Distal radioulnar joint subluxation and dislocation diagnosed by standard roentgenography

The use of standard lateral roentgenography for diagnosing distal radioulnar joint (DRUJ) subluxation and dislocation was investigated. Using a wrist support, bilateral standard lateral roentgenograms of the wrist were obtained in 42 patients with normal wrists and in 56 patients with a unilateral wrist injury. In normal wrists the difference between the radioulnar distance in the right and the left wrist did not exceed 4 mm when the difference in the pisoscaphoid distance was less than 3 mm. Of the 36 patients with wrist injury whose difference in pisoscaphoid distance was less than 3 mm, 15 had a radioulnar distance of 5 mm or more, and computed tomography (CT) confirmed DRUJ dislocation in 14. Concordance between lateral roentgenograms and CT was present in 33 of 36 patients (92%). These results demonstrate the value of a standardized technique for bilateral lateral roentgenography in diagnosing DRUJ subluxation and dislocation.     

The navicular fat stripe: a useful roentgen feature for evaluating wrist trauma.

The navicular fat stripe (NFS) is a useful roentgenographic feature for evaluating traumatic wrist injury. A radiolucent stripe, cast by a thin collection of fat paralleling the lateral surface of the navicular bone, was seen in 96 percent of 400 normal wrists examined because of trauma. Obliteration or displacement of this line (positive NFS sign) is commonly present in acute fractures of the naviculum, radial styloid process, and proximal first metacarpus. A ositive NFS sign serves to alert the radiologist that an underlying fracture is likely. In particular, the NFS sign generally accompanies a navicular fracture.     

应用带骨间掌侧动脉背侧支血管蒂桡骨瓣治疗腕舟骨骨折不愈合

目的　探讨一种良好的治疗腕舟骨骨折不愈合的方法 ,丰富治疗腕舟骨骨折不愈合的手术方式。方法　切除腕舟骨骨折不愈合之硬化骨 ,以克氏针贯穿固定骨折端 ,用带骨间掌侧动脉背侧支血管蒂桡骨瓣翻转移植治疗腕舟骨骨折不愈合 15例。结果　术后随访 3～ 6个月 ,骨折完全愈合 ;9～ 18个月 ,腕关节活动正常无痛。结论　前臂间掌侧动脉背侧支解剖位置恒定 ,变异少 ,位置较表浅 ,血管蒂长、口径粗、游离安全容易 ,血供充分 ,能有效地促进舟骨骨折愈合。     

Wrist Injuries

The wrist is a complex joint and a common site for injury in virtually every type of recreational activity. This article describes a workup that will lay the groundwork for a diagnosis more specific than wrist sprain or strain. Instructions are given for taking a detailed history, palpating the five zones of the wrist, performing provocative maneuvers, giving diagnostic injections, and obtaining imaging studies. Plain x-rays of both wrists may be sufficient to diagnose a fracture or subluxation, but if x-rays are negative and a fracture is still suspected, other imaging studies may be needed. Diagnosis and management of wrist injuries will be described in part 2.     

Multiple occult wrist bone injuries and joint effusions: prevalence and distribution on MRI

This study aims (1) to assess the prevalence and distribution of multiple occult injuries of the carpal bones and the distal forearm in patients with wrist pain and negative radiographs following trauma and (2) to evaluate the distribution and significance of joint effusions in the wrists with multiple osseous injuries. One hundred and thirty-one subjects, 74 men and 57 women, were consecutively examined in two institutions. All were acute trauma patients with negative X-rays whose clinical examination suggested possible fracture at the wrist or the distal forearm. Magnetic resonance (MR) wrist imaging was performed with and without fat saturation sequences. The MR images were analysed for detection of occult trabecular contusions and cortical discontinuity in the carpus, the distal forearm and the metacarpal bases. The prevalence and distribution of the injuries were assessed along with the distribution of joint effusions. Eight patients were excluded due to inadequate image quality. Two patients had bilateral injury. A total of 125 wrists were analysed. Seventy-eight (62.4%) wrists had occult bone injuries. Among these 78, 53 (68%) wrists had more than one injured bone. Twenty-five wrists (32%) had one injured bone. The highest number of injured bones per wrist was six. Injuries with a visible fracture line were seen in 29 (37.1%) wrists on MRI. The distal radius was the most frequent location for occult fracture line (11 cases). The injuries without a fracture line (contusion) were present in 49 (63%) wrists; they were detected more frequently in the scaphoid (35 cases). The lunate (29 cases) and the triquetrum (26 cases) were almost equally affected. The bone that was less frequently injured was the pisiform (four cases). Joint effusions were present in all 53 wrists with multiple bone lesions but more often situated in the ulnocarpal space [27 (50.3%) wrists]. There was no correlation between effusions in multiple locations (grades III and IV) and multiple bone injuries. This study revealed the presence of multifocal trabecular contusions without correlation with increased joint effusions in patients with negative radiographs and persistent pain. The clinical significance of these findings deserves further investigation.     

Scapholunate ligamentous communicating defects in symptomatic and asymptomatic wrists: characteristics

PURPOSE: To determine whether the sizes and locations of scapholunate ligamentous communicating defects are different in symptomatic and asymptomatic cases. MATERIALS AND METHODS: Bilateral wrist arthrograms were reviewed for 30 consecutive patients with a history of wrist trauma and unilateral wrist pain who had at least one scapholunate ligamentous communicating defect and unremarkable conventional radiographs. The location and size of each ligamentous defect was recorded. Differences between symptomatic and asymptomatic wrists were analyzed with the chi(2) or Fisher exact test. RESULTS: Most communicating defects in both groups were incomplete and ranged from pinhole size to large. There was a higher frequency of complete disruption in the symptomatic wrists (nine [32%] of 28 wrists) than in the asymptomatic wrists (two [10%] of 20 wrists; P: =.092). Communicating defects involved the dorsal portion in 18 (64%) of the 28 symptomatic cases and in five (25%) of the 20 asymptomatic cases (P: =.007). CONCLUSION: The data suggest that the demonstration of a complete ligamentous disruption or involvement of the dorsal portion of the ligament may indicate a traumatic cause rather than a degenerative change.     

Scaphoid (navicular) fractures of the wrist in children: attention to the impacted buckle fracture

We retrospectively analyzed the radiographic findings in 76 patients with proven scaphoid (navicular) fractures. The purpose of the study was to determine the incidence of the impacted buckle fracture of the scaphoid bone in children. Fourteen of the 76 patients (17%) demonstrated such a fracture, and all of the fractures occurred in the middle or distal third of the scaphoid bone. The mean age of this group of patients was 13.7 years, as compared to the mean age of 15.6 years in the patients with overt transverse fractures. One out of 14 of the patients with a buckle fracture was female. None developed complicating aseptic necrosis. The fractures were most clearly visualized on AP and oblique views of the wrist, and all cases demonstrated edematous thickening of the soft tissues and/or navicular fat pad obliteration adjacent to the scaphoid bone. The use of comparative views was extremely helpful in the detection of this fracture. Electronic Publication     

Tarsal navicular relations in club foot: is there a role for magnetic resonance imaging?

Objective. To correlate radiographic and MR appearances with surgical findings to determine the accuracy of these modalities in demonstrating tarsal navicular (TN) relations in order to select the appropriate surgical intervention. Design and patients. Fourteen consecutive patients with 19 club feet had anteroposterior and lateral radiographs and magnetic resonance (MR) imaging performed. Blinded retrospective interpretation of these studies was correlated with surgical findings. Movement artifact was responsible for initial non-diagnostic MR scans in 3 out of 19 feet. Results. Plain radiographs and MR imaging had sensitivities of 79% and 84% respectively for TN subluxation, while both modalities had 100% positive predictive value for TN subluxation. Each modality produced indeterminate results in cases where subluxation was present at surgery, but in combination there were no false negatives. Conclusion. Radiography confidently predicted the TN alignment in the majority of cases. MR demonstrated TN relationships in all cases where radiography was indeterminate. It is proposed that MR has a potential role to demonstrate TN relationships when radiography is indeterminate or when there is disparity between the clinical and radiographic assessment.     

Clinical impact of MRI in acute wrist fractures

The purpose of this study was to evaluate the clinical impact of MRI in the early diagnosis of wrist trauma. High-resolution MR imaging was performed on a 1.5-T unit (Symphony Quantum, Siemens, Erlangen, Germany) using coronal and axial T1- and T2-weighted fat-saturated turbo-spin-echo sequence via a dedicated wrist coil within a mean of 6.6 days after initial radiographs in 54 patients (56 wrists) with clinical suspicion of wrist fractures and normal plain or indistinct radiographs. Initial radiographs were evaluated independently by two senior radiologists and the hand surgeon without knowledge of the MRI findings. The initial treatment protocol was based on evaluation of plain films and clinical findings by the hand surgeon. Treatment protocol was changed after MRI examination if necessary. In 31 of 56 wrists MRI findings resulted in a change of diagnosis. There were false-positive diagnoses on plain radiographs in nearly one half (n=25) of the patients. False-negative diagnoses on plain radiographs resulted in 6 cases. Magnetic resonance imaging detected additional injuries of soft tissue in more than one third (n=20). In 22 of 56 wrists the period of immobilization could be shortened or ended, in 12 of 56 it was prolonged, and in 3 of 56 a surgical intervention was necessary. In 19 wrists MRI had no therapeutic consequences. Our data demonstrate the high clinical impact of MRI in the detection of acute wrist fractures. We recommend MRI of the wrist immediately on the day of trauma if there is clinical suspicion and normal plain radiographs. Accurate diagnosis by MRI examination within the first days following trauma may reduce economic costs due to shortened immobilization time in cases with a suspected fracture but plain radiographs. Electronic Publication     

Carpal predominance in rheumatoid arthritis

Radiographic and clinical evaluation of the relative severity of wrist versus hand involvement in 101 patients with rheumatoid arthritis revealed more severe changes in the wrists in 60%, equal involvement in wrists and hands in 37%, and more severe changes in the hands in 3%. There were severe changes in the wrists but little or no bone or joint change in the metacarpophalangeal and proximal interphalangeal joints in 43 (21%) of the 202 extremities studied. Serial examinations showed that, in time, the hand changes tended to overtake those in the wrist. Appreciation of this progression of wrist and hand changes can help the physician avoid diagnostic difficulties in a significant percentage of patients.     

Arthrosis of the lunate-capitate joint

Arthrosis of the lunate-capitate (LC) joint was investigated in 44 wrists from 36 patients. The symptomatology was uncharacteristic and most patients were examined because of pain, swelling or decreased function of the wrist. The LC arthrosis seemed to be secondary to trauma in most patients; 26 wrists had an increased distance between the lunate and scaphoid, indicating a rotatory luxation of the scaphoid; 5 had fracture of the scaphoid with pseudarthrosis; one had a radius fracture healed with volar and ulnar compression and 2 had penetrating trauma to the LC joint. The arthrosis was secondary to pathologic changes in the lunate in 3 patients; lunatomalacia in 2 and a cyst fracturing into the LC joint in one. In 7 wrists arthrosis was found in several carpal joints and the LC arthrosis was one of these.     

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.     

Dorsal fracture of the hamate: distinctive radiographic appearance

Six patients who injured their wrists had radiographs documenting a dorsal, 5- to 10-mm oblong fragment of bone immediately proximal to the base of the fourth and/or fifth metacarpal bones. The fragment was seen on the pronation oblique and/or lateral projections, but not on the posteroanterior projection. The radiographic appearance of the fragment was remarkably similar in all cases. In the one patient in which it was performed, pluridirectional tomography demonstrated that the fragment originated from the dorsal surface of the hamate. Five of the six patients also had associated posterior dislocation of the fourth and/or fifth metacarpals. We conclude that this fragment represents a coronal fracture through the body of the hamate resulting from posterior dislocation or subluxation of the fourth and/or fifth metacarpal.     

Arthroscopic capsulodesis of the lunotriquetral joint

A case series consisting of 20 consecutive patients with persistent ulnar-sided mechanical wrist pain, lunotriquetral interosseous (LTIOL) ligament tears resulting in joint incongruity and increased laxity, and traumatic triangular fibrocartilage complex (TFCC) tears was reviewed. Each patient underwent an arthroscopic reduction and internal fixation (ARIF) of the lunotriquetral joint, arthroscopic disk-carpal (disklunate-ulnocapitate-disktriquetral, DL-UC-DT) ligament plication, and TFCC repair or débridement. There were 12 right wrists and 8 left wrists, of which 12 were dominant. The mean patient age was 33 years; 7 patients had workers' compensation claims and 2 had legal claims. Fourteen patients recalled a specific injury mechanism, such as hyperextension or rotation. The accompanying traumatic TFCC tears were peripheral in 15 and linear radial in 6 patients (one patient had concomitant peripheral and radial linear tears), and in 6 cases, the palmar ulnocarpal extrinsic ligaments were partially torn. The mean preoperative modified Mayo Wrist Score was 50, and at a mean of 3.1 years after surgery, the score had increased to 88. There were 13 excellent, 5 good, and 2 fair results. Four patients had complications, including transient tenderness along the extensor carpi ulnaris and persistent neuritis of a dorsal branch of the ulnar nerve. Overall wrist comfort and function, as indicated by the modified Mayo Wrist Scores, improved after arthroscopic stabilization of ulnar-sided wrist injuries (pinning of the lunotriquetral joint, disk-carpal ligament plication, and TFCC repair or débridement).     

Assessment of the position of the distal portion of the ulna in lateral projection radiographs of the wrist: analysis of the influence of pronation-supination and flexion-extension on the pisoscaphoid and the ulnotriquetral distances: a cadaver study

RATIONALE AND OBJECTIVES: Accurate assessment of the distal radioulnar joint is of paramount importance for the detection of possible dislocation or subluxation. Using a cadaveric model, the authors attempted to establish a quantitative method that would allow identification of normal and abnormal distal radioulnar joint anatomy on well-positioned and rotated conventional radiographs. METHODS: Four cadaveric wrists, in which subsequent sectioning confirmed the absence of disease, and one cadaveric wrist with a circumscribed lesion of the triangular fibrocartilaginous complex were studied. Defined movements in flexion and extension (+/- 10 degrees, 20 degrees, 30 degrees ) and in pronation and supination (+/- 10 degrees, 20 degrees, 30 degrees ) as well as combined flexion/extension and pronation/supination were performed. The ulnotriquetral and the pisoscaphoid distances were assessed in each position. Correlation with cryosections was achieved. RESULTS: A strong linear correlation between the degree of pronation or supination and the pisoscaphoid and ulnotriquetral distances was noted. Flexion and extension produced no significant effect on the pisoscaphoid distance, but a defined shift of the ulnotriquetral distance occurred with increasing flexion and extension. CONCLUSIONS: If all parameters are taken into account, this correlation aids in estimating the degree of possible malpositioning of the wrist during radiography and the degree of subluxation of the distal radioulnar joint. Tabular data with parameters to correct for instances of malrotated images and to estimate the extent of dislocation or malrotation of the distal radioulnar joint are provided.     

Detailed analysis of contrast-enhanced MRI of hands and wrists in patients with psoriatic arthritis

Objective The objective was to perform detailed analysis of the involved soft tissues, tendons, joints, and bones in the hands and wrists of patients with psoriatic arthritis (PsA). Materials and methods We reviewed 23 contrast-enhanced MR imaging studies (13 hands and 10 wrists) in 10 patients with the clinical diagnosis of PsA. We obtained clinical information from medical records and evaluated images for the presence of erosions, bone marrow edema, joint synovitis, tenosynovitis, carpal tunnel, and soft tissue involvement. Two board-certified musculoskeletal radiologists reviewed all images independently. Differences were resolved during a subsequent joint session. Results The average duration of disease was 71.3 months, ranging from 1 month to 25 years. Eight of the 10 wrists (80%) and 6 of the 13 hands demonstrated bone erosions. Bone marrow abnormalities were shown in 5 of the 10 wrists (50%) and 4 of the 14 hands (31%). Triangular fibrocartilage tears were seen in 6 of the 10 wrists (60%). Wrist and hand joint synovitis were present in all studies (67 wrist joints and 101 hand joints). Wrist soft tissue involvement was detected in 9 of the 10 wrists (90%) and hand soft tissue involvement was present in 12 of the 13 wrists (92%). Findings adjacent to the region of soft tissue involvement included synovitis (4 wrists) and tenosynovitis (3 wrists). Bone marrow edema adjacent to the region of soft tissue involvement was seen in one wrist. Bulge of the flexor retinaculum was seen in 4 of the 10 wrists (40%) and median nerve enhancement was seen in 8 of the 10 wrists (80%). Tenosynovitis was seen in all studies (all 10 of the hands and all 13 of the wrists). The “rheumatoid” type of distribution of bony lesions was common in our study. Interobserver agreement for various findings ranged from 83% to 100%. Conclusion Contrast-enhanced MRI unequivocally demonstrated bone marrow edema, erosions, tendon and soft-tissue disease, and median nerve involvement, with good interobserver reliability in patients with PsA of the hands and wrists. Disease was more extensive in the wrists than in the hands.     

Radiography of the wrist. A new device for standardized radiographs

A number of methods exist for determination of carpal bone angles on lateral wrist radiographs. However, there is no general or precise definition of the angles measured. In this study the positioning of the wrist is emphasized and a device used to obtain standardized radiographs is presented. An analysis of variance of two series of patients revealed no radiological difference between the contralateral wrists in the same person. We conclude that the asymptomatic wrist can be used as normal reference in the assessment of carpal bone angles in the pathological wrist and a difference between the carpal bone angles in the two wrists in the same person exceeding 5 degrees can be considered significant.     

Characteristics of triangular fibrocartilage defects in symptomatic and contralateral asymptomatic wrists

PURPOSE: To characterize triangular fibrocartilage (TFC) defects in symptomatic and contralateral asymptomatic wrists. MATERIALS AND METHODS: Communicating and noncommunicating defects of the TFC were depicted on bilateral wrist arthrograms in 56 patients with unilateral wrist pain and without associated lesions of the scapholunate or lunotriquetral ligaments. The exact location of each TFC lesion was noted. RESULTS: Communicating defects were noted in 36 (64%) of 56 symptomatic and in 26 (46%) of 56 asymptomatic wrists. Twenty-five (69%) of 36 communicating defects were bilateral. Except for one defect in each group of symptomatic and asymptomatic wrists, all communicating defects were noted radially. Noncommunicating defects were noted in 28 (50%) of 56 symptomatic wrists and in 15 (27%) of 56 asymptomatic wrists. Eleven (39%) of 28 noncommunicating defects were bilateral. On the symptomatic side, 28 of 36 noncommunicating defects (including eight multiple defects) were located proximally at the ulnar side. On the asymptomatic side, 11 of 17 noncommunicating defects (including two multiple defects) were at or near the ulna. CONCLUSION: Noncommunicating TFC defects, which typically are located on the proximal side of the TFC near its ulnar attachment, have a more reliable association with symptomatic wrists than do communicating defects. Radial-sided communicating defects described in the literature (Palmer type 1A and 1D) as posttraumatic commonly are seen bilaterally and in asymptomatic wrists.     

Stress views in the radiography of scapholunate instability

AIM: On the suspected carpal instabilities stress views are recommended but not often used. The present study evaluates the reliability of the dorsal and volar stress radiographs on patients with posttraumatic wrist pain. PATIENTS AND METHODS: Stress radiographs of the wrists were examined in 22 patients with chronic wrist pain and the results were compared with scaphoid shift test and standard and positional views. The stress examination consists of applying to the wrist dorsal and volar stresses on the hand. RESULTS: Static scapholunate instability was diagnosed in 4 patients in whom 3 of them had positive scaphoid shift test sign as well. There were, however, 18 patients with dynamic scapholunate instability in whom the standard films were normal but dorsal stress radiography showed gap greater than 3mm between the scaphoid and lunate. CONCLUSION: Stress tests may provide considerable information in the evaluation of a patient who has a painful wrist in whom routine and special views do not demonstrate scapholunate dissociation.