Arthrography of the wrist]

The procedure, followed by the normal radiological anatomy of the various joint compartments of the wrist are described. The main indications (especially post-traumatic indications) and abnormal findings are then investigated.     

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.     

Arthrography of the ankle joint in chronic instability

Papers on arthrography of injuries of the lateral ligaments of the ankle relate mainly to recent distortion of the joint. Arthrography performed at a later stage after injury generally is considered useless. In fact, changes in chronic instability are observed; they are subtle and consist either of small recesses adjacent to the lateral malleolus or communication of the joint with the peroneal tendon sheaths. Arthrography was assessed in 61 cases of recurrent lateral sprains of the ankle more than 2 weeks after acute injury; 38 were considered as positive. Twenty-five patients had operative evaluation, with four false negative and one false positive results. Small recesses adjacent to the lateral malleolus or opacification of the peroneal tendon sheaths are sequelae of an acute sprain with tear of the anterior talofibular and/or the calcaneofibular ligaments. Although false negative results occur, arthrography is useful in the preoperative assessment of chronic ankle instability.     

Anterior oblique projection in radiography of the traumatized shoulder

A series of 132 consecutive shoulder radiographs of traumatized patients was analyzed prospectively. Each shoulder examination included anteroposterior projections with external and internal rotation of the humerus and an anterior oblique projection. Each view was evaluated for the abnormalities that were identifiable on it. There were 84 normal examinations and 48 abnormal examinations. There were 29 fractures, dislocations, or acromioclavicular separations identified. Two fractures of the greater tuberosity were seen only on the anteroposterior projection with external rotation. One humeral head fracture and three scapular fractures were visualized only on the anterior oblique projection.     

Arthrography of the post-traumatic knee, shoulder, and wrist. Current status and future trends

The current status of arthrography of the wrist, knee, and shoulder has been discussed with particular emphasis given to those conditions seen in patients following acute or chronic trauma. Cross-sectional techniques that impact on the current usage of arthrography of these joints also were discussed. Wrist arthrography remains the standard procedure for the evaluation of ligamentous abnormalities about the wrist. MR imaging is unlikely to make a large impact in this area until improvements in technique and surface coil technology allow routine visualization of the very small, but important, interosseous ligaments. MR imaging of the knee will likely replace arthrography except in those cases in which cost considerations or availability prevent its implementation. MR imaging undoubtedly will continue to contribute to the evaluation of shoulder abnormalities, but whether or not it will completely replace standard arthrography and CT arthrography depends upon the results of future studies.     

Positioning of the wrist for scaphoid radiography

PURPOSE: The purpose of this cadaver study was to determine the ideal position of the wrist for scaphoid radiography. MATERIALS AND METHODS: Four cadaver wrists were rotated around their longitudinal axis in 15 degrees increments and exposures were taken. Seven postero-anterior images were taken as well. Thus, 18 images of each wrist were available for assessment. Views were determined in which the main anatomic regions of the scaphoid were visualized undistorted. The size and localization of the overlap of other carpal bones were also evaluated. Finally, views with the best visualization of anatomic landmarks were selected. The results of these three investigations were compared to literature data. RESULTS: We consider the following four images the most valuable in the diagnostic imaging of scaphoid bone: (1) Postero-anterior view in ulnar deviation of wrist and fist position of the hand; (2) oblique view in 60 degrees of pronation; (3) oblique view in 60 degrees of supination; (4) lateral view. CONCLUSION: We concluded that our four views are sufficient for proper radiographic evaluation of the scaphoid.     

The carpal ligaments in MR arthrography of the wrist: correlation with standard MRI and wrist arthroscopy

We assessed the value of three-compartment magnetic resonance (MR) wrist arthrography in comparison with non-enhanced magnetic resonance imaging (MRI) for the evaluation of 13 individual wrist ligaments in 35 patients with refractory wrist pain. In 20 of these patients MR findings were correlated with the findings from multiportal wrist arthroscopy. For MR imaging (1.5-T magnet) a three-dimensional volume acquisition with a gradient-recalled echo sequence and 0.6-1.0 mm effective slice thickness was used. The delineation of individual wrist ligaments was rated as "good" in 10% of non-enhanced MR and 90% of MR arthrography images. Ligament evaluation was possible with high diagnostic confidence in 11% by non-enhanced MR imaging and 90% by MR arthrography. With wrist arthroscopy as the standard of reference, average sensitivities/specificities/accuracies for the diagnosis of full-thickness ligamentous defects were 0.81/0.75/0.77 for non-enhanced MR imaging and 0.97/0.96/0.96 for MR arthrography. Our findings suggest that MR arthrography is more accurate than standard MRI in delineating and evaluating the ligaments of the wrist.     

Arthrography of the wrist: procedures and normal results (author's transl)]

The results of 31 opaque arthrographies of the wrist carried out under two different circumstances are reported. --In a first group the investigation was made immediately after or within a longer period following injury to the wrist or forearm. The results supply information to the surgeon on the condition of the triangular ligament in dislocation and partial dislocations of the inferior radioulnar joint, caused by an architectural fault in the radius after trauma (fracture of the head, diaphysis, or lower extremity). Simple reduction of the radius, without intervention on the inferior radio-ulnar joint, provides an excellent functional result when the triangular ligament is simply stretched. When it is torn (sprains, dislocation locally or at a distance) results are not very convincing in spite of the many possible procedures available. Arthrography easily reveals the presence of a reflex dystrophy complicating the injury. Both the radiological and clinical signs give characteristic pictures of the condition. --This examination is still only used infrequently for the diagnosis of chronic inflammatory rheumatic diseases. The arthrographic images appear very early, however, and are characteristic of an inflammatory synovial lesion. Examinations were carried out mainly for evaluation before therapy, surgical in the case of a synovectomy, medical for a chemical or isotopic synovial treatment. Arthrography in a acutely inflammed joint is followed by an injection of corticoid, sometimes associated with a local antibiotic. This rapidly relieves the patient and prevents worsening of the acute inflammatory process. Arthrography of the wrist is a simple, painless, rapidly performed examination. There has never been a failure, any incident, or accident. It appears to be the only direct exploratory procedure for this joint. A precise anatomical evaluation can be made from the image which gives a true picture of the different anatomical structures.     

High-resolution computed tomography of the wrist in patients with carpal tunnel syndrome

High resolution computed tomography (CT) was used to scan the wrists of 19 patients with idiopathic carpal tunnel syndrome. Thirteen normal volunteers were used as controls. Measurements obtained from the CT images included the cross-sectional area of the carpal tunnel, the relative amount of synovium within the carpal tunnel, the attenuation coefficient of the carpal tunnel, and the thickness of the transverse carpal ligament. No significant difference in any of these measurements was found when comparing the wrists of symptomatic patients with controls. High resolution CT of the wrist does not appear to be of value in the preoperative evaluation of patients with idiopathic carpal tunnel syndrome.     

Direct digital radiography versus storage phosphor radiography in the detection of wrist fractures

AIM: To define the value of digital radiography with a clinical flat panel detector system for evaluation of wrist fractures in comparison with state of the art storage phosphor radiography. MATERIAL AND METHODS: Hard copy images of 26 fractured wrist specimens were acquired with the same exposure dose on a state of the art storage phosphor radiography system and a clinical flat panel detector. Image features like cortical bone surface, trabecular bone, soft tissues and fracture delineation were independently analysed by 4 observers using a standardised protocol. Image quality ratings were evaluated with an analysis of variance (ANOVA). RESULTS: Flat panel detector radiographs were rated superior with respect to cortical and trabecular bone representation as well as fracture evaluation, while storage phosphor radiographs produced better soft tissue detail. CONCLUSION: In some of the observed image quality aspects, the performance of caesium iodide/amorphous silicon flat panel detector exceeds state of the art storage phosphor radiography. This makes it well suited for skeletal imaging particularly in trauma as seen in the detection of wrist fractures.     

Streamlining emergent hand and wrist radiography with a modified four-view protocol

This study aims to determine whether a modified four-view hand and wrist study performs comparably to the traditional seven views in the evaluation of acute hand and wrist fractures. This retrospective study was approved by the institutional review board with waiver of informed consent. Two hundred forty patients (50 % male; ages 18–92 years) with unilateral three-view hand (posteroanterior, oblique, and lateral) and four-view wrist (posteroanterior, oblique, lateral, and ulnar deviation) radiographs obtained concurrently following trauma were included in this study. Four emergency radiologists interpreted the original seven images, with two radiologists independently evaluating each study. The patients’ radiographs were then recombined into four-view series using the three hand images and the ulnar deviated wrist image. These were interpreted by the same radiologists following an 8-week delay. Kappa statistics were generated to measure inter-observer and inter-method agreement. Generalized linear mixed model analysis was performed between the seven- and four-view methods. Of the 480 reports generated in each of the seven- and four-view image sets, 142 (29.6 %) of the seven-view and 126 (26.2 %) of the four-view reports conveyed certain or suspected acute osseous findings. Average inter-observer kappa coefficients were 0.7845 and 0.8261 for the seven- and four-view protocols, respectively. The average inter-method kappa was 0.823. The odds ratio of diagnosing injury using the four-view compared to the seven-view algorithm was 0.69 (CI 0.45–1.06, P?=?0.0873). The modified four-view hand and wrist radiographic series produces diagnostic results comparable to the traditional seven views for acute fracture evaluation.     

Conventional diagnosis of carpal luxation and instability

The recognition of ligament disruption in carpal dislocation and the early diagnosis of carpal instability have had implications for the therapy since the evolution of differentiated surgical treatment concepts including ligament reconstruction. Plain radiography and the carpal instability series are helpful in the detection of ligament disruption. The radiological analysis is based on the configuration and arrangement of the carpals, the setting of their axes, and the detection of intercarpal gaps. Mechanisms and characteristic radiological findings in the different types of carpal dislocation and instability (scapholunate dissociation, palmar or dorsal intercalated segment instability) are demonstrated in relation to physiological appearance, and the value of conventional films in the diagnosis of carpal dislocation and instability is discussed.     

Idiopathic carpal tunnel syndrome (ICTS): Correlation between nerve conduction studies and dynamic wrist ultrasonography

Purpose

To evaluate accuracy of ultrasound in assessment of the dynamic wrist movements upon the median nerve for cases of idiopathic carpal tunnel syndrome.

Fluoroscopic and arthrographic evaluation of carpal instability

The efficacy of a diagnostic protocol involving videotape fluoroscopy of carpal motion and radiocarpal arthrography was evaluated in patients with wrist pain unexplained by physical examination and conventional radiographs. Videotape fluoroscopy was performed as the first study in 68 consecutive cases and was positive in 44 (66%). Radiocarpal arthrography was performed after videotape fluoroscopy in 39 of the cases (57%), including the 24 in which videotape fluoroscopy was normal and 15 others in which further information was desired in spite of positive videotape fluoroscopy. The addition of radiocarpal arthrography to videotape fluoroscopy increased the diagnostic yield to 52 (76%) of the 68 cases and excluded significant anatomic or dynamic abnormality in the others. The diagnosis was proven surgically in 25 cases. This protocol was efficacious for ligament tears of the proximal carpal row, triangular fibrocartilage tears, and proximal and midcarpal instability. Videotape fluoroscopy should be the primary method of evaluating patients with unexplained wrist pain, and arthrography should be done in those cases in which fluoroscopy is either normal or does not fully explain physical findings.