Wrist arthrography: review and comparison of normals, rheumatoid arthritis and gout patients

Wrist Arthrography

The ligaments of the proximal row of carpal bones and the triangular fibrocartilage (TFC) strongly influence the function and stability of the wrist. Injury to the ligaments may result in chronic wrist pain or instability. Wrist arthrography is valuable in the investigation of such damage when surgical intervention is considered and plain radiography is unrewarding. There are also several technical modifications of the standard radiocarpal arthrography available. Owing to the possibility of congenital perforations and degenerative changes in these ligaments the arthrographic findings should be related to the clinical signs and the age of the patient. CT has less diagnostic importance in this respect while MR imaging is an alternative and may become the method of choice. Both these methods have great potential in the evaluation of soft tissues of the wrist other than the TFC.

Diagnosis and Treatment of Acute Lunotriquetral Ligament Injuries

Isolated acute lunotriquetral (LT) injuries are an uncommon diagnosis in hand surgery. Diagnosis is aided by a high index of suspicion when pain is localized over the LT joint. Standard radiographs show typically normal findings, leading to advanced diagnostic investigations, including MRI and wrist arthroscopy. Standard treatment options for acute LT injuries include immobilization, arthroscopy, and direct open LT repair.

Exploring cartilage damage in gout using 3-T MRI: distribution and associations with joint inflammation and tophus deposition

OBJECTIVE

Few imaging studies have investigated cartilage in gout. Magnetic resonance imaging (MRI) can image cartilage damage and also reveals other features of gouty arthropathy. The objective was to develop and validate a system for quantifying cartilage damage in gout.

METHODS

3-T MRI scans of the wrist were obtained in 40 gout patients. MRI cartilage damage was quantified using an adaptation of the radiographic Sharp van der Heijde score. Two readers scored cartilage loss at 7 wrist joints: 0 (normal), 1 (partial narrowing), 2 (complete narrowing) and concomitant osteoarthritis was recorded. Bone erosion, bone oedema and synovitis were scored (RAMRIS) and tophi were assessed. Correlations between radiographic and MRI cartilage scores were investigated, as was the reliability of the MRI cartilage score and its associations.

RESULTS

The GOut MRI Cartilage Score (GOMRICS) was highly correlated with the total Sharp van der Heijde (SvdH) score and the joint space narrowing component (R = 0.8 and 0.71 respectively, p < 0.001). Reliability was high (intraobserver, interobserver ICCs = 0.87 [0.57-0.97], 0.64 [0.41-0.79] respectively), and improved on unenhanced scans; interobserver ICC = 0.82 [0.49-0.95]. Cartilage damage was predominantly focal (82% of lesions) and identified in 40 out of 280 (14%) of joints. Cartilage scores correlated with bone erosion (R = 0.57), tophus size (R = 0.52), and synovitis (R = 0.55), but not bone oedema scores.

CONCLUSIONS

Magnetic resonance imaging can be used to investigate cartilage in gout. Cartilage damage was relatively uncommon, focal, and associated with bone erosions, tophi and synovitis, but not bone oedema. This emphasises the unique pathophysiology of gout.

Arthroscopic findings in gout of the wrist

PURPOSE

We have recently treated several patients with gout of the wrist and scapholunate ligament pathology. The purpose of this investigation was to report the arthroscopic findings of 7 such patients.

METHODS

We searched our medical records for patients with a diagnosis of gout and nontraumatic wrist pathology. We retrospectively reviewed the clinical, arthroscopic, radiographic, and pathologic findings in 7 patients who failed nonsurgical management and were treated with wrist arthroscopy.

RESULTS

All 7 wrists had diffuse synovitis and crystalline deposits throughout the radiocarpal joint. There were focal crystalline precipitates on the scapholunate and lunotriquetral ligaments but not on the triangular fibrocartilage complex. Scapholunate or lunotriquetral ligament disruption was noted in 6 and 5 wrists, respectively. An early scapholunate advanced collapse pattern of arthritis was present in 5 patients.

CONCLUSIONS

Gout affecting the wrist may be associated with crystal deposition on the scapholunate and lunotriquetral ligaments. Ligament incompetence and a scapholunate advanced collapse pattern of wrist arthritis was noted in 6 of our 7 patients.

Second metatarsophalangeal joint arthrography: a cadaveric correlation study

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

[Gouty arthritis of the wrist. Five case reports]

Gout is rarely localized to the wrist. Based on five new cases of this condition and literature review, the authors outline the clinical and radiographic signs which differentiate gout from other causes of isolated unilateral chronic synovitis of the wrist. On the clinical basis, this localization was the first appearance of the disease in three of the five cases. On the X-rays, large defects and joint destructions were present. A scapholunate dissociation was evident in 4/5 cases with sometimes bone condensation. Other diagnoses should be eliminated as chondrocalcinosis, rheumatoid arthritis or wrist infections in subacute forms. Final diagnosis is provided by histological examination, demonstrating specific microcrystals.

Low density lipoprotein of synovial fluid in inflammatory joint disease is mildly oxidized

Oxidatively modified low density lipoprotein (LDL) has many biological activities which could contribute to the pathology of the atherosclerotic lesion. Because atherosclerosis has an inflammatory component, there has been much interest in the extent to which LDL could be oxidatively modified in vivo by inflammation. The present study examined LDL present in an accessible inflammatory site, the inflamed synovial joint, for evidence of compositional change and oxidative modification. LDL was isolated from knee joint synovial fluid (SF) from subjects with inflammatory arthropathies and also from matched plasma samples. SF and plasma LDL had similar free cholesterol and alpha-tocopherol content, but SF LDL had a lower content of esterified cholesterol. On electrophoresis, SF LDL was slightly more electronegative than LDL from matched plasma samples, but the changes were much less than those resulting from Cu2+-treatment of LDL. Oxidized cholesterol was not detected in any samples, but cholesterol ester hydroperoxide levels were greater in SF than in plasma LDL. When samples from three subjects were incubated with macrophages, the SF LDL did not cause significant loading of the cells with cholesterol or cholesterol esters, in contrast to the situation with acetylated LDL. Overall, the SF LDL displayed evidence of slightly increased oxidation by comparison with matched plasma samples. Despite their isolation from an environment with active inflammation, changes were modest compared with those resulting from Cu2+ treatment. Thus, extensive LDL oxidation is not a necessary correlate of location in a chronic inflammatory site, even though it is characteristic of atherosclerotic lesions.

Arthrography of the wrist. Assessment of the integrity of the ligaments in young asymptomatic adults

Fifty-two asymptomatic adults who were between twenty and thirty-five years old had arthrography of the wrist with use of a single injection into the radiocarpal joint. The purpose of the study was to evaluate the integrity of the triangular fibrocartilage, the scapholunate ligament, and the lunotriquetral ligament. Contrast medium was injected under fluoroscopic guidance, and posteroanterior and lateral radiographs of the wrist were made after the subjects had performed exercises of the wrist. No patient who had a history of trauma to the wrist, pain in the wrist, or inflammatory arthritis was included in the study. All of the subjects had an examination of both upper extremities that included measurement of the active motion of the wrist with a goniometer, strength-testing with a Jamar dynamometer, ballottement and testing for impingement, and palpation for tenderness. Plain radiographs were evaluated, and the ulnar variance was recorded. The arthrograms revealed an abnormal communication of the contrast medium in fourteen wrists (27 per cent), and four of the fourteen had multiple areas of communication. The abnormal communication was through the triangular fibrocartilage alone in six wrists, the scapholunate ligament alone in two wrists, the lunotriquetral ligament alone in two wrists, and in more than one of these areas in four wrists. A positive arthrogram was associated with a greater positive ulnar variance. All of the subjects had symmetrical motion of the wrists and grip strength, and none of them had tenderness in the wrist. There were no complications related to the arthrography. Perforation of a ligament in the wrist is common in young asymptomatic adults.(ABSTRACT TRUNCATED AT 250 WORDS)

The relevance of ligament tears or perforations in the diagnosis of wrist pain: an arthrographic study

This study was designed to assess the clinical significance of arthrographic abnormalities in the ligaments of a painful wrist. This was accomplished by means of comparison arthrography of the asymptomatic wrist. Fifty-six consecutive patients with unilateral wrist pain underwent selective bilateral arthrography to assess interruptions of continuity of the triangular fibrocartilage, lunotriquetral, and scapholunate ligaments. The prevalence of bilaterally symmetric lesions was high. In patients with ligament defects in the symptomatic wrist, 88% of defects near the radial attachment of the triangular fibrocartilage, 59% of lunotriquetral defects, and 57% of scapholunate defects were bilateral. Furthermore, physical examination was not predictive of specific ligament defects. This study raises questions concerning the relevance of interrupted ligaments in the diagnosis of wrist pain.

Evaluation of chronic wrist pain by arthrography, arthroscopy, and arthrotomy

Arthrography and arthroscopy of the wrist were compared as diagnostic tools in the evaluation of chronic wrist pain. Arthroscopy proved to be a more sensitive procedure than arthrography in 20 consecutive patients with confirmed wrist injuries. There was 86% correlation (the exception--one false negative arthroscopic procedure) between arthroscopy and arthrography in eight patients with triangular fibrocartilage tears. Compared with arthroscopy, there were five false negative and five false positive arthrograms when evaluating interosseous scapholunate and lunotriquetral ligament tears. Arthroscopy more readily identified the location and extent of triangular fibrocartilage and the significance of interosseous ligament tears. Wrist arthrotomy confirmed the findings of wrist arthrography and arthroscopy and demonstrated that arthrography is not as accurate in localizing specific wrist injuries. Furthermore, wrist arthroscopy is a more valuable technique in determining the location, size, and extent of ligament injuries within the wrist.

Diagnostic applications of wrist arthrography

Arthrography of the wrist joint as a dynamic examination aids in confirming lesions of interosseous ligaments of the triangular fibrocartilage complex and soft tissue. The results of arthrography in 185 wrists, classified according to age of patients and pathological disorders with or without trauma demonstrate mostly post-traumatic discus lesions in younger patients. Older patients have an increase in pathological findings with a similar distribution between ligaments and discus. Soft-tissue injuries or discus lesions can be confirmed or excluded before osteoplastic surgery for distal radius fractures or reconstruction of ligaments in cases of carpal instability. Pathological changes of biomechanics of the hand and wrist are noticed more often and consequently are treated surgically. Arthrography of the wrist joint is a valuable means of diagnostic imaging.

The triple-injection wrist arthrogram

The last 100 patients to have wrist arthrography at our institution had, in addition to the standard radiocarpal joint injection, injections into the distal radioulnar joint and midcarpal joint. Seventy-seven of the 100 patients had abnormal arthrograms. In 29 cases abnormalities not identified by the radiocarpal joint injection were demonstrated either by the distal radioulnar joint or the midcarpal joint injection. In 38 patients abnormalities shown by radiocarpal joint injection were not demonstrable by the other two injections. Seven detachments of the triangular fibrocartilage complex from the ulnar styloid could be demonstrated only by the distal radioulnar joint injection. The midcarpal joint injection was far more useful than the radiocarpal joint injection in the evaluation of radiocarpal joint-midcarpal joint communications. All three injections appear to be necessary for a complete arthrographic evaluation.

Wrist arthrography: the value of the three compartment injection technique

Arthrography of the wrist was performed on 50 consecutive patients with obscure post-traumatic wrist pain by injecting contrast separately into the radiocarpal joint, midcarpal compartment, and distal radioulnar joint. When distal radioulnar joint and midcarpal compartment injections were added to the standard radiocarpal injection, many significant unsuspected abnormalities were identified. Of the 25 triangular fibrocartilage complex abnormalities identified, six (24%) were found only with the distal radioulnar joint injection. Of the 29 abnormal communications between the midcarpal compartment and the radiocarpal joint, ten (35%) were found only with the midcarpal injection. Similarly, five of 29 (17%) of the abnormal radiocarpal-midcarpal communications would have been missed if a midcarpal injection alone had been performed. These findings indicate that separate injections into the radiocarpal joint, midcarpal compartment, and distal radioulnar joint are needed to identify a large number of abnormalities not seen with injections into one compartment alone.

Protein traffic in human synovial effusions

Concentrations of 5 marker proteins were measured in synovial fluid and serum samples from knee effusions of 11 patients with rheumatoid arthritis and 9 with osteoarthritis. Indirect determinations of synovial plasma flow and lymphatic drainage were obtained by measuring iodide clearance (ml/minute) and radio-albumin clearance (ml/minute). Together with protein concentrations, these determinations allowed us to calculate: the flux of each marker protein through synovial tissues (mg/minute); the volume of plasma cleared by synovium per unit time (ml/minute); and the fractional extraction per passage through the synovial microcirculation (protein permeance). These measures differed substantially between rheumatoid arthritis and osteoarthritis patient populations and quantified the severity of the microvascular lesion in rheumatoid synovitis.

Arthrotomography of the wrist: an experimental and preliminary clinical study

Experimental arthrotomography including posteroanterior and lateral projections was completed in 18 fresh-frozen wrists from cadavers with an average age of 65 years at death. Arthrotomographic findings were correlated with anatomic dissections. Three types of defects of the triangular fibrocartilage complex were clearly defined in 38% of wrists. Chondromalacia was present in 24% of wrists, in all cases on the ulnar half of the proximal surface of the lunate bone. The palmar radiocarpal ligaments (radiocapitate and radiotriquetral) were visible in all specimens. Experimental arthrotomography appears to be useful in defining the nature and location of soft tissue pathology in clinical practice. Clinical arthrotomography was performed in 16 patients, all with a syndrome of chronic wrist pain. Pathologic findings were observed in 11 wrists, including four perforations of the triangular fibrocartilage complex, two cases of chondromalacia of the lunate, one tear in each of the scapholunate and lunotriquetral ligaments, three occult palmar ganglia, and one recurrent dorsal ganglion. The soft tissues in five wrists were normal. The preliminary clinical experience with wrist arthrotomography has yielded results that have significantly affected the care of patients, including the planning of operative treatment and patient counseling.

Detection of intraarticular loose osteochondral fragments by double-contrast wrist arthrography. A case report of a basketball injury

Gravity was used in a case of double-contrast wrist arthrography to demonstrate the intraarticular loose nature of osteochondral fracture fragments. These calcified loose bodies were successfully removed surgically.

Arthrography of the wrist

Eighty-four wrist arthrograms were performed on 76 patients with posttraumatic wrist pain. Instillation of a small amount of contrast media into the radiocarpal joint under fluoroscopic control was helpful in delineating specific areas of pathology about the wrist. Comparison of the arthrographic findings with the plane films of 74 patients and the operative findings of 24 patients revealed that the arthrogram was most helpful in delineating perforations of the scapholunate ligament, the lunotriquetral ligament, the triangular fibrocartilage complex, and the wrist joint capsule.

A hypothesis on the pathogenesis of rheumatoid and other non-specific synovitides based on a combination of observations often overlooked

In early synovitides the tissue inflammatory cell reaction is often weak and sometimes absent, many alterations being consistent with nonvasculitic exudation (I). Increased permeability to protein may require little, if any, endothelial damage. In rheumatoid arthritis (RA) increased transfer of fluid and protein from vessels is not restricted to joints, suggesting that exudation is more liable to induce inflammation in joints than in other tissues of ambulant individuals (II). At least 17 vascular, rheological and other "primary" mechanisms may contribute to the formation of exudates; combinations of only a few of these may be required to produce joint effusions. Some mechanisms may explain why inflammation in RA favours joints (III). Joint effusions increase intra-articular hydrostatic pressure, contributing to synovial hypoxia, glycolysis and acidosis, which may be important "secondary" mechanisms in synovial inflammation (IV). Only a few of the "primary" mechanisms are strictly local ones, and RA may predominantly be a systemic disease dependent on combinations of minor aberrations in metabolic, endocrine and other functions (V). The combination of contributing mechanisms is not necessarily the same in two patients fulfilling the criteria for RA, and patients with clinically different types of synovitis may share pathogenetic mechanisms (VI).