Joints of the hand: structure and main diseases

The hand comprises several "levels" of joints: the wrist joints, the intercarpal joints, the carpometacarpal joints, the metacarpophalangeal joints, and the interphalangeal joints of the fingers. This multi-level structure allows for both holding objects with great force and performing fine, precise movements.

The wrist joint connects the forearm and the proximal row of carpal bones and enables the fundamental movements of the hand: flexion, extension, abduction, and adduction. However, the actual "mechanics of the wrist" are distributed among several joints and ligaments, so wrist pain often reflects a problem not just at one point, but across the entire complex. [2]

The joints between the carpal bones and the midcarpal joint provide additional mobility and fluidity of movement, and also allow the hand to adapt to the shape of an object. This is why minor injuries to the wrist ligaments can significantly impair grip even without fractures.

The carpometacarpal joints of the second to fifth metacarpal bones are relatively rigid and form a "rigid support" for the palm, while the joint at the base of the thumb is significantly more mobile and is responsible for opposition. This explains why osteoarthritis of the base of the thumb so significantly affects everyday activities, even if the other joints of the hand are relatively intact. [4]

Table 1. Joints of the hand and their main movements

Zone	Joint	What does it provide?	What is more often clinically affected?
Wrist	The wrist and associated joints of the wrist	Flexion, extension, abduction, adduction of the wrist	Ligament injuries, tunnel syndromes, arthritis
Between the wrist bones	Intercarpal and midcarpal	Adaptation of the hand, grip "spring"	Ligamentous injuries, post-traumatic pain
Base of the thumb	Carpometacarpal joint of the thumb	Opposition, pinch grip	Osteoarthritis of the base of the thumb
Knuckles	Metacarpophalangeal joints	Flexion, extension, abduction, adduction	Rheumatoid arthritis, ligament injuries
Finger joints	Interphalangeal joints	Precise finger work	Osteoarthritis, inflammatory arthritis, contractures

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Why the hand is strong and precise: capsule, ligaments, tendons, and "levers"

Every joint in the hand functions as a "node": the articular surfaces determine the pattern of movement, the capsule maintains volume, and the ligaments limit unnecessary displacement. The greater the freedom of movement, the greater the demands on the ligaments and muscles, and the more easily instability develops after injury. [6]

The metacarpophalangeal joints are multiplanar: they must flex and extend, but also abduct and adduct the fingers. The lateral collateral ligaments and palmar plates are responsible for stability, so injuries to these joints often result in pain with lateral loads and decreased grip precision. [7]

The thumb stands out: opposition is possible thanks to the shape of the joint at the base of the thumb and the coordinated action of the thenar muscles. Any inflammation or wear of the cartilage in this joint leads to "loss of leverage," making it difficult to open lids, turn keys, and pinch objects. [8]

Some hand problems are disguised as "joint pain," although the source may lie in the tendons and their sheaths. Typical examples include stenosing tenosynovitis of the fingers and De Quervain's tenosynovitis, where pain is localized near the joints but is primarily associated with tendon friction within a narrow canal. [9]

Table 2. Frequent "mechanical" sources of pain near the joints of the hand

Structure	Where does it hurt most?	How does it manifest itself?	Why is it important to differentiate from arthritis?
Collateral ligaments of the fingers	On the sides of the knuckles and interphalangeal joints	Pain with lateral load, feeling of instability	Treatment often requires bracing and protection from lateral loads.
Palmar plates	Palmar surface of the finger joints	Pain and limitation of extension after hyperextension	Early regimen is important to avoid contracture.
Flexor tendons	Palmar surface of the finger	Clicking or "catching" when bending and straightening	This is tenosynovitis, not joint inflammation.
1 dorsal carpal tunnel	Radial side of the wrist at the thumb	Pain when grasping and deflecting the hand	Typical for De Quervain's tenosynovitis
The median nerve in the carpal tunnel	Palmar surface of the hand, fingers	Numbness, night symptoms, weakness	This is neuropathy, not "arthrosis"

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Osteoarthritis of the wrist: what happens in the joint and what it looks like

Osteoarthritis of the hand often affects the distal and proximal interphalangeal joints of the fingers, as well as the joint at the base of the thumb. Typical complaints include pain with weight-bearing activity, stiffness after rest, decreased grip strength, and gradual deformity. [11]

Osteoarthritis of the base of the thumb is particularly clinically significant: this joint is involved in almost all everyday grips. Therefore, even moderate structural changes can lead to a significant decrease in function, and treatment often involves splints, orthoses, and movement training to relieve the joint and maintain alignment. [12]

Current guidelines for the management of hand osteoarthritis emphasize non-pharmacological measures: education, exercise, ergonomics, orthotics, and thermal methods. Medication is considered an aid to pain control, allowing the individual to remain active and perform exercises. [13]

For persistent pain and significant loss of function, injection and surgical options are discussed. For the base of the thumb, reconstructive surgeries, including arthroplasty, are common when conservative measures fail. [14]

Table 3. Osteoarthritis of the hand: typical areas and practical steps

Zone	What worries you most often?	What usually helps in the beginning	When discussing surgery
Base of the thumb	Pain when pinched, weakness, “fatigue” when gripping	Orthosis, grip training, exercises, pain relief as needed	Persistent pain and significant loss of function despite conservative treatment
Distal interphalangeal joints	Nodules, deformation, pain with fine motor skills	Heat, range of motion exercises, topical pain relievers	Rarely, usually with severe deformation and pain
Proximal interphalangeal joints	Stiffness and pain when bending, decreased accuracy	Orthotics according to indications, exercises, load adaptation	In case of severe deformation and pain, arthrodesis or arthroplasty are possible.

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Inflammatory arthritis of the hand: how to distinguish between rheumatoid and psoriatic variants

Rheumatoid arthritis often begins with inflammation of the metacarpophalangeal and proximal interphalangeal joints: swelling, morning stiffness, and pain at rest and when squeezing the hand appear. An important principle of modern recommendations is early recognition and early initiation of basic therapy to reduce the risk of erosions and permanent deformities. [16]

Clinical criteria, laboratory markers of inflammation and autoantibodies, as well as an assessment of the number of involved joints and the duration of symptoms, are used for confirmation and stratification. The 2010 classification criteria help systematize the assessment, but clinical decisions are still based on the totality of the data. [17]

Psoriatic arthritis can affect various parts of the hand, including the interphalangeal joints and tendon attachments, often associated with skin manifestations and nail changes. The 2023 update of the European Alliance of Rheumatology Associations guidelines emphasizes the early initiation of disease-modifying antirheumatic drugs (DMARDs) in peripheral arthritis and the choice of targeted therapy in cases of inadequate response. [18]

The distinction between inflammatory arthritis and osteoarthritis is crucial: in the inflammatory process, controlling immune inflammation, not just pain relief, is key. Therefore, if you experience persistent morning stiffness, swelling, and nighttime pain, an early in-person evaluation by a rheumatologist is preferable. [19]

Table 4. Osteoarthritis and inflammatory arthritis of the hand: landmarks of differences

Sign	Osteoarthritis	Rheumatoid arthritis	Psoriatic arthritis
Stiffness in the morning	Usually shorter	Often long lasting	Often expressed
Where does inflammation occur most often?	Distal and proximal interphalangeal joints, base of the thumb	Metacarpophalangeal and proximal interphalangeal joints	It varies, possibly "radial" fingers and tendon damage
Pain at rest	Less often	Often	Often
Deformations	Little by little, the nodules	Risk of erosions and deviations	Deformations are possible, including shortening and change in shape of the finger
The main goal of treatment	Pain and function control	Suppressing inflammation and preventing destruction	Suppression of inflammation with consideration of skin and other manifestations

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Crystalline arthritis and "pseudoarthritis" of the hand, which are often confused

Gout can affect the joints of the hand, causing acute attacks with severe pain, redness, and swelling, and, if prolonged, tophi can form. The 2020 American College of Rheumatology guidelines emphasize a "treat to target" approach to urate-lowering therapy and the need for appropriate management during flare-ups. [21]

Calcium pyrophosphate crystals can also cause acute joint inflammation, sometimes mimicking rheumatoid arthritis or infection. The European Alliance of Rheumatology Associations guidelines for imaging of crystal-induced arthropathies emphasize the role of ultrasound and other imaging techniques as adjuncts to clinical evaluation and joint fluid analysis. [22]

Stenosing tenosynovitis of the fingers is often perceived as "joint pain" because it is localized near the metacarpophalangeal joint, but the mechanism is different: the flexor tendon slides poorly under the retaining ligament, causing a clicking or locking sensation. Orthopedic sources consider unloading, splinting, and glucocorticosteroid injections into the tendon canal area as basic measures when indicated. [23]

Another common "pseudoarthritis" is carpal tunnel syndrome, which causes numbness in the fingers and decreased strength. This is actually caused by compression of the median nerve. The 2024 clinical guidelines of the American Academy of Orthopaedic Surgeons provide a current diagnostic and treatment algorithm, including the role of splints, injections, and surgical decompression for persistent symptoms. [24]

Table 5. Acute and subacute conditions of the hand that are important not to confuse

State	What is typical	What confirms	What helps more often?
Gouty arthritis	Sudden severe pain, redness, swelling	Crystals in synovial fluid, clinical presentation	Anti-inflammatory therapy during an attack, urate-lowering therapy when indicated
Pyrophosphate arthropathy	Acute arthritis, often in the elderly	Visualization and analysis of fluid according to indications	Anti-inflammatory therapy, treatment of risk factors
Stenosing tenosynovitis	Clicking, "jamming" of the finger	Examination, symptom provocation	Splint, unloading, injections, surgical treatment if necessary
De Quervain's tenosynovitis	Pain along the radial side of the wrist	Examination and provocative tests	Splint, unloading, injections, surgery if necessary
Carpal tunnel syndrome	Night numbness, weakness of grip	Examination, electrodiagnostics as indicated	Splints, injections, surgery for persistent symptoms

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Diagnosis and treatment: a practical route from complaint to strategy

Four questions are important for the initial assessment: which joint is painful, is there swelling, how long does morning stiffness last, and are there systemic signs of inflammation. This approach helps quickly differentiate between probable osteoarthritis, inflammatory arthritis, crystal-induced arthritis, and periarticular tenosynovitis. [26]

The examination includes an assessment of deformities, range of motion, pain points, pinch and grip strength, and a neurological assessment for numbness. If inflammatory arthritis is suspected, palpation for synovitis and an assessment of the number of involved joints are important, as this influences the diagnostic evaluation and the promptness of treatment. [27]

Tests and imaging are selected based on the specific case. If inflammatory arthritis is suspected, inflammatory markers and autoantibodies are used as indicated. For gout and pyrophosphate arthropathy, joint fluid analysis is particularly valuable. In unclear cases, ultrasound can help identify synovitis, effusion, and crystalline deposits. [28]

Treatment progresses from simple to complex and depends on the underlying cause. For osteoarthritis, the foundation is education, exercise, and orthotics; for inflammatory arthritis, basic anti-inflammatory therapy should begin early; and for tendon and nerve syndromes, unloading, splints, and, if necessary, injections or surgery are used. [29]

Table 6. Which tests to choose for pain in the joints of the hand

Method	What shows better?	When it is especially appropriate
Inspection and functional tests	Synovitis, deformities, instability, tenosynovitis	Always at the first stage
X-ray of the hands	Osteoarthrotic changes, erosions, consequences of injuries	Suspected osteoarthritis, chronic arthritis, trauma
Ultrasound examination	Synovitis, effusion, tendons, signs of crystals	Early assessment of inflammation, crystal arthropathies
Magnetic resonance imaging	Early inflammatory changes and soft tissues	Vague pain, complex cases, tactical planning
Synovial fluid analysis	Crystals, infection, inflammatory profile	Acute swollen joint with no clear cause

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Table 7. Rapid treatment strategy based on probable cause

Probable cause	Basic measures	Medication options	When escalation is needed
Osteoarthritis of the hand	Training, exercises, orthoses, ergonomics	Anesthesia as needed, local agents	Persistent pain and loss of function, discussion of surgery if indicated
Rheumatoid arthritis	Early referral to a rheumatologist, activity monitoring	Basic antirheumatic drugs according to recommendations	Insufficient response, risk of joint destruction
Psoriatic arthritis	Skin and joint assessment, early therapy	Basic and targeted drugs according to algorithms	Active course, damage to several domains
Gout and pyrophosphate arthropathy	Confirmation of diagnosis, modification of risk factors	Anti-inflammatory therapy during an attack, urate-lowering therapy when indicated	Frequent attacks, tophi, complications
Tenosynovitis and carpal tunnel syndrome	Unloading, splints, movement correction	Injections as indicated	Persistent symptoms, weakness, progression

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