What is the best approach to manage hand pain in an adult patient with a normal x-ray and no significant medical history?

Management of Hand Pain with Normal X-ray

For an adult with hand pain and normal radiographs, ultrasound is the most appropriate next imaging study, as it identifies soft tissue pathology in 76% of cases and changes clinical management in two-thirds of patients without trauma history. 1

Initial Diagnostic Approach

First-Line Imaging After Normal Radiographs

• Ultrasound is the preferred next step because it can identify synovitis, joint effusion, tenosynovitis, tendinopathy, tendon injury, pulley injury, carpal tunnel syndrome, and retained foreign bodies. 1
• The American College of Rheumatology supports ultrasound use in patients without definitive diagnosis who present with pain, swelling, or mechanical symptoms of the metacarpophalangeal and interphalangeal joints. 1
• Ultrasound was contributory to clinical assessment in 76% of all patients referred from hand surgeons, including 67% of patients without trauma history. 1, 2
• Ultrasound offers practical advantages: more readily available, less expensive, allows dynamic assessment, and better suited for superficial structures. 2

When to Consider MRI Instead

• MRI without IV contrast is appropriate when soft tissue pathology is suspected but should be reserved for cases where ultrasound is inconclusive or unavailable. 1, 2
• MRI changed clinical management in 69.5% of cases referred to hand surgeons, particularly by reassuring patients that no further follow-up was necessary in 70% of cases. 1, 2
• MRI can demonstrate arthritis, carpal boss, tendinopathy, tenosynovitis, pulley injury, extensor hood injury, sagittal band injury, volar plate injury, chondral injury, and ligament injury. 1
• Important caveat: MRI without IV contrast is of limited benefit in nonspecific pain without clear clinical indication for soft tissue or inflammatory pathology. 1, 2

Specific Clinical Scenarios to Identify

Nerve Compression Syndromes

• Perform Tinel's and Phalen's signs to evaluate for carpal tunnel syndrome. 3, 4
• Ultrasound is a validated technique for measuring median nerve size in carpal tunnel syndrome. 5
• Consider Wartenberg's syndrome (radial sensory nerve compression) in radial-sided pain. 6

Tendon Pathology

• Palpate for tenderness along tendon sheaths to identify tenosynovitis or tendinopathy. 3
• De Quervain's tenosynovitis causes radial-sided wrist pain and can be diagnosed with Finkelstein's test. 5, 7, 6
• Trigger finger presents with catching or locking during finger flexion. 7

Inflammatory Arthritis

• If inflammatory arthritis is suspected, obtain ESR, CRP, rheumatoid factor, and anti-citrullinated protein antibodies. 5, 3
• MRI with IV contrast improves detection of synovitis and helps distinguish it from joint effusion and ganglion cysts. 2, 5
• Bone marrow edema on MRI is the best predictor of future disease progression in early rheumatoid arthritis. 2, 5

Osteoarthritis

• Look for Heberden nodes (DIP joints) and Bouchard nodes (PIP joints) on examination. 3
• Thumb base (CMC-I) osteoarthritis is common and can be assessed with the grind test. 3, 8, 6

Imaging Modalities to Avoid

Do not order these studies for hand pain with normal radiographs:

• Bone scan has no supporting literature for this indication. 1
• CT with or without IV contrast has no supporting literature for this indication. 1
• MR arthrography has no supporting literature for this indication. 1
• Radiographic arthrography has no supporting literature for this indication. 1

Conservative Management Algorithm

First-Line Pharmacological Treatment

• Start with acetaminophen for mild pain: 2 caplets every 8 hours, maximum 6 caplets in 24 hours, do not use for more than 10 days without physician direction. 9
• Topical NSAIDs are first-line for mild-to-moderate pain with musculoskeletal causes. 3
• Oral ibuprofen for moderate pain: 400 mg every 4-6 hours as needed, not to exceed 3200 mg daily. 10
• For osteoarthritis specifically, use acetaminophen, NSAIDs, physical activity, and exercise. 5

Non-Pharmacological Interventions

• Joint protection education and ergonomic training including proper workstation setup. 3, 11
• Range of motion and strengthening exercises to improve function and reduce symptoms. 3, 11
• For carpal tunnel syndrome, splinting combined with tendon and nerve gliding exercises is more effective than exercises alone. 4
• Consider orthotics (splints, braces) if pain impedes functioning. 5

When Conservative Treatment Fails

• If symptoms persist despite 2 weeks of conservative management, proceed with ultrasound or MRI as outlined above. 1, 8
• Refer to hand surgery for severe structural abnormalities, persistent ganglion cysts, or severe thumb base osteoarthritis. 3
• Refer to rheumatology for suspected inflammatory arthritis. 3
• Refer to neurology for suspected focal dystonia, progressive weakness, or signs of motor neuron disease. 3

Common Pitfalls to Avoid

• Never order MRI as the initial imaging study—radiographs must come first to rule out obvious bony pathology. 2
• Do not repeat radiographs earlier than 10-14 days for suspected occult fractures, as earlier imaging has high risk of missing fractures that are still radiographically occult. 2
• Do not order MRI for foreign body detection—CT or ultrasound are superior for this indication. 2
• Recognize that a detailed history alone leads to specific diagnosis in approximately 70% of patients with wrist pain, so thorough clinical evaluation is essential before advanced imaging. 8