Is a bone scan useful for routine evaluation of hand osteoarthritis in older adults with typical clinical findings?

Bone Scan Has No Role in Routine Evaluation of Hand Osteoarthritis

Bone scan is not recommended for routine evaluation of hand osteoarthritis, even when radiographs show typical osteoarthritic changes. The American College of Radiology explicitly states there is no relevant literature to support the use of bone scan in the setting of chronic hand pain with nonspecific arthritis 1. Similarly, bone scans are not routinely used in the evaluation of inflammatory arthritis or erosive osteoarthritis of the hands 1.

Recommended Imaging Approach for Hand Osteoarthritis

First-Line Imaging

• Plain radiographs are the only imaging study needed for typical hand osteoarthritis, as they can establish the diagnosis and assess disease severity through evaluation of joint space narrowing, osteophytes, subchondral sclerosis, and erosions 1.
• The EULAR guidelines confirm that imaging is not required to make the diagnosis in patients with typical presentation of osteoarthritis, and when imaging is needed, conventional radiography should be used before other modalities 1.
• Standard radiographic evaluation includes three views: posteroanterior, lateral, and oblique projections 1.

When Advanced Imaging May Be Appropriate

• MRI without IV contrast or ultrasound should be considered only if atypical features suggest alternative diagnoses such as inflammatory arthritis, infection, or soft tissue pathology 1.
• The EULAR guidelines recommend imaging in atypical presentations to help confirm the diagnosis of OA and/or make alternative or additional diagnoses 1.
• MRI is particularly useful for detecting synovitis and bone marrow edema, which may indicate inflammatory components requiring different management 1, 2.
• Ultrasound can identify synovitis, joint effusion, and tenosynovitis, and the American College of Rheumatology supports its use when the diagnosis is uncertain 1.

Why Bone Scan Is Not Useful

Limited Clinical Utility

• Bone scan findings in hand osteoarthritis are nonspecific and do not change management, as they merely reflect increased bone turnover associated with osteophyte formation and remodeling 3.
• While bone scintigraphy can detect metabolically active bone changes, these findings correlate primarily with osteophyte growth and subchondral sclerosis—features already visible on plain radiographs 3, 4.
• Research shows that bone scan uptake in hand joints increases with age and correlates with radiographic findings, but provides no additional diagnostic or prognostic information beyond what radiographs already demonstrate 4.

Radiation Exposure Without Benefit

• Bone scan exposes patients to ionizing radiation without providing actionable clinical information that would alter treatment decisions 1.
• The American College of Radiology emphasizes that relative radiation level considerations are important when selecting imaging procedures, and unnecessary studies should be avoided 1.

Clinical Scenarios Where Imaging Beyond Radiographs May Be Needed

Red Flags Requiring Further Investigation

• Unexpected rapid progression of symptoms or change in clinical characteristics warrants additional imaging to determine if this relates to OA severity or an additional diagnosis 1.
• Persistent pain lasting more than a few weeks that is non-mechanical in nature requires investigation, as this may indicate alternative pathology including malignancy 5.
• Disproportionate pain relative to radiographic findings may suggest inflammatory synovitis detectable by MRI or ultrasound 2.

Specific Alternative Diagnoses to Consider

• Inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis) can be evaluated with MRI or ultrasound to detect synovitis, bone marrow edema, and erosions 1.
• Erosive osteoarthritis may require MRI or ultrasound to assess the extent of inflammation and guide treatment, as this subset has higher clinical burden and worse outcomes 1, 2, 6.
• Crystal arthropathy (gout, pseudogout) can be confirmed with ultrasound or dual-energy CT, though joint aspiration remains the gold standard 1.

Common Pitfalls to Avoid

• Do not order bone scan simply because radiographs show osteoarthritis—this adds no diagnostic value and exposes patients to unnecessary radiation 1.
• Do not assume that increased bone scan uptake indicates disease activity requiring treatment—uptake reflects bone remodeling that occurs in all osteoarthritis and does not predict treatment response 1, 3.
• Do not use routine imaging for follow-up of established hand osteoarthritis—the EULAR guidelines explicitly state that routine imaging in OA follow-up is not recommended 1.
• Recognize that radiographic severity correlates only weakly to moderately with clinical symptoms—treatment decisions should be based on functional impairment and pain rather than imaging findings alone 2, 7.