What are the possible causes of non‑traumatic hand pain and bruising?

Nontraumatic Hand Pain and Bruising: Causes and Evaluation

Nontraumatic hand pain and bruising requires systematic evaluation for bleeding disorders, vascular pathology, connective tissue disease, inflammatory arthropathy, and medication effects—with the specific cause determined by age, comorbidities, and pattern of presentation.

Bleeding Disorders

Von Willebrand disease is the most common inherited bleeding disorder (prevalence 1 in 1000) and presents with easy bruising and mucocutaneous bleeding, but critically is NOT detected by standard PT/aPTT screening tests. 1

• Hemophilia (Factor VIII or IX deficiency) causes significant bruising even with mild deficiencies, particularly in males 1
• Factor XIII deficiency is not detected by PT/aPTT but causes substantial bruising 1
• Platelet function disorders present with normal platelet counts but abnormal function, requiring specialized testing like platelet aggregation studies 1
• Immune thrombocytopenia (ITP) is characterized by low platelet count with transient, often self-resolving course 1

Vascular Pathology

In patients with occupational hand trauma or repetitive vibration exposure, hypothenar hammer syndrome and hand-arm vibration syndrome must be considered as causes of hand pain and bruising. 2

• Hypothenar hammer syndrome results from acute or chronic trauma to the ulnar artery, causing critical limb ischemia that may require bypass surgery 2
• Hand-arm vibration syndrome is strongly temperature-dependent and must be differentiated from secondary Raynaud's phenomenon 2
• Arteriovenous malformations cause localized bleeding and bruising 1
• In hemodialysis patients, distal hypoperfusion ischemic syndrome causes hand pain through retrograde flow, arterial stenotic lesions, or distal arteriopathy from vascular calcification and diabetes 3

Connective Tissue and Inflammatory Disorders

Hand involvement is often the first clinical manifestation of systemic sclerosis, presenting with pain from fibrosis, synovitis, or overlap with rheumatoid arthritis. 4

• Systemic sclerosis hand findings include: erosions (25%), joint space narrowing (17.9%), radiological demineralization (42.9%), acro-osteolysis (25%), flexion contracture (28.6%), and calcinosis (17.9%) 4
• Hand arthropathy in systemic sclerosis correlates with serious internal organ involvement—arthritis correlates with heart involvement and finger-to-palm distance correlates with lung involvement 4
• Ehlers-Danlos syndrome causes easy bruising through vascular and connective tissue abnormalities 5
• Fibromyalgia is associated with significantly increased odds of hand diseases: carpal tunnel syndrome (OR 2.98), trigger finger (OR 1.77), De Quervain's tenosynovitis (OR 1.96), tendinitis (OR 2.16), and hand osteoarthritis (OR 2.99). 6

Medication and Nutritional Causes

NSAIDs, anticoagulants, antiplatelet agents, and corticosteroids are common medication causes of easy bruising that must be documented in the history. 7

• Alternative therapies and supplements may affect coagulation 7
• Vitamin K deficiency presents with prolonged PT and possibly aPTT, particularly important in infants without prophylaxis 1
• Scurvy (vitamin C deficiency) causes bruising and bleeding 5

Systemic Medical Conditions

• Liver disease/cirrhosis decreases clotting factor production causing spontaneous bruising 1
• Malignancies and infiltrative disorders cause thrombocytopenia or coagulation abnormalities 5, 1
• Disseminated intravascular coagulation (DIC) causes any type of bruising/bleeding including intracranial hemorrhage 1

Diagnostic Approach

Initial laboratory testing should include complete blood count with platelet count, PT, aPTT, and fibrinogen level—but normal PT/aPTT does NOT rule out bleeding disorders. 7, 1

Critical Testing Gaps

• PT/aPTT miss von Willebrand disease, Factor XIII deficiency, and platelet function disorders—these require specific testing including VWF antigen, VWF ristocetin cofactor activity, Factor VIII coagulant activity, and platelet aggregation studies. 1
• Coagulation tests are extremely sensitive to specimen handling and should be performed in experienced laboratories, as inappropriate handling commonly leads to false-positive results 1
• aPTT can be falsely prolonged with lupus anticoagulant or Factor XII deficiency (which does not indicate a true bleeding disorder) 1

Imaging for Hand Pain

Ultrasound is the initial imaging modality of choice, identifying synovitis, joint effusion, tenosynovitis, tendinopathy, tendon injury, and pulley injury—contributing to clinical assessment in 76% of patients and 67% without trauma history. 5

• MRI demonstrates arthritis, carpal boss, tendinopathy, tenosynovitis, pulley injury, extensor hood injury, sagittal band injury, volar plate injury, chondral injury, and ligament injury 5
• MRI changed clinical management in 69.5% of cases referred to hand surgeons 5
• Doppler-Allen test, duplex sonography, and optical acral pulse oscillometry are suitable for objective vascular assessment 2
• Digital subtraction angiography confirms diagnosis and plans treatment in hypothenar hammer syndrome 2

Age-Specific Considerations

In non-mobile infants, any bruising that cannot be explained by normal handling or pressure sites requires evaluation for both abuse and bleeding disorders. 8

• Bruising in infants under 6 months requires immediate evaluation regardless of location 7
• In children, abusive object or hand-patterned bruising, history inconsistent with injury, and absence of independent witness strongly suggest abuse 8
• Senile purpura in elderly patients results from thinning of blood vessels and skin with aging 1

Common Pitfalls

• Assuming normal PT/aPTT rules out bleeding disorders is incorrect—these tests miss the most common inherited bleeding disorder (von Willebrand disease) and other critical conditions. 1
• Overlooking medication effects on both bleeding tendency and test interpretation 7
• Failing to obtain complete arteriogram from aortic arch to palmar arch when vascular pathology is suspected 3
• Delaying bleeding disorder screening if blood product transfusions have been given—wait until elimination of transfused clotting elements 1
• In hemodialysis patients, demonstration of retrograde flow alone does not predict or indicate hand ischemia—arterial stenotic lesions and distal arteriopathy must be evaluated 3

Referral Indications

Referral to hematology is indicated when specialized testing (platelet function studies, VWD multimer analysis, Factor XIII assay) is needed, or when abnormal initial laboratory results require expert interpretation. 1

• Vascular surgery consultation is mandatory for suspected hypothenar hammer syndrome or distal hypoperfusion ischemic syndrome, as delay can lead to catastrophic gangrene and hand amputation 5, 2
• Rheumatology referral for suspected systemic sclerosis, particularly when hand arthropathy is present given correlation with serious internal organ involvement 4