What is the diagnostic workup for a patient presenting with a burning hand sensation?

Diagnostic Workup for Burning Hand Sensation

The diagnostic workup for a patient presenting with a burning hand sensation should begin with standard radiographs (posteroanterior, lateral, and oblique views) as the initial imaging study, followed by appropriate advanced imaging based on clinical suspicion. 1, 2

Initial Evaluation

Imaging

• First-line imaging: Standard radiographs (3 views)
  • Posteroanterior, lateral, and oblique views
  • Evaluates for fractures, dislocations, arthritis, bone tumors, and soft tissue swelling
  • May be sufficient to establish diagnosis in many cases 1, 2

Laboratory Studies (if inflammatory/infectious etiology suspected)

• Complete blood count
• Inflammatory markers (ESR, CRP)
• Urinalysis
• Liver function tests
• Antinuclear antibodies 2

Advanced Imaging (based on initial findings and clinical suspicion)

Ultrasound

• Particularly useful for:
  • Synovitis and joint effusions
  • Tenosynovitis and tendon injuries
  • Soft tissue masses
  • Retained foreign bodies
  • Carpal tunnel syndrome
  • Allows dynamic assessment and comparison with contralateral side 1, 2

MRI Without IV Contrast

• Indicated when ultrasound is inconclusive or for deeper structures
• Evaluates:
  • Bone marrow abnormalities
  • Ligament injuries (scapholunate, lunotriquetral)
  • Triangular fibrocartilage complex (TFC) injuries
  • Tendon abnormalities
  • Nerve pathology 1, 2

MRI With IV Contrast

• Consider when suspecting:
  • Inflammatory arthritis
  • Synovitis
  • Tenosynovitis
  • Infection 1

MR or CT Arthrography

• Superior for evaluating:
  • Ligamentous injuries
  • Early cartilage defects
  • TFC tears 1

Special Considerations for Specific Etiologies

For Suspected Neuropathic Pain

• MRI of the cervical spine may be necessary to rule out central cord syndrome variants like "Burning Hands Syndrome" 3
• Electromyography and nerve conduction studies to evaluate for peripheral neuropathy

For Suspected Vascular Issues

• Duplex Doppler ultrasound to evaluate for:
  • Flow abnormalities
  • Arterial stenosis
  • Venous outflow obstruction 1, 2
• Consider fluoroscopy fistulography if dialysis access-related issues are suspected 1

For Suspected Erythromelalgia

• Diagnosis is primarily clinical, characterized by:
  • Episodic burning pain
  • Erythema and warmth of extremities
  • Symptoms triggered by physical activity or warm temperatures
  • Relief with cooling 1

Important Clinical Pitfalls

1. Normal radiographs do not exclude significant pathology - MRI may be needed even with normal radiographs if symptoms persist 2

2. Intermittent symptoms may lead to missed diagnosis if examination occurs when hands appear normal 1

3. Ultrasound quality is highly operator-dependent despite offering real-time assessment 2

4. Delayed diagnosis risks include:

   • Progression to chronic neuropathic pain, particularly in burn patients 4
   • Potential for permanent hand dysfunction if vascular issues are not promptly addressed 2

By following this systematic approach to evaluating burning hand sensation, clinicians can efficiently identify the underlying cause and initiate appropriate treatment to improve outcomes related to morbidity, mortality, and quality of life.