What could be causing my right arm and hand pain?

Right Arm and Hand Pain: Diagnostic Approach

Begin with plain radiographs (3-view series: posteroanterior, lateral, and oblique) as the initial imaging study for all patients presenting with right arm and hand pain. 1, 2

Initial Diagnostic Workup

First-Line Imaging

• Radiography is the mandatory first step for evaluating chronic hand and arm pain, as it effectively detects fractures, joint malalignment, arthritis patterns, soft tissue calcifications, and bony abnormalities that guide all subsequent imaging decisions. 1, 2
• Standard 3-view 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
• In many cases, radiographs may be the only imaging examination needed to establish or confirm a diagnosis. 1

When Radiographs Are Normal or Show Only Nonspecific Arthritis

For Nonspecific Pain Without Clear Localization

• MRI without IV contrast is the primary recommendation when radiographs are normal or show only nonspecific arthritis and the pain source remains unclear. 2
• MRI changed clinical management in 69.5% of cases in a retrospective review of 316 patients, particularly by providing reassurance that no further follow-up was necessary in 70% of those cases. 2
• MRI accurately depicts abnormalities of bones, bone marrow, articular cartilage, ligaments, synovium, tendons, and neurovascular structures. 3

For Suspected Tendon Pathology

• Both ultrasound and MRI without IV contrast are equivalent first-line options when there is clinical concern for tendon injury, tenosynovitis, or tendinopathy. 1, 2
• Ultrasound was contributory to clinical assessment in 76% of patients referred from hand surgeons, including 67% of patients without trauma history. 1, 2
• Ultrasound offers practical advantages: more readily available, less expensive, allows dynamic assessment, and better suited for superficial structures. 2, 4

For Hand Swelling with Elevated Inflammatory Markers

• Ultrasound is the recommended first imaging modality after radiographs when inflammatory markers are elevated. 4
• Ultrasound effectively identifies synovitis, joint effusion, tenosynovitis, tendinopathy, and soft tissue pathology. 1, 4
• The American College of Rheumatology supports musculoskeletal ultrasound in patients without definitive diagnosis presenting with pain, swelling, or mechanical symptoms. 1, 4

For Suspected Carpal Tunnel Syndrome

• Ultrasound is highly sensitive and specific for diagnosing carpal tunnel syndrome when compared with clinical assessment and electrophysiologic studies. 1
• Multiple systematic reviews and meta-analyses demonstrate ultrasound's diagnostic accuracy, with the ability to identify space-occupying lesions, anatomic variants (bifid median nerve, persistent median artery), and tendon pathology. 1
• MRI can also diagnose carpal tunnel syndrome with high accuracy but is typically not indicated as the first-line test. 1

Common Causes to Consider

Musculoskeletal Pathology

• Osteoarthritis, nonunited fractures, ligament insufficiency and instability, and nerve compression are common causes of chronic hand and arm pain. 1
• Soft tissue masses, including ganglion cysts, are frequent causes of chronic wrist pain. 1

Nonspecific Arm Pain

• Nonspecific arm pain is characterized by vague, diffuse, uncharacteristic symptoms with disproportionate pain and disability. 5
• Physical risk factors include repetition, force, duration, short cycle time, and awkward posture, particularly in occupational settings. 6
• Reduced sensory and autonomic nerve function has been demonstrated in patients with nonspecific arm pain, suggesting a neuropathic component. 7

Vascular Considerations

• Thoracic outlet compression syndrome should be considered, particularly when 40-50% of patients have associated peripheral nerve compression symptoms. 8
• In hemodialysis patients, distal hypoperfusion ischemic syndrome can cause significant hand pain and requires arteriographic evaluation. 9

Critical Pitfalls to Avoid

• Never order MRI as the initial imaging study—radiographs must come first to rule out obvious bony pathology. 2
• Do not repeat radiographs earlier than 10-14 days for suspected occult fractures, as earlier imaging has high risk of missing fractures that remain radiographically occult. 2
• Do not order MRI for foreign body detection—CT or ultrasound are superior for this indication. 2
• Recognize that MRI without IV contrast is of limited benefit for nonspecific hand pain without a clear clinical indication for soft tissue or inflammatory pathology. 2, 4
• Ultrasound accuracy is highly operator-dependent and should be performed by experienced sonographers. 3

When to Add IV Contrast to MRI

• Adding IV contrast improves detection of tenosynovitis and aids in distinguishing synovitis from joint effusion and ganglion cysts. 2
• Contrast-enhanced imaging shows improved sensitivity for detecting inflammation in hand and wrist tendons compared to T2-weighted sequences alone. 2
• For routine tendon or ligament evaluation, contrast is generally not necessary unless there is specific concern for infection or inflammatory arthropathy. 2