When is an X-ray (X-radiation) of the hand indicated and what are the next steps after the X-ray?

Hand X-Ray: Indications and Next Steps

When to Order Hand X-Rays

Plain radiographs of the hand should always be the initial imaging study for both acute trauma and chronic pain presentations. 1

Primary Indications for Hand Radiographs:

• Acute trauma with swelling, bruising, or deformity to detect fractures and joint malalignment 1, 2
• Chronic hand pain as the mandatory first step before any advanced imaging 1
• Suspected inflammatory arthritis to evaluate for bone-level changes, joint space narrowing, and erosions 3
• Joint swelling with elevated inflammatory markers to rule out bony pathology before proceeding to ultrasound 4

Standard Radiographic Protocol:

A three-view examination is essential and should include posteroanterior, lateral, and oblique views. 1, 2 The American College of Radiology recommends this standard three-view series for all finger and hand injuries, as it significantly increases diagnostic accuracy and reduces misdiagnosis rates compared to two-view examinations 2.

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Next Steps After Hand X-Rays

If X-Rays Show Acute Fracture:

• MRI without IV contrast or ultrasound are equivalent first-line options when tendon or ligament injury is suspected alongside the fracture 1
• CT without IV contrast is superior for characterizing complex intra-articular fractures, particularly when surgical planning is needed 5

If X-Rays Are Normal or Equivocal After Acute Trauma:

MRI without IV contrast is the appropriate next study when soft tissue injury is suspected. 1

• For suspected occult fracture, three equivalent options exist: repeat radiographs in 10-14 days, MRI without IV contrast, or CT without IV contrast 1
• Do not repeat radiographs earlier than 10-14 days, as earlier imaging has high risk of missing fractures that remain radiographically occult 1
• MRI is highly sensitive for detecting radiographically occult fractures and bone marrow edema 6

If X-Rays Show Joint Malalignment Without Fracture:

• MRI without IV contrast or ultrasound are appropriate next steps for evaluating ligamentous injury 1

For Chronic Hand Pain with Normal or Nonspecific Radiographs:

MRI without IV contrast is the primary recommendation following normal radiographs or radiographs showing only nonspecific arthritis. 1

• In a retrospective review of 316 patients, MRI changed clinical management in 69.5% of cases, particularly by reassuring patients that no further follow-up was necessary in 70% 1
• MRI can demonstrate arthritis, carpal boss, tendinopathy, tenosynovitis, pulley injury, extensor hood injury, sagittal band injury, volar plate injury, chondral injury, and ligament injury 6

However, MRI without IV contrast is of limited benefit for nonspecific pain without clear clinical indication. 4 A study evaluating hand MRI in erosive osteoarthritis showed no advantage over radiographs for assessing joint space narrowing, bone erosion, and malalignment 6

For Hand Swelling with Elevated Inflammatory Markers:

Ultrasound is the recommended first imaging modality after radiographs. 4

• Ultrasound was contributory to clinical assessment in 76% of patients referred from hand surgeons, including 67% without trauma history 4
• Ultrasound can identify synovitis, joint effusion, tenosynovitis, tendinopathy, tendon injury, carpal tunnel syndrome, metacarpophalangeal joint collateral ligament injury, extensor hood injury, and retained foreign bodies 6
• MRI should be considered only if ultrasound is inconclusive or deeper structures need evaluation 4

For Suspected Tendon or Soft Tissue Pathology:

Both ultrasound and MRI without IV contrast are appropriate and considered equivalent alternatives. 1

• Ultrasound offers practical advantages: more readily available, less expensive, allows dynamic assessment, and better suited for superficial structures 1
• The American College of Rheumatology supports musculoskeletal ultrasound for patients without definitive diagnosis presenting with pain, swelling, or mechanical symptoms 6

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When to Add IV Contrast to MRI

Adding IV contrast improves detection of tenosynovitis and helps distinguish synovitis from joint effusion and ganglion cysts. 1

• Contrast-enhanced MRI shows improved sensitivity for detecting tenosynovitis in hand and wrist tendons compared to T2-weighted sequences alone 1
• For routine tendon or ligament evaluation, contrast is generally not necessary unless there is specific concern for infection or inflammatory arthropathy 1

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Common Pitfalls to Avoid

• Never order MRI as the initial imaging study—radiographs must come first to rule out obvious bony pathology 1
• Do not order MRI for foreign body detection—CT or ultrasound are superior for this indication 1
• Ensure all three radiographic views are obtained—over half of patients in one study lacked complete three-view series, leading to potential missed diagnoses 2
• Do not obtain additional radiographic views in chronic wrist pain with normal or nonspecific initial radiographs, as there is no literature supporting this practice 6
• Avoid bone scan, CT arthrography, or MR arthrography for chronic hand pain with normal radiographs, as there is no relevant literature supporting these modalities 6

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Special Considerations for Inflammatory Arthritis

MRI is superior to clinical examination for detecting joint inflammation (synovitis) and should be considered for more accurate assessment in rheumatoid arthritis. 1

• MRI bone edema is a strong independent predictor of subsequent radiographic progression in early rheumatoid arthritis 1
• MRI can detect inflammation that predicts subsequent joint damage even when clinical remission is present, making it valuable for assessing persistent subclinical disease 1
• Conventional radiography remains the most commonly used imaging tool in rheumatology due to its availability, low cost, safety, and ability to provide immediate information for serial evaluation 3