History of Present Illness for Pediatric Hand Pain
When evaluating a minor with hand pain, immediately establish the mechanism of injury, timing, and presence of red flags that could indicate serious pathology requiring urgent intervention.
Essential History Components
Mechanism and Timing
- Trauma history: Specifically ask about crush injuries (hand caught in closing door—the most common mechanism in younger children) or sports-related injuries (predominant in teenagers) 1, 2
- Onset characteristics: Determine if pain is acute versus chronic (>4 weeks duration is a red flag) 3
- Time of day: Morning stiffness or night pain are concerning features 3
Pain Characteristics
- Location and distribution: Pinpoint whether pain is localized to specific joints, diffuse across the hand, or radiating 4, 5
- Quality and intensity: Use age-appropriate pain scales (Numerical Rating Scale, revised FLACC, Faces Pain Scale-Revised) 3
- Aggravating/relieving factors: Ask about specific tasks or positions that reproduce symptoms 4
Critical Red Flags to Identify
- Systemic symptoms: Fever, unintentional weight loss, tachycardia, or lymphadenopathy 3
- Neurologic deficits: Weakness, numbness, or gait abnormalities 3
- Functional impairment: Inability to perform age-appropriate tasks 4
- Duration: Pain persisting beyond 4 weeks despite conservative measures 3
Physical Examination Focus
Observation
- Resting posture: Note any abnormal hand positioning or visible deformities 4
- Swelling or erythema: Assess for signs of infection or inflammation 5
- Skin integrity: Look for lacerations, burns, or other soft tissue injuries 1
Palpation
- Joint tenderness: Systematically palpate each joint to identify specific areas of pathology 4
- Muscle/tendon assessment: Check for trigger points or tendon tenderness suggesting tenosynovitis 4
- Neurovascular status: Always assess distal perfusion and sensation 1
Functional Testing
- Range of motion: Active and passive movement of all joints 4
- Grip strength: Compare to contralateral side when possible 1
- Task-specific testing: Have the child perform age-appropriate activities to reproduce symptoms 4
Psychosocial Considerations
- Pain amplification factors: In pediatric patients, assess anxiety levels and parental concerns that may influence pain perception 3, 5
- Activity limitations: Determine impact on school, play, and daily activities 5
- Previous treatments: Document what has been tried and response to interventions 5
Common Pitfalls to Avoid
- Underestimating pain: Children's pain is frequently underestimated and inadequately treated; use validated age-appropriate pain scales 3
- Missing occult fractures: Small metacarpal and phalangeal fractures are difficult to diagnose clinically and may require imaging 2
- Overlooking infection: Early signs of infection (atypical mycobacterial, septic arthritis) can be subtle but require urgent intervention 6
- Inadequate trauma history: Crush injuries may cause significant internal damage despite minimal external findings 1, 2