Figure 1 - uploaded by George S I Sulkers
Content may be subject to copyright.
Wrist cineradiography PA series, dynamic SLD. Maximal radial abduction to maximal ulnar abduction. Note the clear widening in the middle image.
Source publication
Ruptures of the scapholunate ligament (SLL) may cause carpal instability, also known as scapholunate dissociation (SLD). SLD may lead to osteoarthritis of the radiocarpal and midcarpal joints. The aim of this retrospective study was to determine the diagnostic value of wrist cineradiography in detecting SLD. All cineradiographic studies made during...
Context in source publication
Context 1
... cause a transarticular dissociation known as a scapholunate dissociation (SLD) (Garcia-Elias et al., 1995; Short et al., 2007; Watson and Ballet, 1984). SLD can be classified as dynamic SLD or static SLD (Chennagiri and Lindau, 2013; Cooney et al., 1990; Larsen et al., 1995; Short et al., 2007). Dynamic SLD causes a distortion of the scaphoid and lunate bones only during motion and return to their normal posi- tion at rest (Schmitt et al., 2006). This explains why dynamic SLD is frequently missed on conventional radiographs (Adolfsson and Povlsen, 2004; Hohendorff et al., 2012; Koh et al., 2012; Slutsky, 2008). Early recognition and consequently treatment of a dynamic SLD may prevent a static SLD, which in turn, may lead to degenerative attritional changes of the radiocarpal and eventually the midcarpal joint (O’Meeghan et al., 2003; Watson and Ballet, 1984). With a sensitivity of 69% and specificity of 64–68% (Marx et al., 1999), the scaphoid shift test (Watson et al., 1988) has been shown to be a poor test in detecting SLD. Therefore, additional imaging studies are needed for diagnosing or disclosing SLD. To diagnose dynamic SLD suggests the need for a dynamic radiodiagnostic technique. Wrist cineradi- ography is the only real-time radiological tool that can visualize bones in motion. This should be able to identify the absence or presence of synchronous movements between the scaphoid and lunate within their row. Therefore, cineradiography should be able to investigate the function of the SLL and, conse- quently, should be able to make a distinction between a dynamic and static SLD. The aim of this retrospective study was to deter- mine the diagnostic value of wrist cineradiography in detecting dynamic and static SLD. This retrospective study was performed at a tertiary care centre for hand and wrist surgery. Records of all consecutive wrist cineradiographies performed in patients with both acute and chronic complaints between July 1987 and May 2011 were reviewed. All patients with suspected carpal instability or wrist lig- ament injury received a wrist cineradiography during this period. Carpal surgery is considered the best confirmation method for diagnosing SLL injuries (Dohi et al., 2012). All patients who had wrist cinera- diography followed by carpal surgery (wrist arthros- copy and/or arthrotomy) were included. In these patients medical history, radiology reports of the cineradiographies, and reports from arthros- copy and/or arthrotomy were reviewed. We excluded cineradiographies of patients who had prior wrist surgery and patients familiar with skeletal and/or connective tissue disorders (e.g., rheumatoid arthri- tis). When patients met the inclusion criteria, we reviewed all conventional radiographies of the included patients. Outcomes of wrist cineradiography (primary objective) and conventional radiography (secondary objective) were compared with the confir- mation method. Wrist cineradiographies were performed by a radi- ologist following a strict protocol that was imple- mented ever since our institution started to use wrist cineradiography as a diagnostic tool. The borders of the field of view were defined proximally with the distal radius and ulna at the level proximal to the distal radioulnar joint (DRUJ) and distally with the first third of the metacarpal bones. Movements of the carpal bones were recorded on videotape, DVD, or digitally in picture archiving and communi- cation system (PACS; Philips Medical Systems, Best, The Netherlands). To familiarize the patient with the examination and compare the injured to the non- injured wrist, the non-injured wrist was examined first. To reach a maximum range of motion, passive flexion/extension and radial/ulnar deviation were performed in both lateral and posteroanterior (PA) projections with continuous fluoroscopy. Additionally, we performed the midcarpal shift test in both direc- tions. Cineradiography was considered positive if the movement of the scaphoid and lunate bones was not synchronous and/or a diastasis between the two bones could be provoked (Figure 1 and 2). On the lat- eral projections, cineradiography was positive when the lunate did not move synchronously with the scaphoid during flexion. The results of the test were reported and stored in the patient record by the radiologist who performed the cineradiography. In this study, we relied on the radiology reports made by the radiologist. Conventional radiographs were made in PA (Figure 3) and lateral views. All measurements were performed in a picture archiving and information system envi- ronment, where all radiographs are stored digitally. Radiographs were considered positive for SLD when a minimum of one of the following was seen: a widened SL gap ( ≥ 3 mm) (Kuo and Wolfe, 2008), increased SL angle ( ≥ 60°) (Garcia-Elias et al., 1995; Megerle et al., 2011), or increased RL angle ( ≥ 12°). Additionally, the “cortical ring sign”, which is a sign ...
Similar publications
Background Scapholunate (SL) interosseus ligament injuries detected at an early stage could allow the surgeon to prevent progression through the spectrum of injury that leads to instability, and eventually osteoarthritis. We contend that early instability following injury can be detected by visualizing the relative motions and distances between the...
Citations
... On plain radiography and fluoroscopy, a SLJW of up to 2 mm is considered normal, while values exceeding 3 mm are indicative of an SL lesion [22,23]. For dynamic fluoroscopy, a sensitivity of 90% and a specificity of 97% has been reported for the detection of carpal instability [24]. In our study, measurements at the medial bone points closely approximated the joint width considered normal on plain radiography and dynamic fluoroscopy, suggesting that future research might consider measurements at the medial landmark to be the most accurate. ...
Introduction:
The scapholunate interosseous ligament is pivotal for wrist stability, and its impairment can result in instability and joint degeneration. This study explores the application of real-time MRI for dynamic assessment of the scapholunate joint during wrist motion with the objective of determining its diagnostic value in efficacy in contrast to static imaging modalities.
Materials and methods:
Ten healthy participants underwent real-time MRI scans during wrist ab/adduction and fist-clenching maneuvers. Measurements were obtained at proximal, medial, and distal landmarks on both dynamic and static images with statistical analyses conducted to evaluate the reliability of measurements at each landmark and the concordance between dynamic measurements and established static images. Additionally, inter- and intraobserver variabilities were evaluated.
Results:
Measurements of the medial landmarks demonstrated the closest agreement with static images and exhibited the least scatter. Distal landmark measurements showed a similar level of agreement but with increased scatter. Proximal landmark measurements displayed substantial deviation, which was accompanied by an even greater degree of scatter. Although no significant differences were observed between the ab/adduction and fist-clenching maneuvers, both inter- and intraobserver variabilities were significant across all measurements.
Conclusions:
This study highlights the potential of real-time MRI in the dynamic assessment of the scapholunate joint particularly at the medial landmark. Despite promising results, challenges such as measurement variability need to be addressed. Standardization and integration with advanced image processing methods could significantly enhance the accuracy and reliability of real-time MRI, paving the way for its clinical implementation in dynamic wrist imaging studies.
... Dynamic imaging modalities such as stress radiography or wrist cineradiography suffer from numerous limitations, however, including exposure to ionizing radiation, lack of direct soft tissue visualization, and the fact that 2D projections are used to assess 3D structures. These limitations have led to only moderate diagnostic accuracy and reproducibility [6] and prevented widespread clinical adoption [2,3,7]. ...
Objective
Clinical-standard MRI is the imaging modality of choice for the wrist, yet limited to static evaluation, thereby potentially missing dynamic instability patterns. We aimed to investigate the clinical benefit of (dynamic) real-time MRI, complemented by automatic analysis, in patients with complete or partial scapholunate ligament (SLL) tears.
Material and methods
Both wrists of ten patients with unilateral SLL tears (six partial, four complete tears) as diagnosed by clinical-standard MRI were imaged during continuous active radioulnar motion using a 1.5-T MRI scanner in combination with a custom-made motion device. Following automatic segmentation of the wrist, the scapholunate and lunotriquetral joint widths were analyzed across the entire range of motion (ROM). Mixed-effects model analysis of variance (ANOVA) followed by Tukey’s posthoc test and two-way ANOVA were used for statistical analysis.
Results
With the increasing extent of SLL tear, the scapholunate joint widths in injured wrists were significantly larger over the entire ROM compared to those of the contralateral healthy wrists ( p <0.001). Differences between partial and complete tears were most pronounced at 5°–15° ulnar abduction ( p <0.001). Motion patterns and trajectories were altered. Complete SLL deficiency resulted in complex alterations of the lunotriquetral joint widths.
Conclusion
Real-time MRI may improve the functional diagnosis of SLL insufficiency and aid therapeutic decision-making by revealing dynamic forms of dissociative instability within the proximal carpus. Static MRI best differentiates SLL-injured wrists at 5°–15° of ulnar abduction.
... If a SL tear is clinically suspected and depending on intra-individually different institutional standard operating procedures, static radiography may be supplemented by dynamic radiography, e.g. in radial/ulnar duction as in the underlying study. In the presented study, diagnostic accuracy of plain radiography was highest using a cut-off at 3 mm, e.g. a sensitivity of 77% and a specificity of 80% for the discrimination of SL tears Geissler's stage ≤ 2 and > 2. This coincides with results in the literature reporting a sensitivity of 81% and a specificity of 80% [21] for the detection of SL dissociation in radiography. ...
Not diagnosed or mistreated scapholunate ligament (SL) tears represent a frequent cause of degenerative wrist arthritis. A newly developed deep learning (DL)-based automated assessment of the SL distance on radiographs may support clinicians in initial image interpretation.
A pre-trained DL algorithm was specifically fine-tuned on static and dynamic dorsopalmar wrist radiography (training data set n = 201) for the automated assessment of the SL distance. Afterwards the DL algorithm was evaluated (evaluation data set n = 364 patients with n = 1604 radiographs) and correlated with results of an experienced human reader and with arthroscopic findings.
The evaluation data set comprised arthroscopically diagnosed SL insufficiency according to Geissler’s stages 0–4 (56.5%, 2.5%, 5.5%, 7.5%, 28.0%). Diagnostic accuracy of the DL algorithm on dorsopalmar radiography regarding SL integrity was close to that of the human reader (e.g. differentiation of Geissler’s stages ≤ 2 versus > 2 with a sensitivity of 74% and a specificity of 78% compared to 77% and 80%) with a correlation coefficient of 0.81 (P < 0.01).
A DL algorithm like this might become a valuable tool supporting clinicians’ initial decision making on radiography regarding SL integrity and consequential triage for further patient management.
... In most cases the ballottement test is used to assess the stability of the DRUJ. SLD can be assessed with wrist cineradiography with a described sensitivity of 90% and a specificity of 97% (Sulkers et al., 2014). ...
... Cineradiography was considered to be positive for a SLD if the scaphoid and lunate did not move synchronously in either of the views or if a gap appeared between the bones during motion. In the lateral view, cineradiography was considered to be positive if the lunate did not cross the 0 line of the radiolunate angle from extension to flexion (Cheriex et al., 2017;Sulkers et al., 2014). Static and dynamic SLD were both considered to be SL unstable. ...
Instability of the distal radioulnar joint and scapholunate dissociation may cause pain, functional impairment and subsequent arthrosis. There is no consensus about whether these injuries should be treated acutely in patients undergoing surgery for distal radial fractures. We conducted a prospective cohort study to determine whether concomitant distal radioulnar joint instability or scapholunate dissociation negatively influence patient-related outcomes in these patients. The primary outcome was the patient-reported wrist/hand evaluation at 6 and 12 months after surgery. Out of 62 patients, 58% and 27% had intraoperative distal radioulnar joint instability and scapholunate dissociation, respectively. No significant differences were found in patient-reported scores at follow-up between patients with stable and unstable distal radioulnar joints, nor between patients with and without scapholunate dissociation. Sixty-three per cent of patients with an unstable distal radioulnar joint during surgery were stable on retesting after 6 months. Our study suggests that a wait-and-see policy in these patients therefore seems reasonable.
Level of evidence: III
... Dynamic fluoroscopy enables the wrist to be moved through a range of motion and identify dynamic changes in real-time. Dynamic fluoroscopy has proven to have a sensitivity of 90%, a specificity of 97% and a diagnostic accuracy of 93% [31] in diagnosing SLI. ...
Scapholunate instability (SLI) is the most common carpal instability described. SLI leads to a degenerative arthritic pattern known as scapholunate advanced collapse (SLAC). Diagnosis of SLI can be challenging in pre-dynamic and dynamic stages. CT arthrogram, MR arthrogram and dynamic fluoroscopy are helpful in diagnosis while arthroscopy remains the gold standard. SLI is a multi-ligament injury, which involves not only the scapholunate interosseous ligament (SLIL) but also the extrinsic carpal ligaments. Hence, it is better described as an injury compromising the 'dorsal scapholunate(dSLL) complex'. A repair can be attempted for acute SLI presenting within 6 weeks of injury. Reconstruction is the mainstay of treatment for chronic SLI without degenerative changes. Multiple repair techniques have been described which include capsulodesis and tenodesis procedures. The clinical outcomes of the techniques have improved over the years. However, a common problem of all these techniques is the lack of long-term data on the outcomes and deteriorating radiological parameters over time. SLI staging is an important factor to be considered in choosing the reconstruction techniques for a better outcome. Currently, there is a trend towards more biological and less invasive techniques. Regardless of the technique, it is important to preserve the nerve supply of the dorsal capsuloligamentous structures of the wrist. Arthroscopic techniques being minimally invasive have the advantage of less collateral damage to the capsuloligamentous structures. Rehabilitation involves a team approach where a protected dart thrower's motion is allowed after a period of immobilization. Strengthening SL-friendly muscles and inhibiting SL-unfriendly muscles is a key principle in rehabilitation.
... 6,18 SLIL injury may be undetectable with traditional radiographs. [19][20][21][22] Static three-dimensional (3D) modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI), may help to detect carpal malalignment; however, they cannot demonstrate carpal displacement during motion. MRI lacks sensitivity or specificity for detecting partial injuries or attenuation within the ligament. ...
... MRI lacks sensitivity or specificity for detecting partial injuries or attenuation within the ligament. 7,17,19 Two-dimensional modalities can be acquired dynamically to demonstrate carpal motion, 8,19,20 but fluoroscopy is limited by anatomic overlap. More invasive procedures, such as wrist arthroscopy, may be used to diagnose instabilities. ...
Background In predynamic or dynamic scapholunate (SL) instability, standard diagnostic imaging may not identify SL interosseous ligament (SLIL) injury, leading to delayed detection and intervention. This study describes the use of four-dimensional computed tomography (4DCT) in identifying early SLIL injury and following injured wrists to 1-year postoperatively.
Description of Technique 4DCT acquires a series of three-dimensional volume data with high temporal resolution (66 ms). 4DCT-derived arthrokinematic data can be used as biomarkers of ligament integrity.
Patients and Methods This study presents the use of 4DCT in a two-participant case series to assess changes in arthrokinematics following unilateral SLIL injury preoperatively and 1-year postoperatively. Patients were treated with volar ligament repair with volar capsulodesis and arthroscopic dorsal capsulodesis. Arthrokinematics were compared between uninjured, preoperative injured, and postoperative injured (repaired) wrists.
Results 4DCT detected changes in interosseous distances during flexion-extension and radioulnar deviation. Generally, radioscaphoid joint distances were greatest in the uninjured wrist during flexion-extension and radioulnar deviation, and SL interval distances were smallest in the uninjured wrist during flexion-extension and radioulnar deviation.
Conclusion 4DCT provides insight into carpal arthrokinematics during motion. Distances between the radioscaphoid joint and SL interval can be displayed as proximity maps or as simplified descriptive statistics to facilitate comparisons between wrists and time points. These data offer insight into areas of concern for decreased interosseous distance and increased intercarpal diastasis. This method may allow surgeons to assess whether (1) injury can be visualized during motion, (2) surgery repaired the injury, and (3) surgery restored normal carpal motion.
Level of Evidence Level IV, Case series.
... Cineradiography makes dynamic assessment of the wrist possible. However, the 2D nature of this method limits it to diagnose complex pathologies like carpal instabilities (Sulkers et al., 2014). The gold standard for diagnosing ligament injuries is wrist arthroscopy, this is however an invasive technique. ...
Wrist pathology is often diagnosed by using the contralateral wrist as a comparison of baseline motion and strength. However, recent range of motion studies suggest that females have different carpal motion patterns compared to males and that the dominant carpal bones have different motion patterns. The purpose of this study is to evaluate the effect of sex and hand dominance on in vivo kinematics of the scaphoid, lunate and capitate using four-dimensional computed tomography (4D-CT) analysis in healthy uninjured volunteers. In this prospective study, both wrist of 20 uninjured Caucasian volunteers (11 men and 9 women) were assessed using 4D-CT during active flexion-extension and radial-ulnar deviation. A linear mixed model was used to compare the carpal motion patterns. Sex had no influence on carpal kinematics. Hand-dominance in males did have a significant effect on carpal kinematics. During flexion-extension of the male wrist, more radial-ulnar deviation of the lunate, scaphoid and capitate of the non-dominant hand was seen. During radial-ulnar deviation of the male wrist, radial-ulnar deviation and pro-supination of the lunate was more in the dominant hand.
This study provides a better understanding of carpal kinematics and the effect of sex and hand-dominance on the scaphoid, lunate and capitate in uninjured wrists.
... Dynamic fluoroscopy provides real-time interactive imaging to differentiate between static and dynamic SLJ instability [14,15,20]. A sensitivity of 90%, a specificity of 97% and a diagnostic accuracy of 93% were reported for dynamic fluoroscopy in detecting SLJ instability [20]. ...
... Dynamic fluoroscopy provides real-time interactive imaging to differentiate between static and dynamic SLJ instability [14,15,20]. A sensitivity of 90%, a specificity of 97% and a diagnostic accuracy of 93% were reported for dynamic fluoroscopy in detecting SLJ instability [20]. ...
Objectives
The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique.
Methods
Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors’ clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of ‘0’, ‘5’ and ‘10’ reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of ‘8’ or higher for 80% or more of the panellists.
Results
Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available.
Conclusions
Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability.
Key Points
• Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability .
• Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability .
• Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects .
... Measuring the dorsal subluxation of the scaphoid observed during the scaphoid shift test would be an improvement, since scaphoid shift test without visualization is a poor diagnostic test, with 69% sensitivity and 64-68% specificity [20,21]. Basic patient work-up, in addition to clinical assessment, consists of conventional plain radiographs, with 43%-81% sensitivity and 80%-93% specificity, depending on the report [22][23][24], for predicting SLIL injury. Conventional radiography appears to have a high specificity for detecting complete SLIL injuries, but a rather low sensitivity for lower grade SLIL tears. ...
... Cineradiography has been the focus of only a few studies, but accuracy appears to be good; sensitivity ranges from 86% to 95% and specificity from 80% to 97% for the detection of all SLIL tears [22,23,26,31]. Sulkers et al. [23,31] reported excellent interobserver agreement for diagnosing scapholunate dissociation (SLD). ...
... Cineradiography has been the focus of only a few studies, but accuracy appears to be good; sensitivity ranges from 86% to 95% and specificity from 80% to 97% for the detection of all SLIL tears [22,23,26,31]. Sulkers et al. [23,31] reported excellent interobserver agreement for diagnosing scapholunate dissociation (SLD). Magnetic resonance imaging (MRI), magnetic resonance arthrography, cine-MRI and computerized tomography arthrography have been proposed for diagnosing SLD [32][33][34], with varying sensitivity and specificity. ...
The present study aimed to develop a reliable dynamic measurement technique, which can be used directly in the outpatient setting, based on dorsal subluxation of the scaphoid on scaphoid shift test. This study was designed to evaluate feasibility and to quantify dorsal subluxation of the scaphoid in relation to the lunate. Based on a scaphoid shift test under ultrasonography, a standardized 3D test model was developed to measure subluxation. Sagittal subluxation ranged between 0 and 6 mm, as checked on the implemented scale. Four hand surgeons trained in ultrasonography (experience level II–V) performed blinded measurements (total of 52, n = 13 per investigator) with a standardized measurement protocol. Dorsal subluxation of the scaphoid was measured in relation to the lunate. Interobserver reliability on intraclass correlation coefficient (ICC) was excellent, at 0.97 (95% confidence interval, 0.930–0.992). Mean overall absolute measurement error was 0.27 mm ± 0.21. Dorsal subluxation of the scaphoid can thus be accurately measured on ultrasound with excellent interobserver reliability, quantifying and improving clinical assessment of scapholunate instability.
... In the last years, various dynamic imaging techniques enabled acquiring real-time functional images. Techniques such as sonography, MRI, and fluoroscopy are presented in the literature, however, all with specific advantages and limitations [23][24][25][26]. Sonography enables us to image joints and ligaments during activities, but bony structures cannot be visualized. ...
Objective
We aimed to establish a quantitative description of motion patterns and establish test-retest reliability of the four-dimensional CT when quantifying in vivo kinematics of the scaphoid, lunate, and capitate.Materials and methodsWe assessed in vivo kinematics of both wrists of 20 healthy volunteers (11 men and 9 women) between the ages of 20 and 40 years. All volunteers performed active flexion-extension and radial-ulnar deviation with both wrists. To test for reliability, one motion cycle was rescanned for both wrists approximately 15 min after the first scan. The coefficient of multiple correlation was used to analyze reliability. When two motion patterns are similar, the coefficient of multiple correlation tends towards 1, whereas in dissimilar motion patterns, it tends towards 0. The root mean square deviation was used to analyze the total motion patterns variability between the two scans.ResultsOverall, mean or median coefficient of multiple correlations were higher than 0.86. The root mean square deviations were low and ranged from 1.17° to 4.29°.Conclusion
This innovative non-invasive imaging technique can reliably describe in vivo carpal kinematics of uninjured wrists in healthy individuals. It provides us with a better understanding and reference values of carpal kinematics of the scaphoid, lunate, and capitate.
