Ulnar-sided wrist pain. II. Clinical imaging and treatment

The "Bubble Test" in the Arthroscopic Diagnosis of Triangular Fibrocartilage Central Lesion: Description and Relevance to Treatment

Background  Ulnarly sided wrist pain is a common and challenging symptom. Arthroscopy has become a safe and effective tool for the correct diagnosis and treatment, proving to be better than all other clinical and imaging diagnostic methods. Some tests have been described for the diagnosis of triangular fibrocartilage (TFC) lesions, such as the trampoline test for peripheral lesions and the hook, ghost, and suction tests for foveal detachments. In tears at the disc level, when they affect all layers of the TFC (complete lesion) at the same point, testing with the probe will usually suffice for the diagnosis. However, in some apparently partial lesions, the probe cannot pass through all layers because the proximal and distal sites of the lesion are not aligned. There has been no arthroscopic test described for such cases. Case Description  We describe a simple and practical test that we have called the "bubble test" in a typical case to diagnose TFC central injuries, aiming to discriminate partial from complete lesions, which are eventually hard to differentiate through direct vision and arthroscopic probing, leading to a direct influence onto the treatment. The bubble test is performed with external compression of the distal radioulnar joint (DRUJ) aspect, with the thumb on the back of the DRUJ and the index and middle fingers onto the volar aspect. The abrupt compression of this region causes the passage of air mixed with synovial fluid from the DRUJ to the radiocarpal joint, generating bubble formation. Clinical Relevance  The bubble test should correlate to physical examination and imaging (magnetic resonance imaging [MRI]) findings and is particularly useful in central and degenerative (Type II) TFC lesions in patients complaining of chronic pain on the ulnar region of the wrist, with no history of trauma and with inconclusive MRI findings. Once the diagnosis is confirmed, arthroscopic treatment consists of wide debridement of the lesion with resection of the injured tissue and the local inflammatory reaction. Thus, it is essential for the correct treatment to define the exact location of the lesion and to know whether the disc injury is complete.

A scoping review to map evidence regarding key domains and questions in the management of non-traumatic wrist disorders

Introduction

Non-traumatic wrist disorders (NTWD) are commonly encountered yet sparse resources exist to aid management. This study aimed to produce a literature map regarding diagnosis, management, pathways of care and outcome measures for NTWDs in the United Kingdom.

Methods

An interdisciplinary team of clinicians and academic researchers used Joanna Briggs Institute guidelines and the PRISMA ScR checklist in this scoping review. A mixed stakeholder group of patients and healthcare professionals identified 16 questions of importance to which the literature was mapped. An a-priori search strategy of both published and non-published material from five electronic databases and grey literature resources identified records. Two reviewers independently screened records for inclusion using explicit eligibility criteria with oversight from a third. Data extraction through narrative synthesis, charting and summary was performed independently by two reviewers.

Results

Of 185 studies meeting eligibility criteria, diagnoses of wrist pain, De Quervain's syndrome and ulna-sided pain were encountered most frequently, with uncontrolled non-randomised trial or cohort study being the most frequently used methodology. Diagnostic methods used included subjective questioning, self-reported pain, palpation and special tests. Best practice guidelines were found from three sources for two NTWD conditions. Seventeen types of conservative management, and 20 different patient-reported outcome measures were suggested for NTWD.

Conclusion

Substantial gaps in evidence exist in all parts of the patient journey for NTWD when mapped against an analytic framework (AF). Opportunities exist for future rigorous primary studies to address these gaps and the preliminary concerns about the quality of the literature regarding NTWD.

Ulnar-Sided Wrist Pain: A Diagnostic Evaluation Guide From 30-Plus Years of Experience

INTRODUCTION

While multiple ulnar-sided wrist pain (USWP) diagnostic evaluation guides have been presented, none have included original clinical data or statistical analysis. The purpose of this study is to provide a diagnostic evaluation guide derived from original clinical data and analysis to help clinicians arrive at a differential diagnosis for USWP.

METHODS

Using a computer search of patients presenting with sprains, instability, and laxity of the wrist, 385 patient charts were identified. Patient demographics, mechanism of injury, subjective complaints, physical findings, and diagnostic test findings were reviewed. Statistical analysis was performed to determine sensitivity and specificity of diagnostic methods on their ability to identify lunotriquetral ligament tears, triangular fibrocartilage complex (TFCC) tears, and ulnar impaction syndrome. Diagnostic arthroscopy was used as the reference standard.

RESULTS

Ninety-three patients, comprising 101 cases of USWP, were included in the study. The onset of injury was traumatic in 83 out of 101 cases with motor vehicle accidents (N=46) being the most common, followed by overuse (N=18), and a fall onto an outstretched hand (N=16). The ulnocarpal tenderness test exhibited sensitivity/specificity of 72%/33%; lunotriquetral ligament laxity test of 42%/62%; bone scan of 80%/33%; radiocarpal arthrogram of 90%/98% for TFCC tears and 50%/91% for lunotriquetral ligament tears; midcarpal arthrogram of 82%/86% for lunotriquetral ligament tears. The mean ulnar variance on standard posteroanterior view radiograph was 0.95 mm, increasing to 2.67 mm on gripping posteroanterior view.

CONCLUSION

Physicians should suspect a lunotriquetral ligament and/or TFCC tear with the acute onset of USWP following a loaded dorsiflexed mechanism of injury. Ulnocarpal tenderness tests and pre-operative ulnar variance measures are effective for increasing suspicion of USW pathology. Bone scans are helpful in diagnosing ulnar impaction syndrome in conjunction with radiographic findings. A combination of midcarpal arthrogram for lunotriquetral ligament tears and radiocarpal arthrogram for TFCC tears should be employed.

Is ulnar shortening osteotomy effective for the treatment of ulnar styloid impaction syndrome compared to ulnar impaction syndrome?

PURPOSE

This study aimed at evaluating the outcomes of ulnar shortening osteotomy (USO) for the treatment of ulnar styloid impaction syndrome (USIS) and to compare them with those of USO for the treatment of ulnar impaction syndrome (UIS).

METHODS

We enrolled 144 patients who underwent USO between March 2015 and October 2021. The patients were divided into a UIS group (group I, n = 93) and a USIS group (group II, n = 51). Clinical and radiological parameters, including Disabilities of the Arm, Shoulder, and Hand (DASH) score, ulnar variance, ulnar styloid length, and ulnar styloid process index (USPI), were collected pre-operatively and one year post-operatively, and a comparative analysis was performed.

RESULTS

The DASH score showed significant improvement in both groups (p < .001 and p < .001), and there was no significant difference between the two groups one year after surgery (p = .143). The USPI was significantly different between the two groups (p < .001). The ulno-lunate and ulno-triquetrum distances showed significant increases in both groups, with significant differences between the two groups (p = .020, and p < .001, respectively). The incidence of post-operative arthritic changes in the distal radioulnar joint was significantly greater in the UIS group than that in the USIS group (21 vs 3, respectively; p = .017). No remarkable differences were observed in the post-operative evidence of chondromalacia at the last follow-up between the two groups.

CONCLUSION

The USO, which was performed as a treatment for USIS showed reliable outcomes compared to the USO for the treatment of UIS. Therefore, USO is a viable option for the treatment of USIS.

Treatment of type II symptomatic ulnar styloid nonunions with reinsertion of the triangular fibrocartilage complex

PURPOSE

The purpose of this retrospective study was to introduce an alternative technique for the treatment of type II symptomatic ulnar styloid nonunion by the reinsertion of the triangular fibrocartilage complex and the ulnar collateral ligament.

METHODS

Between March 2009 and May 2017, 45 patients (34 males and 11 females) suffering from the nonunion of type II ulnar styloid fractures all underwent the subperiosteal resection of the avulsed fragments and the reinsertion of the TFCC and ulnar collateral ligament. Outcome assessments included the ranges of motion of the wrist, grip strength, pain, and Mayo wrist score. The preoperative and postoperative parameters were compared. A P-value less than 0.05 was considered to be statistically significant.

RESULT

The mean follow-up period was 21.66 ± 7.93 months (range, 12 to 26 months). At the final follow-up, the mean preoperative flexion and extension were 79.32 ± 4.52° and 74.40 ± 4.36° respectively. The mean preoperative pain score, grip strength, and Mayo wrist score were 32.48 ± 4.00; 23.88 ± 8.38 kg, and 77.72 ± 8.31 respectively. The mean postoperative flexion and extension of the wrist were 80.56 ± 6.32° and 75.43 ± 3.12° respectively. The mean postoperative pain score, grip strength, and Mayo wrist score were 12.41 ± 3.27, 26.31 ± 8.30 kg, and 90.71 ± 7.97 respectively. There were significant differences in pain, grip strength, and Mayo wrist score (P < 0.05), but no significant differences concerning the range of motion of the wrist.

CONCLUSION

In the treatment of the nonunion of type II ulnar styloid fractures, the resection of the avulsed fragments followed by the reinsertion of the TFCC and the ulnar collateral ligament with an anchor was a reliable alternative technique, bringing the satisfactory function of the wrist.

Visualization of the location and level of pain in common wrist pathologies using color-coded heatmaps

BACKGROUND

Pain of the hand and wrist affects a large patient population. If the onset is unrelated to recent trauma, the first medical contact is rarely established with a specialized hand surgeon.

OBJECTIVE

The objective of this investigation was to (1) visualize the localization of hand pain using pain-related heatmaps in common wrist pathologies, (2) to test whether differences between these pathologies exist with regard to sociodemographic and pain-related aspects, and (3) to evaluate the major patient-reported complaints associated with the pathologies.

METHODS

This observational cross-sectional study included patients suffering from: thumb basal joint arthritis (CMC-1-OA), dorsal wrist ganglions, and TFCC tears. Patients marked the location of maximum pain projection on hand graphics depicting the outline of the palmar and dorsal hand. Color-graded frequency heat maps were generated for the wrist pathologies investigated. Daily life impairments were assessed and clustered into groups of functions/activities.

RESULTS

120 patients with a mean age of 44.3 years were investigated. The diagnostic groups showed significant differences regarding the level and location of pain, as well as daily life impairments. Patients with CMC-1-OA presented with increased pain levels compared to patients with dorsal wrist ganglions and TFCC tears. Daily life impairment was rated highest when household chores were adversely affected, and sport activities were symptomatic/painful. All groups showed significant skin surface pain projection, which was visualized in heatmaps. While general trends in pain localization were visible, pain levels were also reported distal/proximal and palmar/dorsal to the pathology.

CONCLUSIONS

Knowledge of main demographic parameters, pain projection, and degree of impairment in daily activities can help physicians to narrow differential diagnosis of wrist pain during first patient contact. Patients should then be referred to hand surgeons for specialist examination, to further differentiate the origin of the pain.

It Is Not Only the Meniscus That Flips-A Case of TFCC Tear with a Flipped Fragment in the Distal Radioulnar Joint

Acute wrist injuries with ongoing ulnar-sided wrist pain warrant a magnetic resonance imaging (MRI) to diagnose ligamentous injuries. Triangular fibrocartilage complex (TFCC) tears have been classified and described in the literature but complex tear patterns have limited representation. Bucket-handle tears of the TFCC represent only 0.5% of TFCC tears and have recently been identified, posing a diagnostic and management challenge. Preoperative diagnosis is possible with MRI and necessary for optimal and early surgical management. The authors describe a unique case of a flipped tear of the central disc of the TFCC, where the fragment was flipped into the distal radioulnar joint, a site hidden during routine arthroscopy.

Clinical and Radiographic Evaluation of Ulnar-Sided Wrist Pain

PURPOSE OF REVIEW

Ulnar-sided wrist pain is a challenging diagnostic workup. A thorough and complete physical examination followed by appropriate radiographic studies can help the clinician diagnose and treat these conditions.

RECENT FINDINGS

Recent research has been focused on diagnostic modalities such as arthroscopy and high-resolution MRI. Ulnar-sided wrist pain is a challenging clinical workup that must be approached systematically with the aid of adjunctive diagnostic modalities.

Hamatolunate impingement syndrome in golfers: results of arthroscopic burring of the apex of the hamate

Hamatolunate impingement syndrome is an uncommon cause of ulnar-sided wrist pain in the general population. Often misdiagnosed and untreated by non-specialized physicians, it is an important source of chronic ulnar wrist pain in golfers. The purpose of this retrospective study was to report results of arthroscopic burring of the apex of the hamate for hamatolunate impingement, whether isolated or not, in golf players, with a minimum of six months follow-up. Fifteen golf players (10 amateur, 2 semi-professional and 3 professional players), aged 40-61 years, with ulnar carpal pain implicating hamatolunate impingement with Viegas type-II carpal configuration, were included. Treatment consisted in arthroscopic burring of the apex of the hamate. At an average follow-up of 11 months (range, 6-24 months), all patients were satisfied with functional results, except 1 with persistent pain and stiffness; 93% returned to sport to their prior level. Mean range of motion was improved by 17 ° for wrist flexion (range, 15 ° to 30 °) and 15 ° for wrist extension (range, 10 ° to 25 °). All patients except 1 recovered grip strength, improving from 27 kg (range, 12-53) preoperatively to 35 kg (range, 17-61) at last-follow-up, and ulnar-sided pain was alleviated during golf practice. Return to prior sport level was possible by 5.5 months for professional players and by 9 months for amateurs. Arthroscopic burring of the apex of the hamate provided good clinical results for function and pain, with fairly rapid return to sport. Hamatolunate chondritis does not always mean pathology but represents the natural progression of Viegas type II wrists.

One-stop-shop CT arthrography of the wrist without subject repositioning by means of gantry-free cone-beam CT

Modern cone-beam CT systems are capable of ultra-high-resolution 3D imaging in addition to conventional radiography and fluoroscopy. The combination of various imaging functions in a multi-use setup is particularly appealing for musculoskeletal interventions, such as CBCT arthrography (CBCTA). With this study, we aimed to investigate the feasibility of CBCTA of the wrist in a “one-stop-shop” approach with a gantry-free twin robotic scanner that does not require repositioning of subjects. Additionally, the image quality of CBCTA was compared to subsequent arthrograms on a high-end multidetector CT (MDCTA). Fourteen cadaveric wrists received CBCTA with four acquisition protocols. Specimens were then transferred to the CT suite for additional MDCTA. Dose indices ranged between 14.3 mGy (120 kVp/100 effective mAs; full-dose) and 1.0 mGy (70 kVp/41 effective mAs; ultra-low-dose) for MDCTA and between 17.4 mGy (80 kVp/2.5 mAs per pulse; full-dose) and 1.2 mGy (60 kVp/0.5 mAs per pulse; ultra-low-dose) for CBCTA. Subjective image quality assessment for bone, cartilage and ligamentous tissue was performed by seven radiologists. The interrater reliability was assessed by calculation of the intraclass correlation coefficient (ICC) based on a two-way random effects model. Overall image quality of most CBCTA was deemed suitable for diagnostic use in contrast to a considerable amount of non-diagnostic MDCTA examinations (38.8%). The depiction of bone, cartilage and ligaments in MDCTA with any form of dose reduction was inferior to any CBCTA scan with at least 0.6 mAs per pulse (all p < 0.001). Full-dose MDCTA and low-dose CBCTA were of equal quality for bone tissue visualization (p = 0.326), whereas CBCTA allowed for better depiction of ligaments and cartilage (both p < 0.001), despite merely one third of radiation exposure (MDCTA–14.3 mGy vs. CBCTA–4.5 mGy). Moderate to good interrater reliability was ascertained for the assessment all tissues (ICC 0.689–0.756). Overall median examination time for CBCTA was 5.4 min (4.8–7.2 min). This work demonstrates that substantial dose reduction can be achieved in CT arthrography of the wrist while maintaining diagnostic image quality by employing the cone-beam CT mode of a twin robotic X-ray system. The ability of the multi-use X-ray system to switch between fluoroscopy mode and 3D imaging allows for “one-stop-shop” CBCTA in minimal examination time without the need for repositioning.

Calcific tendinopathy of the pronator quadratus muscle: A rare site and cause of ulnar sided wrist pain

Ulnar -sided wrist pain is a common complaint and can present a diagnostic challenge for a musculoskeletal clinician. Calcific tendinopathy is a well-recognised disorder related to the deposition of calcium hydroxyapatite crystals within tendons. Classically, tendons around the shoulder and the hip joints are the most commonly affected sites. We report a rare site of calcific tendinopathy of the Pronator Quadratus muscle presenting with ulnar-sided wrist pain in a 36-year-old male posing a diagnostic dilemma. This case-report highlights the importance of a thorough clinical evaluation and crucial role of cross-sectional imaging in reaching a diagnosis of calcific tendinopathy of the Pronator Quadratus muscle as unusual cause of ulnar-sided wrist pain. This is the first reported case of calcific tendinopathy in pronator quadratus in the literature we could review.

MRI Findings in Patients Undergoing Triangular Fibrocartilage Complex Repairs Versus Patients Without Ulnar-Sided Wrist Pain

Background: The clinical picture of ulnar-sided wrist pain is oftentimes confusing because various pathologies may be coexistent. In this study, we aimed: (1) to compare the prevalence of potential causes of ulnar-sided wrist pain on magnetic resonance imaging (MRI) in patients who underwent triangular fibrocartilage complex (TFCC) repair and control subjects: and (2) to evaluate whether inferior clinical results were associated with specific patient characteristics or other potential causes of ulnar-sided wrist pain. Methods: We included 67 patients who underwent a TFCC repair and 67 control subjects. The MRI scans were examined for sources of ulnar-sided wrist pain. After TFCC repair, 42 patients (63%) completed surveys, including Quick Disabilities of the Arm, Shoulder and Hand and pain scores. Bivariate analysis was performed to compare our groups and to identify factors associated with our outcomes. Results: We found significantly higher rates of distal radioulnar joint (DRUJ) arthritis (P = .033), extensor carpi ulnaris (ECU) pathology (P = .028), and ulnar styloid fractures (P = .028) in patients with TFCC repairs. With increasing age, increasing pathology in the pisotriquetral joint (P = .040), more ulnocarpal abutment (P = .0081), and more degenerative tears (P < .001) were seen in both groups. No demographic characteristics or MRI findings were significantly associated with our outcomes. Conclusions: We observed higher rates of DRUJ arthritis and ECU pathology in patients with TFCC tears undergoing repair compared with age- and sex-matched controls. This may be due to damage to the TFCC itself altering relationships of the DRUJ and the ECU subsheath, or it may reflect various pathologies that cause ulnar-sided wrist pain and drive patients toward surgery.

The Triangular Fibrocartilage Complex In The Human Wrist: A Scoping Review Towards Uniform And Clinically Relevant Terminology

The aim of this scoping review was to assess the composition, terminology, and anatomy of the triangular fibrocartilage complex (TFCC) of the wrist and propose unambiguous terminology regarding the individual components. The review was conducted according to the methodological framework by Arksey and O'Malley (International Journal of Social Research Methodology, 2005, 8, 19–32). Electronic databases were searched from inception until September 1, 2021 for original anatomical studies, using MeSH terms and keywords on terminology and anatomy of TFCC components. Studies using gross dissections or macro‐ or microscopic histology were included. Animal studies, fetal studies and studies with unknown disease status, were excluded. A total of 24 studies were included. The articular disc, the radioulnar ligaments, the meniscus homologue and the extensor carpi ulnaris tendon (sub)sheath were unanimously classified as TFCC components. One study did not include the ulnolunate and ulnotriquetral ligaments and only one study did include the ligamentum subcruentum. The largest disagreement existed regarding the inclusion of the ulnar collateral ligament. Terminological ambiguity was seen in “triangular fibrocartilage,” “triangular ligament,” “igamentum subcruentum,” and the “proximal and distal lamina.” Anatomical ambiguity existed especially regarding the radioulnar ligaments, the ulnar attachments of the TFCC and the ulnar collateral ligament. Definitions of the individual TFCC components are redundant, ambiguous, and ill‐defined and therefore subject to different interpretations. In order to preclude confusion, consensus regarding terminology is recommended. We proposed a concise definition of the healthy TFCC that can be used as a starting point for future studies and current clinical practice.

Evaluation of prestyloid recess morphology and ulnar-sided contrast leakage in CT arthrography of the wrist

Background

In wrist arthrograms, aberrant contrast material is frequently seen extending into the soft tissue adjacent to the ulnar styloid process. Since the prestyloid recess can mimic contrast leakage in CT arthrography, this study aims to provide a detailed analysis of its morphologic variability, while investigating whether actual ulnar-sided leakage is associated with injuries of the triangular fibrocartilage complex (TFCC).

Methods

Eighty-six patients with positive wrist trauma history underwent multi-compartment CT arthrography (40 women, median age 44.5 years). Studies were reviewed by two board-certified radiologists, who documented the morphology of the prestyloid recess regarding size, opening type, shape and position, as well as the presence or absence of ulnar-sided contrast leakage. Correlations between leakage and the presence of TFCC injuries were assessed using the mean square contingency coefficient (r_ɸ).

Results

The most common configuration of the prestyloid recess included a narrow opening (73.26%; width 2.26 ± 1.43 mm), saccular shape (66.28%), and palmar position compared to the styloid process (55.81%). Its mean length and anterior–posterior diameter were 6.89 ± 2.36 and 5.05 ± 1.97 mm, respectively. Ulnar-sided contrast leakage was reported in 29 patients (33.72%) with a mean extent of 12.30 ± 5.31 mm. Leakage occurred more often in patients with ulnar-sided TFCC injuries (r_ɸ = 0.480; p < 0.001), whereas no association was found for lesions of the central articular disc (r_ɸ = 0.172; p = 0.111).

Conclusions

Since ulnar-sided contrast leakage is more common in patients with peripheral TFCC injuries, distinction between an atypical configuration of the prestyloid recess and actual leakage is important in CT arthrography of the wrist.

Evaluation of a Grip-Strengthening Algorithm for the Initial Treatment of Chronic, Nonspecific Wrist Pain in Adolescents

Purpose

Chronic, nonspecific wrist pain in adolescents can be challenging to assess and treat. We hypothesized that an algorithmic approach beginning with grip strengthening can alleviate pain, improve function, and identify patients in need of further intervention.

Methods

We retrospectively reviewed the results of a grip-strengthening protocol for adolescents with chronic, nonspecific wrist pain. Before and after treatment, grip strength was measured using handheld dynamometry, and patient-reported pain and function were measured using the adolescent self-reported Pediatric Outcomes Data Collection Instrument’s (PODCI’s) Pain/Comfort and Upper Extremity Function domains (PODCI/pain and PODCI/UE, respectively).

Results

Thirty-two patients (28 female, 4 male) were included, with a mean age of 14 years (range, 10–18 years) and the dominant hand affected in 19, nondominant hand in 9, and bilateral impacts in 4. The mean symptom duration prior to presentation was 9 months (range, 1–63 months); 17 patients had undergone prior immobilization and 5 prior occupational/physical therapy. Grip-strengthening treatment, lasting a mean of 40 days (range, 21–82 days) with a median of 4 therapy visits (range, 2–6), was associated with significantly improved grip strength (mean, 32–48 lbs), PODCI/pain scores (mean, 49.0–78.2 points), and PODCI/UE scores (mean, 78.2–91.2 points). Improvements in grip strength correlated with improvements in PODCI/pain and PODCI/UE scores (r = 0.64 and 0.70, respectively). Eight patients (25%) had either no or incomplete pain relief: 5 underwent successful further intervention (2 ganglion cyst excisions, 1 triangular fibrocartilage complex repair, 1 arthroscopic debridement, 1 steroid injection), 2 received ongoing pain management for generalized pain syndromes, and 1 was lost to further follow-up. No pretreatment variables were identified that predicted failure.

Conclusions

Grip strengthening relieves pain and improves function in the majority of adolescents with chronic, nonspecific wrist pain. Systematic use of this protocol helps to identify patients who require further intervention.

Type of study/level of evidence

Therapeutic IV.

How to Report: Wrist MRI

Knowledge of the imaging anatomy of the wrist is essential for reporting magnetic resonance imaging (MRI). This familiarity should include the carpal bones, tendons (extensor and flexor compartments), triangular fibrocartilage complex (TFCC), intrinsic and extrinsic ligaments, and nerves, especially the median and ulnar nerves. Limitations of MRI in visualizing these structures, particularly the intrinsic ligaments and the TFCC, need to be considered. This article outlines the main features to comment on when reporting common conditions of the wrist on MRI, with some examples of terminology that can be used to describe these abnormalities.

Advanced Imaging of Ulnar Wrist Pain

Ulnar-sided wrist pain can be a diagnostic challenge for clinicians and radiologists. The ulnar wrist has complex morphology and is composed of many small bone and soft tissue structures. Within these structures, a wide variety of pathologic conditions can occur. To successfully diagnose and treat these pathologic conditions, clinicians and radiologists must have a strong understanding of the advanced imaging techniques available to them. In this review, the authors present a brief review of the normal ulnar wrist anatomy, discuss the differential diagnosis of ulnar-sided wrist pain, and examine the indications for different advanced imaging modalities.

Contrast-enhanced MRI of the wrist: Intravenous application of gadolinium improves diagnosis in ulnar-sided injuries of the TFCC

PURPOSE

Although lesions of the triangular fibrocartilage complex (TFCC) frequently induce ulnar-sided wrist pain and potentially distal radioulnar joint instability, diagnosis can pose a challenge due to the intricate anatomy. This study aims to evaluate the benefits of contrast-enhanced sequences for the detection of TFCC injuries in magnetic resonance imaging of the wrist.

METHOD

94 patients underwent wrist MRI with intravenous application of gadolinium-based contrast agents. For each patient, two datasets were analysed independently by two board-certified radiologists: One set comprised only plain T1- and fat-saturated proton-density-weighted sequences, while the second dataset included contrast-enhanced T1-weighted images with fat suppression. Arthroscopy or clinical reports served as reference standard with the former being used whenever available. Diagnostic confidence and TFCC component assessability were subjectively evaluated. Contrast-to-noise ratios (CNR) were calculated serve as an objective indicator of image contrast.

RESULTS

Lesions of the articular disc, the foveal and styloid ulnar attachment were present in 24 (25.5%), 61 (64.9%) and 53 (56.4%) patients. Access to contrast-enhanced T1 images improved the diagnostic accuracy for injuries of the styloid (R1/R2, 0.68/0.73 vs. 0.86/0.88) and foveal attachment (0.68/0.72 vs. 0.90/0.89) substantially compared to plain MRI (all p < 0.001), while no benefits could be identified for lesions of the central disc (0.89/0.90 vs. 0.87/0.90). Readers' diagnostic confidence and CNR for ulnar-sided lesions improved with contrast-enhanced T1 sequences available (p < 0.001).

CONCLUSIONS

With superior CNR in lesions of the TFCC's foveal and styloid attachment, contrast-enhanced, fat-saturated T1-weighted sequences facilitate higher diagnostic accuracy and confidence than fat-saturated PD- and plain T1-weighted MRI.

Osteoarthritis of the Wrist: Pathology, Radiology, and Treatment

Osteoarthritis (OA) is a degenerative disease that can manifest in any synovial joint under certain conditions. It leads to destruction of articular cartilage and adjacent bone, as well as formation of osteophytes at the edges of afflicted joint surfaces. Regarding the wrist, typical degenerative arthritis affects particular joints at a specific patient age, due to asymmetric load distribution and repetitive microtrauma. However, in the presence of instability or systemic diseases, early-onset degeneration can also impair the range of motion and grip strength in younger patients. Although advanced stages of OA display characteristic signs in radiography, the detection of early manifestations frequently requires computed tomography or magnetic resonance imaging (in some cases with additional arthrography). If a wrist becomes unstable, timely diagnosis and precise treatment are essential to prevent rapid disease progression. Therefore, close collaboration between radiologists and hand surgeons is obligatory to preserve the carpal function of patients.

Postoperative Imaging of Ulnar Wrist Pain

Ulnar wrist pain, caused by a broad spectrum of bone and soft tissue injuries, is the most common clinical condition of the wrist. Multiple surgical techniques and their variants in the treatment of these injuries are constantly evolving. Postoperative evaluation of the wrist for many surgeons is limited to serial clinical and radiographic monitoring. However, imaging methods such as ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and arthrographic techniques (arthrographic CT and arthrographic MRI) play a fundamental role in diagnosing and managing postsurgical complications.The several critical aspects in evaluating the postsurgical wrist imaging spectrum are familiarity with the surgical techniques, knowledge of the original clinical problem, understanding the strength and limitations of the different radiologic modalities, and effective communication between surgeon and radiologist.

Subluxation of the extensor carpi ulnaris on magnetic resonance imaging on neutral wrist position: correlation with tenosynovitis of the extensor carpi ulnaris and translation of the distal radioulnar joint

OBJECTIVE

To identify the subluxation degrees of extensor carpi ulnaris (ECU) tendon on neutral wrist MRI in patients with ulnar-sided wrist pain and to evaluate the relationships of ECU subluxation with accompanying imaging findings such as ECU tenosynovitis, distal radioulnar joint (DRUJ) stability, and triangular fibrocartilage complex (TFCC) pathology.

MATERIALS AND METHODS

A total of 297 MRIs of 292 patients having ulnar side pain were reviewed retrospectively. Degrees of ECU subluxation was classified into four grades: grade 0, no subluxation; grade 1, tendon displacement < 50% of the tendon width; grade 2, tendon displacement 51 to 99% of the tendon width; and grade 3, tendon displacement of 100% of the tendon width. ECU tenosynovitis, ECU tendinosis, injuries of triangular fibrocartilage and distal radioulnar ligaments (DRUL), translation ratio of the DRUJ, rotation angle of the DRUJ, and the width, depth, and length of the ulnar groove were assessed on wrist MRI. The relationships between degree of ECU subluxation and these imaging findings were investigated.

RESULTS

Women had higher subluxation degrees of the ECU tendon (p = 0.001). Tenosynovitis of the ECU, sprain of the dorsal DRUL, dorsovolar translation ratio and rotation angle of the DRUJ, and depth and length of the ulnar groove were statistically significantly related to the subluxation degree of the ECU tendon (p = 0.000).

CONCLUSION

High-grade subluxation of the ECU tendon was strongly correlated with ECU tenosynovitis and DRUJ translation. Clinicians and radiologists should scrutinize imaging findings, particularly when patients with ulnar-sided wrist pain have high-grade subluxation of the ECU tendon.

The Value of the Distal Radioulnar Joint Effusion in Diagnosing Triangular Fibrocartilage Complex Tears on Magnetic Resonance Imaging

BACKGROUND

A retrospective study was conducted to evaluate the role of distal radioulnar joint (DRUJ) effusion in aiding the diagnostic accuracy of central triangular fibrocartilage complex (TFCC) tears on non-contrast MRI.

METHODS

89 consecutive patients who had undergone wrist arthroscopy for ulna sided wrist pain in our unit were identified and their preoperative imaging reviewed. Two consultant musculoskeletal Radiologists independently reported the presence or absence of a DRUJ effusion and or a TFCC tear. The inter-observer variability was calculated using weighted Kappa tests. Two by two tables were constructed to calculate the sensitivity and specificity of reported TFCC tear or DRUJ effusion on MRI in correctly diagnosing central TFCC tears identified at arthroscopy.

RESULTS

Sensitivity of MRI to report a TFCC tear was 0.56 and specificity was 0.79. Sensitivity increased to 0.89 if either a DRUJ effusion or TFCC tear were seen on MRI. When observed together, the presence of both a DRUJ effusion and a TFCC tear seen on the imaging lead to a sensitivity of 0.74 and PPV of 82% when compared to findings at arthroscopy. In the absence of both DRUJ effusion and TFCC tear, the specificity of MRI increased to 0.92. Agreement by the radiologists on the presence of DRUJ effusion was substantial (k value 0.67) and TFCC tear was moderate (k value 0.58).

CONCLUSION

The presence of DRUJ effusion on MRI can further improve sensitivity of MRI in diagnosing central TFCC tears. The sensitivity of detecting a central TFCC tear on MRI scan when both a DRUJ effusion and a TFCC tear were seen (0.74) is comparable to rates demonstrated on MRA meta-analysis results (0.78). Furthermore, considering the absence of both a DRUJ effusion and TFCC tear seen on MRI is useful in excluding the presence of a TFCC tear at arthroscopy.

Improved diagnostic accuracy for ulnar-sided TFCC lesions with radial reformation of 3D sequences in wrist MR arthrography

Objectives

Triangular fibrocartilage complex (TFCC) injuries frequently cause ulnar-sided wrist pain and can induce distal radioulnar joint instability. With its complex three-dimensional structure, diagnosis of TFCC lesions remains a challenging task even in MR arthrograms. The aim of this study was to assess the added diagnostic value of radial reformatting of isotropic 3D MRI datasets compared to standard planes after direct arthrography of the wrist.

Methods

Ninety-three patients underwent wrist MRI after fluoroscopy-guided multi-compartment arthrography. Two radiologists collectively analyzed two datasets of each MR arthrogram for TFCC injuries, with one set containing standard reconstructions of a 3D thin-slice sequence in axial, coronal and sagittal orientation, while the other set comprised an additional radial plane view with the rotating center positioned at the ulnar styloid. Surgical reports (whenever available) or radiological reports combined with clinical follow-up served as a standard of reference. In addition, diagnostic confidence and assessability of the central disc and ulnar-sided insertions were subjectively evaluated.

Results

Injuries of the articular disc, styloid and foveal ulnar attachment were present in 20 (23.7%), 10 (10.8%) and 9 (9.7%) patients. Additional radial planes increased diagnostic accuracy for lesions of the styloid (0.83 vs. 0.90; p = 0.016) and foveal (0.86 vs. 0.94; p = 0.039) insertion, whereas no improvement was identified for alterations of the central cartilage disc. Readers’ confidence (p < 0.001) and assessability of the ulnar-sided insertions (p < 0.001) were superior with ancillary radial reformatting.

Conclusions

Access to the radial plane view of isotropic 3D sequences in MR arthrography improves diagnostic accuracy and confidence for ulnar-sided TFCC lesions.

Key Points

• In multi-compartment arthrography of the wrist, ancillary radial plane view aids assessability of the foveal and styloid ulnar-sided insertions of the triangular fibrocartilage complex.

• Assessment of peripheral TFCC injuries is more accurate with access to radial multiplanar reconstructions.

• Additional radial planes provide greater diagnostic confidence.

Mid- and Long-Term Outcome After Arthroscopically Assisted Transosseous Triangular Fibrocartilage Complex Refixation-Good to Excellent Results in Spite of Some Loss of Stability of the Distal Radioulnar Joint

PURPOSE

To evaluate mid- and long-term outcomes after arthroscopically-assisted transosseous reattachment of the triangular fibrocartilage complex (TFCC) and to analyze the association of distal radioulnar joint (DRUJ) stability with the clinical outcome.

METHODS

Patients treated with an arthroscopically-assisted transosseous reattachment of the deep layer of the TFCC between 2000 and 2009 and a minimum follow-up of 12 months at mid-term and 4 years at long-term follow-up were retrospectively reviewed. Mayo Modified Wrist Score (MMWS); Disabilities of the Arm, Shoulder and Hand (DASH) score; pain visual analogue scale (VAS); grip strength and stability of the DRUJ were assessed at 2 follow-up clinical examinations. At the last follow-up, the Patient-Rated Wrist Evaluation score was additionally recorded.

RESULTS

Thirty patients with a mean age of 29 (±13) years were included. Most of the patients were female (70%, n = 21). The mid-term evaluation took place at a median of 30 months (range, 12-83 months). The assessed scores showed statistically significant clinical improvement (MMWS, P < .001; DASH score P < .001; VAS P < .001). Stability assessment showed a stable DRUJ in 23 (76.7%) patients. At a median of 106 months (range 52-215 months), the long-term clinical assessment was performed. The evaluated scores demonstrated persisting significant improvement (MMWS P < .001; DASH score P < .001; VAS P < .001). Stability assessment showed a stable DRUJ in 19 patients (63.3%). DRUJ instability did not correlate with clinical outcome. No permanent surgery-related complications occurred.

CONCLUSION

Arthroscopically-assisted transosseous reattachment of the deep fibers of radioulnar ligaments leads to excellent and good clinical results in mid- and long-term follow-up. In 95.5% of the analyzed patients, the measured improvement in the DASH score exceeded the in literature reported minimal clinically important difference of 13.5. Loss of DRUJ stability during follow-up was not associated with deterioration of clinical parameters and patient satisfaction.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

[The ulnocarpal complex : New clinical and radiological considerations]

CLINICAL ISSUE

The triangular fibrocartilage complex (TFCC) is an anatomically complex structure with high demands on spatial and contrast resolution in imaging.

RADIOLOGICAL METHODS

The central, predominantly avascular articular disc can be distinguished from the ligamentous, vascularized periphery. Imaging methods include magnetic resonance imaging (MRI, preferably contrast-enhanced) as well as MR and computed tomography (CT) arthrography.

DIAGNOSTIC INNOVATIONS

While high-resolution MRI represents the standard diagnostic tool for the TFCC in general, arthrographic imaging is particularly useful for assessment of the foveal (proximal) lamina of the TFCC. In radiological reporting, the convergence of the TFCC periphery towards the ulnar styloid process and the ulnar fovea must be considered.

ACHIEVEMENTS

The Palmer classification is suitable for evaluating lesions of the articular disc, whereas the Atzei classification is superior for lesions of the ulnar TFCC insertions.

PRACTICAL RECOMMENDATION

Use of a high-resolution examination technique and anatomy-based image interpretation are important for reliable MRI of the TFCC.

Ulnar-Side Wrist Pain Management Guidelines: All That Hurts is Not the TFCC!

BACKGROUND

Ulnar-sided wrist pain is a common clinical problem, most often misdiagnosed as triangular fibrocartilage complex (TFCC) injury. It may be frustrating to the patient, as one may end up wearing a wrist splint for an unusually long period, disrupting their routine.

PURPOSE

Because of the dilemmas in the diagnosing the cause of ulnar-sided wrist pain, various algorithms have been suggested but it is an individual's choice to do a systematic assessment and follow in their routine clinical practice. We propose the 'storey concept' for examining the ulnar side of the wrist, with ulnar styloid as the reference point. The lower storey identifies the pathologies of the DRUJ, the intermediate storey identifies the pathologies of the radiocarpal joint and the upper storey identifies the pathologies of midcarpal and carpometacarpal joint.

CONCLUSION

Also, it is important to ramify the cause of pain into stable or unstable wrist, with or without arthritis, as this will guide us in managing the pain arising from distal radioulnar joint. In addition to methodical clinical examination, ideal radiographs and high-resolution MRI are critical to diagnose wrist pathologies. The role of wrist arthroscopy has consistently increased, and complements in both diagnosis and treatment of wrist pain especially in ambiguous situations.

The triangular fibrocartilage complex on high-resolution 3 T MRI in healthy adolescents: the thin line between asymptomatic findings and pathology

OBJECTIVE

The objective of the study is to provide a reference for morphology, homogeneity, and signal intensity of triangular fibrocartilage complex (TFCC) and TFCC-related MRI features in adolescents.

MATERIALS AND METHODS

Prospectively collected data on asymptomatic participants aged 12-18 years, between June 2015 and November 2017, were retrospectively analyzed. A radiograph was performed in all participants to determine skeletal age and ulnar variance. A 3-T MRI followed to assess TFCC components and TFCC-related features. A standardized scoring form, based on MRI definitions used in literature on adults, was used for individual assessment of all participants by four observers. Results per item were expressed as frequencies (percentages) of observations by all observers for all participants combined (n = 92). Inter-observer agreement was determined by the unweighted Fleiss' kappa with 95% confidence intervals (95% CI).

RESULTS

The cohort consisted of 23 asymptomatic adolescents (12 girls and 11 boys). Median age was 13.5 years (range 12.0-17.0). Median ulnar variance was -0.7 mm (range - 2.7-1.4). Median triangular fibrocartilage (TFC) thickness was 1.4 mm (range 0.1-2.9). Diffuse increased TFC signal intensity not reaching the articular surface was observed in 30 (33%) observations and a vertical linear increased signal intensity with TFC discontinuation in 19 (20%) observations. Discontinuation between the volar radioulnar ligament and the TFC in the sagittal plane was seen in 23 (25%) observations. The extensor carpi ulnaris was completely dislocated in 10 (11%) observations, more frequent in supinated wrists (p = 0.031). Inter-observer agreement ranged from poor to fair for scoring items on the individual TFCC components.

CONCLUSION

MRI findings, whether normal variation or asymptomatic abnormality, can be observed in TFCC and TFCC-related features of asymptomatic adolescents. The rather low inter-observer agreement underscores the challenges in interpreting these small structures on MRI. This should be taken into consideration when interpreting clinical MRIs and deciding upon arthroscopy.

Ulna shortening osteotomy versus arthroscopic wafer procedure in the treatment of ulnocarpal impingement syndrome

Post-traumatic or constitutional ulnar impaction syndrome can be treated by shortening the ulna. This can be achieved by diaphyseal or metaphyseal osteotomy, or by arthroscopic epiphyseal resection. The objective of this study was to compare the results of the diaphyseal shortening osteotomy (USO) and arthroscopic wafer procedure (AWP) of the ulna in this indication. This was a retrospective case series of 33 patients operated for ulnar impaction syndrome by the same surgeon between 1997 and 2017. The diagnosis was made based on pain on the ulnar edge of the wrist with positive provocative tests. Radiographs were made and CT arthrography or MRI were used to confirm the diagnosis. Per-and post-operative assessments were functional (DASH and PRWE scores), clinical (pain, range of motion and grip strength) and radiographic. Diaphyseal ulnar shortening osteotomy (USO) was performed in 9 patients using a volar plate and a cutting guide. Twenty-four patients underwent an arthroscopic wafer procedure. Mean follow-up was 103 ± 8 months in the USO group versus 55 ± 4 months in the AWP group. There was no significant difference between groups in pain levels (1.2/10 in the USO group versus 0.9/10 in the AWP group, p = 0.88), grip strength (39 Kg in the USO group versus 34 Kg in the AWP group, p = 0.27) and PRWE score (5,8/100 in the USO group versus 11,2 in the AWP group, p = 0.34), and DASH score (25/100 in the USO group versus 28 in the AWP group, p = 0.63). The time away from work was long in the USO group than in the AWP group (7.86 months versus 3.75 months) (p = 0.002). Seven patients were reoperated in the USO group (5 plate removal, 1 nonunion and 1 delayed union) versus 3 in the AWP group (1 ECU stabilization, 1 ablation for painful ulnar styloid due to nonunion and 1 wrist denervation) (p = 0.0004). The study found no clinical differences between these two techniques except the return to work time. In our series, diaphyseal USO was associated with a greater number of reoperations than the AWP.

An Evidence-Based Review of Overuse Wrist Injuries in Athletes

Overuse wrist injuries are a common problem in athletes and can be related to tendinopathies or osteoarticular pathology. Fortunately, athletes rarely miss time from their sport due to these conditions because many can be treated nonoperatively. For refractory cases, there often is a curative surgical procedure that can be done during the off-season.

Imaging of Carpal Instabilities

Background The term “carpal instability” describes different debilitating wrist conditions, in which the carpus is unable to maintain its physiological range of motion and load transfer. Depending on the cause and location of the dysfunction, four groups can be defined: dissociative, non-dissociative, complex, and adaptive carpal instability. As the most common form by far, dissociative carpal instability can further be categorized as dorsal or palmar intercalated segment instability, contingent on the afflicted interosseous ligament.

Method This review article outlines the different entities of carpal instability, their pathophysiology, and their clinical presentation. It further discusses the diagnostic significance of different imaging methods as well as the established treatment options for each form of instability in context with the current literature.

Results and Conclusion Early detection and treatment of carpal instability are essential for preventing carpal osteoarthritis. Traumatic lesions of the scapholunate interosseous ligament are the most frequent cause of instability. They can occur in an isolated fashion or in context with other carpal injuries. While stress imaging and fluoroscopy facilitate the differentiation between dynamic and static forms of carpal instability, only MRI and CT/MR arthrography can directly reveal the extent of ligament discontinuity.

Key Points:

Citation Format

What Is the Effect of the Ulnar-Plus Variance on the Outcomes of Arthroscopic Repair of the Peripheral Ulnar-Side Triangular Fibrocartilage Complex Tear?

PURPOSE

To compare the outcomes of arthroscopic repair of peripheral ulnar-side triangular fibrocartilage complex (TFCC) tears between patients with and without ulnar-plus variance (UPV) and to identify factors associated with index surgery failure in these patients.

METHODS

We retrospectively analyzed 50 consecutive patients who underwent arthroscopic repair of peripheral ulnar-side TFCC tears from June 2014 to February 2018. We selected patients who were aged at least 18 years and underwent arthroscopic repair of peripheral ulnar-side TFCC tears. We excluded those with a fractured or dislocated wrist, ulnar impaction syndrome, degenerative or inflammatory arthritis of the wrist, or neurologic conditions that affect upper-extremity function, as well as those who received less than 12 months' follow-up. We evaluated the patients with a visual analog scale for pain in 3 domains (overall, with hard work, and at rest), the Patient-rated Wrist Evaluation, range of motion, and grip strength. Clinical outcomes and arthroscopic findings were compared between patients with and without UPV (UPV group and non-UPV group, respectively). We calculated the relative risk and 95% confidence interval for younger age (<30 years), sex, UPV, and coexisting degenerative central TFCC tear (type 2 tear) to determine the risk factors for arthroscopic repair failure.

RESULTS

No significant differences were noted between the 2 groups regarding visual analog scale pain and Patient-rated Wrist Evaluation scores and rates of excellent or improved outcomes (P > .05). Arthroscopic repair failure was found in 4 patients. A coexisting type 2 TFCC tear was the only significant risk factor (relative risk, 49.5; 95% confidence interval, 2.94-83.96; P = .007) for arthroscopic repair failure.

CONCLUSIONS

UPV did not significantly affect the outcomes of arthroscopic repair of peripheral ulnar-side TFCC tears. However, coexisting type 2 TFCC tears significantly increased the risk of index surgery failure in these patients.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Do magnetic resonance imaging abnormalities of the non-dominant wrist correlate with ulnar-sided wrist pain in elite tennis players?

OBJECTIVE

Ulnar-sided injuries of the non-dominant wrist are common in elite tennis players that use the double-handed backhand technique. This study aimed to define the relationship between ulnar-sided wrist pain in symptomatic and asymptomatic elite tennis players, and the presence of abnormalities on magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Fourteen symptomatic tennis players, 14 asymptomatic tennis players, and 12 healthy controls who did not play tennis, were analyzed prospectively, after undergoing MRI of their non-dominant wrist. Five anatomical regions were analyzed, thought to relate to ulnar-sided wrist pain. These consisted of the triangular fibrocartilage complex (TFCC), ulnar collateral ligament (UCL), extensor carpi ulnaris tendon (ECU), osseous-articular structures, and ganglia. Images were independently reviewed by two blinded musculoskeletal radiologists.

RESULTS

Non-dominant, ulnar-sided, wrist pain in elite tennis players was not statistically significantly associated with an increased number of MRI abnormalities when compared with asymptomatic tennis players (p > 0.05). However, some evidence of statistical association was seen with an increased prevalence of ECU tendon abnormalities (OR = 8.0, 95% CI = (0.74, 20.00), p = 0.07). A statistically significant increase in MRI abnormalities of osseous structures (OR = 15.1, 95% CI = (1.56, 656.05), p = 0.02) and the dorsal radioulnar ligament (DRUL) (OR = 12.5, 95% CI = (2.15, 111.11), p = 0.03), was observed in symptomatic players compared with controls.

CONCLUSIONS

Non-dominant, ulnar-sided, wrist pain in a subgroup of elite tennis players using a double-handed backhand technique is not associated with a statistically significant increased prevalence of MRI abnormalities when compared with asymptomatic tennis players, other than some evidence of statistical association with ECU tendon abnormalities. Therefore, significance of MRI abnormalities should be interpreted in the context of clinical findings.

Imaging of ulnar-sided wrist pain

Ulnar-sided wrist pain is a complex entity to diagnose clinically and frequently requires imaging to help confirm or determine the diagnosis. This article reviews the imaging and the logical imaging pathway of the common causes of ulnar-sided wrist pain, and illustrates various pathologies. It also discusses appropriate imaging modalities for various conditions. The causes of ulnar-sided wrist pain are stratified according to the affected anatomical structures, such as bony, soft tissue or neurovascular aetiologies. This review provides a handy imaging framework for non-radiologist clinicians of the common conditions producing ulnar-sided wrist pain. A linked article (10.12968/hmed.2019.80.8.456) detailing the diagnosis of ulnar-sided wrist pain is included in this issue.

Diagnosis of ulnar-sided wrist pain: a pragmatic approach for the non-specialist

Ulnar-sided wrist pain is often unfairly labelled as the 'back pain' of the wrist. This reputation comes from the complexity of diagnosing problems related to this area of the wrist. This article summarizes the anatomy and biomechanics of the wrist and presents a logical approach to diagnosing the aetiology of the pain. The problems are categorised based on the anatomical structure from which the pain arises: either bony, soft tissue-related or arising from nerves or vascular structures. The article also outlines the relevant examination findings and the most appropriate investigation that would yield a diagnosis with any given presentation. A linked article detailing the imaging of ulnar-sided wrist pain is included in this issue (10.12968/hmed.2019.80.8.461).

Utility of Specialized Imaging for Diagnosis of Chronic Wrist Pain

Background  Patients with chronic wrist pain often undergo imaging (such as magnetic resonance imaging [MRI], computed tomography [CT], or ultrasound [US]) prior to specialist assessment. Questions  Is specialized wrist imaging performed prior to expert consultation necessary? Are there demographic differences between patients who do or do not receive preconsultation imaging? Patients and Methods  A total of 115 patients referred to a tertiary hand center for chronic wrist pain and assessed by a hand surgeon were included. At initial consultation, surgeons were blinded to referral information and previous imaging results. The specialist performed a history, physical examination and reviewed X-rays. They established a clinical diagnosis and whether any additional investigations were needed. Prior MRI, CT, and/or US results were then reviewed and the specialists' clinical diagnosis was compared with the blinded referral diagnosis. Preconsultation imaging was categorized as having no value for diagnosis/management, some value, or high value. Results  A total of 82 patients had imaging prior to specialist referral (69 MRIs, 11 CTs, and 16 ultrasounds). The majority of additional imaging (73%) was classified as unnecessary, including 77% of the MRIs and 100% of the ultrasounds. Of all the investigations performed, two CT scans were labeled highly valuable clinical aids. Older patients and those with radial-sided pain were less likely to receive preconsultation imaging. Six patients required further imaging after consultation. Conclusion  Clinical assessment and X-rays are typically sufficient for a hand specialist to diagnose and manage chronic wrist pain and few patients require additional imaging. Level of Evidence  This is a Level III study.

Positive Ulnar Fovea Sign - Audit of Patient Outcomes Following Nonsurgical and Surgical Management

Background: Patients with ulnar-sided wrist pain and positive ulnar fovea sign are usually treated nonsurgically before surgical options are considered. However, the outcomes of nonsurgical management are unknown. Many of these patients also have unstable distal radioulnar joint, but there has been no comparison between the outcomes of these patients with stable and unstable distal radioulnar joint. The objectives of this study are to (1) determine the outcomes of nonsurgical and surgical treatment of patients with positive ulnar fovea sign, and (2) compare the outcomes of patients with stable and unstable distal radioulnar joint. Methods: A retrospective analysis of the outcomes of patients with ulnar sided wrist pain and positive fovea sign was performed from March 2009 to December 2014. Outcomes were measured based on patient-reported pain improvement, grip strength and range of motion of the affected wrist before and after treatment. A total of 100 wrists in 98 patients were reviewed. Results: 54% of wrists managed nonsurgically experienced pain improvement. 83% of wrists managed surgically experienced pain improvement. The mean grip strength increased by 2.8 kg and 2.7 kg, while the range of motion decreased by 14° and 5° after nonsurgical and surgical treatment respectively. When comparing patients with stable and unstable distal radioulnar joint, there were statistically more wrists with unstable distal radioulnar joint that experienced pain improvement after treatment. Conclusions: The study showed that there is a role for nonsurgical treatment for wrists with positive ulnar fovea sign with more than half of the patients experiencing pain improvement. We also found that positive ulnar fovea sign patients with unstable distal radioulnar joint had better pain outcomes compared to those with stable distal radioulnar joint.

Radiographic/MR Imaging Correlation of the Wrist

In this review article, the authors discuss the imaging features of the most common pathologic conditions of the wrist by putting the emphasis on radiographic and MR imaging correlations. A topographic approach based on the 3 functional columns of the wrist (radial, central, and ulnar) serves as a framework. The pathologic conditions are classified, based on the structures involved, as fractures, ligament injuries, arthropathies, bone abnormalities, and tendinopathies. The authors describe and evaluate classic radiographic signs and explain how they correlate with MR imaging. The advantages and limitations of each technique are thoroughly discussed as well as other imaging modalities.

Ulnar Wrist Pain Revisited: Ultrasound Diagnosis and Guided Injection for Triangular Fibrocartilage Complex Injuries

The triangular fibrocartilage complex (TFCC) serves as the major stabilizer of the wrist. Its injuries can result from trauma or degeneration, both of which are strongly correlated with the loading stress on the ulnar shaft and carpal joints. The TFCC is made of the articular disc, meniscus homologue, ulnocarpal ligament, radioulnar ligament, ulnotriquetral ligament, ulnolunate ligament, and subsheath of the extensor carpi ulnaris tendon. Because of its complexity, it is challenging to confirm the exact component affected in TFCC injuries. The Palmer classification is widely used for investigation of TFCC lesions using magnetic resonance imaging. Recently, high-resolution ultrasound (US) has become more popular in diagnosing musculoskeletal disorders. However, the utility of US imaging in TFCC lesions is less common because its anatomy under US imaging is not described in the current literature. Accordingly, in this review, we aimed to propose a standard US scanning protocol for the TFCC, present relevant images for its pathologies, and illustrate appropriate US-guided injection techniques for their management.

[Radiology of the distal radioulnar joint and the ulnocarpal complex]

X-ray images exposed in neutral position and radiocarpally centred are essential in imaging of the distal radioulnar joint (DRUJ). The anatomic orientation of the DRUJ is favourable for acquiring transaxial scans to display its anatomy, subtle derangements, osteoarthritis and intra-articular fractures free from superpositions. The triangular fibrocartilage complex (TFCC) is the most important stabilizer of the DRUJ. Provided that a focused clinical indication is given, high-resolution images are acquired, and an intra-venous or intra-articular contrast-agent is applied, all TFCC structures and destabilizing lesions can be displayed with the use of CT and MRI.

Functional and Surgical Anatomy of the Upper Limb: What the Radiologist Needs to Know

The anatomy of the upper limb is complex and allows for exceptional functionality. The movements of the joints of the shoulder, elbow, and wrist represent a complex dynamic interaction of muscles, ligaments, and bony articulations. A solid understanding and of the characteristics and reciprocal actions of the anatomic elements of the joints of the upper limb helps explain the mechanisms and patterns of injury. This article focuses on the anatomy and functionality of the shoulder, elbow, and wrist, with emphasis on the stabilizing mechanisms, to set the foundation for understanding the occurrence of pathologic conditions.

Perceptions and experiences of wrist surgeons on the management of triangular fibrocartilage complex tears: a qualitative study

There is lack of consensus on the management of triangular fibrocartilage injuries. The aim of this study was to investigate wrist surgeons' experiences and perceptions regarding treatment of triangular fibrocartilage complex injuries and to explore the rationale behind clinical decision-making. A purposive sample of consultant wrist surgeons (n = 10) was recruited through 'snow-balling' until data saturation was reached. Semi-structured interviews were conducted, digitally recorded and transcribed verbatim. Two researchers independently analysed data using an iterative/thematic approach. Findings suggest that surgeons rely more on their own training and experience, and patient-related factors such as individual expectations, to inform their decision-making, rather than on published material. Current classification systems are largely considered to be unhelpful. Level of evidence: V.

Current perspectives in conventional and advanced imaging of the distal radioulnar joint dysfunction: review for the musculoskeletal radiologist

Distal radioulnar joint (DRUJ) dysfunction is a common cause of ulnar sided wrist pain. Physical examination yields only subtle clues towards the underlying etiology. Thus, imaging is commonly obtained towards an improved characterization of DRUJ pathology, especially multimodality imaging, which is frequently resorted to arrive at an accurate diagnosis. With increasing use of advanced MRI and CT techniques, DRUJ imaging has become an important part of a musculoskeletal radiologist's practice. This article discusses the normal anatomy and biomechanics of the DRUJ, illustrates common clinical abnormalities, and provides a comprehensive overview of the imaging evaluation with an insight into the role of advanced cross-sectional modalities in this domain.

Intra-articular Fracture of the Distal part of the Triquetrum within the Pisotriquetral Joint: Case Report and Review of Literature

Background

Intra-articular fractures of the distal part of the triquetrum within the pisotriquetral joint are uncommon, and can be associated with tears of the dorsal carpal ligaments, pisiform subluxation and/or FCU dislocation. Their diagnosis is difficult and requires a high clinical suspicion and a proper radiological examination including oblique wrist x-rays, computed tomography and MRI scan. These fractures can be delayed diagnosed due to late presentation thus leading to painful nonunion, persistent instability and late pisotriquetral arthritis.

Case Report

We present a case of a 40-year-old male who complained about ulnarsided wrist pain after a fall on his extended wrist during bicycling. The diagnosis of triquetrum fracture was suspected on clinical examination and confirmed using standard and oblique radiographs and CT scan evaluation. He was immobilized in a short-arm cast for 6 weeks followed by a progressive return to wrist motion and subsequent strengthening for another 5 weeks. He reported complete resolution of pain and excellent wrist motion and function one year after the injury, demonstrating a Mayo score of 100.

Conclusion

Isolated intra-articular fractures of the triquetrum within the pisotriquetral joint are rare injuries and may constitute a subcategory of body fractures other than the dorsal cortical (chip), main body and volar lip avulsion fractures. Early clinical suspicion and proper imagine can lead to a successful outcome.

MRI findings in bucket-handle tears of the triangular fibrocartilage complex

The triangular fibrocartilage complex (TFCC) is an intricate ligamentous and cartilaginous structure that helps transmit axial load across the wrist, and provide stability to the ulnocarpal and distal radioulnar joints (DRUJ). Because the blood supply to the TFCC varies depending on location, certain types of tears are more amenable to surgical repair than others. Since Palmer proposed his classification system of TFCC tears in 1989, only 1 case of a "bucket-handle" type tear has been reported. In this article, we describe two new cases of bucket-handle tears of the TFCC. In both cases, the torn fragment was displaced into a previously undescribed location (intra-articular DRUJ and prestyloid recess). Because this type of injury pattern has not been previously well characterized in the literature and such cases rarely reported, MRI findings have not been fully described and its implications on clinical management have largely yet to be determined.

High-resolution 3-T MRI of the triangular fibrocartilage complex in the wrist: injury pattern and MR features

OBJECTIVES

To investigate if using high-resolution 3-T MRI can identify additional injuries of the triangular fibrocartilage complex (TFCC) beyond the Palmer classification.

MATERIALS AND METHODS

Eighty-six patients with surgically proven TFCC injury were included in this study. All patients underwent high-resolution 3-T MRI of the injured wrist. The MR imaging features of TFCC were analyzed according to the Palmer classification.

RESULTS

According to the Palmer classification, 69 patients could be classified as having Palmer injuries (52 had traumatic tears and 17 had degenerative tears). There were 17 patients whose injuries could not be classified according to the Palmer classification: 13 had volar or dorsal capsular TFC detachment and 4 had a horizontal tear of the articular disk.

CONCLUSION

Using high-resolution 3-T MRI, we have not only found all the TFCC injuries described in the Palmer classification, additional injury types were found in this study, including horizontal tear of the TFC and capsular TFC detachment. We propose the modified Palmer classification and add the injury types that were not included in the original Palmer classification.

The "second ulnar groove", a MRI sign suggesting a previous palmar luxation of the ulna at the distal radioulnar joint

INTRODUCTION

A cortical lined impaction on the radiodorsal side of the ulnar head may be at the origin of a "second ulnar groove" (SUG). The goal of this article is to illustrate this MRI sign, prompting for further investigation of the distal radioulnar joint (DRUJ). Hence associated soft tissue pathology may be detected, which may lead to instability.

MATERIAL AND METHODS

Following an anterior luxation of the ulna at the DRUJ a second cortical lined groove in a previously normal distal ulna was discovered. A data base review from January 2008 to August 2016 of the axial FS PD-TSE WI 1.5T MRI views of 1.716 patients was accomplished in search of similar bone defects.

RESULTS

Eight patients with previous severe wrist trauma presented with a similar posttraumatic ulnar bone defect. The preceding anterior luxation at the DRUJ was only clearly demonstrated in five patients. However, two more patients had a residual anterior subluxation. Different imaging techniques are discussed and the differential diagnosis is well illustrated.

CONCLUSIONS

The type of trauma, the specific location and the morphology of a second ulnar groove, all compatible with a sequel of an anterior luxation of the ulna at the DRUJ, should lead to a further specific clinical and MRI revaluation of the DRUJ.