Evaluation of selective wrist arthrography of contralateral asymptomatic wrists for symmetric ligamentous defects

Accuracy of magnetic resonance imaging of the wrist for clinically important lesions of the major interosseous ligaments and triangular fibrocartilage complex; correlation with radiocarpal arthroscopy

OBJECTIVE

To demonstrate the utility of MRI in separating clinically relevant from minor or incidental lesions of the triangular fibrocartilage complex and the major interosseous ligaments in the wrist.

MATERIALS AND METHODS

In this retrospective study, we identified 89 patients and correlated MRI finding with subsequent arthroscopy. Triangular fibrocartilage complex abnormalities have been subdivided into disc lesions-central and radial-or ulnar-sided tears according to MRI appearances and surgical findings as the clinical and surgical approach is very different. Interosseous ligament tears were subdivided into partial or complete, highlighting the principle of recognising surgically relevant lesions.

RESULTS

For simple central to radial tears and perforations of the triangular fibrocartilage complex, MRI was 98.3% accurate. MRI identified all peripheral triangular fibrocartilage complex tears seen at arthroscopy; however, the specificity of 66.7% may reflect partly the use of arthroscopy limited to the radiocarpal joint. MRI proved 95.4% accurate for surgically relevant scapholunate interosseous ligament tears and was highly accurate at separating limited from complete lunotriquetral interosseous ligament tears showing 100% accuracy for complete tears.

CONCLUSIONS

The study shows excellent correlation between MRI and arthroscopic findings that determine surgical relevance with a very high sensitivity for triangular fibrocartilage complex lesions and accurate separation of minor versus surgically relevant ligamentous tears.

Assessing the scapholunate and lunotriquetral interosseous ligament in MR arthrography: Diagnostic advantages of paraxial reformatting

PURPOSE

The scapholunate (SLIL) and lunotriquetral interosseous ligament (LTIL) function as the main stabilizers of the proximal carpal row. Even with MR arthrography, component assessability is often limited in orthogonal standard planes due to their horseshoe-like shape and resulting partial volume effects. This study aims to investigate the diagnostic value of reformatting isotropic 3D sequences with respect to the anatomical orientation of the intrinsic carpal ligaments.

METHOD

In 110 MR arthrograms of the wrist, we investigated the diagnostic accuracy of two radiologists (R1/R2) for SLIL and LTIL injuries in orthogonal standard planes vs. ancillary angulated reformatting of isotropic 3D dual echo steady state sequence. Component assessability and diagnostic confidence were compared between datasets.

RESULTS

The addition of paraxial reformations improved diagnostic accuracy for lesions of the palmar (R1: 0.87 vs. 0.93; R2: 0.86 vs. 0.93; all p < 0.05) and dorsal LTIL (R1: 0.85 vs. 0.93; R2: 0.82 vs. 0.90; all p < 0.05). No significant increase in accuracy could be ascertained for palmar (R1: 0.92 vs. 0.94, p = 0.50; R2: 0.86 vs. 0.92, p = 0.07) and dorsal (R1: 0.95 vs. 0.95, p = 1.00; R2: 0.90 vs. 0.94, p = 0.29) lesions of the SLIL. Interrater reliability was almost perfect with and without angulated planes for SLIL (κ = 0.88 vs. 0.82) and LTIL assessment (κ = 0.88 vs. 0.86). For the LTIL, observer confidence and component assessability were superior with anatomical reformations available (all p < 0.05).

CONCLUSIONS

In contrast to SLIL injuries, diagnosis of LTIL lesions benefits from ancillary paraxial reformations of 3D sequences in MR wrist arthrography.

Initial experience with 3D isotropic high-resolution 3 T MR arthrography of the wrist

Background

Our study was performed to evaluate the image quality of 3 T MR wrist arthrograms with attention to ulnar wrist structures, comparing image quality of isotropic 3D proton density fat suppressed turbo spin echo (PDFS TSE) sequence versus standard 2D 3 T sequences as well as comparison with 1.5 T MR arthrograms.

Methods

Eleven consecutive 3 T MR wrist arthrograms were performed and the following sequences evaluated: 3D isotropic PDFS, repetition time/echo time (TR/TE) 1400/28.3 ms, voxel size 0.35x0.35x0.35 mm, acquisition time 5 min; 2D coronal sequences with slice thickness 2 mm: T1 fat suppressed turbo spin echo (T1FS TSE) (TR/TE 600/20 ms); proton density (PD) TSE (TR/TE 3499/27 ms). A 1.5 T group of 18 studies with standard sequences were evaluated for comparison. All MR imaging followed fluoroscopically guided intra-articular injection of dilute gadolinium contrast. Qualitative assessment related to delineation of anatomic structures between 1.5 T and 3 T MR arthrograms was carried out using Mann–Whitney test and the differences in delineation of anatomic structures among each sequence in 3 T group were analyzed with Wilcoxon signed-rank test. Quantitative assessment of mean relative signal intensity (SI) and relative contrast measurements was performed using Wilcoxon signed-rank test.

Results

Mean qualitative scores for 3 T sequences were significantly higher than 1.5 T (p < 0.01), with isotropic 3D PDFS sequence having highest mean qualitative scores (p < 0.05). Quantitative analysis demonstrated no significant difference in relative signal intensity among the 3 T sequences. Significant differences were found in relative contrast between fluid-bone and fluid-fat comparing 3D and 2D PDFS (p < 0.01).

Conclusions

3D isotropic PDFS sequence showed promise in both qualitative and quantitative assessment, suggesting this may be useful for MR wrist arthrograms at 3 T. Primary reasons for diagnostic potential include the ability to make reformations in any obliquity to follow the components of ulnar side wrist structures including triangular fibrocartilage complex. Additionally, isotropic imaging provides thinner slice thickness with less partial volume averaging allowing for identification of subtle injuries.

Wrist MRI Arthrogram v Wrist Arthroscopy: What are we Finding?

The aim of the study was to compare the radiological findings of wrist arthrogram with wrist arthroscopy. This allowed us to establish the accuracy (sensitivity, specificity) of MRI arthrogram as a diagnostic tool. Thirty patients (20 female and 10 male) have undergone both wrist MRI arthrogram and wrist arthroscopy over the last 3 years at a District General Hospital. The mean age at arthrogram was 42.4 years with an average 6.7 month interval between the two procedures.

The MRI arthrogram was reported by a consultant radiologist with an interest in musculoskeletal imaging and the arthroscopies performed by two upper limb surgeons. Patients who underwent both procedures were identified. The arthrogram reports and operation notes were examined for correlation. Three main areas of pathology were consistently examined: TFCC (triangular fibrocartilage complex), scapholunate and lunotriquetral ligament tears. The sensitivity and specificity of arthrogram was calculated for each. Other areas of pathology were also noted.

In the case of TFCC tears MRI arthrogram had 90% sensitivity and 75% specificity. The lunotriquetral ligament examination with this technique was 100% sensitivity and specificity. However for scapholunate ligament tears it only had 91% sensitivity and 88% specificity.

Wrist arthrogram and arthroscopy are both invasive techniques. In cost terms the arthrogram remains cheaper but is superseded by arthroscopy as it is both diagnostic and therapeutic.

MR arthrography of the wrist: controversies and concepts

Magnetic resonance arthrography (MRA) has become the preferred modality for imaging patients with internal derangement of the wrist. However, several aspects of MRA use need to be clarified before a standardized approach to the imaging of internal derangement of the wrist can be developed. The objective of the study is to evaluate the efficiency of different magnetic resonance (MR) sequences in the detection of lesions of the triangular fibrocartilage complex (TFCC) and scapholunate and lunotriquetral ligaments on direct MRA. Thirty-one consecutive direct magnetic resonance arthrographic examinations of the wrist using a wrist surface coil were performed for the assessment of the TFCC and intrinsic ligaments on a 1.5-T MR imaging system (Signa; 16 channel, Excite, GE Healthcare, Milwaukee, WI, USA). All patients had wrist pain, and in six cases, there was associated clinical carpal instability. The presence, location, and extent of TFCC, scapholunate ligament (SLL), and lunotriquetral ligament (LTL) lesions on T1 fat-saturated, multiplanar gradient recalled (MPGR) and short tau inversion recovery (STIR) images were identified, compared, and analyzed. Forty-one lesions of the TFCC, SLL, and LTL were visualized on contrast-sensitive (T1 fat-saturated) images in 23/31 (74.2%) patients. Twenty-one lesions of the TFCC and intrinsic ligaments were visualized on noncontrast-sensitive (MPGR and STIR) images (15 tears of the TFCC and six tears of the SLL and LTL). All of these lesions were seen on T1 fat-saturated images; 48.8% (20/41) lesions seen on T1 fat-saturated images (eight tears of TFCC and 12 tears of SLL and LTT) were not seen on MPGR and/or STIR images. Superior contrast resolution, joint distention, and the flow of contrast facilitate the diagnosis of lesions of the TFCC and intrinsic ligaments on contrast-sensitive sequences making MRA the preferred modality for imaging internal derangements of the wrist. Little agreement exists regarding the value and location of perforations of the intrinsic ligaments given that both traumatic and degenerative perforations may be symptomatic. Noncommunicating defects of the ulnar attachments of the triangular fibrocartilage (TFC), tears of the dorsal segment of the SLL, and defects at the lunate attachment of the SLL have a higher likelihood of being symptomatic and caused by trauma rather than by degenerative perforation. Although no consensus exists, it would appear that most arthrographies should be started with a radiocarpal injection. Injection into the distal radioulnar joint should be added if no communicational defects are visualized following radiocarpal injection in patients with ulnar-sided wrist pain.

Imagerie du poignet du sportif

Wrist imaging is currently used for diagnosis of sport injuries as part of a global strategy of rapid recovery. Standard x-rays are the first step in this procedure. Although arthrography is still the reference for the diagnosis of intrinsic ligament and cartilaginous lesions, MRI can sometimes be sufficient. Ultrasonography is a dynamic process and is accurate in detecting tendon injuries. Wrist sport injuries are frequent and often asymptomatic. Here we review the usual aspects of bone, ligament, and tendon lesions encountered in each sport, while providing advice on the most appropriate imaging for each clinical symptom.

Carpal instability

This review addresses the pathoanatomical basics as well as the clinical and radiological presentation of instability patterns of the wrist. Carpal instability mostly follows an injury; however, other diseases, like CPPD arthropathy, can be associated. Instability occurs either if the carpus is unable to sustain physiologic loads ("dyskinetics") or suffers from abnormal motion of its bones during movement ("dyskinematics"). In the classification of carpal instability, dissociative subcategories (located within proximal carpal row) are differentiated from non-dissociative subcategories (present between the carpal rows) and combined patterns. It is essential to note that the unstable wrist initially does not cause relevant signs in standard radiograms, therefore being "occult" for the radiologic assessment. This paper emphasizes the high utility of kinematographic studies, contrast-enhanced magnetic resonance imaging (MRI) and MR arthrography for detecting these predynamic and dynamic instability stages. Later in the natural history of carpal instability, static malalignment of the wrist and osteoarthritis will develop, both being associated with significant morbidity and disability. To prevent individual and socio-economic implications, the hand surgeon or orthopedist, as well as the radiologist, is challenged for early and precise diagnosis.

Ultrasonographic evaluation of normal extrinsic and intrinsic carpal ligaments: preliminary experience

OBJECTIVE

To determine normal anatomy of extrinsic and intrinsic carpal ligaments at ultrasonography (US).

DESIGN AND VOLUNTEERS

In the first part of the study, two musculoskeletal radiologists retrospectively reviewed in consensus the photographs of anatomic sections and dissections derived from 20 cadaveric wrists. This cadaveric study gave the two readers the opportunity to learn the anatomy and orientation of the various extrinsic and intrinsic carpal ligaments and, thus, to develop a US protocol to facilitate the recognition of each carpal ligament. In the second part of the study, these two radiologists prospectively and independently evaluated the visibility of extrinsic and intrinsic carpal ligaments in 30 wrists of volunteers, using the same US protocol.

RESULTS

With regard to extrinsic carpal ligaments, the radioscaphocapitate ligament (partially visible, 38%; completely visible, 62%), the radiolunotriquetral ligament (partially visible, 27%; completely visible, 73%), the palmar ulnotriquetral ligament (partially visible, 12%; completely visible, 88%), and the dorsal radiotriquetral ligament (partially visible, 7%; completely visible, 93%) were visualized at US. The dorsal ulnotriquetral ligament (partially visible, 21%; completely visible, 74%), the ulnolunate ligament (partially visible, 5%; completely visible, 70%), and the radial collateral ligament (partially visible, 18%; completely visible, 12%) were more difficult to recognize. The radioscapholunate ligament was never seen. With regard to intrinsic carpal ligaments, the dorsal (partially visible, 11%; completely visible, 89%) and palmar (partially visible, 38%; completely visible, 62%) scaphotriquetral ligaments as well as the dorsal scapholunate ligament (partially visible, 3%; completely visible, 97%) were visualized at US. The dorsal lunotriquetral ligament (partially visible, 39%; completely visible, 61%) and the palmar scapholunate ligaments (partially visible, 12%; completely visible, 81%) were more difficult to recognize.

CONCLUSION

US may be helpful in identifying the major extrinsic and intrinsic carpal ligaments.

Second metatarsophalangeal joint arthrography: a cadaveric correlation study

Arthrography of the second metatarsophalangeal joint is an important diagnostic tool to evaluate the integrity of the plantar plate and to aid in the decision process for surgical intervention. A variety of filling patterns have been identified with lesser metatarsophalangeal joint arthrography and their significance with soft-tissue pathology remains to be completely understood. The purpose of this cadaveric study was to evaluate dye patterns in a series of arthrograms of the second metatarsophalangeal joint and to correlate them with identifiable anatomic lesions or structural variants. Thirty-nine cadaveric specimens (including 28 matched pairs) underwent second metatarsophalangeal joint arthrography with a colored radiopaque dye. Arthrographic findings were observed and recorded. Specimens exhibiting dye extravasation outside of the capsular constraints of the joint were dissected to discover any soft-tissue abnormalities. Twenty-one percent of specimens exhibited abnormal extravasation of dye outside of the joint capsule. A plantar plate tear was identified in 2 of these specimens. Filling of the first intermetatarsophalangeal bursa occurred in 6 specimens. However, because this finding was identified in 2 matched pairs, an anatomic variance is suggested rather than a pathologic entity. This cadaveric study shows that anatomic variances exist concerning the second metatarsophalangeal capsule and that arthrography should be correlated with the clinical scenario.

Carpal bone postures and motions are abnormal in both wrists of patients with unilateral scapholunate interosseous ligament tears

PURPOSE

The recent ability to measure 3-dimensional in vivo carpal kinematics has facilitated the noninvasive study of complex carpal bone motion.

METHODS

In this study we examined the flexion/extension carpal kinematics of both wrists in 8 patients with unilateral scapholunate interosseous ligament (SLIL) tears by using computed tomographic (CT) imaging and a markerless bone registration technique. Carpal bone neutral posture and flexion/extension motion of both wrists of the injured patients were compared with the same parameters in wrists of 10 uninjured male and female volunteers (normals).

RESULTS

The neutral posture of the injured scaphoid and lunate were significantly more extended than those of normals. In these patients, however, the postures of the scaphoid and lunate in the contralateral uninjured wrists also were abnormal and were similar to those of the injured wrist. In addition, extension of the lunate and flexion of the scaphoid in both the injured and uninjured wrist were significantly different from normal but not different from each other.

CONCLUSIONS

This study was unable to attribute altered carpal posture and motion to SLIL tears because abnormalities were found in both wrists of patients with unilateral injury. The etiology of abnormal wrist kinematics in the asymptomatic wrist of patients with unilateral tears of the scapholunate ligament is not known.

Advances in the in vivo measurement of normal and abnormal carpal kinematics

This article presents the development of an in vivo, three-dimensional methodology using markerless bone registration for examining the normal and abnormal kinematics of the wrist carpal bones. The resulting descriptions of three-dimensional kinematics from healthy patients and patients with documented unilateral scapholunate interosseous ligament injuries are briefly presented.

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.

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.

Evaluation of chronic wrist pain

Chronic wrist pain remains a challenge to diagnose and treat. A thorough history and physical examination are key. Various imaging techniques are essential to the evaluation of the patient with chronic wrist pain. Standard radiography, computed tomography, cinearthrography, magnetic resonance imaging, radionuclide imaging, arthroscopy, and arteriography all may have a role in assessment, and the orthopaedic surgeon should be familiar with the indications, strengths, and weaknesses of each. Laboratory tests may also be useful in evaluation. No all-inclusive algorithm can be applied in this setting; therefore, the physician must rely on his or her diagnostic acumen to successfully assess and treat chronic wrist pain.

Wrist arthrography today

In recent years, wrist arthrography has been criticized for having low sensitivity and low specificity. This largely has been due to widely varying and less than rigorous technique and the reliance on criteria for abnormality that are now known to be invalid. Other criticisms have included the length of time needed to perform a three-compartment arthrogram with or without comparison to the contralateral side and the radiation dose to the patient. It is our belief, however, that with the use of the patient's history, symptoms and physical examination to develop a focused examination strategy, and with the use of digital equipment, the examination can be performed quickly and with minimal radiation dose to the patient. In order to improve the accuracy of arthrography, the radiologist must abandon the concept that simply identifying a communicating defect between the carpal compartments is a criterion for abnormality. He or she must utilize a meticulous approach to determine the site of communication to evaluate the features of the defects in order to determine the significance of the defect. As more is learned about the nature of traumatic and attritional defects and with further technologic advancements in cross-sectional imaging and three-dimensional rendering, it is quite possible that arthrographic imaging of the wrist will experience a resurgence of interest in the evaluation of posttraumatic wrist pain, avoiding the fate of such examinations as pneumoencephalography and oral cholecystography as many have predicted.

Triangular fibrocartilage and intercarpal ligaments of the wrist: does MR arthrography improve standard MRI?

The objective of this study was to assess the value of adding MR arthrography to standard MRI for patients with chronic wrist disorders. Thirty consecutive patients (age range, 19-73 years; mean, 36.2 years) were included in the investigation. The images were evaluated blindly and separately by two radiologists with regard to lesions of the scapholunate (SL) and lunotriquetral (LT) ligaments and the triangular fibrocartilage (TFC). Conventional two- or three-compartment arthrography was used as the standard of reference. For TFC lesions, standard MR images had a sensitivity of 92.3% (reader 1) and 84.6% (reader 2) and a specificity of 41.2% (reader 1) and 52.9% (reader 2). For MR arthrography, sensitivity was 84.6% (reader 1) and 84.6% (reader 2) and specificity was 88.2% (reader 1) and 100% (reader 2). For SL ligament tears, standard MRI had a sensitivity of 33.3% (reader 1) and 11.1% (reader 2) and a specificity of 47.6% (reader 1) and 57.1% (reader 2). For MR arthrography, sensitivity was 66.7% (reader 1) and 55.6% (reader 2) and specificity was 52.4% (reader 1) and 81.0% (reader 2). For LT ligament tears, standard MRI had a sensitivity of 28.6% (reader 1) and 35.7% (reader 2) and a specificity of 93.8% (reader 1) and 81.3% (reader 2). For MR arthrography, sensitivity was 35.7% (reader 1) and 23.1% (reader 2) and specificity was 93.8% (reader 1) and 94.1% (reader 2). In conclusion, the diagnostic performance of MRI in suspected lesions of the TFC and the SL and LT ligaments is improved by adding MR arthrography to the standard examination.