114 Part I Chapter 4 Integrating SPECT/CT in the Management of Post-Operative Hand and Wrist Pain Conventional X-rays are always the first line imaging modality in patients with pain after surgery of the hand or wrist and are often sufficient to establish a diagnosis and therapy. In patients with soft tissue disorders, which can be evaluated conclusively with ultrasound, like tendon abnormalities, ganglion cysts or superficial tumors ultrasound can serve as second line, in some cases also as first line imaging modality . MR serves as the best second line imaging inmore complex soft tissue abnormalities. If osseous abnormalities are predominant CT alone visualizes the integrity and position of bones andmetallic implants much better than conventional X-rays. Bone-SPECT/CT can be performed as second- or third line imaging if osseous abnormalities are suspected and additionally increased or decreased bone turnover might help to enhance the diagnostic information given by CT alone. In case of suspected infection white blood cell or antigranulocyte scintigraphy are used instead of bone seeking tracers. Since systematic literature regarding the performance of SPECT/CT in postoperative wrist and hand is missing, this article might encourage further research in this interesting field. A simplified flow-chart for the use of imaging is given in Figure 11. Typical SPECT/CT features are summarized in Table 2. Table 2 Typical Conditions and Findings in SPECT/CT of the Painful Postoperative Wrist Surgery Imaging Findings Diagnosis SPECT CT Arthrodesis Increased bone uptake adjacent to the persisting gap Missing bone bridge Nonunion Arthrodesis, osteosynthesis Increased uptake around hardware (screws) Lucencies around hardware (screws) Loosening of hardware Arthrodesis, osteosynthesis, and others Increased subchondral bone uptake Joint space narrowing, cartilage loss, subchondral sclerosis and cysts, osteophytes OA Osteosynthesis Linear increased uptake Fracture line (Insufficiency) fracture All wrist operations Increased perfusion and early-phase soft tissue uptake, increased uptake in all wrist and finger joints Osteopenia CRPS in active phase CRPS, complex regional pain syndrome; OA, osteoarthritis.