How should I evaluate and manage a patient presenting with right-hand pain?

Evaluation and Management of Right Hand Pain

Start with plain radiographs (three views: posteroanterior, lateral, and oblique) as your initial imaging study, combined with a focused physical examination to localize the pain and identify the underlying pathology. 1, 2, 3

Initial Clinical Assessment

Key History Elements to Obtain

• Pain characteristics: Onset (spontaneous vs. traumatic), quality, intensity, distribution, duration, and what makes it better or worse 3, 4
• Occupational factors: Repetitive computer use, manual labor, or activities involving repetitive loading suggest overuse syndromes or occult fractures 5, 4
• Systemic symptoms: Morning stiffness >30 minutes, multiple joint involvement, or constitutional symptoms suggest inflammatory arthritis 2, 3

Focused Physical Examination

• Observation: Look for visible deformities (Heberden nodes at DIP joints suggest osteoarthritis), posture abnormalities, and hand positioning at rest 2
• Palpation: Systematically palpate each anatomic structure to localize tenderness—joint line tenderness suggests arthritis, while tendon tenderness suggests tendinopathy 2, 6
• Special tests:
  • Tinel's and Phalen's signs for carpal tunnel syndrome 2
  • Finkelstein's test for De Quervain's tenosynovitis 4, 6
  • Grind test for thumb base osteoarthritis 4
• Functional assessment: Have the patient perform specific tasks that reproduce their symptoms 2

Diagnostic Imaging Algorithm

First-Line Imaging

Obtain plain radiographs first (three standard views) for all patients with hand pain—this establishes the diagnosis in most cases and identifies osteoarthritis, fractures, or structural abnormalities 1, 2, 3

Advanced Imaging (When Radiographs Are Normal or Equivocal)

• For suspected tendon pathology or tenosynovitis: Order either ultrasound OR MRI without IV contrast—these are equivalent options 1, 5
• For suspected inflammatory arthritis: Order MRI with or without IV contrast to identify active synovitis, tenosynovitis, and bone marrow edema 1, 3
• For suspected ganglion cyst: Order ultrasound as the preferred modality 1, 3
• For suspected carpal tunnel syndrome: Ultrasound measuring median nerve cross-sectional area is appropriate, though clinical diagnosis with electrodiagnostic studies is standard 1, 5

Management Strategy

Non-Pharmacological Treatment (First-Line for All Patients)

• Education and ergonomic training: Proper workstation setup, activity pacing, joint protection techniques, and use of assistive devices 2, 5
• Exercise regimen: Range of motion and strengthening exercises to improve function and reduce pain 2, 5
• Orthoses (splints): Consider for symptom relief, particularly for thumb base involvement, with long-term use when beneficial 5

Pharmacological Treatment

• Topical NSAIDs: Use as first-line pharmacological treatment due to superior safety profile compared to oral medications 5
• Oral NSAIDs or acetaminophen: Consider for limited duration when topical agents provide insufficient relief 5, 3
• Chondroitin sulfate: May be used for hand osteoarthritis to improve pain and function 5

What NOT to Do

• Do NOT use conventional or biological disease-modifying antirheumatic drugs for hand osteoarthritis or overuse syndromes 1, 5
• Do NOT routinely use intra-articular glucocorticoid injections in hand osteoarthritis, though they may be considered for painful interphalangeal joints in select cases 1, 5

Referral Indications

When to Refer to Specialists

• Neurology: Suspected focal dystonia, progressive weakness, or signs of motor neuron disease 2
• Rheumatology: Suspected inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis) based on laboratory findings (elevated ESR, CRP, rheumatoid factor, anti-CCP antibodies) 2, 3
• Hand surgery: Severe structural abnormalities, persistent ganglion cysts, severe thumb base osteoarthritis, or when other treatment modalities have failed to relieve pain 1, 2

Common Pitfalls to Avoid

• Don't assume all hand pain is benign: Vascular and ischemic causes represent true emergencies requiring prompt intervention 7
• Don't overlook systemic disease: Hand pain may be the first manifestation of serious systemic illness including rheumatoid arthritis, vasculitis, or hypertrophic pulmonary osteoarthropathy 7
• Don't order MRI before plain radiographs: Radiographs are essential first and may be the only imaging needed 1, 3
• Don't continue conservative management indefinitely: If symptoms persist despite appropriate treatment or diagnosis remains unclear, refer to a specialist for further evaluation 4