Role of MR imaging in chronic wrist pain

ACR Appropriateness Criteria® Chronic Hand and Wrist Pain: 2023 Update

Chronic hand and wrist pain is a common presenting complaint. The intricate anatomy results in a variety of pain generators-multiple bones, articular cartilage, intrinsic ligaments, triangular fibrocartilage complex, joint capsules and synovium, tendons and tendon sheaths, muscles, and nerves-in a compact space. The need for imaging and the choice of the appropriate imaging modality are best determined by the patient's presentation, physical examination, and the clinician's working differential diagnosis. Radiography is usually appropriate as the initial imaging study in the evaluation of chronic hand or wrist pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

A rare case of carpal boss lesion with an overlying ganglion cyst: case report and literature review

Carpal boss is a bony protrusion on the dorsal aspect of wrist quadrangular joint. The exact cause and prevalence are not well understood. Most of the patients are asymptomatic, although some experience pain, bony prominence, restricted mobility, and joint instability in sever neglected cases. We are presenting a case of a 24-year-old male had chronic dorsal wrist pain with bony prominence appearance underwent surgical excision of a carpal boss lesion in concomitant with soft tissue ganglion cyst over the carpal boss after failed conservative management, resulting in significant symptom improvement and restored range of motion. Carpal boss lesion is a common condition that can be undiagnosed due to asymptomatic presentation or the presence of overlying soft tissue pathology as ganglion cyst. Although conservative treatment is helpful in some patients, most symptomatic carpal boss lesion patients eventually need surgical excision.

SSR white paper: guidelines for utilization and performance of direct MR arthrography

OBJECTIVE

Direct magnetic resonance arthrography (dMRA) is often considered the most accurate imaging modality for the evaluation of intra-articular structures, but utilization and performance vary widely without consensus. The purpose of this white paper is to develop consensus recommendations on behalf of the Society of Skeletal Radiology (SSR) based on published literature and expert opinion.

MATERIALS AND METHODS

The Standards and Guidelines Committee of the SSR identified guidelines for utilization and performance of dMRA as an important topic for study and invited all SSR members with expertise and interest to volunteer for the white paper panel. This panel was tasked with determining an outline, reviewing the relevant literature, preparing a written document summarizing the issues and controversies, and providing recommendations.

RESULTS

Twelve SSR members with expertise in dMRA formed the ad hoc white paper authorship committee. The published literature on dMRA was reviewed and summarized, focusing on clinical indications, technical considerations, safety, imaging protocols, complications, controversies, and gaps in knowledge. Recommendations for the utilization and performance of dMRA in the shoulder, elbow, wrist, hip, knee, and ankle/foot regions were developed in group consensus.

CONCLUSION

Although direct MR arthrography has been previously used for a wide variety of clinical indications, the authorship panel recommends more selective application of this minimally invasive procedure. At present, direct MR arthrography remains an important procedure in the armamentarium of the musculoskeletal radiologist and is especially valuable when conventional MRI is indeterminant or results are discrepant with clinical evaluation.

Management of Complex Hand and Wrist Ligament Injuries

Ligamentous injuries in the hand and wrist are often underdiagnosed and can present with significant functional limitations if there is untimely recognition of injury. Adequate repair or reconstruction is critical in restoring joint stability and mobility. The purpose of this review is to provide an overview of the metacarpophalangeal joint, scapholunate interosseous ligament (SLIL), and non-SLIL carpal ligament anatomy, diagnosis, imaging, treatment consideration and options, as well as surgical techniques encompassing repair, reconstruction, and fusion.

Isolated Second and Third Carpometacarpal Joint Injuries: A Report of 2 Cases

CASES

Two high-level male athletes with isolated second and third carpometacarpal (2, 3 CMC) joint injuries presented with mid-dorsal wrist pain, decreased grip strength, and painful wrist motion. Both reported inciting trauma-1 acutely and the other months after the original injury. Both exhibited 2, 3 CMC joint tenderness and positive provocative testing on exam. Advanced imaging confirmed 2, 3 CMC joint injuries. Both patients returned to preinjury level of play 3 months after diagnosis and surgical treatment.

CONCLUSION

2, 3 CMC joint injuries should be considered when evaluating radial/mid-dorsal wrist pain. Surgical treatments range from pin stabilization to fusion depending on chronicity and associated degenerative joint changes.

Structurally intact and functionally incompetent foveal triangular fibrocartilage complex injuries : an under-recognized spectrum of injury

Injury to the triangular fibrocartilage complex (TFCC) may result in ulnar wrist pain with or without instability. One component of the TFCC, the radioulnar ligaments, serve as the primary soft-tissue stabilizer of the distal radioulnar joint (DRUJ). Tears or avulsions of its proximal, foveal attachment are thought to be associated with instability of the DRUJ, most noticed during loaded pronosupination. In the absence of detectable instability, injury of the foveal insertion of the radioulnar ligaments may be overlooked. While advanced imaging techniques such as MRI and radiocarpal arthroscopy are well-suited for diagnosing central and distal TFCC tears, partial and complete foveal tears without instability may be missed without a high degree of suspicion. While technically challenging, DRUJ arthroscopy provides the most accurate method of detecting foveal abnormalities. In this annotation the spectrum of foveal injuries is discussed and a modified classification scheme is proposed.Cite this article: Bone Joint J 2023;105-B(1):5-10.

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

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

Middorsal Wrist Pain in the High-Level Athlete: Causes, Treatment, and Early Return to Play

Wrist injuries in the competitive athlete are a common reason for evaluation related to an acute injury or after symptoms have become chronic. While radius- and ulna-sided wrist pain are common topics covered in the literature, middorsal wrist pain is more common than the available literature would suggest. Missed diagnoses and inadequate treatment can significantly increase athlete morbidity and delay return to play. The goal of this article was to review the differential diagnosis of middorsal wrist pain in the athlete and discuss the diagnosis, treatment, and early return to play for each condition.

The 100 Top-Cited Articles about Kienböck’s Disease: A Bibliometric Analysis

Introduction The aim of this study was to analyze the 100 top-cited articles about Kienböck’s disease and their features.

Materials and Methods A search through the Elsevier, Scopus database journal articles about Kienböck’s disease yielded 1,025 results. The 100 top-cited articles were identified and filtered again to exclude self-citations. The 100 top-cited articles without self-citations were analyzed for the number of citation, citation density, publishing journal, language, authorship, and geographic origin. The abstracts of the articles were obtained to review and determine the types of articles and levels of evidence.

Results The mean of the 100 top-cited articles’ absolute number of citations was 63.3 ± 34 (range: 23–199). Citation densities ranged from 1 to 8. A total of 97 (97%) articles were written in English. The leading countries were the United States with 50 (50%) articles followed by Japan with 16 (16%) articles. Forty (40%) articles have been published in the Journal of Hand Surgery American volume. Among the 100 top-cited articles, nine articles were devoted to basic science and 91 articles have dealt with clinical science. There were three articles with level II, 24 articles with level III, 46 articles with level IV, and 18 articles with level V of evidences.

Conclusion The current study presents an insight to the classic articles about Kienböck’s disease. The 100 top-cited articles have established a foundation that the science on Kienböck’s disease has been elaborated. The current study is likely helpful for educational purposes and further research about Kienböck’s disease.

Level of Evidence Economic and decision analysis/Level IV.

Evaluation of ulnar variance on wrist MR imaging: is it a reliable measure?

OBJECTIVE

To determine if ulnar variance can be evaluated by magnetic resonance (MR) imaging and if this measure can be used as a reliable indicator when correlated to the gold standard technique, conventional radiography (CR).

MATERIALS AND METHODS

From January to July 2018, the MR images of 64 participants, comprising 66 wrists (mean age 34.9 years; 33 females; 31 males), were obtained. Among those, 29 were referred for evaluation of the wrist for different medical reasons and 35 were asymptomatic volunteers from our radiology group. All subjects had a plain radiography of the wrist in a posteroanterior view with a mean interval between images of 1 day. Local ethics committee approved the study and written informed consent was obtained from all patients. Two musculoskeletal radiologists evaluated the images. Correlation coefficients and a linear regression model were used for statistical analyses.

RESULTS

Intra- and inter-observer analyses were performed for both diagnostic methods with results showing concordance (intra-observer: kappa score: MR 0.915/CR 0.931; p < 0.05; inter-observer: kappa score: MR 0.857/CR 0.931; p < 0.05). The intraclass correlations of MR and CR to evaluate agreement between the radiologists was slightly higher for radiologist #1 (0.771) than for radiologist #2 (0.659). A linear regression model showed good model fit indicating that MR does correlate with the ulnar variance as measured by CR (CR = 0.554 + 0.897 × MR, R² = 0.665).

CONCLUSION

Although CR is the gold standard method for the evaluation of ulnar variance, our study demonstrated that MR can be used as a reliable qualitative option.

Clinical Applications of Imaging Modalities of the Carpal Joint in Dogs with Particular Reference to the Carpal Canal

The structure of the canine carpal joint is complex. This small joint consists of articulations that include the antebrachiocarpal, middle, carpometacarpal, and intercarpal joint surfaces. A large number of ligaments and tendons support and stabilise the carpus in dogs. Many injuries of this joint in dogs are not correctly recognised, diagnosed, or treated due to the limited use of diagnostic imaging methods. Radiography, the most common of them, has extensive application in diagnosing the causes of lameness in small animals. Other techniques, such as ultrasonography, computed tomography, and magnetic resonance imaging visualise other joint structures and surrounding soft tissues. However, these imaging modalities are rarely used to diagnose diseases and injuries of the canine carpus at present. The main reason for this is the small amount of research carried out and the lack of a properly described methodology for the use of imaging techniques. The wide use of all diagnostic imaging tools in the diagnosis of diseases and injuries of the wrist joint in humans shows that conducting studies on dogs could expand current knowledge. The use of these techniques in veterinary medicine could facilitate diagnosis and subsequent therapy of carpal disorders in dogs. MRI is the most frequently used imaging method in human medicine for visualisation of abnormalities of joints. This method could become a valuable part of the detection of inflammatory, traumatic, and degenerative diseases of the carpal joint in dogs.

Utility of Specialized Imaging for Diagnosis of Chronic Wrist Pain

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

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

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

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.

Accuracy of Pre- and Postcontrast, 3 T Indirect MR Arthrography Compared with Wrist Arthroscopy in the Diagnosis of Wrist Ligament Injuries

Background  Magnetic resonance (MR) is the most important imaging technique to assess intra-articular pathology of the wrist. Among various MR imaging protocols, the diagnostic performance of indirect MR arthrography needs further investigation. Purpose  The purpose of this study was to assess the diagnostic performance of pre- and postcontrast, 3 T indirect MR arthrography in the diagnosis of scapholunate intrinsic ligament (SLIL) and triangular fibrocartilage complex (TFCC) injuries, using wrist arthroscopy as reference standard. Patients and Methods  We retrospectively evaluated consecutive patients with suspected SLIL or TFCC injury, who had indirect MR arthrography done before arthroscopy. Images were assessed independently by two senior radiologists. Results  Arthroscopy of the 53 wrists demonstrated 16 Geissler stages II and III partial tears and 6 stage IV total SLIL ruptures. Central perforation of the TFCC was found in 24 wrists, and 12 wrists had an ulnar class 1B lesion. To detect any SLIL tear, accuracy was higher for the two observers using postcontrast indirect MR arthrography (0.77 and 0.72) than for precontrast MR imaging (0.60 and 0.60). No difference was found for total SLIL ruptures "0.85 and 0.89" versus "0.85 and 0.89." To diagnose class 1B TFCC injuries, accuracy was higher using postcontrast indirect MR arthrography (0.85 and 0.75) than for precontrast MR imaging (0.70 and 0.72). No difference in accuracy was demonstrated for TFCC central tears "0.75 and 0.75" versus "0.70 and 0.77." Conclusion  Postcontrast images at 3 T indirect MR arthrography, compared with precontrast images, have an improved diagnostic performance for the overall detection of SLIL injuries and as well as class 1B TFCC tears. Level of Evidence  This is a Level II, diagnostic study.

An Evaluation of the Reliability of Wrist Arthroscopy in the Assessment of Tears of the Triangular Fibrocartilage Complex

PURPOSE

Wrist arthroscopy is generally considered the reference standard in the diagnosis of triangular fibrocartilage complex (TFCC) injuries. There is a paucity of data examining the reliability of wrist arthroscopy as a diagnostic modality for TFCC injuries. The goal of this study was to evaluate the interobserver and intraobserver reliability of the diagnosis of TFCC pathology during wrist arthroscopy.

METHODS

Twenty-five intraoperative digital videos were captured by the senior author during diagnostic and surgical arthroscopy of the wrist joint for known or suspected articular pathology. The senior author (P.K.B.) confirmed TFCC resilience on visual inspection and ballottement (trampoline effect) to make the diagnosis. Two videos were excluded for poor quality and inadequate visualization. Three hand surgeons subsequently reviewed the remaining 23 videos in a blinded fashion at 2 time points separated by 4 weeks. The reviewers determined if the trampoline test was positive and if a TFCC tear was present. Tears were classified using a morphologic classification. Statistical measures of reliability including percentage agreement and κ coefficients were calculated.

RESULTS

Agreement between observers for the presence or absence of a tear was 66.7%. The average intraobserver agreement regarding the presence or absence of a tear was 67.4% The kappa value for interobserver agreement was 0.33, whereas the intrarater agreement was 0.88. The 3 reviewers identified an average of 11.3 positive trampoline tests. Agreement between observers for a positive trampoline test was 65.2%. The average percentage of intraobserver agreement regarding a positive trampoline test was 49.3%. In cases where all 3 reviewers agreed on the presence of a TFCC tear, the agreement regarding tear location was 76.6%.

CONCLUSIONS

Wrist arthroscopy remains instrumental in the treatment of TFCC tears. However, given that inter-rater reliability in the assessment of these tears is probably too low, reconsideration should be given to arthroscopy as the reference standard in the diagnosis of these tears.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

High-resolution MRI (3T-MRI) in diagnosis of wrist pain: is diagnostic arthroscopy still necessary?

INTRODUCTION

3T MRI has become increasingly available for better imaging of interosseous ligaments, TFCC, and avascular necrosis compared with 1.5T MRI. This study assesses the sensitivity and specificity of 3T MRI compared with arthroscopy as the gold standard.

PATIENTS AND METHODS

Eighteen patients were examined with 3T MRI using coronal T1-TSE; PD-FS; and coronal, sagittal, and axial contrast-enhanced T1-FFE-FS sequences. Two musculoskeletal radiologists evaluated the images independently. Patients underwent diagnostic arthroscopy.

RESULTS

The classifications of the cartilage lesions showed good correlations with the arthroscopy findings (κ = 0.8-0.9). In contrast to the arthroscopy, cartilage of the distal carpal row was very good and could be evaluated in all patients on MRI. The sensitivity for the TFCC lesion was 83%, and the specificity was 42% (radiologist 1) and 63% (radiologist 2). For the ligament lesions, the sensitivity and specificity were 75 and 100%, respectively, with a high interobserver agreement (κ = 0.8-0.9).

DISCUSSION

3T MRI proved to be of good value in diagnosing cartilage lesions, especially in the distal carpal row, whereas wrist arthroscopy provided therapeutic options. When evaluating the surgical therapeutical options, 3T MRI is a good diagnostic tool for pre-operatively evaluating the cartilage of the distal carpal row.

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.

Assessment of pisotriquetral misalignment with magnetic resonance imaging: Is it associated with trauma?

OBJECTIVE

Our objective was to determine whether there is an association between pisotriquetral (PT) malalignment and acute distal radius fracture by using magnetic resonance imaging (MRI).

METHODS

We evaluated 138 patients who underwent 3-T MRI of the wrists. Group A comprised 85 patients with acute distal radius fracture, and group B comprised 53 patients without trauma. PT interval and angle and pisiform excursion were measured on oblique axial and sagittal multiplanar reformats. The presence of abnormalities in the flexor carpi ulnaris tendon (FCU), pisometacarpal ligament (PML), and pisohamate ligament (PHL) were evaluated.

RESULTS

PT interval was wider in group A on both the axial and sagittal planes (P < 0.001). Axial PT angle opened more radially in group A (P < 0.001), and the absolute value of the sagittal PT angle in group A was wider than that in group B (P = 0.006). Abnormalities in FCU, PML, and PHL were more frequently observed in group A (P < 0.001). On multiple linear regression, distal radius fracture remained significant after adjusting for the patient's age and PT osteoarthritis.

CONCLUSIONS

Acute distal radius fracture can affect normal alignment of the PT joint, resulting in associated injuries to the primary PT joint stabilizers.

KEY POINTS

• Acute distal radius fracture is associated with malalignment of PT joints. • Acute distal radius fracture is associated with abnormalities of PT stabilizers. • PT joint alignment can be evaluated with MRI with 3D sequences. • Wrist MRI is useful for evaluating primary PT stabilizer injuries.

Scapholunate Interosseous Ligament Tears: Diagnostic Performance of 1.5 T, 3 T MRI, and MR Arthrography-A Systematic Review and Meta-analysis

RATIONALE AND OBJECTIVES

The study aimed to perform a systematic review and meta-analysis for evaluating the diagnostic accuracy of 1.5 Tesla and 3.0 Tesla magnetic resonance imaging (MRI), and magnetic resonance arthrography (MRA), in the detection of scapholunate interosseous ligament (SLIL) injury.

MATERIALS AND METHODS

A literature search was performed (until July 2015) using the PubMed (MEDLINE), Embase, ISI Web of Science, Scopus, and conference proceedings. Original studies evaluating the diagnostic accuracy of MRI or MRA in the detection of SLIL injuries using arthroscopy or open surgery as the reference standard were included.

RESULTS

Of the initial 930 published records and 103 conference proceedings, 24 studies (1902 MRI examinations) were included (median SLIL injury prevalence: 33% [interquartile range: 25-42]). Heterogeneity was detected for 1.5 T MRI (chi-square: 47.93, P < 0.001) but not for 3.0 T MRI (chi-square: 8.00, P value: 0.09) and MRA (chi-square: 14.54, P value: 0.34) studies. The sensitivities of 1.5 T MRI, 3.0 T MRI, and MRA for detection of SLIL injury were 45.7% (95% confidence interval: 40.1-51.4), 75.7% (66.8-83.2), and 82.1% (76.1-87.2), respectively. The specificities of 1.5 T MRI, 3.0 T MRI, and MRA for detection of SLIL injury were 80.5% (77.3-83.4), 97.1% (89.8-99.6), and 92.8% (90.2-94.9), respectively. The diagnostic odds ratios of 1.5 T MRI, 3.0 T MRI, and MRA for detection of SLIL injury were 5.56 (2.71-11.39), 23.23 (3.16-171.00), and 65.04 (32.89-128.62) (P value < 0.001), respectively. The results were consistent after addressing publication bias and sensitivity analyses.

CONCLUSIONS

MRA is superior to 3.0 T MRI, and 3.0 T MRI is superior to 1.5 T MRI in terms of diagnostic performance. 3.0 T MRI has the highest specificity for the detection of SLIL injuries.

Radiocarpal Injuries: Cone Beam Computed Tomography Arthrography, Magnetic Resonance Arthrography, and Arthroscopic Correlation among 21 Patients

Background and Aims:

Patients with acute or chronic wrist pain often undergo wrist arthroscopy for evaluation of chondral and ligamentous abnormalities. The purpose of this study was to compare findings of wrist arthroscopy with cone beam computed tomography arthrography and magnetic resonance arthrography.

Materials and Methods:

Altogether, 21 patients with wrist pain underwent cone beam computed tomography arthrography, magnetic resonance arthrography, and wrist arthroscopy. Chondral surfaces of the scaphoid, lunate, and radius facing the scaphoid and lunate were evaluated. The scapholunate ligament, the lunotriquetral ligament, and the triangular fibrocartilage complex were classified as either intact or torn. Sensitivity, specificity, positive and negative predictive values, and accuracy with 95% confidence intervals were assessed.

Results:

For chondral lesions (n = 10), cone beam computed tomography arthrograms showed slightly higher specificity than magnetic resonance arthrography. The sensitivity of cone beam computed tomography arthrography was also better for these lesions, except for those on the chondral surface of the lunate. For triangular fibrocartilage complex injuries (n = 9), cone beam computed tomography arthrography showed a better specificity and sensitivity than magnetic resonance arthrography. For ligamentous injuries (n = 6), cone beam computed tomography arthrograms were more sensitive, but less specific than magnetic resonance arthrography images. However, the number of lesions was very small and the 95% confidence intervals are overlapping.

Conclusion:

Cone beam computed tomography is an emerging imaging modality that offers several advantages over computed tomography and magnetic resonance imaging. Its usefulness particularly in ligamentous injuries should be further explored in a larger study. Cone beam computed tomography arthrography seems to offer similar sensitivity, specificity, and accuracy compared to magnetic resonance arthrography and therefore serves as a valuable option in evaluating patients with wrist pain.

Injuries of the Scapholunate Interosseous Ligament: An Update

The scapholunate ligament is both a key ligament in the stability of the carpus and one of the most frequently injured. Thorough understanding of the anatomy, biomechanics, and pathophysiology of the wrist is important in treating injuries to the scapholunate ligament. The presentation of scapholunate instability often includes a vague injury history and pain with grip, wrist extension, and sport or labor. Identified injuries are classified based on dynamic and static radiographic findings, chronicity, and the presence or absence of arthrosis. Surgical options for the treatment of low- and high-grade injuries include both open and arthroscopic procedures and can be broadly classified into four categories: limited arthroscopic procedures, primary ligament repair, reconstructive procedures, and salvage procedures. No strong evidence currently supports any one treatment. Decision making is largely based on expert opinion and surgeon experience. Prognosis is often guarded, and patient expectations should be tempered.

Management of Intercarpal Ligament Injuries Associated with Distal Radius Fractures

The prevalence of ligamentous injury associated with fractures of the distal radius is reported to be as high as 69% with injury to the scapholunate interosseous ligament and lunotriquetral interosseous ligament occurring in 16% to 40% and 8.5% to 15%, respectively. There is a lack of consensus on which patients should undergo advanced imaging, arthroscopy, and treatment and whether this changes their natural history. Overall, patients with high-grade intercarpal ligament injuries are shown to have longer-term disability and sequelae compared with those with lower-grade injuries. This article reviews the diagnosis and treatment options for these injuries.

The carpal boss: a review of different sonographic findings

Carpal boss is an uncommon condition whose incidence is underestimated and that is frequently confused with other causes of development of tumor-like lesions on the dorsum of the wrist. From the clinical point of view, the main obstacle to its recognition is the nonspecificity of symptoms, frequently attributed to dorsal ganglion cysts, since both conditions share a similar location on the dorsum of the wrist. The assessment by ultrasonography allows for a correct diagnosis and appropriate management, with better chances of resolution of the clinical complaint and lower probability of iatrogenic worsening of the lesion. The present review is aimed at describing the different sonographic findings of carpal boss.

Update TFCC: histology and pathology, classification, examination and diagnostics

The TFCC is a crucial stabilizer of the DRUJ. Based on its superficial and deep fibers, the TFCC guarantees unrestricted pronation and supination which is essential for performing sophisticated tasks. The ability to perform complex movements is of uppermost importance for hand function. Therefore, a functional intact TFCC is a prerequisite in this context. The articular disc of the TFCC is a fibrocartilaginous extension of the superficial zone of hyaline articular cartilage which arises from the radius. The peripheral 10-40 % of the TFC is vascularized. Degeneration of the articular disc is common with increasing age. Even though the central part of the articular disc is avascular, potential regeneration of lesions could be detected. The Palmer and Atzei classifications of TFCC lesions are complementary. TFCC innervation is based on different nerves. There is a high variability. A diligent clinical examination facilitates specific tests which help to allocate symptoms to the pathology. Therefore, a thorough clinical examination is not dispensable. Wrist arthroscopy remains the "gold standard" for diagnosing TFCC pathologies despite technical progress in imaging modalities. MR arthrography may have the potential to become a real alternative to wrist arthroscopy for diagnosing TFCC pathologies with technical progress in the future.

[Detection of intrinsic ligament and TFCC lesions of the wrist. Direct versus indirect MRI arthrography]

BACKGROUND

The purpose of this study was to validate the diagnostic value of direct magnetic resonance imaging (dMRI) arthrography and indirect MRI (iMRI) arthrography concerning intrinsic ligament injuries and tears of the triangular fibrocartilage complex (TFCC).

PATIENTS AND METHODS

A randomized prospective trial was conducted with patients who presented with wrist pain potentially due to carpal lesions and 10 patients aged 19-60 years (3 female and 7 male) were included. Between the clinical examination and the diagnostic and therapeutic arthroscopy, dMRI and iMRI arthrography were performed for the diagnostics of injuries of the intrinsic ligaments or the TFCC. The results of dMRI and iMRI arthrography were evaluated by two radiologists blinded to the injuries of the patients and a consensus was reached. The results were compared with the findings obtained by arthroscopy.

RESULTS

In the arthroscopy five lesions of the scapholunate ligament (SL), one of the lunotriquetral ligament (LT) and seven of the TFCC were identified. The sensitivity of iMRI and dMRI for carpal ligament lesions (SL and LT) was low (50 %) whereas the specificity was high (93 %). For injuries of the TFCC the sensitivity (up to 100 %) and the specificity (100 %) were both excellent. The area under the curve (AUC) in the receiver operating characteristics (ROC) analysis was high for TFCC lesions in both dMRI and iMRI arthrography.

CONCLUSION

Indirect MRI arthrography is a suitable method for detection of injuries of the TFCC and intrinsic ligaments of the wrist with good sensitivity and specificity. Despite the low number of patients the results of this study showed that there were no essential differences between dMRI and iMRI arthrography with respect to the diagnostic value for carpal injuries of the wrist.

Pathomorphologic findings of wrist arthroscopy in children and adolescents with chronic wrist pain

PURPOSE

The purposes of this diagnostic study were to show pathomorphologic findings of children and adolescents with persistent wrist pain and to compare these arthroscopic findings with preoperative magnetic resonance imaging (MRI).

METHODS

A total of 41 arthroscopies in 39 patients were retrospectively reviewed. The patients underwent diagnostic wrist arthroscopy because of persistent wrist pain after at least 3 months of unsuccessful conservative treatment. Of the patients, 22 (56.4%) reported an injury before the onset of pain. The mean age at arthroscopy was 15.3 years (range, 9.8 to 19.4 years), and the mean duration between the onset of symptoms and arthroscopic exploration was 19.9 months (range, 3.0 to 121.0 months).

RESULTS

Among all affected wrists, 33 (80.5%) showed a triangular fibrocartilage complex (TFCC) tear on arthroscopy, with 75.6% also showing other pathomorphologic findings. Retrospectively, the condition of the TFCC was correctly identified by MRI in only 17 wrists (41.5%). In contrast, 23 wrists were incorrectly classified as having "no tear" whereas arthroscopy later indeed showed a TFCC tear. Concerning the TFCC, MRI and arthroscopy showed a significant difference of outcome (P < .01), indicating low agreement (κ = 0.09) for the outcome of the 2 methods. A larger proportion of TFCC tears was found for patients with injuries (91.3%) as compared with the other patients (66.7%), although this was not significant on statistical analysis (P = .11). No significant difference in the time to surgery was found between patients with TFCC tears and those without TFCC tears classified by MRI (P = .76) and by arthroscopy (P = .99).

CONCLUSIONS

Wrist arthroscopy in children and adolescents with chronic wrist pain shows TFCC lesions in a high percentage. However, most of these lesions have not been correctly identified by MRI before arthroscopy. Thus diagnostic wrist arthroscopy may be recommended to rule out underlying pathologies and initiate further therapeutic steps.

LEVEL OF EVIDENCE

Level III, diagnostic study of nonconsecutive patients.

Scapholunate instability: current concepts in diagnosis and management

Injuries to the scapholunate joint are the most frequent cause of carpal instability and account for a considerable degree of wrist dysfunction, lost time from work, and interference with activities. Although it is insufficient to cause abnormal carpal posture or collapse on static radiographs, an isolated injury to the scapholunate interosseous ligament may be the harbinger of a relentless progression to abnormal joint mechanics, cartilage wear, and degenerative changes. Intervention for scapholunate instability is aimed at arresting the degenerative process by restoring ligament continuity and normalizing carpal kinematics. In this review, we discuss the anatomy, kinematics, and biomechanical properties of the scapholunate articulation and provide a foundation for understanding the spectrum of scapholunate ligament instability. We propose an algorithm for treatment based on the stage of injury and the degree of secondary ligamentous damage and arthritic change.

Cone-beam computed tomography arthrography: an innovative modality for the evaluation of wrist ligament and cartilage injuries

PURPOSE

Cone-beam computed tomography (CBCT) has become an important modality in dento-facial imaging but remains poorly used in the exploration of the musculoskeletal system. The purpose of this study was to prospectively evaluate the performance and radiation exposure of CBCT arthrography in the evaluation of ligament and cartilage injuries in cadaveric wrists, with gross pathology findings as the standard of reference.

MATERIALS AND METHODS

Conventional arthrography was performed under fluoroscopic guidance on 10 cadaveric wrists, followed by MDCT acquisition and CBCT acquisition. CBCT arthrography and MDCT arthrography images were independently analyzed by two musculoskeletal radiologists working independently and then in consensus. The following items were observed: scapholunate and lunotriquetral ligaments, triangular fibrocartilage complex (TFCC) (tear, integrity), and proximal carpal row cartilage (chondral tears). Wrists were dissected and served as the standard of reference for comparisons. Interobserver agreement, sensitivity, specificity, and accuracy were determined. Radiation dose (CTDI) of both modalities was recorded.

RESULTS

CBCT arthrography provides equivalent results to MDCT arthrography in the evaluation of ligaments and cartilage with sensitivity and specificity between 82 and 100%, and interobserver agreement between 0.83 and 0.97. However, radiation dose was significantly lower (p < 0.05) for CBCT arthrography than for MDCT arthrography with a mean CTDI of 2.1 mGy (range 1.7-2.2) versus a mean of 15.1 mGy (range 14.7-16.1).

CONCLUSION

CBCT arthrography appears to be an innovative alternative to MDCT arthrography of the wrist as it allows an accurate and low radiation dose evaluation of ligaments and cartilage.

Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears

Ulnar-sided wrist pain is a common cause of upper extremity disability. Presentation can vary from acute traumatic injuries to chronic degenerative conditions. Because of its overlapping anatomy, complex differential diagnosis, and varied treatment outcomes, the ulnar side of the wrist has been referred to as the "black box" of the wrist, and its pathology has been compared with low back pain. Common causes of ulnar-sided wrist pain include triangular fibrocartilaginous complex injuries, lunotriquetrial ligament injuries, and ulnar impaction syndrome.

Subluxation of the distal radioulnar joint as a predictor of foveal triangular fibrocartilage complex tears

PURPOSE

The triangular fibrocartilage complex (TFCC) with its ulnar foveal attachment is the primary stabilizer of the distal radioulnar joint (DRUJ). The purpose of this study was to describe a technique for measuring the degree of subluxation of the DRUJ in wrist magnetic resonance imaging (MRI) examinations to predict tears involving the foveal attachment of the TFCC.

METHODS

We measured DRUJ geometry in wrist MRI examinations of 34 patients who were found to have foveal TFCC tears at surgery. We compared the results with DRUJ geometry in 11 asymptomatic controls. Subluxation of the ulnar head was assessed using transaxial MRI images obtained at the level of the DRUJ with the wrist in pronation. We quantified subluxation with a line spanning the sigmoid notch of the radius and a perpendicular line through the center of curvature of the articulating surface of the ulna. We calculated the ratio of the lengths of the dorsal and volar segments and normalized it to the center of the sigmoid notch.

RESULTS

A total of 34 patients with intraoperatively confirmed tears of the foveal attachment of the TFCC had a mean dorsal ulnar subluxation measurement of 16% ± 4%, whereas the 11 controls had a mean subluxation measurement of 5% ± 4%.

CONCLUSIONS

The results confirm the hypothesis that subluxation of the ulnar head relative to the sigmoid notch of the radius, as assessed by MRI with the wrist in pronation, is a predictor of tears of the foveal attachment of the TFCC.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Vascularized bone grafting in a canine carpal avascular necrosis model

BACKGROUND

Limited experimental research has been performed on the treatment of avascular necrosis (AVN) by vascularized bone grafting.

QUESTIONS/PURPOSES

A new model simulating carpal AVN was created to investigate surgical revascularization of necrotic bone.

METHODS

In seven mongrel dogs, AVN was induced by removal of the radial carpal bones bilaterally, deep-freezing, coating in cyanoacrylate, and reimplantation. A reverse-flow vascularized bone graft from the distal radius was implanted in the avascular radial carpal bone. The contralateral side served as an untreated ischemic control. Bone blood flow, bone volume, radiography, histomorphometry, histology, and MRI were analyzed at 4 weeks.

RESULTS

Blood flow was substantially higher in grafted bones when compared with controls (14.68 ± 15.43 versus 0.27 ± 0.28 mL/minute/100 g). Blood flow correlated with increased osteoid formation and higher levels of bone turnover. T1 and T2 signals on MRI did not correlate with quantitative bone blood flow measurements. Necrotic bones with no blood flow had normal T1 and T2 signals, whereas revascularized bones had signal changes when compared with adjacent carpal bones. No major collapse occurred in any radiocarpal bone.

CONCLUSION

In a canine experimental model, investigation of carpal AVN shows the ability of vascularized bone grafting to revascularize and remodel avascular bone.

CLINICAL RELEVANCE

Surgical revascularization of necrotic bone induced by vascularized bone grafting results in increased bone perfusion and bone remodeling as compared with untreated necrotic bone. MRI T1 and T2 signals can be normal in necrotic avascular bone.

Is dynamic gadolinium enhancement needed in MR imaging for the preoperative assessment of scaphoidal viability in patients with scaphoid nonunion?

PURPOSE

To compare the accuracy of dynamic gadolinium-enhanced magnetic resonance (MR) imaging with that of standard MR imaging for assessing the viability of the proximal pole of the scaphoid in patients with nonunion.

MATERIALS AND METHODS

The study protocol was submitted to the institutional review board, and the need to obtain additional approval was waived for this retrospective study. Twenty-eight patients (mean age ± standard deviation, 24.3 years ± 6.4) with nonunion of a scaphoid fracture underwent dynamic gadolinium-enhanced MR imaging of the wrist 28 days ± 19 before surgery. Dynamic gadolinium-enhanced MR imaging consisted of acquisition of 40 consecutive coronal T1-weighted images over 1 minute. Two readers retrospectively evaluated MR images obtained with a standard protocol and rated the viability of the proximal scaphoid pole. The steepest upslope of gadolinium uptake was calculated in a region of interest placed in the proximal scaphoid pole by a third reader. Receiver operating characteristic curves were calculated, and the areas under the receiver operating characteristic curve (A(z) values) were compared. Diagnostic performance in determining scaphoid viability was calculated for readers 1 and 2. Histologic findings in 11 patients and surgical findings in all patients served as the standard of reference.

RESULTS

The sensitivity, specificity, and accuracy of standard MR imaging in the detection of scaphoid necrosis were 54%, 93%, and 75%, respectively, for reader 1 and 62%, 93%, and 78% for reader 2. Interreader reliability was excellent (κ = 0.92). The A(z) was 0.82 for reader 1 and 0.87 for reader 2. The diagnostic performance of dynamic gadolinium-enhanced MR imaging, determined with the steepest upslope value, was inferior to that of standard MR imaging, with an A(z) of 0.57. Findings at histologic examination (viable bone, necrotic bone, callus formation) did not correlate with those at dynamic gadolinium-enhanced MR imaging.

CONCLUSION

Because the diagnostic performance of dynamic gadolinium-enhanced MR imaging in the evaluation of scaphoid viability was inferior to that of a standard MR imaging protocol, dynamic acquisition may not be needed in patients with nonunion of scaphoid fractures.

Direct magnetic resonance arthrography of the wrist with axial traction: a feasibility study to assess joint cartilage

PURPOSE

To assess the impact of axial traction during acquisition of direct magnetic resonance (MR) arthrography of the wrist with regard to joint space width and amount of contrast material between the opposing cartilage surfaces.

MATERIALS AND METHODS

Fifteen consecutive patients (12 male, mean age 38.1 years) were included in this Institutional Review Board-approved prospective study. Three-compartment wrist MR arthrographies were performed between October and December 2009 on a 3 T unit using a fat-suppressed T1-weighted isotropic high-resolution volumetric interpolated breathhold examination (VIBE) sequence in the coronal plane, with and without axial traction (3 kg). Two radiologists measured radiocarpal (radioscaphoid, radiolunate) and midcarpal (lunocapitate, hamatolunate) joint space widths, with and without traction, and assessed the amount of contrast material between the opposing cartilage surfaces using a three-point scale: 0 = absence, 1 = partial, 2 = complete.

RESULTS

With traction, joint space width increased significantly at the radioscaphoid (Δ = 0.78 mm, P < 0.01), radiolunate (Δ = 0.18 mm, P < 0.01), and lunocapitate (Δ = 0.45 mm, P < 0.01) spaces, and both observers detected significantly more contrast material between the cartilage surfaces. At the hamatolunate space, the differences in joint space width (Δ = 0.14 mm, P = 0.54) and amount of contrast material were not significant.

CONCLUSION

Direct wrist MR arthrography with axial traction of 3 kg increases joint space width at the radiocarpal and lunocapitate spaces, and prompts better coverage of the articular cartilage by the contrast material.

Pitfalls that may mimic injuries of the triangular fibrocartilage and proximal intrinsic wrist ligaments at MR imaging

Diagnosis of injuries to the ligamentous structures of the wrist can be a challenge, particularly when there is involvement of the small, complex structures of the proximal wrist. Recent advances in magnetic resonance (MR) imaging, especially in spatial and contrast resolution, have facilitated more precise visualization of these structures. However, there are a number of pitfalls that may cause difficulty in diagnosis of injuries to the triangular fibrocartilage complex (TFCC), lunotriquetral ligament, and scapholunate ligament. Use of inappropriate MR imaging sequences and MR imaging artifacts may decrease the accuracy of diagnosis of injuries to the TFCC and wrist ligaments, whereas variant anatomy of the proximal wrist structures may mimic disease of the TFCC and wrist ligaments. Knowledge of the detailed anatomy of the wrist, as well as variant patterns of structure morphology and signal intensity, can help differentiate actual disease from normal or variant appearances at assessment with MR imaging.

Carpal contusions in an elite platform diver

Wrist and hand injuries are common in elite divers, as all correctly performed dives end with a head first entry into the water with the hands extended above the head. This case presentation was an Olympic level diver with 3 months of persistent dorsal wrist pain. MRI findings showed contiguous contusions to the lunate, capitate, hamate and distal radius and also a peripheral tear of the ulnar attachment of the triangular fibrocartilage complex (TFCC). The repeated dorsiflexion stress of entry into the water likely caused these injuries. Although the authors had suspected a TFCC injury and did find an isolated ulnar-sided peripheral tear, the complicating carpal contusions led us to choose a conservative treatment plan, which was the only intervention the patient ultimately required.

[Carpal instability]

Carpal instability can be understood as a disturbed anatomical alignment between bones articulating in the carpus. This disturbed balance occurs either only dynamically (with movement) under the effect of physiological force or even statically at rest. The most common cause of carpal instability is wrist trauma with rupture of the stabilizing ligaments and adaptive misalignment following fractures of the radius or carpus. Carpal collapse plays a special role in this mechanism due to non-healed fracture of the scaphoid bone. In addition degenerative inflammatory alterations, such as chondrocalcinosis or gout, more rarely aseptic bone necrosis of the lunate or scaphoid bones or misalignment due to deposition (Madelung deformity) can lead to wrist instability. Under increased pressure the misaligned joint surfaces lead to bone arrosion with secondary arthritis of the wrist. In order to arrest or slow down this irreversible process, diagnosis must occur as early as possible. Many surgical methods have been thought out to regain stability ranging from direct reconstruction of the damaged ligaments, through ligament replacement to partial stiffening of the wrist joint.

Stress fractures of the metacarpal bones in adolescent tennis players: a case series

BACKGROUND

There are 12 reported cases of metacarpal stress fractures in athletes, with only 4 of them involving the second metacarpal.

PURPOSE

The authors describe stress fracture of the second metacarpal bone in teenaged tennis players and the relationship with sport intensity and type of grip used. They also demonstrate that magnetic resonance imaging is the diagnostic study of choice to differentiate this entity from the most common cause of pain in this region of the hand in tennis players-the carpal boss.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Seven adolescent tennis players (mean age, 16.5 years; 6 female, 1 male) with dorsal hand pain produced by playing tennis were examined by radiographs and initial magnetic resonance imaging. In 2 cases, bone scintigraphy was performed. In the first 2 cases, the presumptive diagnosis was a carpal boss, but with this experience, the diagnostic evaluation of the last 5 cases was oriented toward a stress reaction at this level. Radiologic follow-up was performed. The authors also evaluated the grip type used by each tennis player.

RESULTS

Clinical evaluation and imaging studies resulted in a diagnosis of stress injury of the second metatarsal in 6 of 7 cases, with the seventh case involving the third metacarpal. Initial imaging was positive in 3 cases, revealing an increased signal in the marrow without hairline crack and cortical thickening of the shaft or simply an increased signal in the marrow. In all cases, there was a history of recent increase in the sport training load. Six of the 7 tennis players were using a semi-Western or Western grip.

CONCLUSION

Stress fractures of the second metacarpal are characteristic of adolescent tennis players and are associated with an increased intensity of tennis play and may be associated with use of the semi-Western or Western grip. Magnetic resonance imaging is the most useful tool for obtaining a definitive diagnosis.