Hand PainAPPROACH

MUSCULOSKELETAL AND EXTREMITIES · 19 SECTIONS

⚲

662 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Shoulder Pain Elbow Pain Wrist Pain Hand Pain Hip Pain Knee Pain Ankle Pain Foot Pain Cast Or Splint Complication Symptoms Wound Check And Suture Related Visits Joint Swelling And Monoarthritis Suspected Septic Joint Presentation Suspected Tendon Rupture Presentation Limp Or Refusal To Bear Weight

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx95

Presenting features

›Symptom profile

›Location

›Laterality

›Dominant hand

›Single digit

›Multiple digits

›Palm

›Dorsum

›Wrist involvement

›Swelling pattern

›Stiffness pattern

›Trauma mechanism

›Overuse pattern

›Bite history

›Human bite

›Animal bite

›Puncture wound

›Foreign body concern

OPQRST

›OPQRST framework

›Onset

›Sudden

›Gradual

›Time since onset

›Time since trauma

›Provocation and palliation

›Worse with grip

›Worse with pinch

›Worse with finger flexion

›Worse with finger extension

›Worse with wrist motion

›Relief with rest

›Relief with immobilization

›Relief with elevation

›Quality

›Sharp

›Aching

›Burning

›Throbbing

›Electric

›Region and radiation

›Localized

›Radiates to forearm

›Radiates to fingers

›Radiates from neck

›Severity

›Pain scale 0 to 10

›Functional limitation

›Timing

›Constant

›Intermittent

›Morning predominance

›Night predominance

›Progressive

›Improving

Associated symptoms

›Associated symptoms

›Fever

›Chills

›Malaise

›Redness

›Warmth

›Drainage

›Numbness

›Tingling

›Weakness

›Color change

›Coldness

›Finger locking

›Clicking

›New rash

›Oral ulcers

›Eye pain

›Urethral symptoms

Baseline and prior episodes

›Baseline status

›Prior similar episodes

›Baseline ROM

›Baseline strength

›Baseline sensation

›Baseline deformity

›Occupational baseline function

Infectious exposure context

›Infection context

›Recent skin break

›Recent manicure

›IV drug use

›Recent aquatic exposure

›Freshwater exposure

›Saltwater exposure

›Farm exposure

›Tuberculosis exposure

Inflammatory and crystal context

›Inflammatory context

›Morning stiffness duration

›Other joint involvement

›Prior gout

›Prior pseudogout

›Psoriasis history

›IBD history

02Alarm Features/alarm52

Immediate escalation triggers

›High risk patterns

›Rapidly progressive pain

›Pain out of proportion

›Severe pain with passive stretch

›Tense swelling

›Paresthesia

›Pallor

›Pulselessness

›Paralysis

›Poikilothermia

›Rapidly spreading erythema

›Bullae

›Skin necrosis

›Crepitus

›Toxic appearance

›Altered mental status

Vital sign danger thresholds

›Vital sign danger thresholds

›SBP < 90 mmHg

›HR > 120

›RR > 24

›SpO2 < 92 percent

›Temperature >= 38.0 C

High risk infection features

›Deep hand infection red flags

›Flexor tendon sheath pattern

›Finger held in flexion

›Fusiform swelling

›Pain with passive extension

›Tenderness along flexor sheath

›Septic arthritis pattern

›Severe pain with minimal ROM

›Joint effusion

›Necrotizing infection pattern

›Severe pain

›Systemic toxicity

›Disproportionate exam findings

High risk trauma features

›Trauma red flags

›Open fracture concern

›Neurovascular compromise

›Compartment syndrome concern

›Tendon laceration concern

›Rotational deformity

›Fight bite over MCP

›High pressure injection injury

Special populations red flags

›High risk hosts

›Immunocompromised

›Diabetes mellitus (E11.9)

›Hemodialysis

›Systemic steroids

›Neutropenia

›Pregnancy

›Anticoagulated

›Sickle cell disease (D57.1)

03Medications/meds23

Current and recent medications

›Medication inventory

›Prescribed medications

›OTC analgesics

›NSAIDs

›Acetaminophen

›Supplements

›Recent antibiotic exposure

›Recent steroid exposure

High risk medication classes

›Medication risks

›Anticoagulants

›Antiplatelets

›Immunosuppressants

›Biologics

›Chronic opioids

Contraindications and interactions

›Therapy constraints

›NSAID contraindications

›CKD

›Peptic ulcer disease

›Anticoagulation

›Opioid precautions

›OSA

›Sedative co use

›Antibiotic allergies

04Diet/diet10

Exposures relevant to hand pain

›Dietary and exposure patterns

›Hydration status

›Alcohol intake pattern

›Purine rich intake pattern

›High fructose intake pattern

›Caffeine and energy drinks

Nutrition related healing context

›Healing modifiers

›Low protein intake concern

›Vitamin C deficiency risk

›Poor caloric intake

05Review of Systems/ros35

Constitutional and infection

›Constitutional and infection

›Fever

›Chills

›Night sweats

›Weight loss

›Fatigue

Skin and mucosal

›Skin and mucosal

›Rash

›Psoriatic plaques

›Oral ulcers

›Vesicular lesions on finger

Musculoskeletal

›Musculoskeletal

›Other joint pain

›Joint swelling

›Morning stiffness

›Back pain

›Tendon pain

Neurologic

›Neurologic

›Numbness

›Tingling

›Weakness

›Neck pain

›Radicular symptoms

Cardiopulmonary and vascular

›Cardiopulmonary and vascular

›Chest pain

›Dyspnea

›Raynaud type color changes

›Claudication symptoms

GU and GI inflammatory clues

›Systemic inflammatory clues

›Diarrhea

›Blood in stool

›Urethral discharge

›Dysuria

›Eye redness

›Eye pain

06Collateral History and Family History/chafh14

Collateral and reliability

›Collateral context

›Source

›Reliability

›Baseline functional status confirmation

Family history

›Family history

›Rheumatoid arthritis (M06.9)

›Psoriatic arthritis (L40.50)

›Gout (M10.9)

›Early vascular disease

›Connective tissue disease

Household and exposure

›Exposure context

›Sick contacts

›MRSA exposure

›Animal exposures

07Risk Factors/rf28

Trauma and occupational

›Mechanical risk factors

›Contact sports

›Repetitive grip work

›Vibration tools

›Recent fall on outstretched hand

›Crush mechanism

Infection risks

›Infection risks

›Skin break

›Bite

›Fight bite

›Diabetes mellitus (E11.9)

›Immunosuppression

›IV drug use

›Prior MRSA

Thrombosis and ischemia

›Vascular risks

›Atrial fibrillation (I48.91)

›Peripheral arterial disease (I73.9)

›Smoking

›Known hypercoagulable state

Inflammatory and crystal disease

›Inflammatory risks

›Chronic kidney disease

›Diuretic use

›Psoriasis (L40.9)

›Inflammatory bowel disease

Procedure and device

›Iatrogenic risks

›Recent injection

›Recent surgery

›Implanted hardware

08Differential Diagnosis/ddx101

Life threatening

›Life threatening causes

›Acute compartment syndrome (T79.A0)

›Pain out of proportion

›Pain with passive stretch

›Tense compartments

›Paresthesia

›Necrotizing soft tissue infection (M72.6)

›Rapid progression

›Severe pain

›Systemic toxicity

›Bullae

›Crepitus

›Flexor tenosynovitis

›Kanavel signs cluster

›Rapid loss of function

›Septic arthritis of hand joint (M00.9)

›Severe pain with minimal ROM

›Effusion

›Fever

›Acute limb ischemia of upper extremity (I74.2)

›Sudden pain

›Pallor

›Pulselessness

›Poikilothermia

›Open fracture (S62.90)

›Wound near fracture site

›Neurovascular compromise

Common

›Common causes

›Fracture of hand bones (S62.9)

›Trauma history

›Point tenderness

›Swelling

›Sprain or strain

›Overuse

›Pain with specific motion

›Contusion

›Direct blow

›Ecchymosis

›Cellulitis (L03.119)

›Erythema

›Warmth

›Tenderness

›Paronychia

›Nail fold swelling

›Drainage

›Felon

›Pulp space tenderness

›Tense swelling

›Osteoarthritis of hand (M19.049)

›Bony enlargement

›Activity related pain

›Carpal tunnel syndrome (G56.0)

›Median distribution paresthesia

›Night symptoms

›Ulnar neuropathy

›Ring and small finger paresthesia

›Intrinsic weakness

›Trigger finger

›Locking

›A1 pulley tenderness

Less common

›Less common causes

›Gout (M10.9)

›Episodic severe pain

›Erythema

›Tophi history

›Pseudogout (M11.20)

›Acute synovitis

›Chondrocalcinosis history

›Rheumatoid arthritis (M06.9)

›Symmetric small joint swelling

›Prolonged morning stiffness

›Psoriatic arthritis (L40.50)

›Dactylitis

›Nail changes

›Osteomyelitis (M86.9)

›Chronic wound

›Persistent pain

›Systemic symptoms variable

›Herpetic whitlow

›Vesicles

›Burning pain

›Complex regional pain syndrome (G90.50)

›Disproportionate pain

›Allodynia

›Temperature asymmetry

›Tendon rupture

›Loss of active motion

›Sudden pop

›Foreign body reaction

›Puncture history

›Persistent focal pain

Mimics and pitfalls

›Mimics and pitfalls

›Cervical radiculopathy

›Neck pain

›Dermatomal symptoms

›Referred cardiac ischemia

›Atypical arm pain

›Risk factors

›Early infection with minimal skin change

›Severe pain

›Function loss

09Past Medical History/pmh18

Relevant conditions

›Comorbidities

›Diabetes mellitus (E11.9)

›Chronic kidney disease (N18.9)

›Peripheral arterial disease (I73.9)

›Atrial fibrillation (I48.91)

›Immunodeficiency

›Rheumatoid arthritis (M06.9)

›Gout (M10.9)

›Psoriasis (L40.9)

Prior episodes and procedures

›Prior history elements

›Prior hand fractures

›Prior hand surgery

›Prior joint aspiration

›Prior septic arthritis

›Prior MRSA infection

Devices and hardware

›Hardware and implants

›Orthopedic hardware in hand

›Vascular access devices

10Physical Exam/exam51

General and vitals

›General and vitals

›Toxic appearance

›Fever pattern

›Hemodynamic stability

Inspection

›Inspection

›Deformity

›Swelling distribution

›Erythema distribution

›Ecchymosis

›Wounds

›Bite marks

›Nail fold changes

›Vesicles

›Skin necrosis

Palpation

›Palpation

›Point tenderness

›Crepitus

›Fluctuance

›Pulp space tension

›Flexor sheath tenderness

›Joint line tenderness

Range of motion

›Range of motion

›Active ROM limitation

›Passive ROM limitation

›Pain with passive stretch

›Rotational alignment with finger flexion

Neurovascular

›Neurovascular

›Capillary refill

›Skin temperature

›Radial pulse

›Ulnar pulse

›Allen test perfusion symmetry

›Two point discrimination

›Median nerve motor

›Ulnar nerve motor

›Radial nerve motor

Tendon and ligament function

›Tendon and ligament function

›FDP function

›FDS function

›Extensor function

›Thumb IP extension

›Collateral ligament stability

›Central slip integrity

Focused infection findings

›Infection exam

›Kanavel signs cluster

›Fusiform swelling

›Finger held in flexion

›Pain with passive extension

›Flexor sheath tenderness

›Joint effusion

›Lymphangitic streaking

11Lab Studies/labs18

Basic and inflammatory markers

›Baseline labs

›CBC with differential

›CRP

›ESR

Infection and sepsis evaluation

›Infection evaluation

›Blood cultures

›Serum lactate

›BMP

Crystal and inflammatory arthritis workup

›Crystal and inflammatory evaluation

›Synovial fluid analysis if effusion present

›Gram stain

›Culture

›Cell count

›Crystal analysis

Special scenarios

›Scenario directed tests

›Creatine kinase for crush injury

›Glucose for infection risk context

›Coagulation studies for significant hematoma on anticoagulation

12Imaging/img45

Scoring Systems

›Decision tools and risk stratification

›LRINEC score for necrotizing infection

›When to use

›Suspected necrotizing soft tissue infection

›Adjunct to clinical assessment

›When not to use

›Low suspicion with reassuring exam

›Not a rule out tool

›Limitations

›Variable performance

›False reassurance possible

MRI

›MRI applications

›Occult fracture

›Osteomyelitis

›Septic arthritis evaluation adjunct

›Tendon and ligament injury

›Deep space infection extent

›Contraindications

›Non compatible implants

›Severe claustrophobia

›Contrast considerations

›Renal function context

›Allergy history

›CT applications

›Complex fractures

›Intra articular fracture mapping

›Foreign body detection

›Gas in soft tissues

›Contrast considerations

›Renal impairment

›Allergy history

›Radiation considerations

›Pregnancy

›Pediatrics

Ultrasound

›Ultrasound applications

›POCUS abscess evaluation

›Tenosynovitis fluid

›Joint effusion guidance

›Foreign body detection

›Vascular flow screening

›Doppler signals

›Symmetry comparison

›Pitfalls

›Deep space infection underestimation

›Operator dependence

13Special Tests/spec22

Bedside maneuvers

›Bedside tests

›Kanavel signs for flexor tenosynovitis

›Phalen test for carpal tunnel

›Tinel sign at carpal tunnel

›Froment sign for ulnar neuropathy

›Finkelstein test for first dorsal compartment tenosynovitis

›Grind test for thumb CMC osteoarthritis

Procedural diagnostics

›Procedures as diagnostics

›Joint aspiration when effusion present

›Synovial fluid studies

›Gram stain

›Culture

›Cell count

›Crystal analysis

›Wound exploration when foreign body suspected

›High pressure injection injury escalation

›Surgical consultation timing sensitive

Functional testing

›Tendon and ligament integrity tests

›Elson test for central slip

›Collateral ligament stress testing

›FDP isolation

›FDS isolation

14ECG/ecg9

Indications tied to hand pain presentations

›ECG indications

›Atypical arm pain with cardiac risk

›Systemic illness with tachycardia

›Electrolyte abnormality concern

High risk patterns

›High risk findings

›STEMI patterns

›New ischemic ST T changes

›Wide QRS with hyperkalemia concern

›Malignant arrhythmia patterns

15Assessment/ax29

Problem representation

›Hand pain syndrome summary

›Traumatic versus non traumatic

›Infectious versus non infectious

›Ischemic concern present versus absent

›Neuro deficit present versus absent

Working diagnoses

›Working diagnosis options

›Hand fracture (S62.9)

›Supporting features

›Imaging correlation

›Cellulitis (L03.119)

›Local signs

›Systemic signs

›Flexor tenosynovitis

›Kanavel signs cluster

›Time course

›Septic arthritis (M00.9)

›Severe ROM pain

›Effusion

›Gout (M10.9)

›Episodic pattern

›Prior history

Severity and risk stratification

›Risk level

›Limb threat features

›Deep infection features

›Open injury features

›Host risk factors

Diagnostic uncertainty

›Uncertainty management

›Alternative diagnoses tracked

›Early disease timing pitfalls

16Plan/plan50

Approach to critical patient

›First 5 minutes

›Monitoring

›Cardiac monitor for toxic appearance

›Pulse oximetry for systemic illness

›IV access

›Two large bore IV for sepsis concern

›One IV for moderate infection concern

›Analgesia early

›Acetaminophen PO 1000 mg once

›Ibuprofen PO 400 mg once

›Avoid NSAIDs in CKD or GI bleed risk

›Time critical consult triggers

›Hand surgery for flexor tenosynovitis concern

›Hand surgery for compartment syndrome concern

›Vascular surgery for acute limb ischemia concern

Diagnostic sequencing

›Diagnostic plan

›Plain radiographs

›Hand views

›Wrist views if overlap symptoms

›Labs when infection or inflammatory concern

›CBC

›CRP

›Blood cultures if febrile

›Aspiration when effusion present

›Cell count

›Gram stain and culture

›Crystal analysis

›Advanced imaging escalation

›CT for complex fracture mapping

›MRI for osteomyelitis concern

Therapeutics

›Symptom control and definitive care

›Immobilization

›Neutral position splint

›Buddy taping for stable phalanx injury

›Elevation

›Above heart level

›Reassessment of swelling response

›Antibiotics for suspected bacterial infection

›Local protocol dependent selection

›Avoid delay for deep hand infection with systemic toxicity

›Tetanus prophylaxis

›Update based on immunization status

›Contaminated wound timing dependent

Reassessment loop

›Reassessment loop

›Pain trajectory

›Neurovascular status changes

›Swelling progression

›ROM progression

›Vital sign trend

›Compartment syndrome evolution concern

17Disposition/dispo26

ICU and resuscitation level care

›ICU criteria

›Sepsis with hypotension

›Lactate elevated with end organ dysfunction

›Necrotizing infection concern

›Rapidly progressive ischemia

Inpatient admission

›Admission criteria

›Flexor tenosynovitis concern

›Septic arthritis concern

›Osteomyelitis concern

›Open fracture

›Uncontrolled pain

›Significant functional impairment without safe supports

Observation pathway

›Observation criteria

›Moderate cellulitis without systemic toxicity

›Serial neurovascular checks needed

›Need for repeat imaging or specialist reassessment

Discharge criteria and follow up

›Discharge criteria

›No neurovascular compromise

›No deep infection concern

›Pain controlled with oral meds

›Safe splint plan

›Reliable follow up

›Follow up timing

›Hand specialist 1 to 3 days for suspected tendon injury

›Fracture clinic 5 to 10 days for stable fracture patterns

›Primary care 2 to 3 days for cellulitis reassessment

18Discharge Instructions/di30

Copy discharge instructions

›Diagnosis summary

›Hand pain likely from

›Injury

›Overuse

›Infection

›Inflammation

›Medications

›Acetaminophen

›Maximum daily dose per label

›Ibuprofen

›Avoid if kidney disease or stomach bleeding history

›Antibiotics

›Finish the full course if prescribed

›Activity and protection

›Splint use as directed

›Elevation above heart level

›Ice 15 to 20 minutes at a time

›Follow up

›Follow up with

›Timeframe

›Return to ED now if

›Fever

›Rapidly worsening redness or swelling

›Severe pain not controlled

›New numbness

›New weakness

›Blue or pale fingers

›Cold fingers

›Pus drainage

›Pain with passive finger extension

19References/r6

Guidelines and key sources

›Evidence sources

›Infectious Diseases Society of America clinical practice guideline for skin and soft tissue infections 2014

›American College of Radiology Appropriateness Criteria acute hand and wrist trauma most recent update local protocol dependent

›American College of Radiology Appropriateness Criteria suspected osteomyelitis septic arthritis or soft tissue infection most recent update local protocol dependent

›SANJO guideline for management of septic arthritis in native joints 2023

›American College of Rheumatology guideline for management of gout 2020

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Hand PainAPPROACH

MUSCULOSKELETAL AND EXTREMITIES · 19 SECTIONS

⚲

662 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx95

Presenting features

›Symptom profile

›Location

›Laterality

›Dominant hand

›Single digit

›Multiple digits

›Palm

›Dorsum

›Wrist involvement

›Swelling pattern

›Stiffness pattern

›Trauma mechanism

›Overuse pattern

›Bite history

›Human bite

›Animal bite

›Puncture wound

›Foreign body concern

OPQRST

›OPQRST framework

›Onset

›Sudden

›Gradual

›Time since onset

›Time since trauma

›Provocation and palliation

›Worse with grip

›Worse with pinch

›Worse with finger flexion

›Worse with finger extension

›Worse with wrist motion

›Relief with rest

›Relief with immobilization

›Relief with elevation

›Quality

›Sharp

›Aching

›Burning

›Throbbing

›Electric

›Region and radiation

›Localized

›Radiates to forearm

›Radiates to fingers

›Radiates from neck

›Severity

›Pain scale 0 to 10

›Functional limitation

›Timing

›Constant

›Intermittent

›Morning predominance

›Night predominance

›Progressive

›Improving

Associated symptoms

›Associated symptoms

›Fever

›Chills

›Malaise

›Redness

›Warmth

›Drainage

›Numbness

›Tingling

›Weakness

›Color change

›Coldness

›Finger locking

›Clicking

›New rash

›Oral ulcers

›Eye pain

›Urethral symptoms

Baseline and prior episodes

›Baseline status

›Prior similar episodes

›Baseline ROM

›Baseline strength

›Baseline sensation

›Baseline deformity

›Occupational baseline function

Infectious exposure context

›Infection context

›Recent skin break

›Recent manicure

›IV drug use

›Recent aquatic exposure

›Freshwater exposure

›Saltwater exposure

›Farm exposure

›Tuberculosis exposure

Inflammatory and crystal context

›Inflammatory context

›Morning stiffness duration

›Other joint involvement

›Prior gout

›Prior pseudogout

›Psoriasis history

›IBD history

02Alarm Features/alarm52

Immediate escalation triggers

›High risk patterns

›Rapidly progressive pain

›Pain out of proportion

›Severe pain with passive stretch

›Tense swelling

›Paresthesia

›Pallor

›Pulselessness

›Paralysis

›Poikilothermia

›Rapidly spreading erythema

›Bullae

›Skin necrosis

›Crepitus

›Toxic appearance

›Altered mental status

Vital sign danger thresholds

›Vital sign danger thresholds

›SBP < 90 mmHg

›HR > 120

›RR > 24

›SpO2 < 92 percent

›Temperature >= 38.0 C

High risk infection features

›Deep hand infection red flags

›Flexor tendon sheath pattern

›Finger held in flexion

›Fusiform swelling

›Pain with passive extension

›Tenderness along flexor sheath

›Septic arthritis pattern

›Severe pain with minimal ROM

›Joint effusion

›Necrotizing infection pattern

›Severe pain

›Systemic toxicity

›Disproportionate exam findings

High risk trauma features

›Trauma red flags

›Open fracture concern

›Neurovascular compromise

›Compartment syndrome concern

›Tendon laceration concern

›Rotational deformity

›Fight bite over MCP

›High pressure injection injury

Special populations red flags

›High risk hosts

›Immunocompromised

›Diabetes mellitus (E11.9)

›Hemodialysis

›Systemic steroids

›Neutropenia

›Pregnancy

›Anticoagulated

›Sickle cell disease (D57.1)

03Medications/meds23

Current and recent medications

›Medication inventory

›Prescribed medications

›OTC analgesics

›NSAIDs

›Acetaminophen

›Supplements

›Recent antibiotic exposure

›Recent steroid exposure

High risk medication classes

›Medication risks

›Anticoagulants

›Antiplatelets

›Immunosuppressants

›Biologics

›Chronic opioids

Contraindications and interactions

›Therapy constraints

›NSAID contraindications

›CKD

›Peptic ulcer disease

›Anticoagulation

›Opioid precautions

›OSA

›Sedative co use

›Antibiotic allergies

04Diet/diet10

Exposures relevant to hand pain

›Dietary and exposure patterns

›Hydration status

›Alcohol intake pattern

›Purine rich intake pattern

›High fructose intake pattern

›Caffeine and energy drinks

Nutrition related healing context

›Healing modifiers

›Low protein intake concern

›Vitamin C deficiency risk

›Poor caloric intake

05Review of Systems/ros35

Constitutional and infection

›Constitutional and infection

›Fever

›Chills

›Night sweats

›Weight loss

›Fatigue

Skin and mucosal

›Skin and mucosal

›Rash

›Psoriatic plaques

›Oral ulcers

›Vesicular lesions on finger

Musculoskeletal

›Musculoskeletal

›Other joint pain

›Joint swelling

›Morning stiffness

›Back pain

›Tendon pain

Neurologic

›Neurologic

›Numbness

›Tingling

›Weakness

›Neck pain

›Radicular symptoms

Cardiopulmonary and vascular

›Cardiopulmonary and vascular

›Chest pain

›Dyspnea

›Raynaud type color changes

›Claudication symptoms

GU and GI inflammatory clues

›Systemic inflammatory clues

›Diarrhea

›Blood in stool

›Urethral discharge

›Dysuria

›Eye redness

›Eye pain

06Collateral History and Family History/chafh14

Collateral and reliability

›Collateral context

›Source

›Reliability

›Baseline functional status confirmation

Family history

›Family history

›Rheumatoid arthritis (M06.9)

›Psoriatic arthritis (L40.50)

›Gout (M10.9)

›Early vascular disease

›Connective tissue disease

Household and exposure

›Exposure context

›Sick contacts

›MRSA exposure

›Animal exposures

07Risk Factors/rf28

Trauma and occupational

›Mechanical risk factors

›Contact sports

›Repetitive grip work

›Vibration tools

›Recent fall on outstretched hand

›Crush mechanism

Infection risks

›Infection risks

›Skin break

›Bite

›Fight bite

›Diabetes mellitus (E11.9)

›Immunosuppression

›IV drug use

›Prior MRSA

Thrombosis and ischemia

›Vascular risks

›Atrial fibrillation (I48.91)

›Peripheral arterial disease (I73.9)

›Smoking

›Known hypercoagulable state

Inflammatory and crystal disease

›Inflammatory risks

›Chronic kidney disease

›Diuretic use

›Psoriasis (L40.9)

›Inflammatory bowel disease

Procedure and device

›Iatrogenic risks

›Recent injection

›Recent surgery

›Implanted hardware

08Differential Diagnosis/ddx101

Life threatening

›Life threatening causes

›Acute compartment syndrome (T79.A0)

›Pain out of proportion

›Pain with passive stretch

›Tense compartments

›Paresthesia

›Necrotizing soft tissue infection (M72.6)

›Rapid progression

›Severe pain

›Systemic toxicity

›Bullae

›Crepitus

›Flexor tenosynovitis

›Kanavel signs cluster

›Rapid loss of function

›Septic arthritis of hand joint (M00.9)

›Severe pain with minimal ROM

›Effusion

›Fever

›Acute limb ischemia of upper extremity (I74.2)

›Sudden pain

›Pallor

›Pulselessness

›Poikilothermia

›Open fracture (S62.90)

›Wound near fracture site

›Neurovascular compromise

Common

›Common causes

›Fracture of hand bones (S62.9)

›Trauma history

›Point tenderness

›Swelling

›Sprain or strain

›Overuse

›Pain with specific motion

›Contusion

›Direct blow

›Ecchymosis

›Cellulitis (L03.119)

›Erythema

›Warmth

›Tenderness

›Paronychia

›Nail fold swelling

›Drainage

›Felon

›Pulp space tenderness

›Tense swelling

›Osteoarthritis of hand (M19.049)

›Bony enlargement

›Activity related pain

›Carpal tunnel syndrome (G56.0)

›Median distribution paresthesia

›Night symptoms

›Ulnar neuropathy

›Ring and small finger paresthesia

›Intrinsic weakness

›Trigger finger

›Locking

›A1 pulley tenderness

Less common

›Less common causes

›Gout (M10.9)

›Episodic severe pain

›Erythema

›Tophi history

›Pseudogout (M11.20)

›Acute synovitis

›Chondrocalcinosis history

›Rheumatoid arthritis (M06.9)

›Symmetric small joint swelling

›Prolonged morning stiffness

›Psoriatic arthritis (L40.50)

›Dactylitis

›Nail changes

›Osteomyelitis (M86.9)

›Chronic wound

›Persistent pain

›Systemic symptoms variable

›Herpetic whitlow

›Vesicles

›Burning pain

›Complex regional pain syndrome (G90.50)

›Disproportionate pain

›Allodynia

›Temperature asymmetry

›Tendon rupture

›Loss of active motion

›Sudden pop

›Foreign body reaction

›Puncture history

›Persistent focal pain

Mimics and pitfalls

›Mimics and pitfalls

›Cervical radiculopathy

›Neck pain

›Dermatomal symptoms

›Referred cardiac ischemia

›Atypical arm pain

›Risk factors

›Early infection with minimal skin change

›Severe pain

›Function loss

09Past Medical History/pmh18

Relevant conditions

›Comorbidities

›Diabetes mellitus (E11.9)

›Chronic kidney disease (N18.9)

›Peripheral arterial disease (I73.9)

›Atrial fibrillation (I48.91)

›Immunodeficiency

›Rheumatoid arthritis (M06.9)

›Gout (M10.9)

›Psoriasis (L40.9)

Prior episodes and procedures

›Prior history elements

›Prior hand fractures

›Prior hand surgery

›Prior joint aspiration

›Prior septic arthritis

›Prior MRSA infection

Devices and hardware

›Hardware and implants

›Orthopedic hardware in hand

›Vascular access devices

10Physical Exam/exam51

General and vitals

›General and vitals

›Toxic appearance

›Fever pattern

›Hemodynamic stability

Inspection

›Inspection

›Deformity

›Swelling distribution

›Erythema distribution

›Ecchymosis

›Wounds

›Bite marks

›Nail fold changes

›Vesicles

›Skin necrosis

Palpation

›Palpation

›Point tenderness

›Crepitus

›Fluctuance

›Pulp space tension

›Flexor sheath tenderness

›Joint line tenderness

Range of motion

›Range of motion

›Active ROM limitation

›Passive ROM limitation

›Pain with passive stretch

›Rotational alignment with finger flexion

Neurovascular

›Neurovascular

›Capillary refill

›Skin temperature

›Radial pulse

›Ulnar pulse

›Allen test perfusion symmetry

›Two point discrimination

›Median nerve motor

›Ulnar nerve motor

›Radial nerve motor

Tendon and ligament function

›Tendon and ligament function

›FDP function

›FDS function

›Extensor function

›Thumb IP extension

›Collateral ligament stability

›Central slip integrity

Focused infection findings

›Infection exam

›Kanavel signs cluster

›Fusiform swelling

›Finger held in flexion

›Pain with passive extension

›Flexor sheath tenderness

›Joint effusion

›Lymphangitic streaking

11Lab Studies/labs18

Basic and inflammatory markers

›Baseline labs

›CBC with differential

›CRP

›ESR

Infection and sepsis evaluation

›Infection evaluation

›Blood cultures

›Serum lactate

›BMP

Crystal and inflammatory arthritis workup

›Crystal and inflammatory evaluation

›Synovial fluid analysis if effusion present

›Gram stain

›Culture

›Cell count

›Crystal analysis

Special scenarios

›Scenario directed tests

›Creatine kinase for crush injury

›Glucose for infection risk context

›Coagulation studies for significant hematoma on anticoagulation

12Imaging/img45

Scoring Systems

›Decision tools and risk stratification

›LRINEC score for necrotizing infection

›When to use

›Suspected necrotizing soft tissue infection

›Adjunct to clinical assessment

›When not to use

›Low suspicion with reassuring exam

›Not a rule out tool

›Limitations

›Variable performance

›False reassurance possible

MRI

›MRI applications

›Occult fracture

›Osteomyelitis

›Septic arthritis evaluation adjunct

›Tendon and ligament injury

›Deep space infection extent

›Contraindications

›Non compatible implants

›Severe claustrophobia

›Contrast considerations

›Renal function context

›Allergy history

›CT applications

›Complex fractures

›Intra articular fracture mapping

›Foreign body detection

›Gas in soft tissues

›Contrast considerations

›Renal impairment

›Allergy history

›Radiation considerations

›Pregnancy

›Pediatrics

Ultrasound

›Ultrasound applications

›POCUS abscess evaluation

›Tenosynovitis fluid

›Joint effusion guidance

›Foreign body detection

›Vascular flow screening

›Doppler signals

›Symmetry comparison

›Pitfalls

›Deep space infection underestimation

›Operator dependence

13Special Tests/spec22

Bedside maneuvers

›Bedside tests

›Kanavel signs for flexor tenosynovitis

›Phalen test for carpal tunnel

›Tinel sign at carpal tunnel

›Froment sign for ulnar neuropathy

›Finkelstein test for first dorsal compartment tenosynovitis

›Grind test for thumb CMC osteoarthritis

Procedural diagnostics

›Procedures as diagnostics

›Joint aspiration when effusion present

›Synovial fluid studies

›Gram stain

›Culture

›Cell count

›Crystal analysis

›Wound exploration when foreign body suspected

›High pressure injection injury escalation

›Surgical consultation timing sensitive

Functional testing

›Tendon and ligament integrity tests

›Elson test for central slip

›Collateral ligament stress testing

›FDP isolation

›FDS isolation

14ECG/ecg9

Indications tied to hand pain presentations

›ECG indications

›Atypical arm pain with cardiac risk

›Systemic illness with tachycardia

›Electrolyte abnormality concern

High risk patterns

›High risk findings

›STEMI patterns

›New ischemic ST T changes

›Wide QRS with hyperkalemia concern

›Malignant arrhythmia patterns

15Assessment/ax29

Problem representation

›Hand pain syndrome summary

›Traumatic versus non traumatic

›Infectious versus non infectious

›Ischemic concern present versus absent

›Neuro deficit present versus absent

Working diagnoses

›Working diagnosis options

›Hand fracture (S62.9)

›Supporting features

›Imaging correlation

›Cellulitis (L03.119)

›Local signs

›Systemic signs

›Flexor tenosynovitis

›Kanavel signs cluster

›Time course

›Septic arthritis (M00.9)

›Severe ROM pain

›Effusion

›Gout (M10.9)

›Episodic pattern

›Prior history

Severity and risk stratification

›Risk level

›Limb threat features

›Deep infection features

›Open injury features

›Host risk factors

Diagnostic uncertainty

›Uncertainty management

›Alternative diagnoses tracked

›Early disease timing pitfalls

16Plan/plan50

Approach to critical patient

›First 5 minutes

›Monitoring

›Cardiac monitor for toxic appearance

›Pulse oximetry for systemic illness

›IV access

›Two large bore IV for sepsis concern

›One IV for moderate infection concern

›Analgesia early

›Acetaminophen PO 1000 mg once

›Ibuprofen PO 400 mg once

›Avoid NSAIDs in CKD or GI bleed risk

›Time critical consult triggers

›Hand surgery for flexor tenosynovitis concern

›Hand surgery for compartment syndrome concern

›Vascular surgery for acute limb ischemia concern

Diagnostic sequencing

›Diagnostic plan

›Plain radiographs

›Hand views

›Wrist views if overlap symptoms

›Labs when infection or inflammatory concern

›CBC

›CRP

›Blood cultures if febrile

›Aspiration when effusion present

›Cell count

›Gram stain and culture

›Crystal analysis

›Advanced imaging escalation

›CT for complex fracture mapping

›MRI for osteomyelitis concern

Therapeutics

›Symptom control and definitive care

›Immobilization

›Neutral position splint

›Buddy taping for stable phalanx injury

›Elevation

›Above heart level

›Reassessment of swelling response

›Antibiotics for suspected bacterial infection

›Local protocol dependent selection

›Avoid delay for deep hand infection with systemic toxicity

›Tetanus prophylaxis

›Update based on immunization status

›Contaminated wound timing dependent

Reassessment loop

›Reassessment loop

›Pain trajectory

›Neurovascular status changes

›Swelling progression

›ROM progression

›Vital sign trend

›Compartment syndrome evolution concern

17Disposition/dispo26

ICU and resuscitation level care

›ICU criteria

›Sepsis with hypotension

›Lactate elevated with end organ dysfunction

›Necrotizing infection concern

›Rapidly progressive ischemia

Inpatient admission

›Admission criteria

›Flexor tenosynovitis concern

›Septic arthritis concern

›Osteomyelitis concern

›Open fracture

›Uncontrolled pain

›Significant functional impairment without safe supports

Observation pathway

›Observation criteria

›Moderate cellulitis without systemic toxicity

›Serial neurovascular checks needed

›Need for repeat imaging or specialist reassessment

Discharge criteria and follow up

›Discharge criteria

›No neurovascular compromise

›No deep infection concern

›Pain controlled with oral meds

›Safe splint plan

›Reliable follow up

›Follow up timing

›Hand specialist 1 to 3 days for suspected tendon injury

›Fracture clinic 5 to 10 days for stable fracture patterns

›Primary care 2 to 3 days for cellulitis reassessment

18Discharge Instructions/di30

Copy discharge instructions

›Diagnosis summary

›Hand pain likely from

›Injury

›Overuse

›Infection

›Inflammation

›Medications

›Acetaminophen

›Maximum daily dose per label

›Ibuprofen

›Avoid if kidney disease or stomach bleeding history

›Antibiotics

›Finish the full course if prescribed

›Activity and protection

›Splint use as directed

›Elevation above heart level

›Ice 15 to 20 minutes at a time

›Follow up

›Follow up with

›Timeframe

›Return to ED now if

›Fever

›Rapidly worsening redness or swelling

›Severe pain not controlled

›New numbness

›New weakness

›Blue or pale fingers

›Cold fingers

›Pus drainage

›Pain with passive finger extension

19References/r6

Guidelines and key sources

›Evidence sources

›Infectious Diseases Society of America clinical practice guideline for skin and soft tissue infections 2014

›American College of Radiology Appropriateness Criteria acute hand and wrist trauma most recent update local protocol dependent

›American College of Radiology Appropriateness Criteria suspected osteomyelitis septic arthritis or soft tissue infection most recent update local protocol dependent

›SANJO guideline for management of septic arthritis in native joints 2023

›American College of Rheumatology guideline for management of gout 2020

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.