MRI Diagnostics of the Fingers: Current Developments and Clinical Relevance

• Abstract
• Introduction
• Anatomy of the finger
• Examination technique
• Orthopedic/traumatic finger MRIs
• Collateral ligaments
• Volar plates
• Pulley ligaments
• Tendon pathologies
• Osseous injuries
• Inflammatory/rheumatic diseases of the finger
• Tumors and tumor-like lesions of the finger
• Limitations/outlook for MRI
• Conclusion
• References

Abstract

Background

Magnetic resonance imaging (MRI) is an excellent method for visualizing the complex anatomical structures of the fingers. The high diagnostic standard is based on numerous recent technical developments to improve soft tissue differentiation and detail recognition, and includes time-resolved functional imaging

Method

This review highlights the current status of MRI in finger diagnostics. The content of this narrative review is based on a literature search in the PubMed and Google Scholar databases using the search terms “finger MRI” and “finger imaging”.

Conclusion

Due to numerous technical optimizations and the increasing clinical availability of MRI, this examination has become indispensable in routine use for the further clarification of traumatic and orthopedic clinical pictures. MRI is also playing an increasingly important role in rheumatic and inflammatory issues, as well as tumors, whereby the particularly high potential for early detection and the detailed soft tissue imaging are especially advantageous.

Key Points

• MRI enables precise differential diagnosis of all clinical pictures of the fingers and is useful in the clarification of traumatic, orthopedic, rheumatic, inflammatory, and neoplastic issues.

• Multi-channel hand coils, scanners with high magnetic field strengths, and the use of contrast agents have led to an evaluation with resolutions in the submillimeter range in some cases.

• High-resolution MRI, including the possibility of functional examination, makes it easier to determine adequate therapy and avoid subsequent damage while meeting high standards.

Citation Format

• Bayer T, Lutter C, Janka R et al. MRI Diagnostics of the Fingers: Current Developments and Clinical Relevance. Rofo 2025; DOI 10.1055/a-2594-7451

Introduction

Anatomy of the finger

The anatomy of the finger is characterized by a complex interaction of bones, joints, tendons, ligaments, nerves, and blood vessels ([Fig. 1]a, b) [1] [2]. In the long fingers, the distal and proximal interphalangeal joints (DIP, PIP) serve functionally as hinge joints, while the metacarpo-phalangeal joints (MCP) have the function of ellipsoid joints to a limited extent [3]. The joint capsules of the long fingers (digs. 2–5) are reinforced on the radial and ulnar sides by two obliquely running, V-shaped collateral ligaments (lig. collateralia and lig. collateralia accessoria) [1] [2]. The volar (or palmar) plates (VP) are mobile, anatomically complex, flexor-side meniscoid fibrocartilaginous structures with a stabilizing function of the joint capsules against hyperextension, as well as translational and rotational stress [1] [4]. The MCP digs. 1–4 are connected to each other functionally by the metacarpo-phalangeal junction nuclei (Zancolli); between these run transverse ligaments (ligg. metacarpalia transversa profunda), which, together with the adjacent lumbrical muscle and interosseous tendons, stabilize the ellipsoid joints [5]. The long flexor and extensor tendons (m. flexor digitorum superficialis & profundus, m. extensor digitorum, m. flexor pollicics longus, m. extensor pollicis longus) originate on the forearm and insert on the respective phalanges [1]. Distally, the tendons of the flexor digitorum profundus (FDP) and the flexor digitorum superficialis (FDS) run in a common synovial tendon sheath [6]. In the chiasma tendineum, the FDS splits and forms a point of passage for crossing under the FDP [1]. This makes it possible for the FDS to insert separately at the middle phalanx base and the FDP further distally at the end phalanx [1]. The chiasma tendineum is particularly clinically relevant, as injuries here usually have a critical prognosis (tendon zone 2 = “danger zone”). The tendon sheaths are reinforced on the flexor side by locally limited retinacular fiber bundles in the form of five annular (proximal-distal: A1–A5) and three cruciate pulleys (C1 to C3) [1]. This creates a functional flexor tendon support system that guides the tendons to transmit force near the joints and phalanges [7]. The A2 and A4 annular pulleys are particularly strong and insert directly to the bone, while A1, A3, and A5 insert at the VP [8]. The extensor tendons run in dorsal [9] tendon sheaths, divide at the level of the proximal phalanx and insert proximally as the middle tract (tractus intermedius) at the base of the middle phalanx and distally via two lateral tracts (tractus laterales) together at the base of the distal phalanx [6]. At the level of the metacarpal, the extensor tendons form a dorsal aponeurosis as an extensor hood, in which six extensor tendon compartments can be differentiated anatomically and into which radiate fibers of the lumbrical and interosseous tendons [6].

The thumb saddle joint enables the ability to oppose and reposition, which is a basic prerequisite for fine motor activities in humans [1]. The stabilization of the thumb saddle joint is provided by a collateral ligament system and several diagonal and horizontal ligaments to the wrist and the adjacent os-metacarpale-2 base [10]. The anatomy of the thumb muscles is complex and includes, in addition to the long thumb muscles mentioned above, the short muscles of the thenar eminence: m. abductor pollicis brevis, m. flexor pollicis brevis, m. opponens pollicis, and m. adductor pollicis brevis [1]. On the ulnar side, at the level of the metacarpo-phalangeal joint of the thumb, tendon fibers of the adductor pollicis muscle radiate into the extensor hood, forming the adductor aponeurosis ([Fig. 1]c). On the radial side, the tendons of the flexor pollicis brevis muscle and the abductor pollicis brevis muscle form a common thenar aponeurosis [1].

Examination technique

Optimized MRI of the finger is characterized by the use of dedicated multi-channel high-frequency surface coils for improved signal reception on modern scanners with a strong gradient system [9]. High-field MRI (>1.5 Tesla) offers advantages because the additionally higher MR signal can improve spatial resolution while simultaneously reducing scan time. [11] [12]. Layer thicknesses of maximum 2.5 mm in 2-D technology or voxel sizes of ≤ 0.5mm³ isotropic in 3D technology are considered standard ([Table 1], see also protocol recommendations of the German Radiological Society AG MSK) [5]. Positioning in the Superman position while avoiding shoulder hyperextension allows optimal artifact-free examination results to be achieved [5]. The slice guidance is centered on the respective finger in neutral position as standard, on the thumb, due to the special anatomy, a separate sequence planning should be carried out separately from the long fingers [10]. Typical protocols include native proton, T1- and T2-weighted turbo spin echo (TSE) sequences, both with and without fat saturation (fs), as well as corresponding gradient echo (GRE) sequences in 3D technology [5]. Intravenous administration of contrast medium (CM) should be considered liberally, as it facilitates the diagnosis of acute concomitant inflammatory and chronic fibrovascular repair processes [6]. Depending on the question, it may be useful to extend the imaging from the finger to the hand/forearm, particularly in the case of pathologies of the long finger tendons. Functional examinations in different positions and during movement can also be used [4] [13] [14].

Orthopedic/traumatic finger MRIs

Soft tissue injuries of the finger and thumb are usually the result of acute and/or chronic repetitive trauma – e.g. as a result of sports or work-related injuries – as well as a variety of mechanical causes resulting from falls or other accidents. MRI is particularly helpful as an additional diagnostic tool after clinical examination, X-ray, and ultrasound for the assessment of ligament and tendon injuries as well as bony (stress) fractures. Complications such as ligament dislocations can be excluded with MRI, which allows for appropriate management of therapy and the prevention of subsequent damage. MRI is also playing an increasing role in degenerative diseases such as osteoarthritis or tendon degeneration as part of increasingly individualized therapeutic approaches.

Collateral ligaments

In cases of avulsions following radial/ulnar distortion of the DIP, PIP, and MCP, MRI often confirms a bony fragment that was already radiographically identifiable, but purely ligamentous collateral ligament ruptures can also be easily detected with MRI ([Fig. 2]a) [10]. More serious injuries with ligament dislocation usually result from dislocations that can also affect other joint structures such as the VP [15]. Severe ligament dislocations are rare beyond the classic Stener lesion at the metacarpo-phalangeal joint of the thumb, but can then be a criterion for surgical treatment [10]. For optimal differentiation of the various injury patterns and for detailed visualization of the two fiber bundles of the collateral ligaments, additional oblique paracoronal sequences along the fiber direction have proven useful.

Distortions caused by twisting the thumb are the most common cause of the classic “skier’s thumb injury” and usually involve a rupture of the ulnar collateral ligament (UCL) of the first digit. [16]. MRI is particularly important for further clarification in order to exclude concomitant injuries such as ligament dislocation with/without involvement of avulsion fragments, sesamoid bones, or other complications [5]. The so-called Stener lesion ([Fig. 2] b,c) represents a particular complication of skier’s thumb due to anatomical conditions in which the ruptured UCL ligament is dislocated over the adductor aponeurosis (yo-yo sign) [5]. This can be seen clearly in the MRI and is therapeutically important, as conservative treatment approaches in such situations almost always fail due to ligament dislocation [17].

Volar plates

Ruptures of the VP usually occur due to hyperextension trauma and/or as an accompanying injury during dislocation [10] [18]. The injuries are almost always located at the distal insertion at the level of the respective phalange base on level with the “cul du sac” recess [19]. This may already be visible radiologically in cases of bony avulsion [10]. VP injuries are especially easy to detect with MRI in the case of a pure soft tissue lesion ([Fig. 2] d–f) [20]. The VP dislocation in the proximal direction, which often occurs in rupture, is an important criterion for any surgical treatment [19].

Pulley ligaments

Pulley ligament ruptures typically occur due to acute overloading of the finger, such as when climbing, particularly when tensile overloads occur with the finger in a strongly bent position (“crimp grip” position). [21] [22]. MRI protocols with high technical quality can now directly visualize the particularly fine, ruptured ligaments (A2, A3, A4) ([Fig. 3]a) and thus enable a detailed evaluation of the injury pattern [11] [23] [24]. In the case of a pulley ligament rupture, typically what is known as a bowstringing sign ([Fig. 3]b) is found, which is a deviation with a widened gap between the flexor tendon and the phalanx [7]. This increases under forced flexion and can be provoked [25]. With regard to the determination of therapy, identification of the rupture pattern and bowstringing are relevant, as these determine the indications for conservative therapy with a ring splint and/or for surgical reconstruction [15]. In addition, MRI allows the exclusion of complications such as ligamentary dislocation, e.g. due to pulley stump intercalation [12], and is therefore crucial for preoperative management in order to prevent subsequent damage such as flexion contracture. A targeted assessment of the functionally relevant, but at the same time very thin A3 pulley ligament can be achieved not only by direct MRI imaging but also indirectly by functional images in the crimp grip position ([Fig. 3]b) or with CINE-MRI during finger flexion [13] [26]. In contrast to the A2–A4 pulley ligaments, the A5 pulley ligament has little trauma-pathological significance due to its location at the distal phalanx. The A1 pulley above the MCP also rarely ruptures, but can be chronically degeneratively thickened and, in the case of concurrent degenerative tendon changes, cause “snapping” or “trigger” finger symptoms [6]. MRI can be used here for planning before surgical ring ligament splitting.

Tendon pathologies

MRI enables the diagnosis of complete or partial tendon tears, and helps to determine the location and extent of any tendon retraction [6]. Injuries are usually the result of open trauma such as knife cuts, etc. Closed flexor tendon ruptures are rare [10]. The flexor tendons are clearly visible as hypointense, linear-fibrillar structures in T2-weighted, fat-suppressed, and proton-weighted sequences. 3D sequences allow for particularly good differentiation of the separate FDS and FDP fiber bundles in healthy individuals and post-traumatically in cases of injury. Tendon retractions can also extend far proximally to the forearm; accordingly, the field of view (FOV) in the MRI should be planned to be sufficiently large ([Fig. 3] c–f). Typically, a fluid signal is present at the injury site; hemorrhages may also result in an increased T1 and T2 signal. Flexor tendon injuries are almost always detectable in native MRI, but can be associated with tenosynovitis, especially in subacute or chronic cases. Here, contrast application can provide additional insights, as inflammation can lead to thickening of the tendon sheaths, capsules and VP [5] [6]. In the case of underlying rheumatic diseases (see below), advanced stages can lead to well-known deformities, such as buttonhole and swan-neck finger, due to musculo-ligamentary imbalances and associated tendon and joint destruction.

Extensor tendon ruptures are particularly common in clinical practice [6] [10] [27]. High-resolution axial and sagittal MRI can differentiate the various elements of the extensor tendons and extensor hood, such as the lateral tract, the intermediate tract, and the intertendinal connexus, as well as their involvement in an injury. In addition to the sagittal and axial T2 and PD sequences, the production of 3D sequences can be advantageous for this purpose. Ruptures are sometimes associated with avulsion fragments, which are clearly visible in both MRI and conventional X-rays. If conservative scarring is insufficient in extensor tendon injuries, which can be caused, for example, by insufficient immobilization and severe tendon stump dislocation (with or without avulsion fragment), this can lead to what is known as a hammer-finger deformity (syn. mallet finger) [27].

In bacterial tendonitis, MRI can clearly demonstrate spread along tendon sheath compartments ([Fig. 3]g) and the presence of associated abscesses and/or osteomyelitis, which is why it has proven useful for preoperative imaging before debridement in acute septic hand and finger injuries [5] [6].

We should also mention inflammatory tendon changes of non-rheumatic origin in tendon sheath compartments in the context of chronic friction phenomena such as De Quervain’s stenosing tenosynovitis ([Fig. 3]h) [20].

Osseous injuries

In addition to visible fractures or avulsion fragments, osseous injuries are often accompanied by contusional changes in the bone marrow, which are best detected in fluid-sensitive, fat-suppressed sequences. Fracture lines are visualized very well, especially in T1 sequences. In addition to acute traumatic changes, stress phenomena due to chronic repetitive overload through sport ([Fig. 4]a) or through work play an increasingly important role [28] [29] [30]. Insufficient fracture healing of the carpal bones with contact to finger tendons can lead to chronic tendinous irritations ([Fig. 4] b–e) and even to the complications of a tendon rupture [31] [32]. In some cases, fracture fragments of the finger are particularly small and cannot always be detected radiologically without overlap. For this reason, MRI imaging benefits from high resolution, which is particularly good at visualizing incomplete, radiologically occult, or trabecular fractures. Conversely, however, conventional X-rays should not be omitted under any circumstances, since even radiologically visible fragments cannot always be visualized by MR imaging ([Fig. 4] f,g).

Inflammatory/rheumatic diseases of the finger

MRI is the gold standard in the diagnosis of synovial diseases and, in addition to conventional X-rays, is therefore becoming increasingly important for the diagnosis of rheumatic diseases [6] [33]. Finger or hand/finger MRI has the potential to detect progression to rheumatoid arthritis early in patient populations with undifferentiated arthritis [34] [35]. It is also helpful in early rheumatic differential diagnosis, in order to be able to assign the inflammatory distribution pattern (e.g. synovitis, tenosynovitis, enthesitis, osteitis, erosion, etc. ([Fig. 5])) to the various diseases [36]. This can be an important complement to conventional X-rays, especially when looking to detect early soft tissue changes before osteodestructive-erosive and osteoproliferative changes. In addition, MRI is playing an increasingly important role in therapy monitoring after anti-rheumatic medication [37] [38]. Even in cartilage, despite the small spatial extent, early inflammation-associated changes can be used with compositional imaging techniques to assess cartilage quality [39].

Inflammatory changes in the finger joints are in many cases of a chronic degenerative origin, especially in the context of erosive osteoarthritis. In addition to conventional X-rays, MRI is used to confirm the diagnosis and show the extent of inflammatory activity.

Tumors and tumor-like lesions of the finger

MRI allows for detailed imaging and differential diagnosis of all tumors and tumor-like lesions of the finger [40] [41]. Benign tumors include ganglia, bone cysts, neuromas, lipomas, fibromas, etc. The benign synovial ganglion is easy to diagnose at first glance using MR imaging due to its smooth border and homogeneous T2 hyperintense and T1 hypointense signal pattern. The most common tumor originating from bone is the benign enchondroma ([Fig. 6] a,c), also with a typical appearance with sharp margins, T1 moderately low, T2 predominantly hyperintense signal, and T1 post-contrast strong enhancement along the serrated edges and septa [40] [41]. The glomus tumor ([Fig. 6] d,f) is a benign tumor of the small blood vessels, which is often located under the fingernail and is often no larger than a few millimeters [42]. The tumor-like, benign lesions with an aggressive growth pattern include the giant cell tumor ([Fig. 6] g,i), which originates from the tendon sheaths and was referred to as extra-articular pigmented villonodular synovitis according to the WHO classification until 2020 [40] [41]. One differential diagnosis is finger bursitis ([Fig. 6]j). In the case of rare malignant tumors such as synovial sarcoma, chondrosarcoma, and osteosarcoma, MRI also plays a very important role in early differential diagnosis and detailed imaging, including follow-up imaging during therapy.

Limitations/outlook for MRI

Despite its many advantages, MRI also has limitations. These include the considerable amount of time required for procedures, the higher costs compared to conventional X-ray diagnostics or ultrasound, the sometimes still limited availability of state-of-the-art scanning technology, and the fact that motion artifacts and metal implants can reduce image quality. New dimensions in finger diagnostics are opening up with the continued development of technical standards, such as CINE-MRI [13], as well as dynamic (4D) contrast-enhanced MRI, high-field MRI, and new coil technologies. Future developments, such as artificial intelligence (AI)-powered analytics, could also further refine and accelerate diagnostics.

Conclusion

Finger MRI, depending on the issue, has become indispensable in clinical practice today. Its biggest advantage lies in early diagnosis and precise differentiation of pathological processes. Therapy planning in hand surgery and sports medicine benefits significantly from it, especially when finger MRI with modern protocols enables high levels of detail recognition and soft tissue differentiation. MRI is also playing an increasingly important role for rheumatic and inflammatory issues, as well as tumors, because it offers a particularly high potential for early detection.

Conflict of Interest

The authors declare that they have no conflict of interest.

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Correspondence

Publication History

Received: 14 March 2025

Accepted after revision: 10 April 2025

Article published online:
26 May 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

• References

• 1 Schmidt HM, Lanz U. Chirurgische Anatomie der Hand. Stuttgart, New York: Thieme; 1992
  Search in Google Scholar
• 2 Hentz VR. Functional anatomy of the hand and arm. Emerg Med Clin North Am 1985; 3: 197-220
  PubMedSearch in Google Scholar
• 3 Moran CA. Anatomy of the hand. Phys Ther 1989; 69: 1007-1013
  CrossrefPubMedSearch in Google Scholar
• 4 Bayer T, Schweizer A, Muller-Gerbl M. et al. Proximal interphalangeal joint volar plate configuration in the crimp grip position. J Hand Surg Am 2012; 37: 899-905
  CrossrefPubMedSearch in Google Scholar
• 5 Schmitt R. Ligament injuries of fingers and thumbs. Radiologe 2017; 57: 43-56
  CrossrefPubMedSearch in Google Scholar
• 6 Schmitt R, Hesse N, Grunz JP. Tendons and Tendon Sheaths of the Hand – An Update on MRI. Rofo 2022; 194: 1307-1321
  Thieme ConnectPubMedSearch in Google Scholar
• 7 Hauger O, Chung CB, Lektrakul N. et al. Pulley system in the fingers: Normal anatomy and simulated lesions in cadavers at MR imaging, CT, and US with and without contrast material distention of the tendon sheath. Radiology 2000; 217: 201-212
  CrossrefPubMedSearch in Google Scholar
• 8 Zafonte B, Rendulic D, Szabo RM. Flexor pulley system: anatomy, injury, and management. J Hand Surg Am 2014; 39: 2525-2532
  CrossrefPubMedSearch in Google Scholar
• 9 Dalili D, Fritz J, Isaac A. 3D MRI of the Hand and Wrist: Technical Considerations and Clinical Applications. Semin Musculoskelet Radiol 2021; 25: 501-513
  Thieme ConnectPubMedSearch in Google Scholar
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  CrossrefPubMedSearch in Google Scholar
• 11 Bayer T, Bachter L, Lutter C. et al. Comparison of 3T and 7T magnetic resonance imaging for direct visualization of finger flexor pulley rupture: An ex-vivo study. Skeletal Radiol 2024; 53: 2469-2476
  CrossrefPubMedSearch in Google Scholar
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  CrossrefPubMedSearch in Google Scholar
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