What is the workup for a crampy feeling in the hands and fingers?

Workup for Crampy Feeling in Hands and Fingers

The workup for a crampy feeling in the hands and fingers should begin with radiography of the affected area as the initial imaging study, followed by appropriate advanced imaging based on clinical findings and suspected pathology.

Initial Diagnostic Approach

• Standard radiographic evaluation of both hand and wrist should include three views: posteroanterior, lateral, and oblique 1
• These radiographs allow assessment of alignment, joint spaces, impaction syndromes, static instability, chronic healed and nonunited fractures, soft tissue mineralization, erosions, and soft tissue swelling 1
• Radiographs may be the only imaging examination needed to establish a diagnosis or confirm a clinically expected diagnosis 1

Clinical Evaluation Focus Areas

• Assess for sensory symptoms in the median nerve distribution (thumb, index, middle, and radial half of ring finger) which may indicate carpal tunnel syndrome 2, 3
• Evaluate for "triggering" or abnormal resistance to smooth flexion and extension of affected fingers, which could suggest trigger finger 3
• Check for swelling of extensor tendons at the wrist, which may indicate de Quervain tenosynovitis 3
• Perform the Ten Test for sensory evaluation, which has been shown to be reliable and reproducible for hand and finger injuries 4
• Assess for clicking, locking, or crepitus, which may indicate different underlying pathologies 5

Advanced Imaging Based on Clinical Suspicion

Ultrasound

• Recommended when soft tissue pathology is suspected 1
• Particularly useful for:
  • Carpal tunnel syndrome - can demonstrate enlargement of median nerve cross-sectional area, space-occupying lesions, and anatomic variants 2
  • Dynamic assessment of the hand and wrist 1
  • Evaluation of the contralateral side for comparison 1
  • Tendon pathology assessment 2

MRI

• Indicated when radiographs are normal or show nonspecific findings but symptoms persist 1
• Useful for:
  • Detailed evaluation of soft tissues including ligaments, tendons, and nerves 1
  • Detection of carpal tunnel syndrome with high accuracy 2
  • Identification of associated tendon pathology 2
  • Assessment of nerve compression syndromes 2

Electrodiagnostic Testing

• Recommended for suspected nerve compression syndromes, particularly when proximal compression is suspected 3
• More than 80% sensitive and 95% specific for carpal tunnel syndrome 3

Special Considerations

• For suspected muscle cramps without structural abnormalities, consider:

  • Evaluation of electrolyte abnormalities, especially hypokalemia and hypomagnesemia 6
  • Assessment for heat-related factors 6
  • Consideration of medication side effects 6

• For hand-arm vibration syndrome (particularly in those with occupational exposure to vibrating tools):

  • Consider both HAVS and carpal tunnel syndrome as potential diagnoses 7
  • Assess for occupational Raynaud's disease and digital polyneuropathy 7

Common Pitfalls to Avoid

• Relying solely on two-point discrimination for sensory testing, which has limited reproducibility and reliability 4
• Failing to consider systemic conditions when bilateral symptoms are present, as bilateral carpal tunnel syndrome may be an early sign of certain systemic conditions or amyloidosis 2
• Neglecting to evaluate for occupational exposures, particularly vibration, which can cause specific syndromes 7
• Ordering advanced imaging before appropriate radiographs have been obtained 1