One-liner#
Adult/geriatric approach to hand pain: separate joint (OA/inflammatory) vs tendon (overuse/triggering) vs nerve (CTS/ulnar) vs infection/trauma, and identify hand emergencies early.
Quick nav#
Red flags / send to ED#
- Open fracture, gross deformity, or severe crush injury
- Neurovascular compromise: pale/cool finger, diminished cap refill, progressive numbness/weakness
- Suspected deep space infection or flexor tenosynovitis: rapidly worsening swelling/pain, fever, pain with passive extension, finger held flexed
- Suspected septic arthritis: hot, swollen joint with severe pain and systemic illness
- Rapidly progressive swelling with pain out of proportion (rare: compartment syndrome/necrotizing infection)
Key history#
- Trauma vs atraumatic; dominant hand; occupational/repetitive use
- Location: thumb base (CMC), knuckles (MCP), PIP/DIP joints; palmar vs dorsal pain; single digit vs multiple
- Stiffness pattern: morning stiffness/prolonged stiffness (inflammatory) vs brief stiffness (OA)
- Mechanical symptoms: locking/catching (trigger finger), clicking, weakness, dropping objects
- Numbness/tingling distribution (median vs ulnar)
- Infection clues: bite/puncture wound, cuticle infection, rapidly spreading redness, fever
- PMH: diabetes, RA/psoriasis, gout, immunosuppression
Focused exam#
- Inspect swelling, erythema, deformity (Heberden/Bouchard nodes), atrophy; check skin for wounds
- ROM of wrist and all finger joints; pain with passive ROM (joint concern)
- Palpation: CMC, MCP/PIP/DIP, flexor tendons; A1 pulley tenderness/clicking (trigger finger)
- Thumb CMC grind test (CMC OA); evaluate pinch/grip as tolerated
- Neurovascular: cap refill, pulses (when relevant), sensation, thenar/hypothenar strength
- If infection concern: look for Kanavel signs (flexor tenosynovitis) and fluctuance/abscess
Differential (quick pattern recognition)#
Common/likely (outpatient)#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|
| Hand OA (DIP/PIP) | “Stiff,” “achy,” “knobby joints” | Gradual; brief morning stiffness | Bony enlargement; crepitus | Topical NSAID, splints as needed, hand therapy |
| Thumb CMC OA | “Base of thumb pain,” “jar opening hurts” | Worse pinch/grip | +CMC grind; localized tenderness | Thumb spica brace, topicals, activity modification |
| Trigger finger (stenosing tenosynovitis) | “Locks,” “clicks,” “stuck bent” | Single digit; worse mornings | Tender A1 pulley; triggering | Splint/activity modification; consider injection/referral |
| Carpal tunnel syndrome | “Pins and needles,” night numbness | Median distribution; worse at night | +Phalen/Tinel; thenar weakness late | Night splint, ergonomics; consider EMG/referral if severe |
| Ganglion cyst | “Bump,” waxing/waning | Dorsal wrist/hand mass | Transilluminates; firm cyst | Observe; refer if painful/functional limits |
| Inflammatory arthritis | “Swollen,” prolonged morning stiffness | Multiple joints; systemic/inflammatory history | Synovitis, warmth | Labs and rheum pathway as indicated |
Can’t-miss / urgent#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|
| Flexor tenosynovitis | “Finger is swollen and hurts to move” | Rapid progression; possible puncture | Kanavel signs | ED now; surgical evaluation/IV antibiotics |
| Septic arthritis | “Hot,” severe on any motion | Fever/risk factors; single joint | Pain with passive ROM; effusion | ED now; aspiration/labs/IV antibiotics |
| Fracture/dislocation | “Bent,” after injury | Trauma | Deformity; point tenderness | X-ray and immobilize; urgent referral per findings |
Workup#
- X-ray for trauma, deformity, focal bony tenderness, or suspected OA when it changes management.
- Labs (CBC, ESR/CRP, RF/CCP/uric acid context) only when inflammatory arthritis/infection suspected; avoid shotgun testing without a clinical pattern.
- Ultrasound/advanced imaging rarely first-line; consider for unclear mass or tendon injury.
Initial management#
- Protect function: brief immobilization/splinting when painful, followed by guided ROM to prevent stiffness.
- Overuse/OA: activity modification, topicals/analgesics as appropriate—see medication tables below.
- Hand therapy/home exercises, targeted braces.
- Escalate urgently when infection is in the differential (bites, rapidly spreading cellulitis, Kanavel signs, hot swollen joint).
Analgesic options for hand pain#
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|
| Acetaminophen | 650–1000 mg q6–8h; max 3 g/day | Severe hepatic impairment | LFTs if prolonged use | $ | Safe first-line |
| Diclofenac gel 1% | Apply 4 g to affected joints QID; max 16 g/day | Avoid on broken skin | Minimal systemic absorption | $$ | First-line for hand OA; lower systemic risk |
| Ibuprofen | 400–600 mg q6–8h with food; max 2400 mg/day | CKD, GI bleed, HF, anticoagulation | Cr, BP if prolonged | $ | Effective for inflammatory component |
| Naproxen | 250–500 mg q12h; max 1000 mg/day | Same as ibuprofen | Same as ibuprofen | $ | Convenient BID dosing |
| Capsaicin cream 0.025–0.075% | Apply TID–QID | Avoid on broken skin, mucous membranes | Local burning (improves with use) | $ | Takes 2–4 weeks; useful adjunct for OA |
Injection options (verify local protocol)#
| Condition | Agent/Dose | Indications | Notes |
|---|
| Thumb CMC OA | Triamcinolone 10–20 mg + 0.5–1 mL lidocaine | Pain limiting function despite conservative care | Provides weeks–months relief; may be done with fluoroscopy |
| Trigger finger | Triamcinolone 10–20 mg + 0.5 mL lidocaine | Persistent triggering/locking after 4–6 weeks conservative care | High success rate (60–90%); inject into A1 pulley sheath |
| Small joint OA (PIP/DIP) | Triamcinolone 5–10 mg + 0.25–0.5 mL lidocaine | Severe pain in isolated joint | Small volume; limited evidence but can provide relief |
When NOT to inject:
- Suspected infection (aspirate first)
- Overlying cellulitis or skin breakdown
- Uncertain diagnosis
Management by diagnosis#
Thumb CMC osteoarthritis#
- Education: common “pinch joint” arthritis; flares respond to bracing and load modification.
- Treatment:
- Thumb spica brace (or CMC-specific brace), topical NSAID, and adaptive tools (jar openers, larger grips).
- Hand therapy for joint protection strategies and strengthening.
- Consider injection/hand referral if persistent and function-limiting (verify local protocol).
- Follow-up: 6–12 weeks.
Trigger finger#
- Education: tendon sheath irritation causes catching/locking.
- Treatment:
- Activity modification (reduce repetitive gripping/pinching); consider nighttime splinting strategy per hand-therapy guidance.
- Consider injection/hand referral if persistent locking, recurrent triggering, or significant functional limitation (verify local protocol).
- Follow-up: 4–8 weeks.
Carpal tunnel syndrome#
- Education: night symptoms are common; prolonged severe compression can cause weakness.
- Treatment: night splint in neutral, ergonomic changes; consider EMG/referral if weakness/thenar atrophy, constant numbness, or persistent symptoms.
- Follow-up: 4–8 weeks.
Inflammatory arthritis concern#
- Education: prolonged morning stiffness and multiple swollen joints suggest inflammatory disease.
- Treatment: appropriate labs/imaging and early rheumatology pathway; symptom control while awaiting evaluation.
- Follow-up: based on severity; sooner if rapid progression.
Follow-up#
- Reassess in 4–8 weeks for OA/overuse/triggering after brace/therapy started.
- Reassess in 1–2 weeks after trauma or when diagnosis uncertain.
- Urgent return for rapidly worsening swelling/redness, fever, new numbness/weakness, or a finger that becomes pale/cool.
- If not improving after 6–12 weeks of appropriate conservative care, escalate (hand therapy, injection pathway, imaging, EMG/referral) based on the working diagnosis.
Patient instructions#
- Avoid repetitive painful gripping/pinching for 1–2 weeks; use a brace/splint if recommended.
- Use ice/heat and over-the-counter pain options if safe for you.
- Seek urgent care for rapidly spreading redness, severe swelling, fever, or worsening pain with finger movement.
Smartphrase snippets (optional)#
Hand pain consistent with ____. No red flags; neurovascularly intact. Plan: splint/brace, activity modification, hand therapy/home exercises, analgesic options, and return precautions.
Related pages#
Complaint pages#
Problem pages#
- Osteoarthritis — comprehensive OA management including hand and CMC-specific considerations
- Gout — crystal arthropathy can affect hand joints
Coding/billing notes (optional)#
- Document distribution (which joints/digits), presence/absence of synovitis and neuro symptoms, and infection screening (wounds/Kanavel signs).