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.     

Magnetic resonance imaging of thehand and wrist

The application of magnetic resonance imaging (MRI) to the hand and wrist has lagged behind its use in larger joints. Recent advances in hardware and software technology have allowed faster imaging with excellent anatomic resolution. After routine radiography, MRI is the imaging procedure of choice for evaluation of chronic wrist pain. The most common indications for MRI within the hand and wrist include scapholunate-lunate ligament tears, triangular fibrocartilage complex (TFCC) tears, avascular necrosis, and soft tissue masses. MRI may occasionally help evaluate tendon abnormalities, atypical or postoperative recurrent carpal tunnel syndrome, and complications of inflammatory arthritides. Future applications of MRI will likely include improved anatomic imaging of smaller structures such as the lunatotriquetral ligament and the extrinsic ligaments, as well as MR angiography (MRA).     

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.     

MRI of the wrist

In the past, the diagnostic imaging algorithm for evaluating the painful wrist included initial plain radiographic examination followed by arthrography, tomography, bone scintigraphy, or computed tomography. In recent years, magnetic resonance imaging (MRI) has been proven efficacious for diagnosing a number of maladies of the bones, ligaments, and soft tissues. MRI can be of aid in evaluation of carpal instability, disorders of the triangular fibrocartilage, ulnar impaction syndrome, distal radioulnar joint (DRUJ) instability, fracture, avascular necrosis (AVN), tendinopathy, nerve entrapment syndromes, synovial abnormalities, and soft tissue masses.     

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.     

Current status of magnetic resonance imaging of the wrist.

Conventional imaging of the wrist has relied heavily on plain radiography, tomography, fluoroscopy and arthrography. More recently, computed tomography and magnetic resonance imaging (MRI) have been added to this armamentarium. In this article the authors review the normal anatomy of the wrist and demonstrate a variety of pathologic conditions that can be assessed with MRI, including avascular necrosis and tears of the intrinsic and the extrinsic ligaments and the triangular fibrocartilage. MRI of the wrist is still evolving rapidly, and its place in the work-up of wrist disorders is only now being defined.     

99mTc-MIBI characterization of breast microcalcifications. Correlations with scintigraphic and histopathologic findings

PURPOSE: To investigate the clinical role of Magnetic Resonance Arthrography (MRA) of the wrist in subjects with chronic pain. MATERIAL AND METHODS: Thirty-five patients complaining of wrist pain for more 6 months were submitted to MRI and MRA. All patients received an intra-articular (monocompartment radiocarpal joint) injection of 2-10 mL of a 10 mmol saline solution of Gd-DPTA. Two radiologists independently evaluated the conspicuity of the intrinsic intercarpal ligaments and of the triangular fibrocartilage complex and expressed it on a 3-grade semiquantitative scale. On MRI images, complete visualization of the two structures was graded as 0, partial visualization as 1 and no visualization as 2. On MRA images, no contrast agent passage through the ligament or the complex was graded as 0, minimal passage as 1 and complete passage as 2. Sixteen patients had surgical confirmation (arthroscopy in 10 and open surgery in 6 patients). RESULTS: On MRI images the scapholunate ligament was completely visualized in 7 patients (21%) and partially or not visualized in 28 patients (89%). MRA images showed an intact ligament in 15 cases (44%) and a partial or total tear in 20 cases (48% and 8% respectively, 56% in all). On MRI images the luno-pyramidal ligament was completely visualized in 6 patients (18%) and partially or not visualized in 29 cases (82%). On MRA images the luno-pyramidal ligament was intact in 21 cases (58%) and had a partial or total tear in 14 cases (27% and 15% respectively, 42% in all). On MRI images the triangular fibrocartilage complex was normal in 27 cases (76%) and it was only partially visualized in 8 cases (24%). On MRA images the triangular fibrocartilage complex was normal in 13 cases (37%) and had a partial injury in 22 cases (63%). There were no severe side-effects to contrast agent injection, nor severe complications. The overall diagnostic accuracy rates of MRI and MRA were 40% and 81% respectively, with sensitivity and specificity of 63% and 39% (MRI) and of 82% and 79% (MRA). CONCLUSIONS: Compared with MRI, MRA can be considered a useful tool for the visualization of interosseous carpal ligaments and of the triangular fibrocartilage complex. MRA also helps detect injuries in these structures.     

Cross-sectional imaging of internal derangement of the wrist with arthroscopic correlation

Wrist arthroscopy has become an indispensable tool for the surgeon treating internal derangement of the wrist. The role of arthroscopy in both the diagnosis and treatment of intrinsic ligaments and triangular fibrocartilage complex (TFCC) pathology is well established. Arthroscopy remains a surgical procedure with potential complications, and it does not obviate the need for a careful history, physical examination, and conventional radiography. When the diagnosis remains unclear after these initial investigations, cross-sectional imaging studies play a valuable role in the assessment of internal derangement of the wrist. These studies include magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and computed tomography arthrography (CTA), the choice of which depends on the specific clinical query. The radiologist must have exact knowledge of the performance of each diagnostic test to select the appropriate one and interpret it in a clinically relevant manner. With continued refinements in the technological aspects of cross-sectional imaging, its potential to replace diagnostic arthroscopy will surely be realized in the near future. This article focuses on the role of cross-sectional imaging and arthroscopy in the evaluation and management of wrist internal derangement, namely of intrinsic ligaments and TFCC pathology.     

Is a subset of wrist ganglia the sequela of internal derangements of the wrist joint? MR imaging findings.

PURPOSE: To determine if there is an association between wrist ganglia and internal derangements of the wrist joint by reviewing magnetic resonance (MR) images. MATERIALS AND METHODS: Two observers retrospectively reviewed MR images of the wrist obtained in 625 patients at 1.5 T for the presence of ganglia and associated triangular fibrocartilage complex, scapholunate ligamentous, or lunotriquetral ligamentous tears that were within 3 mm of the ganglion. When available, surgery and/or pathology records were reviewed. RESULTS: There were 122 ganglia and 37 internal derangements. Of the 22 ulnar-sided ganglia, 10 (45%) demonstrated associated triangular fibrocartilage complex tears. Of the 97 radial-sided ganglia, 27 (28%) demonstrated ligamentous tears related to the site of the ganglion. The radial-sided tears involved the radial aspect of the triangular fibrocartilage complex in 12 ganglia; the scapholunate ligament, in isolation, in eight ganglia; and both the triangular fibrocartilage complex and the scapholunate ligament in six ganglia. Only one of the ganglia demonstrated an associated lunotriquetral ligamentous tear. Surgical findings confirmed the ligamentous tears in 25 patients. CONCLUSION: Wrist ganglia are associated, not infrequently, with internal derangements of the wrist.     

MRI of the wrist joint]

Due to the development of new surface coils and the use of thin slices, MRI has become an essential diagnostic tool in wrist pathology. After several technical considerations, the authors describe the normal MRI appearance of the various anatomical structures of the wrist, particularly the triangular fibrocartilaginous complex of the wrist and the elements of the carpal tunnel. They review the principal indications for MRI: chronic diseases such as carpal tunnel syndrome and traumatic ligamentous and cartilaginous lesions. The bone marrow lesions detected in the presence of occult fractures and osteonecrosis of the lunate or scaphoid are then briefly considered. The diagnostic criteria of median nerve compression (carpal tunnel syndrome) include morphological and signal changes in the nerve, abnormal palmar convexity of the flexor retinaculum and signs of tenosynovitis of the intracarpal flexor tendons. However, in practice, MRI is only useful when there is disagreement between the clinical and EMG findings and in postoperative recurrences, in which case it may reveal insufficient section of the retinaculum or the presence of exuberant postoperative fibrosis responsible for persistent nerve compression. Traumatic tears of the triangular fibrocartilage are characterised by a linear high signal intensity image (on T1 and T2 weighted sequences), usually situated in the periphery of the articular disk. Degenerative lesions tend to be central, within the disk and are frequently observed after the age of 40 years.     

3-Tesla imaging of the wrist and hand: techniques and applications

MR imaging of the wrist is complicated by its size and small critical ligamentous structures, such as the triangular fibrocartilage complex, intrinsic and extrinsic radiocarpal ligaments. 3-T magnetic resonance (MR) imaging with its nearly linear increase in signal-to-noise ratio allows for imaging the wrist with small fields of view and high spatial resolution, which in turn has potential to improve visualization of these small ligaments. Dedicated radiofrequency coils and appropriate imaging tools are required to optimize the potential of high field imaging of the wrist. Early results suggest improvement in diagnostic accuracy for the wrist when compared with 1.5 T in small studies; as larger series are acquired this will certainly become more evident. As experience with 3 T for the wrist and hand grows, it is becoming clear that it is the new standard for MR imaging of these small joints.     

A comparison of arthrography and magnetic resonance tomography in painful limited movements of the hand

In 18 patients with unclear pain in the wrist limiting hand movement, arthrography and magnetic resonance imaging (MRI) were compared. The FISP gradient echo sequence turned out to be superior to the T1 weighted spin-echo sequence in the imaging of the triangular fibrocartilage complex. MRI is very sensitive in detecting triangular fibrocartilage lesions and therefore represents a suitable non-invasive screening method. It is, however, not possible to assess the degree of the lesion. Ruptures in carpal tendons could only be diagnosed by means of arthrography.     

腕关节的MR成像研究

目的探讨不同ＭＲ成像序列与方法在腕关节检查中的应用价值。材料与方法选取１６位健康志愿受试者的腕关节为研究对象,年龄２４～３５岁,对五种不同ＭＲ成像序列包括Ｔ。Ｗ１、ＰＤＷＩ、Ｔ２ＷＩ、ＳＴＩＲ和３Ｄ—ＧＥ及横断面、冠状面与矢状面三种成像平面进行研究。结果Ｔ１ＷＩ可以提供最佳解剖结构的细节,而Ｔ２ＷＩ可以很好地区分肿块、液体及软组织结构。ＳＴＩＲ成像有利于观察腕骨间韧带及三角纤维软骨（ＴＦＣ）结构。３Ｄ－ＧＥ成像可作连续薄层扫描,具有高信噪比、高分辨率、良好的组织对比及成像时间短等优点。横断面图像很好地显示腕管的结构;冠状面图像显示腕骨及腕骨间的相互关系、腕骨间韧带、ＴＦＣ及尺桡骨下端结构;矢状面图像可显示月骨、桡骨及头状骨间的相互关系及掌侧和背侧桡腕韧带。扫描时使用表面线圈,小ＦＯＶ,薄层可获得理想的ＭＲ图像。结论不同的ＭＲ序列及检查平面对腕关节不同组织的显示各具特异性。     

Pathology of extrinsic ligaments: a pictorial essay

The role of the extrinsic ligaments, together with the intrinsic ligaments, appears to be much more important than previously thought in the setting of carpal stability. The anatomy and pathology of the extrinsic wrist ligaments is complex. Magnetic resonance imaging (MRI) with thin slices is essential for visualization. This article describes the pathological appearance of the extrinsic palmar and dorsal radiocarpal and ulnocarpal ligaments on MRI, correlated with arthroscopy (performed by two skilled hand surgeons), clinical findings, and follow-up. High-resolution MRI, especially using isotropic three-dimensional sequences with orthogonal multiplanar reconstructions on 3T MR systems, allows detailed depiction of many of the extrinsic ligaments affected in carpal injuries. Recognition of ligament abnormalities is improved by intra-articular or intravenous injection of contrast before the examination. Both techniques may help to determine the precise localization, size, and extent of dorsal and palmar radiocarpal and ulnocarpal ligament lesions. Further experience with these techniques is needed to define the place of MRI in the management of traumatic wrist injuries.     

High-resolution outpatient imaging of the wrist

The authors describe their experience with magnetic resonance imaging (MRI) in the evaluation of pathologic conditions of the wrist in an outpatient setting. In that setting, because time and quality are both important factors, they have concentrated on developing protocols that will allow effective, time-efficient, high-resolution MRI of the wrist. With these wrist imaging protocols, they have evaluated the majority of commonly encountered pathologic conditions of the wrist. They have found that high-resolution images, which can be acquired in a very timely fashion when fast spin echo sequences are used in imaging protocols, will demonstrate the most common pathologic conditions, including triangular fibrocartilage and ligament tears in the wrist. They present the practical issues of patient position and imaging sequences as well as the imaging findings in those pathologic conditions.     

Is MR better than arthrography for evaluating the ligaments of the wrist? In vitro study

The purpose of this study was to determine the relative merits of MR imaging and three-compartment digital arthrography in the assessment of carpal ligaments in vitro. We performed MR imaging and arthrography in 10 normal wrists of fresh cadavers ranging in age from 48 to 71 years, and compared the appearance of the interosseous ligaments and triangular fibrocartilage complex with findings on anatomic sections of the joints. In six of the specimens, relatively T1-weighted MR images, 800/20 (TR/TE), preceded three-compartment digital arthrography performed with standard contrast material. In the other four specimens, arthrography, using an MR solution of iodinated contrast material mixed with cupric sulfate and gelatin, was performed before MR imaging. This was done to mimic the intraarticular fluid that might be seen in an injured wrist. MR allowed accurate assessment of the triangular fibrocartilage complex and scapholunate ligament in eight of 10 cases. Consistent MR visualization of the lunotriquetral ligament was difficult. Three-compartment digital arthrography allowed accurate assessment of the triangular fibrocartilage complex and scapholunate and lunotriquetral ligaments in all 10 cases. We concluded that MR is useful but inferior to arthrography in the evaluation of interosseous ligaments and the triangular fibrocartilage complex.     

Internal derangement of the wrist: indirect MR arthrography versus unenhanced MR imaging

PURPOSE: To compare indirect magnetic resonance (MR) arthrography with unenhanced MR imaging of the wrist for evaluation of the central disk of the triangular fibrocartilage complex (TFCC) and the scapholunate and lunotriquetral interosseous ligaments. MATERIALS AND METHODS: Eighty-six wrists were evaluated at MR imaging (41 indirect MR arthrography and 45 unenhanced MR imaging examinations). Three musculoskeletal radiologists independently evaluated the central disk of the TFCC and scapholunate and lunotriquetral ligaments and compared the results with those of wrist arthroscopy. Sensitivity and specificity were calculated for each of the readers, and the means were obtained. Sensitivities and specificities were compared with the Student t test. RESULTS: Thirty-three tears of the central disk of the TFCC and 13 scapholunate and 18 lunotriquetral ligament tears were identified at arthroscopy. Sensitivities and specificities were 54%-73% and 83%-91%, respectively, in the evaluation of the central disk of the TFCC, with no significant difference between indirect MR arthrography (P =.666) and unenhanced MR imaging (P =.559). Sensitivities and specificities in the evaluation of the scapholunate ligament were 38%-69% and 75%-99%, respectively, with a significant improvement in sensitivity at indirect MR arthrography (P =.017) and no significant difference in specificity (P =.876). Sensitivities in the evaluation of the lunotriquetral ligament were poor, 0%-22%, though the specificities were 88%-99%, with no significant difference between indirect MR arthrography and unenhanced MR imaging (P =.592 and P =.354, respectively, for sensitivity and specificity. CONCLUSION: Indirect MR arthrography significantly improves sensitivity in the evaluation of the scapholunate ligament when compared with unenhanced MR imaging of the wrist but does not significantly improve the ability to evaluate the central disk of the TFCC or the lunotriquetral ligament.     

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.     

Diagnostic wrist arthroscopy

Wrist arthroscopy has become an essential tool for the hand and upper extremity surgeon. It is useful in diagnosing and/or staging a wide range of conditions of the wrist, including cartilage injury, early arthritis, ligament injury, and triangular fibrocartilage complex tears. It can be of great benefit in evaluating wrist pain of unclear cause when imaging studies fail to elucidate the disease. In the hands of an experienced arthroscopist, it can be a more accurate diagnostic tool than studies such as magnetic resonance imaging or arthrography. The rate of complications is very low if proper attention is paid to details. Familiarity with the equipment, thorough knowledge of the anatomy, and development of a systematic approach are all critically essential for a surgeon performing arthroscopy of the wrist. The surgeon must also know when arthroscopy does not provide sufficient access to the wrist and an arthrotomy should be performed.     

MR imaging of the wrist: comparison between 1.5- and 3-T MR imaging--preliminary experience

Institutional review board approval and informed consent were obtained from 25 healthy volunteers and 15 consecutive patients with chronic wrist pain or suspected carpal mass, and 1.5- and 3-T magnetic resonance (MR) imaging of the wrist was prospectively performed with comparable sequence parameters and surface coils of the same geometric design. Imaging protocols at both field strengths included a T1-weighted spin-echo sequence, two intermediate-weighted fast SE sequences with different echo times and with and without fat saturation, and a three-dimensional fast field-echo sequence. The contrast-to-noise ratio (CNR) between muscle and bone and between bone and cartilage was calculated for both field strengths. The visibility of various anatomic structures, including the triangular fibrocartilage complex, carpal ligaments, nerves, and cartilage, was analyzed with a four-point grading scale. CNRs were significantly higher on 3-T MR images than on 1.5-T MR images (P < .001; analysis of variance) for all sequences. Visibility of the triangular fibrocartilage complex and intercarpal ligaments and cartilage was significantly better on 3-T MR images than on 1.5-T MR images (paired sign test).