What imaging study, MRI (Magnetic Resonance Imaging) or CT (Computed Tomography), should be ordered for a patient with tingling wrist pain near the scaphoid (navicular) bone and normal wrist and scaphoid X-ray imaging?

MRI Without Contrast is the Preferred Imaging Study for Tingling Wrist Pain Near the Scaphoid with Normal X-rays

For a patient with tingling wrist pain near the scaphoid (navicular) bone and normal X-ray findings, MRI without contrast is the most appropriate next imaging study. 1, 2

Rationale for MRI Without Contrast

MRI without contrast offers several advantages in this clinical scenario:

• Superior soft tissue evaluation: MRI provides excellent visualization of:

  • Ligamentous structures (particularly scapholunate ligament)
  • Triangular fibrocartilage complex (TFCC)
  • Occult fractures not visible on X-ray
  • Bone marrow edema
  • Neural structures that could explain tingling symptoms 1, 2

• High sensitivity for occult fractures: Up to 70% of scaphoid fractures may be radiographically occult initially, making MRI particularly valuable 2

• Ability to detect nerve compression: The tingling symptoms suggest possible nerve involvement, which MRI can evaluate better than CT 1

When to Consider CT Instead

While MRI is preferred in this case, CT without contrast may be considered in specific situations:

• When MRI is contraindicated (pacemaker, claustrophobia, etc.)
• When detailed bony architecture assessment is the primary concern
• For specific suspected fractures (e.g., hook of hamate) where CT may be superior 1
• When faster acquisition time is needed (e.g., patient unable to remain still) 1

Important Clinical Considerations

1. Tingling symptoms: The presence of tingling suggests possible nerve involvement, making MRI particularly valuable for evaluating:

   • Carpal tunnel syndrome
   • Nerve compression from ganglion cysts
   • Neural inflammation

2. Normal X-rays with persistent symptoms: This combination strongly indicates the need for advanced imaging, as many wrist pathologies remain occult on conventional radiography 3

3. Scaphoid area pain: Pain near the scaphoid with normal X-rays raises concern for:

   • Occult scaphoid fracture
   • Scapholunate ligament injury
   • Early avascular necrosis
   • Ganglion cysts

Pitfalls to Avoid

• Relying solely on imaging findings: MRI of asymptomatic wrists frequently shows abnormalities (average 3.15 findings per wrist in asymptomatic individuals) 4

• Delayed diagnosis: Waiting too long for advanced imaging can lead to complications, particularly with occult scaphoid fractures 3

• Overlooking nerve involvement: The tingling symptoms should not be ignored, as they suggest neural involvement that requires evaluation 1

• Unnecessary CT arthrography: This is not routinely recommended for initial evaluation of chronic wrist pain with normal X-rays 1

By choosing MRI without contrast as the next imaging study for a patient with tingling wrist pain near the scaphoid and normal X-rays, you can provide the most comprehensive evaluation to guide appropriate treatment and improve patient outcomes.