Accuracy of direct magnetic resonance arthrography in the diagnosis of triangular fibrocartilage complex tears of the wrist

Wrist Arthroscopy Is Effective for the Diagnosis and Treatment of Chronic Wrist Pain in Pediatric Patients

Purpose

To determine the outcomes of diagnostic and therapeutic arthroscopy in patients with chronic wrist pain who are younger than 16 years of age.

Methods

We retrospectively analyzed collected data from medical records of patients who had undergone wrist arthroscopy by the senior author between 2015 and 2017 for longstanding wrist pain and were 16 years old or younger. Findings from preoperative magnetic resonance imaging (MRI) were compared with the intraoperative diagnosis, and midterm results were gathered by a telephone interview.

Results

Ten patients were included. Eight of 10 patients had undergone conservative therapy before surgery, and 60% had a history of single trauma. In 6 of 10 patients, the arthroscopic diagnosis correlated with the MRI findings. Eight of 10 wrists (80%) showed a tear of the triangular fibrocartilage complex (TFCC). Only 4 of the 8 TFCC tears were correctly identified by 3-Tesla MRI.

Conclusions

In our study, wrist arthroscopy was an effective tool not only to diagnose but also to treat relevant TFCC lesions both in adolescents and children suffering from persistent wrist pain. A 3-Tesla MRI was neither sensitive nor specific enough to correctly diagnose lesions in small pediatric wrists.

Level of Evidence

IV, Therapeutic case series.

Narrative Review of Ligamentous Wrist Injuries

Ligamentous wrist injuries are common occurrences that require complex anatomical mastery and extensive understanding of diagnostic and treatment modalities. The purpose of this educational review article is to delve into the most clinically relevant wrist ligaments in an organized manner to provide the reader with an overview of relevant anatomy, function, clinical examination findings, imaging modalities, and options for management. Emphasis is placed on elucidating reported diagnostic accuracies and treatment outcomes to encourage evidence-based practice.

Evaluation and Management of Hand, Wrist and Elbow Injuries in Ice Hockey

Ice hockey continues to be a popular, fast-paced, contact sport enjoyed internationally. Due to the physicality of the game, players are at a higher risk of injury. In the 2010 Winter Olympics, men’s ice hockey had the highest injury rate compared to any other sport. In this review, we present a comprehensive analysis of evaluation and management strategies of common hand, wrist, and elbow injuries in ice hockey players. Future reseach focusing on the incidence and outcomes of these hand, wrist and elbow injuries in ice hockey players is warranted.

Comparison of MRI & direct MR arthrography with arthroscopy in diagnosing ligament injuries of wrist

Introduction

Ligament injuries around the wrist leading to chronic wrist pain are often a diagnostic dilemma.Various imaging modalities like wrist radiographs, CT and MRI have been used to improve the diagnostic accuracy. The objective of this study was to assess the value of MRI & direct magnetic resonance arthrography (MRA) of the wrist for detecting & evaluating tears of the triangular fibrocartilage complex (TFCC) & scapholunate & luno triquetral interosseous ligament (LTIL & SLIL) injuries in comparison with arthroscopy of the wrist.

Materials & methods

All patients presenting with chronic wrist pain of more than 3 months duration with suspected ligament injuries were included. MRI was performed with 8 channel wrist coil on 1.5 T machine. (PHILIPS, Netherlands). MRA was performed after obtaining consent. Retrospective MR findings were then correlated with results in those patients who underwent arthroscopy. Arthroscopic correlation was obtained in 22 (46.8%) cases out of the 45 patients who underwent both MRI & MRA.

Results

The gold standard arthroscopic procedure diagnosed 15 peripheral & 6 central TFCC tears in 22 patients. 4 scapholunate ligament tears were also identified. MRI diagnosed 16 peripheral & 5 central TFCC tears in these 22 patients. MRA identified 9 central tears and 14 peripheral tears. The sensitivity in diagnosing an overall TFCC tears with MRI as well as MRA was 94.4 & 100%. The specificity of the MRI and MRA in diagnosing an overall TFCC tear was 100% & 75% respectively.

Discussion & conclusions

Direct MRA has better sensitivity in detecting TFCC central tears. In view of 'substantial' agreement between MRI & MRA with Kappa analysis, conventional MRI can be relied on, in diagnosing TFCC injury. With comparatively low specificity, caution and restraint is advised in interpreting MRA, which may influence decision on surgery.

Comparison between conventional MRI and MR arthrography in the diagnosis of triangular fibrocartilage tears and correlation with arthroscopic findings

PURPOSE

The triangular fibrocartilage complex is one of the most important stabilizers of the wrist and a defect in its anatomical structure is a possible cause of ulnar sided wrist pain. The aim of this study is to compare the diagnostic accuracy between conventional MRI and MR arthrography (MRA) in the depiction of triangular fibrocartilage complex (TFCC) tears.

METHODS-MATERIALS

A total of 60 patients with clinical findings that suggested TFCC tears underwent wrist MRI and MRA. All the MRI and MRA results were compared with the arthroscopic findings.

RESULTS

40 tears were confirmed by arthroscopy. 38/40 tears were identified by MRA while MRI identified 26/40 tears. There were also 8 false positives and 13 false negative results identified by MRI. Two false negative results were identified by MRA. No false positive results were identified.

CONCLUSION

MR arthrography is more sensitive and specific method in terms of the diagnosis of TFCC tears compared to conventional wrist MRI. There was no difference in the diagnostic accuracy between wrist arthroscopy and MRA.

MR arthrography versus conventional MRI and diagnostic arthroscope in patients with chronic wrist pain

Objective

To assess the diagnostic accuracy of direct wrist MR arthrography (MRA) compared to conventional MRI in diagnosis of different pathologic entities causing chronic wrist pain.

Materials and methods

37 consecutive patients 22 males and 15 females, with age range from 16 to 49 years "mean age 28 years" complaining of unexplained chronic wrist pain were prospectively examined by using MRI and MRA with arthroscopic correlation in 25 of them. Findings were divided into 5 main groups of lesions including triangular fibrocartilage complex (TFCC) lesions, ligamentous injuries, osseous lesions, tendon pathology and ganglion.

Results

MRA picked up more ligamentous injuries and triangular fibrocartilage complex (TFCC) lesions that couldn`t be detected on MRI study while both were equal in detection of other types of lesions. TFCC lesions were the most common pathologic findings in both MRI and MRA. Arthroscopic correlation in 25 suspected TFCC lesions (clinically, radiologically or both) revealed that the sensitivity / specificity / accuracy of MRI and MRA were 87.5% / 100% / 96% and 100% / 100% / 100% respectively for central lesions while were 71.4% / 81.3% / 76% and 100% / 90.9% / 96% respectively For peripheral lesions. Extra-capsular lesions, like tenosynovitis and fracture hook of hamate couldn`t be confirmed arthroscopically.

Conclusion

MRA can replace both MRI and diagnostic arthroscopy in detecting causes of chronic wrist pain.

TFCC Injuries: Meta-Analysis and Comparison of Diagnostic Imaging Modalities

Background  Imaging of the triangular fibrocartilaginous complex (TFCC) remains difficult, as no single imaging modality demonstrates perfect sensitivity and specificity. Purpose  This study performs a meta-analysis of multiple previous publications to guide noninvasive imaging selection for the diagnosis of TFCC injuries. Methods  A literature search was performed and conducted. Studies were included that compared the diagnostic accuracy of magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and computed tomography (CT)/computed tomographic arthrography (CTA) for the evaluation of TFCC injuries. All studies included either arthroscopic or open surgical findings as the "gold standard." A meta-analysis was performed comparing the diagnostic accuracy of MRA, MRI, and CT for the detection of TFCC injuries. Results  Initial search returned 2,568 candidate articles. Studies were then reviewed and narrowed yielding a total of 28 independent studies (20 MRI, 9 MRA, 4 CT/CTA with some studies including multiple modalities) considered in the qualitative data synthesis. Pooling of the raw data in a meta-analysis demonstrated sensitivities of 0.76 (0.72-0.80), 0.78(0.70-0.84), and 0.89 (0.81-0.95) for MRI, MRA, and CT arthrogram, respectively, with specificities of 0.82 (0.77-0.86), 0.85 (0.77-0.92), and 0.89 (0.81-0.95), respectively. Additionally, across all imaging modalities, diagnostic accuracy was highest for central TFCC lesions versus peripheral lesions. Conclusion  This study represents the largest meta-analysis to date to compare multiple imaging modalities for the diagnosis of TFCC injuries. Pooled data demonstrated that CTA and MRA had statistically equivalent sensitivity and specificity for the diagnosis of TFCC injuries. Diagnostic accuracy was highest for central TFCC injuries.

MR arthrography is slightly more accurate than conventional MRI in detecting TFCC lesions of the wrist

Introduction

In case of clinical suspicion of triangular fibrocartilage complex (TFCC) injury, different imaging techniques are used. The aim of this study was to determine whether MRA is superior to MRI and whether 3.0 T is better than 1.5 T (expresses in sensitivity, specificity and accuracy) in detecting TFCC injury, using arthroscopy as the gold standard.

Materials and methods

The arthroscopic and MR findings of 150 patients who underwent arthroscopy for ulnar-sided wrist pain between January 2009 and November 2016 were retrospectively reviewed.

Results

MRA was slightly more accurate compared to conventional MRI, and 1.5 T was slightly more accurate than 3.0 T. 1.5 T wrist MRA had a sensitivity of 80%, a specificity of 100% and accuracy of 90%; 3.0 T wrist MRA 73, 100 and 86%, resp. Conventional 1.5 T wrist MRI had a sensitivity of 71%, a specificity of 75% and accuracy of 73%. For 3.0 T conventional MRI, this was 73, 67 and 70%, resp.

Conclusions

MRA seems slightly superior to conventional MRI, but one could question whether this difference in diagnostic accuracy outweighs the burden and risks of an invasive procedure for patients with its additional costs. Furthermore, we could not confirm the superiority of 3 T compared to 1.5 T.

Diagnostic accuracy of single-compartment magnetic resonance arthrography in detecting common causes of chronic wrist pain

We reviewed a series of 50 consecutive wrist arthroscopy patients who had been investigated pre-operatively by direct magnetic resonance arthrography and calculated the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of magnetic resonance arthrography in detecting full-thickness triangular fibrocartilage complex tears, intrinsic carpal ligamentous lesions, wrist synovitis and chondral lesions in the radiocarpal joint. The sensitivities of magnetic resonance arthrography in detecting central triangular fibrocartilage complex tears, peripheral triangular fibrocartilage complex tears, scapholunate ligament tears, lunotriquetral ligament tears, dorsal synovitis and radiocarpal chondral lesions were 89%, 63%, 71%, 100%, 32% and 65%, respectively, and its specificities in detecting these lesions were 91%, 98%, 89%, 94% 94% and 97%, respectively. This study suggests that single compartment direct wrist magnetic resonance arthrography can provide high diagnostic accuracy for full-thickness triangular fibrocartilage lesions, intrinsic carpal ligament tears and chondral lesions in the radiocarpal joint, but that it is much less accurate in diagnosing synovitis of the radiocarpal joint.

LEVEL OF EVIDENCE

III.

The wrist insufflation test: a confirmatory test for detecting intercarpal ligament and triangular fibrocartilage complex tears

PURPOSE

The purpose of this study was to determine the accuracy of the wrist insufflation test based on mean radiocarpal and midcarpal joint space volumes.

METHODS

Twenty-nine patients underwent 3-4 portal radiocarpal and radial midcarpal portal insufflation before wrist arthroscopy. The volume remaining in the radiocarpal space at equilibrium was recorded, and the contour of the dorsal wrist and distal radioulnar joint was palpated for a fluid wave. After insufflation, wrist arthroscopy was performed and diagnoses were recorded. The mean volumes of the intact radiocarpal and midcarpal spaces were then compared with those of the compromised radiocarpal and midcarpal spaces to determine the overall sensitivity and specificity of the test.

RESULTS

A total of 29 patients (18 male and 11 female) underwent wrist insufflation before wrist arthroscopy. The mean age of the patients was 42 years (range, 17 to 69 years). Intact radiocarpal spaces accepted a mean of 3.5 ± 0.16 mL of fluid, whereas compromised radiocarpal spaces accepted a mean of 5.5 ± 0.48 mL of fluid (P < .01; 95% confidence interval, 2.87 to 3.30). Intact midcarpal spaces accepted a mean of 2.5 ± 0.18 mL, whereas compromised midcarpal spaces accepted a mean of 5.6 ± 0.38 mL (P < .01; 95% confidence interval, 1.70 to 2.30). The overall sensitivity of the test was 83.3%, and the overall specificity was 100%.

CONCLUSIONS

Complete scapholunate interosseous ligament and triangular fibrocartilage complex tears can be detected when there is an increased radiocarpal joint space volume with insufflation through the 3-4 portal combined with a fluid wave over the radial midcarpal space or the distal radioulnar joint. Complete scapholunate interosseous ligament and lunotriquetral interosseous ligament tears can also be detected when there is an increased midcarpal space volume with insufflation through the radial midcarpal portal combined with a fluid wave over the radial radiocarpal space or the ulnar radiocarpal space.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

THE BEAUTY OF STABILITY: DISTAL RADIOULNAR JOINT STABILITY IN ARTHROSCOPIC TRIANGULAR FIBROCARTILAGE COMPLEX REPAIR

The triangular fibrocartilage complex (TFCC) has an important role in the stability of the distal radioulnar joint (DRUJ) stability. We designed a new method of TFCC tear repair that has satisfactory post-operative DRUJ stability. From May 2004 to August 2010, 14 patients who underwent this operation were reviewed. The average post-operative follow-up period was 8.2 months; 66.7% of the patients with TFCC tear in sigmoid notch had clinical DRUJ instability, while only 50% of tear in fovea and 16.7% of tear in base of ulnar styloid had clinical DRUJ instability. Transosseous suture via inside-outside technique was used for repair. At the final follow-up, all 14 patients have soft end point with < 5 mm translations of the DRUJ shown by the stress test. Based on this small sample with satisfactory outcome assessed by the Mayo modified wrist score and DRUJ stability, we recommend TFCC tear in sigmoid notch, which has a higher chance of DRUJ instability, to be repaired by transosseous suture.

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.

Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis

BACKGROUND

Triangular fibrocartilaginous complex (TFCC) tears are common sources of ulnar-sided wrist pain and resultant functional disability. Diagnosis is based on the history and clinical examination as well as radiographic evidence of a TFCC central perforation or a radial/ulnar tear. The purpose of this study was therefore to evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) in the detection of TFCC injury in the adult population.

METHODS

Published and unpublished literature databases were searched. Two-by-two tables were constructed to calculate the sensitivity and specificity of MRI or MRA investigations against arthroscopic outcomes. Pooled sensitivity and specificity values and summary receiver operating characteristic curve evaluations were performed. The methodological quality of each study was assessed with use of the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) tool.

RESULTS

Twenty-one studies were included in the review, and these series included a total of 982 wrists. On meta-analysis, MRA was superior to MRI in the investigation of full-thickness TFCC tears, with a pooled sensitivity of 0.75 and a pooled specificity of 0.81 for MRI compared with 0.84 and 0.95, respectively, for MRA. MRA and MRI performed at greater field strengths were reported to have greater sensitivity and specificity than those performed at lower field strengths. There were insufficient data to assess the diagnostic test accuracy for partial-thickness TFCC tears.

CONCLUSIONS

Given its acceptable diagnostic test accuracy, it is recommended that MRA, rather than MRI, be performed in when there are questions about the diagnosis and subsequent management of patients with ulnar-sided wrist pain.

Radial side (1D) tears

The triangular fibrocartilage complex (TFCC) is the key structure at the wrist that facilitates the rotation of the radius and the carpus on the distal ulnar. The radial or type 1D tears of the TFCC are uncommon, but they pose a major disruption of the articular contact between the carpus and the distal ulna. The tears can heal by arthroscopically repairing the TFCC back to the radius using sutures through bone tunnels. This procedure allows patients to return to their work and sports activities with significant recovery of strength and range of motion.

The rate of triangular fibrocartilage injuries requiring surgical intervention

Triangular fibrocartilage complex injuries are one of the most common causes of ulnar-sided wrist pain. Although pain and discomfort may improve with simple immobilization for a short period of time, a significant number of patients eventually require surgical intervention. The purpose of this study was to investigate the incidence of surgical intervention on patients with a clinical diagnosis of a triangular fibrocartilage complex injury. A retrospective chart review was performed to identify patients with ulnar-sided wrist pain identified with the appropriate ICD-9 code from September 2005 to September 2007. All patients were evaluated and treated by a board-certified, fellowship-trained hand surgeon. Any patients with associated pathology were excluded from the study. All patients were initially treated with a minimum of 4 weeks of either a volar wrist splint worn all the time or a short-arm cast. Magnetic resonance images were obtained on patients without symptomatic relief, and in these cases, surgical arthroscopy was performed. Of the 84 patients identified, 36 patients required surgical intervention. All 36 patients had evidence of triangular fibrocartilage complex injury during arthroscopy. All patients had symptomatic improvement postoperatively. The use of short-arm cast versus a splint did not affect the rate of surgical intervention (P=.38). Among the patients with clinical diagnosis of triangular fibrocartilage complex injury, the rate of surgical intervention required after a minimum 4 weeks of immobilization was 43%. The use of a short-arm cast or volar wrist splint did not affect the rate of surgical intervention.

Accuracy of MRI scan in the diagnosis of ligamentous and chondral pathology in the ankle

BACKGROUND

The aim of our study is to determine the accuracy of magnetic resonance imaging (MRI) scan in relation to arthroscopic findings in patients presenting with chronic ankle pain and/or instability.

METHODS

All patients who underwent arthroscopy of the ankle as well as MRI from December 2005 to July 2008 in our institution were reviewed by the Orthopaedic surgeons. Twenty-four patients were identified and the results of MRI scans were compared with arthroscopic findings. This study specifically looked at anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and osteochondral lesions (OCD). Arthroscopic findings were considered as a gold standard. There were 12 female and 12 male patients with an average age 39 years (11-65 years). Time interval between MRI scan and arthroscopy was 7.0 months (2-18 months).

RESULTS

In our study MRI showed 100% specificity for the diagnosis of ATFL and CFL tears and osteochondral lesions. However sensitivity was low particularly for CFL tears. Accuracy of MRI in detecting ATFL tear was 91.7%, CFL tear was 87.5% and osteochondral lesion was 83.3%.

CONCLUSIONS

We conclude that MRI scan has very high specificity and positive predictive value in diagnosing tears of ATFL, CFL and osteochondral lesions. However sensitivity was low with MRI. In a symptomatic patient negative results on MRI must be viewed with caution and an arthroscopy may still be required for a definitive diagnosis and treatment. However high resolution scans may differ in their ability to pick up these lesions and further research is required to assess their efficiency as evidence is not currently available.