What is the best use of MRI for evaluating hand and finger pain?

MRI for Evaluating Hand and Finger Pain

MRI without IV contrast is the most appropriate imaging modality for evaluating chronic hand and finger pain after initial radiographs are normal or show nonspecific findings, as it can effectively identify soft tissue abnormalities including tendinopathy, tenosynovitis, ligament injuries, and cartilage damage that may be causing pain. 1

Initial Imaging Approach

1. Standard Radiographs (First Step)

   • Begin with standard 3-view radiographs (posteroanterior, lateral, and oblique)
   • Radiographs assess alignment, joint spaces, static instability, chronic fractures, soft tissue mineralization, and erosions 1

2. When Radiographs Are Normal or Show Nonspecific Findings:

MRI Without IV Contrast

• Primary recommended modality for further evaluation
• Provides detailed assessment of:
  • Bone marrow abnormalities
  • Soft tissue structures (ligaments, tendons, nerves)
  • Triangular fibrocartilage complex (TFC)
  • Cartilage injuries
• In a retrospective review, MRI changed clinical management in 69.5% of cases referred to hand surgeons 1
• Particularly valuable for reassuring patients that no further follow-up was necessary in 70% of cases 1
• Can identify various causes of pain including:
  • Arthritis
  • Carpal boss
  • Tendinopathy
  • Tenosynovitis
  • Pulley injuries
  • Extensor hood injuries
  • Sagittal band injuries
  • Volar plate injuries
  • Ligament injuries 1

Specific MRI Applications by Pathology

For Ligament Injuries

• MRI without contrast shows sensitivity of 70-87% and specificity of 90-97% for scapholunate tears 1
• For lunotriquetral tears: sensitivity 50-63%, specificity 94-97% 1
• For triangular fibrocartilage complex tears: sensitivity 63-100%, specificity 42-100% 1
• Especially useful for detecting ulnar and radial collateral ligament injuries 1

For Tendon Injuries

• Excellent for evaluating both flexor and extensor tendon injuries 1
• Can assess tendon retraction, quality of tendon stump, and associated injuries 1
• Helpful for diagnosing tendinopathy, tenosynovitis, and intersection syndromes 1

For Arthritis Evaluation

• Can identify synovitis, periarticular bone marrow edema, and tenosynovitis 1
• Can monitor treatment response in arthritis, as demonstrated in cases of osteoarthritis treatment with intra-articular steroids 2

Special Considerations

When to Consider MR Arthrography Instead

• Consider MR arthrography for suspected:
  • Intrinsic ligament injury
  • TFC complex injury
  • Cartilage abnormality
  • Surgical planning 1
• MR arthrography provides higher sensitivity and specificity for detection of scapholunate ligament injury, lunotriquetral ligament injury, and TFC injury compared to standard MRI 1
• An interdisciplinary consensus concluded that "MR arthrography provides better diagnostic accuracy for the determination of scapholunate interosseous ligament tears than MRI" 1

When to Consider MRI With IV Contrast

• Not routinely indicated for nonspecific pain
• Consider when there is clinical suspicion of:
  • Rheumatoid arthritis
  • Seronegative spondyloarthropathy
  • Septic arthritis
  • Soft tissue infection 1
• Helps distinguish synovitis from joint effusion and ganglion cysts 1

Alternative Imaging Options

Ultrasound

• Can identify synovitis, joint effusion, tenosynovitis, tendon injuries, pulley injuries, carpal tunnel syndrome, and foreign bodies 1
• The American College of Rheumatology supports its use in patients with pain, swelling, or mechanical symptoms of the metacarpophalangeal and interphalangeal joints 1
• Contributed to clinical assessment in 76% of all patients referred from hand surgeons 1
• Advantages include dynamic examination capability and lower cost
• Limited in evaluation of bone marrow and deep structures

CT Scanning

• Not routinely recommended for nonspecific hand pain 1
• More appropriate for detailed bone assessment, fracture healing, malunion evaluation

Practical Considerations for MRI of the Hand and Fingers

• Optimal imaging requires:
  • Proper positioning
  • Dedicated surface coils
  • Specific protocols for suspected abnormalities 3
• Both T1 and T2-weighted sequences are important
• Normal ligaments and tendons have low signal intensity, while disruption shows increased signal intensity 3

Pitfalls and Caveats

1. Overreliance on MRI without clinical correlation

   • MRI findings should always be interpreted in the context of clinical presentation

2. Inadequate technical factors

   • Small structures of the hand require high-resolution imaging with appropriate coils and protocols

3. False negatives in partial tears

   • Some partial ligament tears may be missed on standard MRI

4. Cost considerations

   • MRI is more expensive than ultrasound, which may be an appropriate alternative for certain conditions

5. Contraindications

   • Patients with certain implants, claustrophobia, or inability to remain still may not be candidates for MRI

MRI has been shown to affect clinical management in 29% of cases with trauma-related lesions of the hand, wrist, or forearm, demonstrating its value in clinical decision-making 4.