Aim: To examine the validity of US in assessing hand osteoarthritis (OA) and to study the relationship between ultrasonographic findings and OA symptoms. Methods: This study was carried out on thirty patients with primary hand OA, and fifteen healthy subjects serving as a control group. Patients were classified according to ultrasonographic findings of joint involvement into two subgroups: 15 patients with interphalangeal (IP) OA and 15 patients with IP and first carpometacarpal (CMC) joint OA. All hand joints were examined for tenderness, soft tissue swelling, hard tissue enlargement (nodes), and deformity. Functional assessment by AUSCAN questionnaire, grip and pinch strength measurement and pain assessment by Visual Analogue Scale (VAS) were carried out. Plain X-rays of both hands were taken and classified according to the Kellgren–Lawrence (K–L) grading scale. High resolution US of the hand joints was performed which focused on examining cartilage thinning, joint space narrowing (JSN), and osteophytes (OST). Results: There was a positive correlation between the K–L grading and US findings regarding JSN and OST. There was a positive correlation of AUSCAN score with cartilage thinning, OST and JSN. There was a negative correlation of grip strength with cartilage thinning and OST. There was a negative correlation between pinch strength and US findings (cartilage thinning, OST and JSN). There was a positive correlation between pain and US findings. Heberden’s nodes were associated with underlying distal IP cartilage thinning, OST and JSN. On comparing the two subgroups of patients; patients with both IP and first CMC joint involvement experienced significantly higher levels of pain and disability and had weaker pinch strength. Conclusions: Ultrasonographic findings correlated with clinical findings as nodes, functional parameters as grip and pinch strength, and pain. The increased detection of OA structural pathology by US may make this a useful tool for hand OA assessment.