Published online before print January 7, 2002, 10.1148/radiol.2222010182
(Radiology 2002;222:447-452.)
© RSNA, 2002
MR Imaging of the Metacarpophalangeal Joints of the Fingers
Part II. Detection of Simulated Injuries in Cadavers1
Christian W. A. Pfirrmann, MD,
Nicolas H. Theumann, MD,
Michael J. Botte, MD,
Jean-Luc Drapé, MD, PhD,
Debra J. Trudell, RA and
Donald Resnick, MD
1 From the Department of Radiology, Veterans Administration Medical Center, 3350 La Jolla Village Dr, San Diego, CA 92161 (C.W.A.P., N.H.T., D.J.T., D.R.); Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (N.H.T.); Division of Orthopedic Surgery, Scripps Clinic and Research Foundation, La Jolla, Calif (M.J.B.); and Department of Radiology B, CHU Cochin, Assistance Publique-Hôpitaux de Paris-Université Paris V, France (J.L.D.). Received December 18, 2000; revision requested February 8, 2001; final revision received July 25; accepted July 30. Supported by the Swiss National Science Foundation and the Swiss Radiological Society. Address correspondence to D.R. (e-mail: dresnick@ucsd.edu). © RSNA, 2001
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ABSTRACT
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PURPOSE: To evaluate and compare conventional magnetic resonance (MR) imaging and MR arthrography in the diagnosis of the most common traumatic metacarpophalangeal (MCP) joint injuries, which were created surgically in cadavers.
MATERIALS AND METHODS: Injuries to various MCP joint structures were surgically created randomly in 28 fingers of seven human cadaveric hands. Injuries to the main collateral ligaments (CLs) (n = 12), accessory CL (n = 15), sagittal band (n = 14), transverse fibers of the extensor hood (n = 5), first annular pulley (n = 16), deep transverse metacarpal ligament (DTML) (n = 5), and palmar plate (n = 10) were analyzed. Conventional MR images and MR arthrograms were evaluated, with differences in interpretation resolved in consensus. The sensitivities, specificities, and accuracies of both MR imaging methods were determined, and the differences were tested for significance by using the McNemar test.
RESULTS: Sensitivity was 28.6%–93.8% with conventional MR imaging versus 50.0%–93.3% with MR arthrography. Specificity was 66.7%–100% with conventional MR imaging versus 83.3%–100% with MR arthrography. Although the MR arthrographic results usually were higher, the differences were not significant. The 
values for interobserver agreement were 0.314–0.638 for conventional MR imaging versus 0.364–1.00 for MR arthrography. Sensitivity for the detection of lesions of the main and accessory CLs and the first annular pulley was slightly higher than that for the detection of lesions of the extensor hood, DTML, and palmar plate structures.
CONCLUSION: MR imaging and MR arthrography enable the diagnosis of simulated MCP joint injuries. MR arthrography does not have a significant advantage over conventional MR imaging.
Index terms: Extremities, MR, 437.121411, 437.12143, 437.124 • Fingers and toes, injuries, 437.41 • Hand, arthrography, 437.12143, 437.124 • Magnetic resonance (MR), arthrography, 437.12143, 437.124
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INTRODUCTION
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The anatomy of the metacarpophalangeal (MCP) joints of the fingers is complex (1,2). Various structures of the MCP joints may be injured or involved in a variety of pathologic processes (2–6). The effectiveness of magnetic resonance (MR) imaging in depicting the anatomic details of the main structures about the MCP joints has been demonstrated (1). The diagnostic performance of MR imaging in the assessment of injuries of some of the structures of the MCP joints, such as the extensor hood and the collateral ligaments of the thumb, has been reported on previously (2,7). To our knowledge, however, a comprehensive assessment of MR imaging in cases of injury of the MCP joints has not been performed. Because these injuries are relatively rare and the treatment of them frequently—but not invariably—is nonsurgical (4,8), surgical findings, which otherwise might be considered the reference standard, often are not available. Therefore, the purpose of our study was to evaluate and compare MR imaging and MR arthrography in the diagnosis of the most common traumatic MCP joint lesions that were created surgically in a cadaveric model.
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MATERIALS AND METHODS
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Specimens
Twenty-eight MCP joints in seven index, seven middle, seven ring, and seven little fingers of seven hands were harvested from fresh, nonembalmed human cadavers (three women, four men; age range at death, 72–88 years; mean age at death, 79 years). The specimens were from arms cut through the distal portions of the radius and ulna. The specimens were immediately deep frozen at -40°C (Forma Bio-Freezer; Forma Scientific, Marietta, Ohio). Standard radiographs in two projections were obtained prior to the surgical procedure to confirm the absence of traumatic or articular disorders in each MCP joint. The specimens were allowed to thaw for 24 hours at room temperature prior to the surgical procedure and MR imaging, which were performed in separate sessions within 5 weeks of each other. The delay was due to the limited availability of the MR imaging unit.
Simulated Injuries
All of the injuries were planned and created surgically by an experienced hand surgeon (M.J.B.). Identical longitudinal 5-cm midline incisions were made at the palmar and dorsal aspects of each finger so that the type of skin incision, when viewed on MR images, would not enable the identification of any specific anatomic lesion. All lesions were full-thickness cuts through the whole structure. The lesions were randomly distributed so that each joint had a different pattern of injured and intact structures. The number of lesions was based mainly on the number of available structures and was varied to prevent possible bias. Lesions of the main collateral ligament were created in 12 (21%) of 56 collateral ligaments. Four of these lesions involved the proximal insertion of the main collateral ligament; five lesions, the body of the main collateral ligament; and three lesions, the distal insertion of the main collateral ligament. Fifteen (27%) of 56 accessory collateral ligaments were surgically injured: six at the body of the accessory collateral ligament and nine at its distal insertion in the palmar plate (PP). Injuries were created in 14 (25%) of 56 sagittal bands. Five (9%) of 56 transverse fibers of the extensor hood were injured. Sixteen (57%) of 28 first annular (A1) pulleys were surgically opened longitudinally. Lesions were created in five (24%) of 21 deep transverse metacarpal ligaments (DTMLs). A lesion was created in 10 (36%) of 28 PPs: five to the proximal attachment and five to the distal attachment.
During the surgical creation of the injuries, very careful attention was paid to prevent damage to other structures. To minimize artifacts related to air in the soft tissues, the incisions were irrigated and filled with saline. After careful approximation of the dissected tissues, skin closure was performed by using a single layer of 4-0 monofilament suture in a running locking fashion, with the specimens submerged entirely in saline.
Image Acquisition
Image acquisition was performed by using the protocol followed in the first part of our investigation (1). Conventional MR images and MR arthrograms were acquired by using a 1.5-T unit (Signa; GE Medical Systems, Milwaukee, Wis) with either a dedicated receive-only wrist coil for assessment of the MCP joints extended or a wrap coil for assessment of the MCP joints flexed. Two transverse T1-weighted spin-echo MR sequences (500/12 [repetition time msec/echo time msec], 2-mm section thickness, 0.5-mm interspace, two signals acquired, 6 x 6-cm field of view, 512 x 256 matrix) were performed separately in the second and third MCP joints and in the fourth and fifth MCP joints, with the joints in extension. With the same imaging parameters, two sets of coronal T1-weighted spin-echo MR images were obtained.
Subsequently, the MCP joints were taped in 90° of flexion. Transverse T1-weighted spin-echo MR images (500/12, 2-mm section thickness, 0.5-mm interspace, three signals acquired, 9 x 9-cm field of view, 512 x 256 matrix) were obtained. With use of the technique performed in the first part of our investigation (1), the same sequences were repeated after the intraarticular injection of approximately 1–3 mL of a solution consisting of 1 mL of gadopentetate dimeglumine (Magnevist; Schering, Berlin, Germany) diluted in 250 mL of saline and mixed with an equal amount of the iodinated contrast agent iohexol (Omnipaque 350; Nycomed Amersham, Princeton, NJ). The injection was stopped immediately when contrast agent extravasation was noted. Additionally, two sagittal T1-weighted spin-echo MR sequences were performed with the MCP joints in extension (500/12, 2.5-mm section thickness, 0.6-mm interspace, two signals acquired, 6 x 6-cm field of view, 512 x 256 matrix) and then in flexion (500/12; 2.5-mm section thickness, 0.5-mm interspace, three signals acquired, 9 x 9-cm field of view, 512 x 256 matrix).
Image Analysis
The MR images were independently reviewed by two musculoskeletal radiologists (C.W.A.P., N.H.T.). Interpretation differences were resolved by means of consensus. The readers assessed whether each structure was normal or abnormal—that is, surgically cut. Both radiologists were aware of the purpose of the study and that injuries had been created surgically; however, they were blinded with regard to the type, distribution, and number of injuries. The conventional MR imaging and MR arthrographic studies of each specimen were analyzed separately. Two joints were analyzed at one time. All images obtained with either the conventional MR imaging or MR arthrographic sequences were viewed simultaneously. The conventional MR images and MR arthrograms were read on separate occasions that were spaced approximately 2 months apart. The order of the cases also was changed for the interpretation of conventional MR imaging and arthrographic studies.
Statistical Analyses
The sensitivities, specificities, and accuracies of MR imaging with and without arthrography in the detection of each type of lesion achieved by both readers independently and at the consensus reading were determined. Any difference in detection values between the two types of MR studies was analyzed for significance by using the McNemar test (9). A P value of less than .05 indicated a significant difference. Interobserver agreement was tested separately for conventional MR imaging and arthrographic studies by calculating statistics (10). Agreement was rated as follows: values of 0–0.20 indicated slight agreement; 0.21–0.40, fair agreement; 0.41–0.60, moderate agreement; 0.61–0.80, substantial agreement; and 0.81–0.99, excellent agreement. A value of 1.00 indicated absolute agreement (11).
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RESULTS
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The results of analysis of the simulated MCP joint injuries detected with MR imaging and MR arthrography are summarized in Table 1. Sensitivity for the detection of lesions of the collateral ligament complex—that is, the main and accessory collateral ligaments—and the A1 pulley was high. Sensitivity was somewhat lower for the detection of structures of the extensor hood, DTML, and PP. Specificity was invariably high for the detection of lesions of all investigated structures on the conventional MR imaging and arthrographic studies.
At comparison of conventional MR imaging and MR arthrography, the sensitivity of the conventional studies (28.6%–66.7%) in the detection of injuries of the collateral ligament complex (Fig 1) and the extensor hood—that is, the sagittal bands and transverse fibers (Fig 2)—was slightly lower than that of the arthrographic studies (60.0%–93.3%). The specificities of conventional MR imaging and MR arthrography (90.2%–100% and 92.9%–98.0%, respectively) for the detection of injuries to these structures, however, were at the same level. The differences in sensitivities and specificities between conventional MR imaging and MR arthrography were not statistically significant (P = .125 to >.999). There were no significant differences in sensitivity and specificity values between conventional MR imaging and MR arthrography in the detection of lesions of the A1 pulley (Fig 3) and DTML (Fig 4).
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Figure 1a. Lesions of the collateral ligament complex. (a) Transverse T1-weighted MR arthrogram (500/12) of the third MCP joint flexed. The main ulnar collateral ligament (arrowheads) is detached at its distal insertion site. The main radial collateral ligament (arrow) is intact. (b) Transverse T1-weighted MR arthrogram (500/12) of the third MCP joint extended. The accessory ulnar collateral ligament (arrowheads) is detached at its distal insertion site (curved arrow) at the PP (straight arrow).
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Figure 1b. Lesions of the collateral ligament complex. (a) Transverse T1-weighted MR arthrogram (500/12) of the third MCP joint flexed. The main ulnar collateral ligament (arrowheads) is detached at its distal insertion site. The main radial collateral ligament (arrow) is intact. (b) Transverse T1-weighted MR arthrogram (500/12) of the third MCP joint extended. The accessory ulnar collateral ligament (arrowheads) is detached at its distal insertion site (curved arrow) at the PP (straight arrow).
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Figure 2a. (a) Surgical exposure of the extensor hood at the dorsal and ulnar aspects of the MCP joint of the third finger. The sagittal bands (arrowheads) stabilize the common extensor tendon (straight arrows). The transverse fibers (curved arrows) of the extensor hood extending distally are lifted for better visualization. Transverse T1-weighted (b) conventional MR image (500/12) and (c) MR arthrogram (500/12) of the third MCP joint with a simulated injury to the extensor hood show that the ulnar sagittal band (curved arrow) is disrupted and the radial sagittal band (straight arrow) is intact. Note the radial subluxation of the common extensor tendon (arrowhead). (d) Conventional transverse T1-weighted MR image (500/12) of the fourth and fifth MCP joints with a simulated injury of the extensor hood. The radial transverse fibers of the extensor hood (straight arrow) are disrupted. The curved arrows point to intact transverse fibers.
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Figure 2b. (a) Surgical exposure of the extensor hood at the dorsal and ulnar aspects of the MCP joint of the third finger. The sagittal bands (arrowheads) stabilize the common extensor tendon (straight arrows). The transverse fibers (curved arrows) of the extensor hood extending distally are lifted for better visualization. Transverse T1-weighted (b) conventional MR image (500/12) and (c) MR arthrogram (500/12) of the third MCP joint with a simulated injury to the extensor hood show that the ulnar sagittal band (curved arrow) is disrupted and the radial sagittal band (straight arrow) is intact. Note the radial subluxation of the common extensor tendon (arrowhead). (d) Conventional transverse T1-weighted MR image (500/12) of the fourth and fifth MCP joints with a simulated injury of the extensor hood. The radial transverse fibers of the extensor hood (straight arrow) are disrupted. The curved arrows point to intact transverse fibers.
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Figure 2c. (a) Surgical exposure of the extensor hood at the dorsal and ulnar aspects of the MCP joint of the third finger. The sagittal bands (arrowheads) stabilize the common extensor tendon (straight arrows). The transverse fibers (curved arrows) of the extensor hood extending distally are lifted for better visualization. Transverse T1-weighted (b) conventional MR image (500/12) and (c) MR arthrogram (500/12) of the third MCP joint with a simulated injury to the extensor hood show that the ulnar sagittal band (curved arrow) is disrupted and the radial sagittal band (straight arrow) is intact. Note the radial subluxation of the common extensor tendon (arrowhead). (d) Conventional transverse T1-weighted MR image (500/12) of the fourth and fifth MCP joints with a simulated injury of the extensor hood. The radial transverse fibers of the extensor hood (straight arrow) are disrupted. The curved arrows point to intact transverse fibers.
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Figure 2d. (a) Surgical exposure of the extensor hood at the dorsal and ulnar aspects of the MCP joint of the third finger. The sagittal bands (arrowheads) stabilize the common extensor tendon (straight arrows). The transverse fibers (curved arrows) of the extensor hood extending distally are lifted for better visualization. Transverse T1-weighted (b) conventional MR image (500/12) and (c) MR arthrogram (500/12) of the third MCP joint with a simulated injury to the extensor hood show that the ulnar sagittal band (curved arrow) is disrupted and the radial sagittal band (straight arrow) is intact. Note the radial subluxation of the common extensor tendon (arrowhead). (d) Conventional transverse T1-weighted MR image (500/12) of the fourth and fifth MCP joints with a simulated injury of the extensor hood. The radial transverse fibers of the extensor hood (straight arrow) are disrupted. The curved arrows point to intact transverse fibers.
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Figure 4. Conventional transverse T1-weighted MR image (500/12) of the third to fifth MCP joints shows that the DTML (white arrows) is disrupted between the fourth and fifth MCP joints at the ulnar attachment site (black arrow) at the PP.
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The results of interobserver agreement analysis are presented in Table 2. Agreement was fair to excellent. The absolute agreement regarding the detection of DTML lesions at MR arthrography was related to the very low sample number: five injured lesions in 21 ligaments. Similar to the sensitivity and specificity values, the interobserver agreement values were somewhat lower for the detection of lesions of the extensor hood and PP (Fig 5) ( = 0.314–0.503) compared with those for the detection of lesions of the collateral ligament complex and the A1 pulley ( = 0.486–0.744).
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TABLE 2. Interobserver Agreement on MR Image and MR Arthrogram Interpretations in the Depiction of Simulated MCP Joint Injuries
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Figure 5. Sagittal T1-weighted MR arthrogram (500/12) of the third MCP joint. Note the detachment (curved arrow) of the PP (arrowheads) near the distal insertion of the PP at the base of the proximal phalanx in close relation to the distal recess (straight arrow) of the PP.
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DISCUSSION
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Collateral ligament injuries in the MCP joints of the fingers are rare compared with those of the thumb. Almost all collateral ligament tears in the fingers occur on the radial side (4). The most commonly involved digit is the index finger, followed by the little finger. Although the majority of lesions are treated conservatively, surgery has been advocated in cases of severe MCP instability or intraarticular displacement of the torn ligament (4,12). On the ulnar side of the little finger, displacement of the torn ligament over the intact sagittal band of the extensor hood may occur, similar to the Stener lesion of the first MCP joint (7,13,14). The displacement of the torn ligament interferes with healing and necessitates surgery (4,15). MR imaging has been shown to be accurate in the diagnosis of collateral ligament lesions of the thumb. The diagnostic performance of MR imaging in the detection of lesions of the collateral ligament complex in our study was comparable to that in previous studies of the MCP joints of the thumb (7,16).
The extensor hood is an important stabilizer of the common extensor tendon at the MCP joints (17). Tears of the extensor hood lead to subluxation of the common extensor tendon (3). Injuries of the extensor hood occur most commonly with valgus or varus forces applied to the MCP joints. The choice of treatment for extensor hood injuries is controversial; however, reconstruction of the extensor hood leads to satisfactory results (3,18). Untreated injuries may result in chronic subluxation of the common extensor tendon, with a snapping tendon and pain with gripping (19). Early diagnosis allows initiation of the proper treatment. MR imaging may be helpful, because accurate clinical assessment of the MCP joint may be impossible in the acute stage following injury owing to tenderness and swelling (2).
MR imaging of injuries of the extensor hood of the fingers was evaluated by Drapé and co-workers (2). In that series, the lesions in all nine patients were diagnosed correctly by using MR imaging. In our study, the sensitivity of conventional MR imaging and MR arthrography in the detection of lesions of the extensor hood—that is, the sagittal bands and transverse fibers—ranged from 28.6% to 85.7%. However, the sensitivities for the detection of lesions of the extensor hood were the lowest, as compared with those for the detection of the other types of lesions. Both major components of the extensor hood—the sagittal bands and the transverse fibers—are very thin linear structures. In a cadaveric model, no secondary findings such as hemorrhage or scarring, which would facilitate the detection of the lesion, are observed. Thus, the accurate diagnosis in cadavers is based on the detection of frank discontinuity of a particular structure.
The A1 pulley is second in strength only to the second annular pulley and serves as an important stabilizer of the flexor tendon to the PP. The A1 pulley also has an important role in the pathogenesis of a trigger finger (20). Lesions of the A1 pulley were diagnosed accurately in our series. The role of MR imaging in the assessment of the integrity of the pulley system has been previously emphasized (5,21). Hauger and colleagues (5) evaluated the second to fifth annular pulleys. They were able to delineate the second and fourth annular pulleys with standard MR imaging in all cases. Additional contrast agent injection into the tendon sheath was needed for adequate visualization of the third and fifth annular pulleys, however (5). In our study, lesions of the A1 pulley could be identified well without injection of contrast agent into the tendon sheath.
The DTML connects the PPs and serves as a stabilizer of the metacarpal heads. Closed rupture of the DTML is an unusual injury that occurs in combination with other injuries to structures adjacent to the MCP joints (22). Frequently, the DTML between the fourth and fifth fingers is torn. Affected patients present with painful ulnar deviation of the small finger (22). Open lacerations of the DTML occur more frequently. Lesions of the DTML were difficult to analyze in our study.
Lesions of the PP can occur in cases of dislocation of the MCP joints or from hyperextension injuries. In distal injuries, a bone fragment that facilitates detection of the injury often is present. Injuries to the PP were analyzed with MR arthrographic sequences by using sagittal images of the finger in extension and flexion. In our series, it was sometimes difficult to distinguish a distal injury of the PP from the central recess at the distal attachment of the PP. Proximal detachments of the PP also are difficult to diagnose because the checkrein ligaments attaching the PP to the base of the metacarpal head are much less distinct compared with those about the interphalangeal joints.
In our study, both MR imaging and MR arthrography invariably had high specificity in the detection of all lesions. Although the sensitivity values for the MR arthrograms of all investigated lesions were almost always higher and the MR arthrographic studies were subjectively easier to analyze for both readers, these differences were not statistically significant.
There were several limitations to this study. The injuries were created surgically. Although we made every effort to simulate clinically evident lesions and to prevent the surgical introduction of air that might create artifacts, we did not study lesions in patients. Although careful attention was paid to the repositioning of all structures after the creation of the injuries, leakage of contrast agent was common and, as usual, led to less joint distention. As indicated earlier, cadaveric studies prevent the evaluation of swelling, bleeding, or scarring that would be expected with similar lesions in patients. However, this study design enabled us to investigate the use of conventional MR imaging and MR arthrography in the detection of injuries of the MCP joints with a well-defined reference standard that would be impossible to use clinically.
All specimens were taken from the cadavers of elderly humans; therefore, some of the investigated structures might have been subjected to degeneration already; this might explain some of the false-positive results. Although the readers were blinded regarding the type, distribution, and number of injuries, they were aware that surgically simulated injuries were present. Therefore, some reader bias was introduced. For many structures, a reasonable number of lesions could be created; however, in the unilateral structures, such as the A1 pulley, DTML, and PP, the numbers of lesions and control areas were small.
In conclusion, MR imaging and MR arthrography enable the diagnosis of simulated injuries of structures about the MCP joints in cadavers. MR arthrography does not have a significant advantage over conventional MR imaging in this setting.
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FOOTNOTES
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See also the article by Theumann et al (pp 437–445
) in this issue.
Abbreviations: A1 = first annular,
DTML = deep transverse metacarpal ligament,
MCP = metacarpophalangeal,
PP = palmar plate
Author contributions: Guarantors of integrity of entire study, C.W.A.P., N.H.T., D.R.; study concepts, C.W.A.P., J.L.D., N.H.T., D.R.; study design, C.W.A.P., M.J.B., D.R.; literature research, C.W.A.P.; experimental studies, M.J.B., D.J.T.; data acquisition, C.W.A.P., N.H.T., D.J.T.; data analysis/interpretation, C.W.A.P., N.H.T.; statistical analysis, C.W.A.P.; manuscript preparation, C.W.A.P.; manuscript definition of intellectual content, C.W.A.P., D.R.; manuscript editing, D.R.; manuscript revision/review, D.R., J.L.D.; manuscript final version approval, D.R., C.W.A.P.
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[Abstract]
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ABSTRACT
INTRODUCTION
