The hand is one of the anatomical regions most frequently explored by ultrasonography (US) in rheumatology. The last generation US systems equipped with high frequency probes allow for a quick and accurate assessment of even minimal pathological changes in patients with rheumatic conditions affecting the small joints and the soft tissues of the hand and wrist. Several studies have demonstrated the great value of US imaging of the hand and wrist in rheumatology but there are still controversial issues which yet have to be adequately addressed, particularly with regard to US semi-quantitative evaluation of synovitis and bone erosions in patients with chronic arthritis. This paper provides the basic knowledge, reviews the available evidence and discusses the potential of US in the evaluation of the hand and wrist.