When is an MRI of the hand recommended?

When to Order MRI of the Hand

MRI of the hand should be ordered after initial radiographs when there is clinical concern for soft tissue pathology (tendon injury, tenosynovitis, ligament injury), suspected occult fracture, or inflammatory arthritis requiring detailed assessment—though ultrasound is often the preferred next step for most soft tissue and inflammatory conditions.

Initial Imaging Approach

• Always begin with plain radiographs of the hand as the initial imaging study for both acute trauma and chronic pain presentations 1.
• Radiographs effectively detect fractures, joint malalignment, and bony abnormalities that guide subsequent imaging decisions 1.

When MRI is Usually Appropriate

Acute Trauma Settings

• MRI without IV contrast is appropriate when initial radiographs are negative or equivocal after acute hand trauma, particularly when soft tissue injury is suspected 1.
• For suspected tendon or ligament trauma with acute hand fracture, MRI without IV contrast or ultrasound are equivalent first-line options 1.
• When metacarpophalangeal, proximal interphalangeal, or distal interphalangeal joint malalignment is present without fracture, MRI without IV contrast or ultrasound are appropriate next steps 1.
• If occult fracture is suspected, repeat radiographs in 10-14 days, MRI without IV contrast, or CT without IV contrast are equivalent alternatives 1.

Chronic Pain Settings

• MRI without IV contrast is the primary recommendation for chronic hand pain following normal radiographs or radiographs showing only nonspecific arthritis 1.
• For tendon injury, tenosynovitis, or tendon pathology concerns, both ultrasound and MRI without IV contrast are appropriate, though they are considered equivalent alternatives 1.
• MRI demonstrates superior soft tissue contrast resolution for assessing tendinopathy, tendon tears, and tenosynovitis 1, 2.

Inflammatory Arthritis

• MRI is superior to clinical examination for detecting joint inflammation (synovitis) and should be considered for more accurate assessment in rheumatoid arthritis 1.
• MRI bone edema is a strong independent predictor of subsequent radiographic progression in early rheumatoid arthritis and should be considered as a prognostic indicator 1.
• MRI can detect inflammation that predicts subsequent joint damage even when clinical remission is present, making it valuable for assessing persistent subclinical disease 1.
• For rheumatoid arthritis evaluation, bilateral hand MRI is more optimal than unilateral hand MRI, as 5-15% of inflammatory features may be misdiagnosed when only one hand is imaged 3.

When Ultrasound May Be Preferred Over MRI

• For initial evaluation of hand swelling with elevated inflammatory markers, ultrasound is recommended as the first imaging modality after radiographs 4.
• Ultrasound offers several practical advantages: more readily available, less expensive, allows dynamic assessment, and better suited for superficial structures 4.
• Ultrasound was contributory to clinical assessment in 76% of patients referred from hand surgeons, including 67% without trauma history 1, 4.
• For tendon and soft tissue pathology, ultrasound and MRI are considered equivalent alternatives by the American College of Radiology 1.

Enhanced MRI Considerations

• Adding IV contrast to MRI improves detection of tenosynovitis, with contrast-enhanced imaging showing 40% sensitivity in hand tendons and 67% in wrist tendons compared to T2-weighted sequences alone 1, 5.
• Postcontrast imaging aids in distinguishing synovitis from joint effusion and ganglion cysts, which is particularly valuable in suspected inflammatory arthritis 1.
• For routine tendon or ligament evaluation, contrast is generally not necessary unless there is specific concern for infection or inflammatory arthropathy 1.

Common Pitfalls to Avoid

• Do not order MRI as the initial imaging study—radiographs must come first to rule out obvious bony pathology 1.
• 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 1, 6.
• Do not assume the dominant or clinically more severe hand represents the contralateral hand in rheumatoid arthritis—bilateral imaging provides significantly more diagnostic information 3.
• Do not order MRI for foreign body detection—CT or ultrasound are superior for this indication 1.
• Consider that MRI without IV contrast is of limited benefit for nonspecific hand pain without a clear clinical indication for soft tissue or inflammatory pathology 4.

Specific Clinical Scenarios

Rheumatoid Arthritis Monitoring

• MRI and ultrasound can detect inflammation even in clinical remission and should be used to assess persistent subclinical disease activity 1.
• Wrist bones and second metacarpophalangeal joints show bone erosion earliest in early rheumatoid arthritis, while second through fifth metacarpal bases show more erosion in mid-to-late stage disease 3.

Tendon Pathology

• MRI can diagnose tendinopathy, tendon tears, intersection syndrome, stenosing tenosynovitis, and pulley injuries with excellent soft tissue contrast 1, 2.
• Carpal tunnel flexor tendons are most frequently affected in inflammatory arthritis, followed by second and third digit flexor tendons 5.

Prognostic Value

• In a retrospective review of 316 patients, MRI changed clinical management in 69.5% of cases, particularly by reassuring patients that no further follow-up was necessary in 70% 1.