What is the appropriate referral for hand pain presenting with a gullwing appearance?

From the Guidelines

The appropriate referral for hand pain presenting with a gullwing appearance is to a rheumatologist, as this clinical finding is highly suggestive of rheumatoid arthritis (RA). The gullwing appearance refers to the characteristic deformity where the metacarpophalangeal joints appear swollen with ulnar deviation of the fingers, resembling a seagull's wings in flight. While awaiting the rheumatology consultation, initial management may include NSAIDs such as naproxen 500mg twice daily or ibuprofen 600mg three times daily for pain relief, as recommended by the 2018 update of the EULAR recommendations for the management of hand osteoarthritis 1.

Key Considerations

• The gullwing deformity is a characteristic feature of rheumatoid arthritis, and early referral to a rheumatologist is crucial for prompt initiation of disease-modifying antirheumatic drugs (DMARDs) like methotrexate, which can significantly improve outcomes and prevent permanent joint damage.
• The EULAR recommendations suggest that education and training in ergonomic principles, pacing of activity, and use of assistive devices should be offered to every patient with hand osteoarthritis, and exercises to improve function and muscle strength, as well as to reduce pain, should be considered for every patient 1.
• Orthoses should be considered for symptom relief in patients with thumb base OA, and topical treatments are preferred over systemic treatments because of safety reasons, with topical NSAIDs being the first pharmacological topical treatment of choice 1.

Diagnostic Approach

• Radiographs are essential for the diagnosis of hand osteoarthritis, and a posteroanterior radiograph of both hands on a single film/field of view is adequate for diagnosis, as recommended by the EULAR evidence-based recommendations for the diagnosis of hand osteoarthritis 1.
• Blood tests are not required for diagnosis of hand osteoarthritis but may be required to exclude coexistent disease, and in a patient with hand osteoarthritis who has marked inflammatory symptoms and/or signs, especially involving atypical sites, blood tests should be undertaken to screen for additional inflammatory arthritides 1.

Management

• The management of hand osteoarthritis should be individualized according to localisation of OA, risk factors, type of OA, presence of inflammation, severity of structural change, level of pain, disability, and restriction of quality of life, comorbidity, and co-medication, as well as the wishes and expectations of the patient, as recommended by the EULAR evidence-based recommendations for the management of hand osteoarthritis 1.
• Local treatments are preferred over systemic treatments, especially for mild to moderate pain and when only a few joints are affected, and topical NSAIDs and capsaicin are effective and safe treatments for hand osteoarthritis 1.

From the Research

Hand Pain with Gullwing Appearance

• The gullwing appearance is often associated with syndactyly, a condition where two or more fingers are joined together 2.
• In cases of hand pain presenting with a gullwing appearance, referral to a hand surgeon or an orthopedic specialist may be necessary for proper evaluation and treatment.
• The treatment approach may involve surgical separation of the affected fingers, using techniques such as the dorsal gullwing flap 2.
• Other conditions, such as osteoarthritis, may also cause hand pain, but the gullwing appearance is not typically associated with this condition 3.
• Referral to a specialist is crucial to determine the underlying cause of the hand pain and to develop an appropriate treatment plan.
• The gullwing appearance can also be related to other medical conditions, such as urethral reconstruction or sacral fractures, but these are not directly related to hand pain [(4,5)].
• Pain and hand function are closely related, and assessment of hand function is an important aspect of evaluating hand pain 6.