What causes hand pain and how is it treated?

Hand Pain: Causes and Treatment

Initial Diagnostic Approach

Begin with standard three-view radiographs (posteroanterior, lateral, and oblique) as the first imaging study for any chronic hand or wrist pain, which establishes diagnosis in many cases and guides all subsequent management. 1

Key Historical Features to Elicit

• Spontaneous onset or vague/distant trauma history suggests carpal bone nonunion or avascular necrosis 2
• Repetitive loading activities point toward tendinopathy or overuse syndromes 2, 3
• Pain with numbness/tingling in thumb, index, middle, and radial half of ring finger indicates carpal tunnel syndrome 4
• Radial-sided pain with gripping suggests de Quervain tenosynovitis 5
• Ulnar-sided pain with sensory changes in fourth and fifth digits suggests ulnar neuropathy 5

Physical Examination Priorities

• Palpate systematically to localize tenderness to specific anatomic structures 2
• Perform Finkelstein's test for de Quervain tenosynovitis (positive test with negative grind test confirms diagnosis) 5
• Assess for carpal tunnel syndrome with median nerve distribution sensory testing 4
• Evaluate for trigger finger with palpable nodule and catching during finger flexion 6

Common Causes by Location

Thumb Base Pain (Carpometacarpal Joint)

• Affects 33% of postmenopausal women, with 20% requiring treatment for pain and disability 7
• Absence of swelling or redness suggests thumb CMC osteoarthritis as most likely diagnosis 7

Radial Wrist Pain

• De Quervain tenosynovitis from overuse of first extensor compartment 5
• Scaphoid fracture (most commonly fractured carpal bone) from fall on outstretched hand 5

Ulnar Wrist Pain

• Ulnar neuropathy from repetitive wrist extension (cycling, karate, baseball catching) 5
• Triangular fibrocartilage complex tears 1

Finger Pain

• Infectious causes: cellulitis, tenosynovitis, paronychia, felon requiring antibiotics ± drainage 6
• Trigger finger from pulley inflammation 8
• Rheumatoid arthritis or other systemic rheumatic disease 6

Treatment Algorithm

Step 1: Conservative Non-Pharmacological Management

All patients should receive education on joint protection (avoiding adverse mechanical factors) combined with exercise regimens involving both range of motion and strengthening exercises. 1, 7

• Apply local heat (paraffin wax or hot packs) before exercise for symptomatic relief (77% recommendation strength) 1, 7
• Use thumb splint for CMC joint osteoarthritis, which improves function at long-term follow-up 7
• Implement activity modification as first-line for trigger finger 8

Step 2: Pharmacological Management

Start with acetaminophen up to 4g/day as the oral analgesic of first choice due to efficacy and safety profile. 7, 8

• For mild to moderate pain affecting few joints, use topical NSAIDs as preferred over systemic treatments 1, 7, 8
• If acetaminophen fails, use oral NSAIDs (ibuprofen 400mg every 4-6 hours) at lowest effective dose for shortest duration 7, 8
• Add gastroprotective agents or use COX-2 inhibitors for patients with GI risk 1, 7, 8
• Avoid COX-2 inhibitors in patients with cardiovascular risk 1, 7, 8

Step 3: Advanced Imaging When Initial Radiographs Normal or Nonspecific

If radiographs are normal or show only nonspecific arthritis and pain persists, proceed to ultrasound or MRI based on suspected pathology. 1

• Ultrasound identifies synovitis, joint effusion, tenosynovitis, tendinopathy, tendon injury, pulley injury, and carpal tunnel syndrome 1
• Ultrasound is contributory in 76% of all hand/wrist patients and 67% without trauma history 1
• MRI without contrast demonstrates arthritis, carpal boss, tendinopathy, tenosynovitis, pulley injury, extensor hood injury, chondral injury, and ligament injury 1
• MRI changes clinical management in 69.5% of cases, particularly useful in reassuring patients when no further follow-up necessary (70% of cases) 1
• CT arthrography has 92-94% sensitivity/specificity/accuracy for triangular fibrocartilage tears and 80-100% for intrinsic ligament tears 1

Step 4: Invasive Non-Surgical Treatment

Intra-articular corticosteroid injection is effective for painful flares, especially in trapeziometacarpal (CMC) joint osteoarthritis. 7, 8

• Consider corticosteroid injection when oral analgesics and topical treatments provide inadequate relief 7
• Use when pain significantly limits activities of daily living 7

Step 5: Surgical Referral Indications

Refer to hand surgeon when conservative treatments (including corticosteroid injections) have failed and patient has marked pain and/or disability limiting activities of daily living. 7, 8

• Refer for occupational/physical therapy for splint fabrication, exercise regimens, and self-efficacy training 7, 8
• Vascular and ischemic causes represent true emergencies requiring prompt intervention to preserve tissue viability 6
• Certain infectious causes (deep space infections, flexor tenosynovitis) require urgent hand surgery referral 6

Critical Pitfalls to Avoid

• Do not rely solely on initial radiographs for scaphoid fractures—conventional radiography misses up to 30% of cases 5
• Obtain specialized views (posteroanterior in ulnar deviation, pronated oblique) and repeat radiography in 10-14 days for suspected scaphoid fractures 5
• Do not offer platelet-rich plasma (PRP) injections for thumb CMC osteoarthritis due to insufficient evidence of benefit 7
• Mandate stepwise progression through non-pharmacological, pharmacological, and invasive non-surgical options before proceeding to surgery 7, 8
• Recognize that detailed history alone leads to specific diagnosis in approximately 70% of patients with wrist pain 2