What is the differential diagnosis for an adult presenting with palmar hand pain?

Differential Diagnosis for Palmar Hand Pain in Adults

The differential diagnosis for palmar hand pain in adults should systematically evaluate osteoarthritis (particularly thumb base involvement), carpal tunnel syndrome, tenosynovitis, dialysis-related ischemia in at-risk patients, inflammatory arthropathies, and vascular causes, with initial assessment guided by age, joint distribution pattern, presence of systemic symptoms, and dialysis access status.

Primary Diagnostic Categories

Osteoarthritis

• Hand osteoarthritis primarily targets DIP joints, PIP joints, and thumb base, with occasional involvement of index and middle MCP joints 1
• Pain is typically usage-related with only mild morning stiffness (<30 minutes), affecting one or few joints intermittently 1
• Clinical diagnosis can be made confidently in adults over 40 with characteristic joint distribution and Heberden/Bouchard nodes 1
• Risk factors include female sex, age >40, menopausal status, obesity, prior hand injury, and occupational hand usage 1, 2
• Women show dramatically increased incidence after age 40 (likelihood ratio 3.73) 1, 2

Inflammatory Arthropathies

• Rheumatoid arthritis primarily affects MCP joints, PIP joints, and wrists with prolonged morning stiffness and symmetrical involvement 3
• Psoriatic arthritis may target DIP joints or affect a single ray in asymmetric pattern 1, 3
• Gout can superimpose on pre-existing osteoarthritis with acute flares 1, 3
• Haemochromatosis mainly targets MCP joints and wrists 1, 3

Nerve Compression Syndromes

• Carpal tunnel syndrome presents with palmar pain, paresthesias, and median nerve distribution symptoms 1, 4
• Ulnar neuropathy may contribute to hand pain patterns 5
• Sensory neuropathies can manifest as finger and palmar pain 4

Tendon and Soft Tissue Pathology

• Tenosynovitis, tendinopathy, and pulley injuries cause localized palmar pain 1
• Trigger finger involves palmar nodularity and catching sensation 1
• Dupuytren's contracture may present with palmar discomfort 4

Vascular and Ischemic Causes

• In hemodialysis patients, distal hypoperfusion ischemic syndrome (DHIS) causes significant palmar and hand pain requiring urgent evaluation 1, 6
• Arterial stenoses, retrograde flow from AV access, and distal arteriopathy contribute to ischemia 1, 6
• Complete arteriography from aortic arch to palmar arch is essential in dialysis patients with hand pain 1
• Vascular emergencies require prompt intervention to preserve tissue viability 4

Other Considerations

• Complex regional pain syndrome (CRPS) type 1 can develop after minor trauma with pain, swelling, and vasomotor instability 7
• Infectious causes include cellulitis, tenosynovitis, and septic arthritis requiring antibiotics 4
• Ganglion cysts may cause localized pain 8
• Referred pain from cervical radiculopathy or systemic illness 4, 9

Diagnostic Approach Algorithm

Initial Clinical Assessment

• Age and gender: Osteoarthritis likelihood increases dramatically after age 40, especially in women 1, 2
• Joint distribution pattern: DIP/PIP/thumb base suggests osteoarthritis; MCP/wrist suggests rheumatoid arthritis; asymmetric DIP suggests psoriatic arthritis 1, 3
• Timing of stiffness: Brief (<30 min) suggests osteoarthritis; prolonged (>1 hour) suggests inflammatory arthritis 1
• Dialysis access status: Presence of AV fistula/graft mandates evaluation for DHIS 1, 6
• Trauma history: Recent injury raises concern for CRPS or fracture complications 7

Initial Imaging

• Plain radiographs (PA view of both hands) serve as gold standard for morphological assessment 1, 3
• Classical osteoarthritis features include joint space narrowing, osteophytes, subchondral sclerosis, and cysts 1, 3
• Erosive changes suggest erosive osteoarthritis, rheumatoid arthritis, or psoriatic arthritis 1

Advanced Imaging When Indicated

• Ultrasound evaluates synovitis, tenosynovitis, tendon pathology, and carpal tunnel syndrome 1, 3
• MRI without contrast demonstrates tendinopathy, occult pathology, and soft tissue abnormalities 1, 3
• In dialysis patients with hand pain, duplex ultrasound shows flow patterns but does not diagnose clinical steal 1

Laboratory Testing

• Blood tests are not required for osteoarthritis diagnosis but may exclude coexistent inflammatory disease 1
• Elevated inflammatory markers (CRP, ESR) with atypical features warrant evaluation for inflammatory arthropathy 1, 3

Critical Diagnostic Pitfalls

Composite Assessment Required

• Single clinical or radiographic features have limited sensitivity and specificity; diagnosis requires combining age, gender, joint distribution, examination findings, and imaging 3
• Pain on usage alone has extremely low sensitivity (0.01-0.10) despite high specificity for osteoarthritis 1

Coexistent Conditions

• Hand osteoarthritis commonly coexists with CPPD, gout, or rheumatoid arthritis 3
• Careful evaluation for additional inflammatory arthritides is essential when atypical features present 3

Dialysis-Specific Considerations

• Retrograde flow on ultrasound does not predict clinical ischemia; most AV accesses show retrograde flow without symptoms 1, 6
• Arterial stenoses contribute to ischemia in 62-100% of dialysis patients with hand pain 1
• Non-ischemic causes of hand pain must be ruled out before attributing symptoms to vascular steal 6

Vascular Emergencies

• Acute ischemic causes represent true emergencies requiring immediate intervention to preserve tissue viability 4
• Failure to recognize arterial stenoses before surgical intervention for steal syndrome may cause access thrombosis 1