What is the initial approach to treating painful lesions on the hands?

Initial Approach to Painful Hand Lesions

Begin with a biopsychosocial assessment that combines simple diagnostic testing (X-rays to exclude trauma, ESR for inflammatory disease) with immediate non-pharmacological interventions, followed by topical NSAIDs as first-line pharmacological treatment. 1, 2

Immediate Assessment Strategy

Obtain targeted history focusing on:

• Onset, quality, intensity, distribution, and duration of pain 3
• Mechanism of injury or repetitive activities (computer use, trauma) 2
• Presence of systemic symptoms (fever, systemic illness suggesting infection) 4
• Psychosocial factors that may amplify pain and disability 1

Perform focused physical examination looking for:

• Signs of infection (erythema, swelling, warmth, severe pain, stiffness) - these require urgent intervention as deep space infections can rapidly progress to abscess, sepsis, or limb-threatening necrotizing infection 4
• Joint involvement patterns (nodal changes, deformities) 1
• Soft tissue masses (ganglion cysts, vascular lesions) 5, 6

Initial diagnostic testing should be limited and targeted:

• Plain radiographs (three views: posteroanterior, lateral, oblique) are the appropriate first-line imaging for chronic hand pain and may be the only imaging needed 2, 3
• ESR if inflammatory arthritis suspected 1
• Avoid excessive investigation cycles 1

First-Line Treatment Algorithm

Non-pharmacological interventions (initiate immediately for all patients):

• Education and ergonomic training regarding joint protection, proper workstation setup, activity pacing, and assistive devices 2
• Exercise regimen involving range of motion and strengthening exercises for symptomatic relief and functional improvement 1, 2
• Local heat application (paraffin wax, hot packs) especially before exercise 1
• Orthoses/splints particularly for thumb base involvement or to prevent lateral angulation and flexion deformities 1, 2

Pharmacological management (stepwise approach):

1. Topical NSAIDs are the first pharmacological choice due to superior safety profile, especially for mild-to-moderate pain affecting few joints 1, 2

2. Oral paracetamol (up to 4 g/day) is the oral analgesic of first choice if topical agents insufficient, and is the preferred long-term oral analgesic due to efficacy and safety 1

3. Oral NSAIDs only if inadequate response to paracetamol, using lowest effective dose for shortest duration 1, 2

   • In patients with increased GI risk: add gastroprotective agent or use selective COX-2 inhibitor 1
   • In patients with increased cardiovascular risk: COX-2 inhibitors are contraindicated 1

Advanced Imaging When Initial Treatment Fails

Ultrasound or MRI without IV contrast are equivalent appropriate options for:

• Suspected tendon injury, tenosynovitis, or tendon pathology 2
• Suspected ganglion cysts 5, 3
• Carpal tunnel syndrome (ultrasound measures median nerve cross-sectional area) 2

MRI without IV contrast specifically for:

• Tendinopathy, tendon tears, intersection syndrome, stenosing tenosynovitis 2
• Suspected occult ganglion or solid tumors 5
• Inflammatory arthritis (with or without contrast to identify active synovitis, tenosynovitis, bone marrow edema) 3

Critical Pitfalls to Avoid

Never neglect early signs of infection - what appears as "trivial" hand injury can rapidly progress to deep space infection requiring immediate drainage, debridement, and IV antibiotics 4

Do NOT use:

• Conventional or biological disease-modifying antirheumatic drugs for hand osteoarthritis or overuse syndromes 2
• Intra-articular glucocorticoid injections generally in hand osteoarthritis (may consider for painful interphalangeal joints in select cases) 2

Avoid continuous investigation cycles - utilize biopsychosocial assessment rather than endless testing 1

Reassessment and Escalation

Review patient management plan within 6 months 1

If no improvement:

• Develop individualized pain management plan with ongoing assessment 1
• Consider referral to specialist or hand therapist 1, 7
• Surgical intervention reserved for structural abnormalities when conservative treatments have failed (e.g., severe thumb base OA, ganglion cysts with persistent symptoms) 1, 5