What could be causing right hand pain in an otherwise healthy adult?

Right Hand Pain in an Otherwise Healthy Adult

Initial Diagnostic Approach

Begin with plain radiographs of the hand as the first imaging study, which can establish specific diagnoses including osteoarthritis, inflammatory arthritis, fracture complications, and bone tumors. 1 Standard views should include posterior-anterior and lateral projections. 2

Key Clinical Features to Elicit

Age and gender matter significantly: Adults over 40 with hand pain should raise suspicion for hand osteoarthritis (HOA), which predominantly affects women (relative risk 1.23 for prevalence). 1 A confident clinical diagnosis of HOA can be made in adults over 40 when typical features are present. 1

Pain characteristics help narrow the differential:

• Pain with usage and minimal morning stiffness (less than 30 minutes) affecting DIP, PIP, or thumb base joints suggests HOA 1
• Prolonged morning stiffness (greater than 1 hour) with soft tissue swelling suggests inflammatory arthritis 1
• Numbness and tingling in the thumb, index, middle, and radial ring fingers indicates carpal tunnel syndrome 3

Joint distribution patterns are diagnostic:

• HOA targets DIP joints most commonly, followed by thumb base, PIP, and index/middle MCP joints 1
• Rheumatoid arthritis predominantly affects MCP and PIP joints, typically sparing DIP joints 1
• Psoriatic arthritis may target DIP joints or affect a single ray 1

Physical Examination Priorities

Look for these specific findings:

• Heberden nodes (DIP) and Bouchard nodes (PIP) indicate HOA 1, 4
• Bony enlargement with lateral deviation or subluxation at characteristic sites confirms HOA 1
• Perform Durkan maneuver (firm digital pressure across carpal tunnel): 64% sensitive and 83% specific for carpal tunnel syndrome 3
• Assess for triggering during finger flexion/extension, which affects up to 20% of diabetics and 2% of the general population 3
• Palpate the first dorsal compartment for tenderness suggesting de Quervain tenosynovitis 3

Imaging Algorithm When Radiographs Are Normal or Nonspecific

Ultrasound is the most appropriate next imaging study for hand pain with normal radiographs, as it identifies soft tissue pathology in 76% of cases and changes clinical management in two-thirds of patients. 5, 1 The American College of Rheumatology supports ultrasound for patients presenting with pain, swelling, or mechanical symptoms of the metacarpophalangeal and interphalangeal joints. 5, 1

Ultrasound effectively identifies:

• Synovitis, joint effusion, and tenosynovitis 5, 1
• Tendinopathy, tendon tears, and pulley injuries 1, 5
• Carpal tunnel syndrome (highly sensitive and specific compared to electrodiagnostic studies) 1
• Retained foreign bodies 5

Reserve MRI without IV contrast for cases where ultrasound is inconclusive or unavailable. 5, 1 MRI changed clinical management in 69.5% of hand surgery referrals, particularly by reassuring 70% of patients that no further follow-up was necessary. 1, 5

Add IV contrast to MRI when inflammatory arthritis is suspected, as it improves detection of synovitis and distinguishes it from joint effusion. 1 Bone marrow edema on contrast-enhanced MRI is the best predictor of future disease progression in early rheumatoid arthritis. 1, 2

Imaging to Avoid

Do not order bone scan, CT (with or without contrast), MR arthrography, or radiographic arthrography for hand pain with normal radiographs. 5, 1 These modalities lack supporting evidence in this clinical scenario.

Common Causes by Clinical Presentation

Osteoarthritis (Most Common in Adults Over 40)

• Risk factors include female sex, age over 40, menopause, family history, obesity, prior hand injury, and repetitive occupational use 1
• Erosive HOA presents with abrupt onset, marked pain, inflammatory signs (stiffness, swelling, erythema), and mildly elevated CRP 1
• Functional impairment can be as severe as rheumatoid arthritis 1

Carpal Tunnel Syndrome

• More common in women, obesity, diabetes, and keyboard/vibrating tool users 3
• Electrodiagnostic testing is over 80% sensitive and 95% specific when proximal compression is suspected 3
• Ultrasound cross-sectional area measurements of the median nerve are highly sensitive and specific 1

Trigger Finger

• Affects up to 20% of diabetics versus 2% of general population 3
• Steroid injection is first-line but less effective in insulin-dependent diabetes 3

De Quervain Tenosynovitis

• More common in women, median age 40-59 years 3
• Associated with frequent mobile phone use 3
• Ultrasound can identify septum or subcompartmentalization affecting surgical planning 1

Thumb Carpometacarpal Arthritis

• Affects 33% of postmenopausal women radiographically, with 20% requiring treatment 3

Management Algorithm

For osteoarthritis: Start with topical NSAIDs for mild-to-moderate pain, acetaminophen, physical activity, and exercise. 5, 2 Consider orthotics if pain impedes function. 5, 2

For carpal tunnel syndrome: Begin with splinting or steroid injection for temporary relief. 3 Patients unresponsive to conservative therapy should undergo open or endoscopic carpal tunnel release. 3

For trigger finger: Steroid injection is first-line therapy. 3 Consider early surgical release in diabetics and those with recurrent symptoms. 3

For de Quervain tenosynovitis: Steroid injection combined with immobilization relieves symptoms in approximately 72% of patients. 3 Surgical release is appropriate for recurrent symptoms. 3

For inflammatory arthritis: Obtain ESR, CRP, rheumatoid factor, and anti-citrullinated protein antibodies. 2 Refer to rheumatology for pharmacological treatment according to guidelines. 2

Critical Pitfalls to Avoid

Never order MRI as the initial imaging study—radiographs must come first to rule out obvious bony pathology. 5 This is a common error that wastes resources and delays diagnosis.

Do not dismiss hand pain as benign in adults over 40 with typical HOA features—functional impairment can equal that of rheumatoid arthritis and requires careful assessment with validated outcome measures. 1

Recognize erosive HOA early: It presents with abrupt onset, marked inflammatory signs, and worse outcomes than non-erosive disease, requiring more aggressive management. 1

Screen for generalized OA: Patients with polyarticular HOA are at increased risk for knee and hip OA and should be examined accordingly. 1