Capitate-lunate instability: recognition by manipulation under fluoroscopy

Videotape fluoroscopy was used to diagnose a previously undescribed carpal dissociation, the capitate lunate instability pattern. In eight patients with midcarpal pain and clicking, the examiner simultaneously applied pressure to the scaphoid tuberosity while applying longitudinal traction and flexion to the wrist under fluoroscopic control. This maneuver revealed dorsal subluxation of the proximal carpal row and capitate lunate subluxation in each of the eight patients. Plain radiography and arthrography were not helpful in the diagnosis. All eight cases were managed conservatively. Videotape fluoroscopy is the best radiologic method of diagnosing capitate-lunate instability.     

The value of multi-detector CT arthrography of the wrist joint in evaluation of ligamentous and capsular injuries in post-traumatic pain

The wrist joint is a complex joint containing several intrinsic and extrinsic ligaments that contribute to carpal stability. There is increased incidence of ligamentous/capsular injury following trauma.

Role of MR imaging in chronic wrist pain

Magnetic resonance (MR) imaging for chronic wrist pain is challenging. Correct assessment of the triangular fibrocartilage, hyaline cartilage, ligaments, and tendons has become mandatory for comprehensive decision making in wrist surgery. The MR technique, potential and limits of MR imaging in patients with chronic wrist pain will be discussed. MR arthrography with injection of gadolinium-containing contrast material into the distal radioulnar joint is suggested for evaluation of the triangular fibrocartilage. The clinically meaningful ulnar-sided peripheral tears are otherwise hard to diagnose. The diagnostic performance of MR imaging for interosseous ligament tears varies considerably. The sensitivity for scapholunate ligament tears is consistently better than for lunotriquetral ligament tears. Gadolinium-enhanced MR imaging is considered to be the best technique for detecting established avascularity of bone, but the assessment of the MR results remains challenging. Most cases of ulnar impaction syndrome have characteristic focal signal intensity changes in the ulnar aspect of the lunate. Avascular necrosis of the lunate (Kienböck’s disease) is characterized by signal changes starting in the proximal radial aspect of the lunate. MR imaging is extremely sensitive for occult fractures. Questions arise if occult posttraumatic bone lesions seen on MR images only necessarily require the same treatment as fractures evident on plain films or computed tomography (CT) images. MR imaging and ultrasound are equally effective for detecting occult carpal ganglia. Carpe bossu (carpal boss) is a bony protuberance of a carpometacarpal joint II and III which may be associated with pain.     

Association between extrinsic and intrinsic carpal ligament injuries at MR arthrography and carpal instability at radiography: initial observations

PURPOSE: To retrospectively compare the presence or absence of carpal instability on radiographs with the findings of magnetic resonance (MR) arthrographic evaluation of intrinsic and extrinsic ligament tears in patients with chronic wrist pain. MATERIALS AND METHODS: The institutional review board approved this study and did not require informed consent. Signs of carpal instability were assessed on static and dynamic radiographs of the wrist obtained in 72 patients (24 female, 48 male; mean age, 36 years; age range, 14-59 years) with posttraumatic wrist pain. MR arthrography was subsequently performed. Two musculoskeletal radiologists independently analyzed the radiographs and MR images. Each intrinsic and extrinsic ligament was individually evaluated for the presence of a ligament tear. The extent of the tear also was recorded. Interobserver agreement regarding MR arthrographic findings was tested by calculating kappa statistics. Statistical comparison between radiography and MR arthrography was performed by using the Fisher exact test. RESULTS: Twenty-five triangular fibrocartilage complex, 18 (five partial, 13 complete) scapholunate ligament, and 25 (10 partial, 15 complete) lunotriquetral ligament tears were visualized. Twenty-two (all complete) extrinsic ligament tears were detected: two radial collateral ligament, 10 radioscaphocapitate ligament, and 10 radiolunotriquetral ligament tears. Interobserver agreement regarding intrinsic and extrinsic ligament tear detection at MR arthrography was excellent (kappa = 0.80). Nineteen patients had evidence of carpal instability on radiographs. Fourteen (52%) of 27 patients with at least one complete intrinsic lesion had no sign of carpal instability. On the other hand, the association of scapholunate ligament and/or lunotriquetral ligament and extrinsic ligament tears was significantly correlated (P < .001) with carpal instability at radiography. CONCLUSION: The presence or absence of carpal instability on radiographs depends on the association between intrinsic and extrinsic ligament tears-even partial ones-rather than on the presence of intrinsic ligament tears alone, even when the tears are complete.     

The clinical efficacy of triple-injection wrist arthrography

The author describes his personal experience of triple-injection wrist arthrography in a study of 50 patients with traumatized wrists. The aim of this trial was to determine the true false-negative rate of the wider spread and less-time consuming radiocarpal injection and to compare it to the results in the current literature.In the present patients an initial radiocarpal injection was performed with large amounts of contrast medium supported by DSA and only followed by a midcarpal or distal radiocarpal arthrography if there was no direct connection to those compartments (50–60%). An improvement of the initial results after reinjection could be seen in only 2% of cases and in 10% if partial tears of intercarpal ligaments or the triangular fibrocartilage complex were included. All of these findings could be proven surgically.The author suggests that double- and triple-injection wrist arthrography could be reduced to a single- or double-injection technique if oriented to the clinical symptoms and concluded as soon as one ligamentous perforation was identified. This technique does accelerate the procedure, lowers the cost and increases the false-negative rate only minimally.     

Diagnostic value of MR arthrography in detection of intrinsic carpal ligament lesions: use of cine-MR arthrography as a new approach

Twenty-five patients with chronic wrist pain and a preliminary diagnosis of carpal instability were examined with conventional MR imaging and MR arthrography with single compartment intra-articular injection. A new cine-MR arthrography technique, with image acquisition at every 5 s during intra-articular injection, was performed in 17 subjects. The purpose of this study was to determine the diagnostic value of MR arthrography in ligamentous lesions of the wrist and to assess the value of cine-MR arthrography in comparison with arthroscopy and/or surgery. Magnetic resonance arthrography, a semi-invasive technique, increased the diagnostic accuracy of intrinsic carpal ligament injuries. Cine-MR arthrography can be considered as a promising technique especially for the evaluation of lunatotriquetral and scapholunate ligament injuries of the wrist. Received 6 December 1995; Revision received 29 November 1996; Accepted 24 February 1997     

Imaging of ulnar-sided wrist pain

Ulnar-sided wrist pain has long been a diagnostic problem, partly because of the complex anatomy and many possible causes of pain in this region. This article discusses anatomy, pathophysiology, and imaging appearance of the more common causes, including tears of the triangular fibrocartilage complex, disorders of the distal radioulnar joint, tears of the lunotriquetral ligament, disorders of the extensor carpi ulnaris tendon, disorders of the pisotriquetral joint, the impingement and impaction syndromes, and ulnar wrist masses. Along with clinical history and physical examination, imaging is important in evaluation of ulnar-sided wrist pain. Conventional radiographs, conventional arthrography, CT, MRI, and MR arthrography are useful modalities that are often used in concert to help guide diagnosis and treatment.     

Ultrasound of intrinsic wrist ligament and triangular fibrocartilage injuries

Objective The objective of this study was to evaluate ultrasound as a diagnostic tool for investigating scapholunate and lunatotriquetral ligamentous and triangular fibrocartilage (TFC) tears. Ultrasound findings were compared to conventional arthrogram findings, as the reference gold standard.Design and patients In total 26 patients, 17 males and 9 females ranging in age from 17 to 35 (mean age, 34), were evaluated on referral for investigation of wrist pain. All patients were examined by high resolution ultrasound, using a 9–13 MHz transducer. All wrist ultrasound examinations were also compared to conventional tricompartmental arthrography, as the diagnostic gold standard reference.Results All ten scapholunate tears confirmed on arthrography were detected on ultrasound. Two of 8 lunatotriquetral and 7 of 11 TFC tears were correctly diagnosed on ultrasound. Sensitivity of ultrasound diagnosis ranged from 25% for lunatotriquetral tears to 100% for scapholunate tears. No false positive results were recorded for any of the three examined structures.Conclusion The study results suggest that sonography is accurate for scapholunate tears, but is not accurate for evaluation of lunate-triquetral tears. It has intermediate accuracy for triangular fibrocartilage tears.     

Bilateral three-compartment wrist arthrography in patients with unilateral wrist pain: findings and implications for management

Bilateral three-compartment wrist arthrography was performed in 30 patients with unilateral posttraumatic wrist pain to assess the incidence of bilateral findings. The mean age of patients was 30 (range 18–55) years. Thirty-three percent of patients were normal bilaterally, 30% had unilateral communication in the symptomatic wrist, 30% had communications in both the symptomatic and asymptomatic wrists and 7% had communication in the asymptomatic wrist only. Unilateral three-compartment wrist arthrography is not recommended in the assessment of unilateral post-traumatic wrist pain; no advantage of three-compartment injection over radiocarpal injection alone was shown.     

Unidirectional joint communications in wrist arthrography: an evaluation of 250 cases

Although arthrographically demonstrable communications between various compartments of the wrist occur in older persons without symptoms, similar communications in younger persons may indicate clinically significant posttraumatic ligament tears and other pathologic processes. However, detection of communications varies depending on the arthrographic technique used. It has been claimed that if triple-compartment arthrography is not used in all patients, clinically significant unidirectional ligament tears may be overlooked. We determined the frequency and distribution of unidirectional intercompartmental communications, using a modification of techniques described in the literature. Separate injections of contrast material were made in sequence into the midcarpal, distal radioulnar, and radiocarpal joints of 250 consecutive patients. We found 38 unidirectional communications (17 lunotriquetral, nine scapholunate, three radial capsular, one ulnar capsular, six combined sites, and two indeterminate sites) between the midcarpal and radiocarpal joints. Nine unidirectional communications between the radiocarpal and distal radioulnar joints were found. Comparison of these results with the frequency and direction of unidirectional communications reported by others suggests that demonstration of communications depends on specific technical factors, such as which joint is injected first, the amount of contrast material used, and the delay between injections. This dependence on technical factors raises questions about the value of routine three-compartment wrist arthrography.     

Isolated rotatory subluxation of the carpal navicular.

Rotatory subluxation of the carpal navicular can cause wrist pain and may lead to severe and disabling degenerative changes. Correct diagnosis depends on recognition of the typical roentgenographic signs. Sixteen patients with neither rheumatoid arthritis nor a lunate or a perilunate dislocation had rotatory subluxation in nineteen wrists. Many had only vague or remote histories of trauma. There were a navicular-lunate gap in all nineteen wrists, and foreshortening of the navicular in sixteen wrists, usually with a ring sign. The abnormalities were best demonstrated on well-centered posteroanterior roentgenograms of the wrist with the hand in slight radial deviation. In two patients, wrist arthrography demonstrated abnormal communication between radiocarpal and intercarpal joints.     

间接法MRI膝关节造影对半月板撕裂的评价

目的　评价间接法MRI膝关节造影对半月板撕裂的诊断价值。方法　回顾性分析 75例常规MRI膝关节扫描和 6 4例间接法MRI膝关节造影病例资料 ,以膝关节镜检查为诊断金标准 ,对比分析常规MRI和间接法MRI膝关节造影对半月板撕裂的诊断。结果　间接法MRI膝关节造影对内侧半月板撕裂的诊断敏感性、特异性、准确性、阳性预测值和阴性预测值分别为 72 %,10 0 %,89.1%,10 0 %和 84.8%;对外侧半月板撕裂分别为 83.8%,90 .9%,87.5 %,89.6 %和 85 .7%。与常规MRI比较 ,间接法MRI膝关节造影对内外侧半月板撕裂的诊断能力都没有统计学差异。结论　尽管间接法MRI膝关节造影对内外侧半月板撕裂诊断价值很高 ,但与常规MRI比较没有统计学差异。     

The hamatolunate facet: characterization and association with cartilage lesions--magnetic resonance arthrography and anatomic correlation in cadaveric wrists

The objective of this study was to characterize the appearance of the hamatolunate facet using high-resolution magnetic resonance (MR) arthrography in cadavers and to correlate the presence of this anatomic variant with the presence of osteoarthritis in the wrist. High-resolution MR images of 22 cadaveric wrist specimens were obtained after tri-compartmental arthrography. Two readers in consensus analyzed the MR images and recoded the presence or absence of a hamatolunate facet. Geometric characteristics and cartilage and ligament integrity were analyzed. A third reader, who was blinded to the purpose of the study, recorded cartilage lesions of all the bones of the proximal and distal carpal rows. A hamatolunate facet was present in 11 of 22 wrists (50%). The mean coronal size of the lunate facet at the lunate (type II lunate) was 4.5 mm (range, 2-6 mm). The highest frequencies of cartilage lesions were seen in the scapho-trapezio-trapezoid joint (45.5%) and at the proximal pole of the hamate (54.4% and 40.9% for consensus reading/blinded reading, respectively). In cases with a hamatolunate facet, the frequency of cartilage lesions in the proximal pole of the hamate was 81.8% and 63.6% versus 27.3% and 18.2% without such a facet (chi-squared, P=0.01/ P=0.03). No correlation of the presence of a hamatolunate facet with interosseous ligament tears or lesions of the triangular fibrocartilage was seen. In conclusion, the hamatolunate facet is a very common anatomic variant. The presence of a hamatolunate facet is associated with cartilage damage in the proximal pole of the hamate.     

掌骨受轴向压力作用下的腕部生物力学分析

目的 研究正常腕部载荷传递及关节接触应力分布情况,以及腕横韧带切除对腕部生物力学的影响.方法 通过CT扫描图像数据对腕部进行三维有限元建模,计算并分析掌骨受轴向压力作用下正常腕部载荷传递及接触应力的分布,以及腕横韧带切开前后腕骨运动的变化情况.结果 腕部载荷传递及关节接触应力分布情况与前人实验数据相当接近;腕横韧带的切除导致舟骨发生向桡侧和掌侧的偏移,以及掌向屈曲和向桡侧的转动,而整个腕管结构则产生更大的桡侧偏移.结论 立体构架了包括整个腕管结构、远端尺骨和桡骨以及近端掌骨的腕部整体三维有限元模型.本模型可以较好地模拟腕管和桡腕关节载荷传递与接触应力的分布情况,为进一步探讨腕部结构的力学行为提供了一个可操作的平台.通过计算分析腕管松解术对腕骨运动的影响,为腕管综合征的临床手术、术后康复等提供了相关的理论依据.     

Chronic wrist pain: evaluation with high-resolution MR imaging

The diagnostic performance of magnetic resonance (MR) imaging in the evaluation of the triangular fibrocartilage complex and the intrinsic and extrinsic ligaments of the wrist was assessed in 43 patients with chronic wrist pain. Forty-one patients underwent correlative arthrography. Twenty-three patients underwent arthroscopy or arthrotomy or both. The normal anatomy of the triangular fibrocartilage and the intrinsic and extrinsic ligaments could be demonstrated effectively with MR imaging. MR imaging was effective in the evaluation of triangular fibrocartilage tears with a sensitivity of 1.0, a specificity of 0.93, and an accuracy of 0.95 when compared with arthrography; 0.89, 0.92, and 0.90, respectively, when compared with arthroscopy and arthrotomy. MR imaging could also be used effectively to evaluate tears of the intercarpal ligaments, particularly the scapholunate ligament. Disruptions of the extrinsic ligaments, articular cartilage defects, and subluxations of the distal radioulnar joint were also well demonstrated. MR imaging is an effective procedure in assessing patients with chronic wrist pain.     

The clinical efficacy of triple-injection wrist arthrography

Triple-injection wrist arthrography has been demonstrated to increase the likelihood that all the ligamentous perforations in an injured wrist will be diagnosed. However, compared with imaging after single injection of contrast material into the radiocarpal joint, triple-injection arthrography not only increases patient expense but also significantly increases the time required of both patients and arthrographers to obtain the diagnosis. With the goal of decreasing the number of triple injections, the author reviewed 50 consecutive triple-injection wrist arthrograms. Using a technique based on high-volume injection of contrast material to achieve complete distention of the joint, the author achieved a false-negative rate for demonstration of complete perforations with radiocarpal injection alone of only 2% (10% if partial perforations were included). In none of these cases was patient treatment altered by the additional information provided by the second and third injections. This false-negative rate is significantly lower than that reported previously and raises the question of whether there are circumstances in which the easier and less time-consuming single radiocarpal injection might be appropriate.     

Evaluation of lesions of the internal ligaments of the wrist; conventional magnetic resonance imaging versus MR arthrography (MRA)

Objective

The aim of this study is to assess the diagnostic value of direct MR arthrography compared to conventional MR imaging in the diagnosis of different pathologic entities affecting the internal ligaments of the wrist mainly the scapholunate and lunotriquetral ligaments.

Subjects and methods

This study included 51 patients complaining of chronic wrist pain. Conventional MRI and MR arthrography (MRA) were done in all cases.

Results

A comparison of the sensitivity of conventional MRI versus MRA was done by correlating the final diagnosis of each modality with the results of arthroscopy. Regarding complete SLL tears, MRI revealed a SEN, SPE and ACC of 61.54%, 96.77%, and 86.36%, while MRA showed a SEN, SPE and ACC of 92.31%, 100%, and 97.73% respectively, partial SLL tears, un-enhanced MRI revealed SEN, SPE and ACC of 10%, 94.12%, and 75%, while MRA showed 66.67%, 85.71%, and 81.82% respectively, complete LTL tears un-enhanced MRI revealed a SEN, SPE, and ACC of 25%, 100%, and 79.5% respectively, while MRA showed 91.67%, 100%, and 97.73% respectively.

Conclusion

MR arthrography is a potent additional tool facilitating the diagnosis of different pathologic entities affecting the major internal ligaments of the wrist joint and helps to reduce arthroscopic interventions.     

Virtual MR arthroscopy of the wrist joint: a new intraarticular perspective

Objective The aim of this study is to investigate whether virtual MR arthroscopy could be used to visualize the internal architecture of the radiocarpal compartment of the wrist joint in comparison to surgical arthroscopy.Design Diluted paramagnetic contrast material was injected into the radiocarpal compartment prior to MR examination in all patients. A fat-suppressed T1-weighted three-dimensional fast spoiled gradient echo sequence was acquired in addition to our standard MR imaging protocol in each patient. Three-dimensional data sets were then transferred to an independent workstation and were postprocessed using navigator software to generate surface rendered virtual MR arthroscopic images.Patients Nineteen patients referred for chronic ulnar-sided wrist pain were evaluated with conventional MR arthrography prospectively.Results and Conclusion Virtual MR arthroscopic images demonstrating the triangular fibrocartilage complex (TFCC) in an intraarticular perspective were achieved in 12 out of 19 patients. Our preliminary investigation suggests that although it has several limitations, virtual MR arthroscopy shows promise in visualizing the TFCC from an intraarticular perspective.     

Digital subtraction wrist arthrography: use of double contrast technique as a supplement to single contrast arthrography

A new technique using double contrast after digital subtraction wrist arthrography is presented. Results of the double contrast wrist arthrograms were essential to the diagnosis, confirmed the diagnosis, or salvaged an otherwise poor or nondiagnostic examination. It was found that intra-articular injection of air augments the information obtained during postarthrogram active motion studies under fluoroscopy. Double contrast wrist arthrography has proved valuable when the standard contrast arthrogram fails to yield diagnostic information.