Figure 22 - uploaded by David Linkous
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Normal radiocarpal arthrogram demonstrates the dorsal recess (thin black arrows), prestyloid recess (white arrowhead), ventral scaphoid recess (black arfowheads), and ventral radial recess (thick black arfow).
Source publication
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 ar...
Citations
... Injection technique for arthrography of the wrist has been described using a single (radiocarpal), double (radiocarpal and midcarpal or radiocarpal and distal radioulnar) or triple (midcarpal, radiocarpal and distal radioulnar joint [DRUJ]) compartment approach [26,27]. Fluoroscopy, at the cost of low-dose ionizing radiation, provides both precise needle guidance and dynamic evaluation of contrast passage between the multiple compartments of the wrist joint. ...
Ligamentous injuries of the pediatric wrist, once thought to be relatively uncommon, are increasingly recognized in the context of acute high-energy mechanism trauma and chronic axial loading, including those encountered in both recreational and high-performance competitive sports. Recent advances in MR-based techniques for imaging the pediatric wrist allow for sensitive identification of these often radiographically occult injuries. Detailed knowledge of the intrinsic and supportive extrinsic ligamentous complexes, as well as normal developmental anatomy and congenital variation, are essential to accurately diagnose injuries to these structures. Early identification of ligamentous injury of the pediatric wrist is essential within the conservative treatment culture of modern pediatric orthopedics because treatment of these lesions often necessitates surgery, and outcomes often depend on early and sometimes aggressive intervention. In this article, we review MR arthrogram technique and pediatric wrist anatomy, and correlate appearances on MR and selected ligamentous pathologies of the pediatric wrist.
... 8 Historically, tricompartment wrist arthrography has been the gold standard for evaluating the intrinsic wrist ligaments. 9 However, at our institution, tricompartment wrist arthrography is not routinely requested. This may be because of time constraints and/or the questionable clinical value of the diagnosis of small intrinsic ligament tears. ...
... The three-compartment arthrogram (DRUJ, radiocarpal and midcarpal joint injection) was considered the standard technique to evaluate the integrity of TFCC and interosseous ligaments by earlier authors. [21,22] However, subsequent authors described a false-negative rate of only 2% for complete perforations and 10% for complete and partial perforations together for single-compartment arthrograms of the radiocarpal joint. [1,23] We achieved a technical success rate of 100% for radiocarpal joint injection, and apart from mild pain lasting a few hours, no other complication was encountered. ...
Aims:
To compare conventional magnetic resonance imaging (MRI) and direct magnetic resonance (MR) arthrography in the evaluation of triangular fibrocartilage complex (TFCC) and intrinsic wrist ligament tears.
Materials and Methods:
T1-weighted, fat suppressed (FS) proton density plus T2-weighted (FS PD/T2), 3D multiple-echo data image combination (MEDIC) sequences and direct MR arthrography were performed in 53 patients with wrist pain. Images were evaluated for the presence and location of TFCC, scapholunate ligament (SLL) and lunatotriquetral ligament (LTL) tears, and imaging findings were compared with operative findings in 16 patients who underwent arthroscopy or open surgery (gold standard).
Results:
Sixteen patients underwent arthroscopy/open surgery: 12 TFCC tears were detected arthroscopically out of which 9 were detected on FS PD/T2 sequence, 10 on MEDIC sequence, and all 12 were detected on MR arthrography. The sensitivities of FS PD/T2, MEDIC sequences, and MR arthrography in the detection of TFCC tears were 75%, 83.3%, and 100%, respectively. Out of the eight arthroscopically confirmed SLL tears, three tears were detected on FS PD/T2 sequence, five on MEDIC sequence, and all eight were visualized on MR arthrography. The sensitivities of FS PD/T2, MEDIC sequences, and MR arthrography in detecting SLL tears were 37.5%, 62.5%, and 100%, respectively. One arthroscopically confirmed LTL tear was diagnosed on FS PD/T2 sequence, three on MEDIC sequence, and all five arthroscopically confirmed LTL tears were detected with MR arthrography. The sensitivities of PD, MEDIC sequences, and MR arthrography in detecting LTL tears were 20%, 40%, and 100%, respectively.
Conclusions:
MR arthrography is the most sensitive and specific imaging modality for the evaluation of wrist ligament tears.
... Wrist arthrography is an important diag- nostic tool in the evaluation of wrist pain or instability. A variety of diagnostic algorithms exist including conventional radiography, nonathrographic wrist MRI, and wrist ar- thrography using single-compartment, dou- ble-compartment, or triple-compartment in- jections that may be supplemented with MRI or CT [1][2][3][4]8]. ...
Objective:
We describe a technique of radiocarpal arthrography using the lateral approach. This technique may be used as an alternative to conventional dorsal techniques.
Conclusion:
Radiocarpal injection using the lateral approach can be considered as an alternative to conventional dorsal approaches in the evaluation of wrist pain and instability.
... 46,47 Wrist arthrography can be performed using a single-compartment (radiocarpal), double-compartment (radiocarpal and midcarpal or radiocarpal and distal radioulnar), or triple-compartment (midcarpal, radiocarpal, and distal radioulnar joint[DRUJ]) injection technique. 48 This procedure is generally performed under fluoroscopic guidance, but other techniques such as US, CT, or MR may also be used for needle placement. 49,50 Different sites can be chosen for midcarpal and radiocarpal joint injection. ...
... Extension of contrast medium into the radiocarpal joint suggests a scapholunate or a lunotriquetral ligament degeneration, and communication between scapholunate and lunotriquetral articulations is frequently found. 48 Radiocarpal joint injection can be performed simply using a palpable landmark without imaging guidance. This palpable landmark is an anatomic sulcus between the extensor pollicis longus and the index finger extensor digitorum communis tendon. ...
Joint injection is a useful tool in the diagnosis of intra-articular pathology that may improve diagnostic performance of computed tomography (CT) and magnetic resonance (MR) imaging. Historically, conventional arthrography under fluoroscopy was the first method to be used to image indirectly the intra-articular soft tissues, but with the advent of CT, CT arthrography offered better soft tissue depiction. The development of conventional MR allowed even better visualization of soft tissues, and in the early 1990s, MR arthrography surpassed CT arthrography in popularity. Joint injections may also be performed for therapeutic reasons with different drugs, such as corticosteroids, anesthetics, or hyaluronic acid, which have been shown to provide pain relief in various circumstances. In this article, the technical principles for joint injection of the shoulder, knee, elbow, hip, ankle, and wrist, used for therapeutic or diagnostic reasons, are discussed. Indications, expected benefits, and risks are also analyzed.
... Sonographic, CT, or MR imaging guidance may be also used [12 – 14]. Multiple sites can be selected to successfully distend the midcarpal and radiocarpal joints (Fig. 1) [15]. The injection site of choice should be on the side of the patient's wrist opposite the symptoms to help distinguish iatrogenic spill into the dorsal soft tissues from a true capsular disruption. ...
... The injection site of choice should be on the side of the patient's wrist opposite the symptoms to help distinguish iatrogenic spill into the dorsal soft tissues from a true capsular disruption. Injection sites for the midcarpal compartment include the distalmost scaphocapitate and triquetrohamate spaces [15]. Injection should continue until the contrast is readily visualized in the capitolunate joint space. ...
... Alternatively, the needletip can be directed into the proximal scaphoid at the margin of the radial styloid. Contrast generally fills the dorsal recess of the radiocarpal joint; however, care must be taken not to inject the area from the scaphoid distal to the scaphoid tubercle or inadvertent filling of the midcarpal joint may occur [15] The radiocarpal joint communicates with the pisotriquetral joint in 34% to 70% of patients. The DRUJ surrounds the head of the ulna and extends to, but does not include, the ulnar aspect of the radius. ...
MR imaging of the wrist frequently represents a diagnostic challenge for radiologists because of the complex anatomy of this joint, small size of its components, and little known pathologic conditions. MR arthrography combines the advantages of conventional MR imaging and arthrography by improving the visualization of small intra-articular abnormalities. This article reviews the current role of MR arthrography in the evaluation of wrist joint disorders considering the relevant aspects of anatomy, techniques, and applications.
... L'arthro-IRM améliore significativement les performances de l'IRM dans le diagnostic de ces lésions (fig. 24 et 25)(85)(86)(87)(88)(89)(90). En ce qui concerne l'étude du complexe fibrocartilagineux triangulaire, l'IRM simple présente des performances satisfaisantes et il n'est pas certain que l'arthro-IRM lui soit supérieure(88). ...
D Loeuille (2), S Iochum (1), R Kohlmann (1), B Grignon (1) et H Coudane (3) ABSTRACT MR-arthrography: general principles and applications The recent approval by the French Ministry of Health of the use of intra-articular Gadolinium could promote the increasing use of MR-arthrography in France. Although useful in specific pathologies, it should not be overly prescribed and should be considered only if it provides a more accurate diagnosis than other less invasive techniques. The technical aspects and medico-legal implications of MR-arthrography as well as its various indications are reviewed in this article. There are three possible techniques : indirect MR-arthrography with IV Gadolinium injection, direct MR-arthrography with intra-articular Gadolinium injection and lastly, direct MR-arthrography with intra-articular injection of iodinated contrast media (or saline solution). Indirect MR-arthrography cannot be recommended because of insufficient contrast enhancement and the absence of joint filling. Conversely, direct MR-arthrography allows joint expansion which smooths out capsule and liga-ments, better delineates articular surfaces and yields a homogeneous high intensity signal of the entire joint. Direct MR-arthrography with iodinated contrast media combines standard arthrography with conventional MRI. Direct MR-arthrography with intra-articular injection of dilute Gadolinium is associated with T1WI, usually of higher quality than T2WI, even though the latter remains part of the protocol. Although, the last two techniques yield higher image quality and are often performed for various articular pathologies, they should not be randomly carried out in the evaluation of joint pathology. However, they should be recommended as the first step in the diagnosis of painful shoulders or hips in young adults and athletes. RÉSUMÉ L'octroi récent de l'autorisation de mise sur le marché (AMM) pour l'utilisation intra-articulaire du Gadolinium pourrait facili-ter la diffusion de l'arthro-IRM en France mais l'intérêt de cette technique, évident dans certaines pathologies, ne doit pas conduire à sa prescription irraisonnée. Elle ne devrait être envisagée que si elle se révèle plus performante que les autres techniques d'imagerie ostéo-articulaire. Trois méthodes sont utilisées : l'arthro-IRM indirecte au Gadolinium, l'arthro-IRM directe au Gadolinium et l'arthro-IRM aux produits de contraste iodés (ou au sérum physiologique). L'arthro-IRM indirecte, en raison de ses limites importantes et de sa valeur diagnostique incertaine, ne présente pas grand intérêt. Les arthro-IRM directes s'accompagnent d'un remplissage articulaire qui déplisse les structures capsulo-ligamentaires, souligne les surface articulaires et procure un signal intense et homogène dans toute l'articulation. L'arthro-IRM aux produits de contraste iodé est l'association synergique de deux techniques éprouvées, l'arthrographie et l'IRM réalisées de façon conventionnelle. L'injection intra-articulaire de Gadolinium est associée à la production de séquences pondérées T1, en général de meilleure qualité que les séquences pondérées T2 mais ces dernières restent indispensables. Les meilleures indications de l'arthro-IRM sont représentées par l'épaule et la hanche douloureuse du sportif ou de l'adulte jeune.
... The technique of wrist arthrography in this study was standard for all patients and follows the technique outlined by Linkous and Gilula (19). For each injection, the hand was secured in a pronated position, and the skin along the dorsal aspect of the wrist was prepared and draped by using an aseptic technique. ...
To determine whether the sizes and locations of scapholunate ligamentous communicating defects are different in symptomatic and asymptomatic cases.
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.
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).
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.
... If no communicating defect was shown, then the radiocarpal joint also was injected to evaluate for a one-way TFC defect. The detailed technique has been described previously (13). Special attention was paid to profiling the inner surface of the base of the ulnar styloid process (the fovea) and the ulnocarpal space (Fig 1), with cranial-caudal and radial-ulnar tilting of the image intensifier to optimally evaluate the TFC and its peripheral attachment sites. ...
To characterize triangular fibrocartilage (TFC) defects in symptomatic and contralateral asymptomatic wrists.
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.
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.
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.
The majority of wrist diseases seen in clinical practice relate to joints, tendons, and neurologic injuries and diseases. This, in combination with the superficial location of the anatomic structures, makes ultrasound an ideal imaging modality for interrogation of the region and guidance of therapeutic procedures. While the anatomy of the wrist may be complex, mastery of diagnostic and ultrasound-guided procedures can be attained through regular review of regional diseases and injuries along with the application of basic procedural techniques.
