What are the possible diagnoses and treatments for abnormalities shown on an X-ray of the left hand?

Diagnostic Approach to Left Hand X-ray Abnormalities

For left hand X-ray abnormalities, a standard posteroanterior radiograph of both hands on a single film is adequate for initial diagnosis, with additional imaging modalities selected based on specific clinical findings. 1

Initial Radiographic Assessment

• Standard radiographic examination should include posteroanterior (PA), lateral, and oblique views to maximize diagnostic yield for hand abnormalities 2
• Plain radiographs provide the gold standard for morphological assessment of hand osteoarthritis (HOA), showing characteristic features such as joint space narrowing, osteophytes, subchondral bone sclerosis, subchondral cysts, and subchondral erosion in erosive hand OA 1
• For suspected fractures, an internally rotated oblique projection in addition to the standard externally rotated oblique increases diagnostic yield for phalangeal fractures 2

Common Radiographic Findings and Diagnoses

Hand Osteoarthritis

• Characteristic radiographic findings include joint space narrowing, osteophytes, subchondral bone sclerosis and cysts, primarily affecting distal interphalangeal joints (DIPJs), proximal interphalangeal joints (PIPJs), thumb base, and index and middle metacarpophalangeal joints (MCPJs) 1
• Erosive hand OA shows radiographic subchondral erosion and may progress to marked bone and cartilage attrition, instability, and bony ankylosis 1
• Clinical hallmarks include Heberden and Bouchard nodes and/or bony enlargement with or without deformity affecting characteristic target joints 1

Tendon and Ligament Injuries

• Radiographs may show carpal instability patterns such as scapholunate diastasis >4 mm and dorsal tilt of the lunate >10° suggesting dorsal intercalated segmental instability 1
• Mallet finger deformities may show palmar displacement of the distal phalanx or fractures involving the articular surface 2

Advanced Imaging Recommendations

For Soft Tissue Injuries

• MRI is ideal for evaluating tendon injuries and helping with surgical planning with high sensitivity and specificity for detecting tendon tears 1, 3
• MRI is particularly useful for diagnosing Stener lesions of the thumb (100% sensitivity and specificity) and pulley system injuries 1
• For extensor hood injuries, MRI sensitivity ranges from 28% to 85% 1, 3

For Ligamentous Injuries

• When conventional radiographs do not show carpal malalignment but ligamentous injury is suspected, MRI or MR arthrography should be performed 1
• CT arthrography has the highest sensitivity (nearly 100%) and specificity for detecting scapholunate ligament tears compared to other modalities 1
• 3T MRI offers better sensitivity (65-89%) than 1.5T MRI for diagnosing interosseous ligament tears 1

For Nerve Injuries

• MRI without IV contrast is the preferred advanced imaging modality for evaluating posterior interosseous nerve injuries, as it can detect both nerve compression and associated soft tissue abnormalities 3

Treatment Considerations Based on Imaging Findings

• For hand osteoarthritis, treatment options include immobilization, steroid injection, and pain medication for symptom relief, with surgery considered for patients unresponsive to conservative treatments 4
• For mallet finger with fractures involving more than one-third of the articular surface, operative fixation is typically required 2
• For carpal instability patterns, treatment depends on the specific ligamentous injury identified and may range from immobilization to surgical repair 1

Common Pitfalls in Hand X-ray Interpretation

• Relying on only 2 views is inadequate for detecting fractures in the fingers; a minimum of 3-view radiographic examination is necessary 2
• Initial radiographs may be negative in acute ligamentous injuries; if clinical suspicion remains high, options include splinting and repeating radiographs in 10-14 days or proceeding to MRI 2
• CT has limited use for the diagnosis of soft tissue injuries of the hand but may be helpful if bony involvement is suspected 1, 3