MR imaging of the metacarpophalangeal joints of the fingers: evaluation of 38 patients with chronic joint disability

ACR Appropriateness Criteria® Chronic Hand and Wrist Pain: 2023 Update

Chronic hand and wrist pain is a common presenting complaint. The intricate anatomy results in a variety of pain generators-multiple bones, articular cartilage, intrinsic ligaments, triangular fibrocartilage complex, joint capsules and synovium, tendons and tendon sheaths, muscles, and nerves-in a compact space. The need for imaging and the choice of the appropriate imaging modality are best determined by the patient's presentation, physical examination, and the clinician's working differential diagnosis. Radiography is usually appropriate as the initial imaging study in the evaluation of chronic hand or wrist pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

The Accuracy and Cost-Effectiveness of MRI Assessment of Collateral Ligament Injuries of the Lesser Digits’ Proximal Interphalangeal Joints

Background

Collateral ligament injuries of the thumb and lesser digits are simple injuries, but they may lead to disabilities in hand function. This study aimed to evaluate the accuracy and cost-effectiveness of magnetic resonance imaging (MRI) in diagnosing proximal interphalangeal (PIP) collateral ligament injuries of lesser digits.

Methods

A retrospective evaluation was conducted on 18 fingers that had undergone surgery for PIP joint complete collateral ligament injury. Pre-operative MRI results were compared with the intra-operative findings. The data from MRI and direct intraoperative findings were analyzed by the Chi-square test in paired groups. The McNemar test analyzed the accuracy of the MRI test for detecting volar plate injuries. Statistical Packages for Social Sciences (SPSS) version 25 (IBM Inc., Armonk, New York) software program was used for the analysis. 

Results

In digits other than the thumb, the accuracy of MRI for detecting collateral injuries was 38.89%, and detection was incorrect in 11 (61.11%) of 18 patients. There are significant differences between MRI and Intraoperative results (p<0.001). MRI findings for seven fingers (38.89%) of the 18 fingers involved were compatible with the surgery results (38.88%). By comparison, the MRI findings of 11 fingers (61.11%) were inconsistent with the intra-operative results. Eight patients (44.44%) were diagnosed preoperatively with MRI as having volar plate ruptures, three patients (16.67%) were diagnosed with open surgery, but only three of the volar plate diagnosed patients with MRI were verified as ruptures during open surgery (38.0%). In addition, preoperatively undetected volar plate injuries by MRI (n=10) were detected intra-operatively in three cases (30.0%). Therefore, the accuracy of MRI was found not to be statistically significant for the detection of volar plate injuries (p=0.727).

Conclusion

This study concluded that a 1.5-Tesla MRI with a slice thickness of 2-3 mm should not be relied on as a decisive tool for diagnosing collateral ligament injuries of the PIP joint of the lesser digits. Additionally, MRI was found insufficient for diagnosing volar plate injuries that accompanied collateral ligament injuries. Given these findings, one might conclude that MRI is not cost-effective in diagnosing collateral ligament injuries of the lesser digits PIP joint.

Injuries to the Collateral Ligaments of the Metacarpophalangeal and Interphalangeal Joints: Sonographic Appearance

Injuries to the collateral ligaments of the metacarpophalangeal (MCP) and interphalangeal (IP) joints are commonly encountered in both athletes and nonathletes. They require prompt evaluation to ensure proper management and prevent loss of joint motion and permanent disability. Imaging is often required to confirm the diagnosis and assess injury severity. This review article aims to provide physicians with guidelines for sonographic assessment of the collateral ligaments of the MCP and IP and related injuries. Sonographic features of ligament injuries ranging from sprains and partial-thickness tears to full-thickness tears are described. Specific lesions of the ulnar collateral ligament of the thumb MCP joint, such as gamekeeper's thumb, skier's thumb, and Stener lesions, are also included. In conclusion, sonography is effective in evaluating the collateral ligaments of the MCP and IP joints and related injuries and represents a valuable tool for diagnosis.

Injury to ulnar collateral ligament of thumb

Injury of the ulnar collateral ligament (UCL) of thumb can be incapacitating if untreated or not treated properly. This injury is notorious for frequently being missed by inexperienced health care personnel in emergency departments. It has frequently been described in skiers, but also occurs in other sports such as rugby, soccer, handball, basketball, volleyball and even after a handshake. The UCL of the thumb acts as a primary restraint to valgus stress and is injured if hyperabduction and hyperextension forces are applied to the first metacarpophalangeal joint. The diagnosis is best established clinically, though MRI is the imaging modality of choice. Many treatment options exist, surgical treatment being offered depending on various factors, including timing of presentation (acute or chronic), grade (severity of injury), displacement (Stener lesion), location of tear (mid-substance or peripheral), associated or concomitant surrounding tissue injury (bone, volar plate, etc.), and patient-related factors (occupational demands, etc.). This review aims to identify the optimal diagnostic techniques and management options for UCL injury available thus far.

[Metacarpophalangeal joint injuries and sequelae]

Injuries of the metacarpophalangeal joints of the thumb and fingers are of a bony or ligamentous nature. They can heal without subsequent problems if correctly diagnosed and treated but incorrect or absent diagnostics and therapy can result in chronic instability, dislocation, fusion as well as subsequent arthritis and functional limitations. They can lead to substantial impairment of the gripping function. Fractures with inclusion of joints and with fragments sufficiently large for refixation are as a rule treated operatively just as differences in torsion and instability. Persisting instabilities are secondarily stabilized by ligamentoplasty and arthritis of the metacarpophalangeal joint of the thumb is treated by fusion. For metacarpophalangeal joints of the fingers the main concern is preserving motion. Established salvage operations for arthritis include denervation, resection arthroplasty and systematic arthrolysis for impairment of the joint and contractures with intact joint surfaces. Even in chronic conditions, with appropriate treatment good functional results for metacarpophalangeal joints of the thumb and fingers can be achieved. This article presents the current pathophysiological principles and concepts for diagnostics and therapy of acute and chronic injuries of the metacarpophalangeal joints of fingers and thumbs.

Utility of MRI for diagnosing complete tears of the collateral ligaments of the metacarpophalangeal joints of the lesser digits

BACKGROUND

MRI has been shown to be highly accurate in assessing collateral ligament injuries of the metacarpophalangeal joint (MPJ) of the thumb. The purpose of this study is to evaluate the accuracy of MRI for diagnosing collateral ligament tears of the MPJ of the fingers. Our hypothesis is that MRI would accurately detect complete tears of collateral ligaments of the lesser digit MPJs.

METHODS

We retrospectively evaluated 22 digits in 20 patients undergoing finger MPJ collateral ligament repair. All patients had preoperative MRI scans. The findings on preoperative imaging studies were compared to the intraoperative findings.

RESULTS

All patients had surgically confirmed complete tears of the collateral ligament in question. In 8 of 22 MRI scans (36 %), the preoperative imaging study was inaccurate. Of these eight patients, MRI was interpreted as no tear in one and a partial tear in seven. The sensitivity of MRI for diagnosing a complete tear was 64 %. In all three digits in which 3-T MRI scanning was utilized and documented, the preoperative imaging results did not correlate with the intraoperative findings.

CONCLUSIONS

Although MRI can be considered a useful adjunct to evaluating patients with collateral ligament injuries of the fingers, the sensitivity is poor and the imaging results can underestimate the extent of injury. In light of this, the emphasis for determining appropriate course of treatment remains on history and mechanism of injury, physical examination, and patient disability.

Evaluation of Collateral Ligament Injuries of the Metacarpophalangeal Joints with Magnetic Resonance Imaging and Magnetic Resonance Arthrography

Injuries of the collateral ligaments of the metacarpophalangeal (MCP) joints of the hand require accurate diagnosis and prompt treatment to prevent loss of function. The most common and well-known collateral ligament injury is injury to the ulnar collateral ligament of the first MCP joint of the hand, often referred to as a gamekeeper injury. Although less common, injuries involving the collateral ligaments of the second through fifth digits and the radial collateral ligament of the first digit also occur. The diagnosis of collateral ligament injury is often made clinically, however, magnetic resonance imaging and magnetic resonance arthrography of the MCP joints can be very useful in the evaluation of severity of the injury. This provides important information for the hand surgeon and aids in treatment planning. Imaging of the collateral ligaments requires small fields of view and several technical considerations can provide improved image quality. These factors will be discussed and illustrated in this article.

Collateral ligament injuries of the metacarpophalangeal joints of the fingers

Although complete collateral ligament tear and instability involving the metacarpophalangeal joints of the fingers, especially those on the radial aspect of the index finger, are rare, they may be underdiagnosed, underestimated, and potentially disabling. Awareness and suspicion of the injury, coupled with careful physical and imaging examinations, confirm the diagnosis and its extent. Early operative repair results in favorable outcomes in most cases. Chronic instability may lead to pain, weakness, and arthritis. Late ligament repair or reconstruction is typically slightly less reliable than acute repair, yet often improves outcomes. Arthritic joints may require reconstruction.