnar nerve compression/entrapment
Endocrine: diabetic neuropathy

What is the most likely diagnosis?
The patient’s presentation is typical of carpal tunnel syndrome, mainly the gradual onset and intermittent nature of the burning sensation in a unilateral distribution corresponding to the areas covered by the median nerve (thumb, index, middle finger and medial half of ring finger).
The pain is also worse at night, a typical feature of carpal tunnel syndrome. Importantly, the patient describes numbness which, alongside the pain, is relieved by shaking the hand.
The patient has type 2 diabetes, which can predispose to carpal tunnel syndrome. Tinel’s and Phalen’s tests can be performed to help confirm this diagnosis.

Management
After providing advice and resources on lifestyle changes, what would be the most appropriate management option for this patient given their clinical features at this time?
Seeing as the patient has presented early with mild symptoms of carpal tunnel syndrome, a conservative approach is best followed at first. Typically, after lifestyle changes (such as minimising exacerbating activities), a wrist splint worn at night may help the patient sleep and improve their symptoms.
In this patient, it is also worth optimising their type 2 diabetes treatment to improve their outcomes in terms of recurrence and severity of symptoms

When might you refer a patient with suspected carpal tunnel syndrome to a specialist for the management of their condition?
According to NICE, you might consider referral to a specialist if any of these apply:

Unclear diagnosis
Persistent symptoms despite trying conservative treatment(s)
Progressive symptoms/severe disease affecting activities of daily living
Recurrent/persistent symptoms after carpal tunnel surgery

Specialists that you might consider referring to include a rheumatologist, orthopaedic surgeon or neurologist who might carry out nerve conduction studies and/or carpal tunnel surgery.

Complications
Describe two complications of carpal tunnel syndrome
The main complications of carpal tunnel syndrome are:

Difficulties with activities of daily living
Sleep disruption due to symptoms (pain, paraesthesia)
Weakness and/or muscle wasting in the affected hand
Reduced fine motor function in the affected hand
Untreated, long-term carpal tunnel syndrome can lead to severe nerve damage

Editor
Dr Jess Speller

References

NICE Clinical Knowledge Summaries (CKS). Carpal Tunnel Syndrome. Available from: [LINK]
BMJ Best Practice. Carpal Tunnel Syndrome. Available from: [LINK]
Patient.info. Carpal Tunnel Syndrome and Median Nerve Lesions. Available from: [LINK]