What conditions can cause dorsal hand pain in an adult without a specific history?

Dorsal Hand Pain: Diagnostic Considerations

Dorsal hand pain in adults most commonly indicates occult dorsal ganglion cysts (76% of cases), followed by scapholunate ligament pathology, hand osteoarthritis targeting DIP/PIP joints, or inflammatory tenosynovitis. 1, 2

Primary Diagnostic Categories

Soft Tissue and Cystic Lesions

• Occult dorsal ganglion cysts are the leading cause of dorsal wrist pain, particularly when pain occurs with weight-bearing in wrist extension (push-ups, yoga, plank positions). 2
• These cysts demonstrate 76% prevalence in patients with dorsal wrist pain during extended wrist loading, compared to only 12% in control patients with ulnar-sided pain. 2
• MRI reveals identifiable dorsal abnormalities in 84% of patients with this specific pain pattern. 2

Ligamentous Pathology

• Scapholunate ligament tears or degeneration represent the second most common cause of dorsal central wrist pain. 2, 3
• Peri-scapholunate ligament injury produces dorsal central wrist pain that can significantly impair functional performance. 3
• Scapholunate and lunotriquetral ligament tears cause chronic wrist pain detectable with MR arthrography or CT arthrography. 1

Osteoarthritis

• Hand osteoarthritis primarily targets DIP joints, PIP joints, and thumb base, with occasional involvement of index and middle MCP joints. 4, 5
• A confident clinical diagnosis can be made in adults over 40 years with characteristic joint distribution, pain on usage, and brief morning stiffness (<30 minutes). 4, 5
• Risk factors include female sex, age >40, menopausal status, obesity, prior hand injury, and occupational hand usage. 4, 5
• Women show dramatically increased incidence after age 40 (likelihood ratio 3.73). 5

Tendinopathy and Tenosynovitis

• De Quervain tenosynovitis affects the first dorsal compartment (abductor pollicis longus and extensor pollicis brevis). 4
• Intersection syndromes represent another form of tendon inflammation detectable on MRI. 1
• Inflammatory tenosynovitis may be more conspicuous after IV contrast administration on MRI. 4

Neurologic Causes

• Radial sensory nerve (RSN) compression or injury historically considered difficult to treat, but contemporary understanding recognizes that the lateral antebrachial cutaneous nerve (LABCN) overlaps the RSN dermatome in 75% of people. 6
• Selective nerve blocks of multiple nerves (not just RSN) are essential for accurate diagnosis. 6
• Ultrasound is reasonable to assess for median or ulnar nerve entrapment. 1

Inflammatory Arthritis

• Rheumatoid arthritis warrants rheumatology referral within 6 weeks, as early arthritis can occur with negative serologies. 1, 5
• Inflammatory arthritis presents with prolonged morning stiffness (>1 hour) versus brief stiffness (<30 minutes) in osteoarthritis. 5
• MRI with IV contrast quantifies active synovitis and identifies enhancing bone marrow edema (osteitis), the best predictor of future disease progression. 4

Vascular Causes

• Upper extremity deep vein thrombosis (UEDVT) accounts for up to 10% of all DVTs, presenting with ipsilateral edema, pain, and prominent superficial veins. 1
• Arterial insufficiency warrants upper extremity arterial testing for unilateral cold painful hand. 1

Infectious Causes

• Septic arthritis and soft tissue infection require MRI without and with IV contrast to distinguish synovitis from joint effusion. 1
• Radiographs should be obtained first to look for soft tissue gas, foreign bodies, periosteal reaction, or bone destruction. 1

Diagnostic Algorithm

Initial Assessment

• Begin with standard three-view radiographs to assess alignment, joint spaces, fractures, soft tissue mineralization, erosions, and soft tissue swelling. 1, 5
• Evaluate age (>40 suggests osteoarthritis), gender (female increases risk), joint distribution pattern (DIP/PIP/thumb base suggests osteoarthritis; MCP/wrist suggests rheumatoid arthritis), and timing of stiffness. 4, 5

If Radiographs Normal or Nonspecific

• Ultrasound is the next appropriate study to evaluate tendons, synovitis, tenosynovitis, nerve entrapment, ganglion cysts, and fluid collections. 4, 1
• Ultrasound accuracy for ganglion cysts is similar to MRI. 4, 7

If Soft Tissue Pathology Suspected

• MRI without IV contrast is indicated when ligament tears, triangular fibrocartilage complex pathology, bone marrow abnormalities, or deeper soft tissue structures require evaluation. 1, 2
• MRI is particularly warranted when patients complain of dorsal wrist pain during extended loading positions (push-ups, yoga, Pilates). 2

If Inflammatory Arthritis Suspected

• MRI with IV contrast distinguishes synovitis from effusion and identifies bone marrow edema (osteitis), the best predictor of progression. 4, 1
• Ultrasound with power Doppler can identify active synovitis and erosions in early rheumatoid arthritis. 4

If Vascular Compromise Suspected

• Duplex ultrasound must be performed urgently with sensitivity and specificity above 80% for suspected UEDVT based on swelling, pain, and prominent superficial veins. 1

Critical Diagnostic Pitfalls

• Pain on usage alone has extremely low sensitivity (0.01-0.10) despite high specificity for osteoarthritis; diagnosis requires combining multiple clinical features. 4, 5
• Single clinical or radiographic features have limited diagnostic value; combine age, gender, joint distribution, examination findings, and imaging. 5
• Conventional radiography alone can miss up to 30% of scaphoid fractures; specialized views or repeat radiography in 10-14 days improves sensitivity. 8
• Failure to recognize that multiple cutaneous nerves (RSN, LABCN, dorsal ulnar cutaneous nerve) innervate the dorsoradial wrist leads to incomplete diagnostic nerve blocks and unsuccessful surgical treatment. 6