Detection of scapholunate interosseous ligament injury using dynamic computed tomography-derived arthrokinematics: A prospective clinical trial

Scapholunate interosseous ligament injuries are a major cause of wrist instability and can be difficult to diagnose radiographically. To improve early diagnosis of scapholunate ligament injuries, we compared injury detection between bilateral routine clinical radiographs, static CT, and dynamic four-dimensional CT (4DCT) during wrist flexion-extension and radioulnar deviation. Participants with unilateral scapholunate ligament injuries were recruited to a prospective clinical trial investigating the diagnostic utility of 4DCT imaging for ligamentous wrist injury. Twenty-one participants underwent arthroscopic surgery to confirm scapholunate ligament injury. Arthrokinematics, defined as distributions of interosseous proximities across radioscaphoid and scapholunate articular surfaces at different positions within the motion cycle, were used as CT-derived biomarkers. Preoperative radiographs, static CT, and extrema of 4DCT were compared between uninjured and injured wrists using Wilcoxon signed rank or Kolmogorov-Smirnov tests. Median interosseous proximities at the scapholunate interval were significantly greater in the injured versus the uninjured wrists at static-neutral and maximum flexion, extension, radial deviation, and ulnar deviation. Mean cumulative distribution functions at the radioscaphoid joint were not significantly different between wrists but were significantly shifted at the scapholunate interval towards increased interosseous proximities in injured versus uninjured wrists in all positions. Median and cumulative distribution scapholunate proximities from static-neutral and 4DCT-derived extrema reflect injury status.

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.

Diagnostic performance of high-resolution ultrasound in the evaluation of intrinsic and extrinsic wrist ligaments after trauma

PURPOSE

To investigate the role of ultrasound (US) in the evaluation of intrinsic and extrinsic ligaments of the wrist with magnetic resonance arthrography (MRA) as the reference standard.

MATERIALS AND METHODS

This prospective study included patients referred for MRA after wrist trauma. US examination was performed just before MRA. On the dorsal and palmar sides of the wrist, the intrinsic interosseus and midcarpal, extrinsic, and collateral ligaments were evaluated. MRA was performed on a 1.5-T unit. In the first 20 patients included, ligament thickness was independently assessed using US and MRA and thickness reproducibility was calculated. Ligament integrity was evaluated in all patients.

RESULTS

38 patients (22 men, 16 women; mean age: 38 years) were included. Ligament thickness reproducibility ranged between 44% for the palmar ulnocapitate ligament and 71% for the palmar scaphotriquetral ligament. US had a sensitivity, specificity, positive and negative predictive values, and accuracy of 100% in the identification of tears of the palmar (n=8) and dorsal (n=3) bands of the scapholunate ligament and the ulnar collateral ligament (n=3). It had a sensitivity of 100%, specificity of 97%, positive predictive value of 50%, negative predictive value of 100%, and accuracy of 97% in the identification of tears of the palmar ulnolunate ligament (n=1).

CONCLUSION

Compared to MRA, US showed good reproducibility in the assessment of wrist ligament thickness and similar accuracy with respect to identifying tears of the scapholunate, palmar ulnolunate, and ulnar collateral ligaments.

Imaging Diagnosis and Management of Carpal Trauma and Instability-An Illustrated Guide

Understanding the subtle signs of carpal instability and other unique injury patterns in the wrist is a critical skill for radiologists. Proper patient management and outcomes are directly dependent on the accurate interpretation of wrist imaging studies. This review will provide a detailed overview of typical imaging features of carpal trauma and instability, management, and complications, using multimodality imaging and original medical illustrations. A detailed overview of the osseous, ligamentous, arterial anatomy of the wrist, arcs of Gilula, and zones of vulnerability will be provided. Carpal fractures, dislocations, special radiographic views, and imaging pearls will be discussed. Instability patterns and the myriad of associate abbreviations (CID, CIND, CIC, CIA, VISI, DISI, SLD, LTD, MCI, SLAC, SNAC) will be clarified. Expected outcomes, potential complications, and management will be reviewed.

[Establishing a standardized diagnostic Procedure for sonographic Imaging and Evaluation of the scapholunate Ligament]

BACKGROUND

Ultrasound has not yet been established in the diagnostic workup of scapholunate ligament lesions. We aimed to develop a standardised examination procedure to visualise and evaluate the SL ligament.

PATIENTS AND METHODS

Forty patients (70 hands) were examined prospectively with ultrasonography and the results were compared with arthroscopy and MRI findings. We studied the visibility of the SL ligament and the SL distance on side-to-side comparison and performed a method comparison between MRI/arthroscopy and ultrasound, testing for distinction and accordance. Cut-off values for the SL distance indicating a lesion were determined and all parameters were used for developing a score.

RESULTS

An intact ligament appears as a hyperechogenic, fibrillary structure and shows discontinuity or a hypoechogenic space when injured. An intact ligament was visible dorsally in 89.6 % and palmarly in 83.3 %. The SL distance for an intact ligament was 5/2/5.1 mm for the dorsal/middle/palmar aspect (range 3.2-6.7/0.9-4/3.1-7.8 mm) and 6.4/3/6.3 mm (range 5-9.4/2-6.2/4-9.3 mm) for a lesion. The difference between the right and left hand with an intact ligament was a maximum of 2.1/1.1/1.8 mm, an average of 0.4/0.2/0.2 mm; in case of an injury, the maximum difference was 1.2/0.9/1.1 mm. Distance values for radial and ulnar deviation were physiological but partly unpredictable. The cut-off values determined for a lesion are 5.05 mm for the dorsal aspect (sensitivity/specificity 0.95/0.60), 1.95 mm for the middle (1/0.62) and 6.15 mm for the palmar aspect (0.55/0.85). The created sonographic SL ligament score has a high AUC (area under the curve) of 0.93, a sensitivity of 85 % and a specificity of 90 %.

CONCLUSION

The parameters, especially when combined to a score, allow to state whether the SL ligament is intact or not. Ultrasound can, therefore, be recommended as a diagnostic and screening method for an SL ligament lesion und should be used as a routine tool. The criteria must be checked from a perspective with high case numbers.

Usefulness of the Ultrasound in Hand Surgery: Part I

In the last years, ultrasonography (US) of the wrist and hand have increased in popularity. Technical advances led us to improve image quality and have the ability to see superficial soft-tissue structures with high resolution with the patient in our office.

The advantages of US are the fact that it is noninvasive, its lack of ionising radiation, low cost, and portability. The dynamic real-time assessment in the office is an additional benefit.

Ultrasound can be used in hand surgery for both diagnostic and therapeutic purposes. We can use US for injections with needle guidance, for the evaluation of soft-tissue masses, foreign bodies, tendon injuries, compressive neuropathies, and rheumatologic joint disease. It also helps us perform ultrasound-guided procedures: carpal tunnel syndrome, trigger finger, and intersection syndrome or compartimental syndrome.

The aim of the present review is to describe different uses of US in hand surgery to show its important role of providing to the surgeon more information on the diseases of their patients.

Sonoanatomy and Stepwise/Systematic Ultrasound Examination of the Extrinsic/Intrinsic Wrist Ligaments

Ultrasound has emerged as the most useful imaging tool for investigating wrist and hand disorders, with several published ultrasound protocols having demonstrated their practicality in scanning the wrist tendons and nerves. However, ligaments of the wrist are networked in a complex manner, deterring sonographers from examining them with an organized strategy. Furthermore, because of the non-parallel alignment between the radiocarpal, mid-carpal, and carpal-metacarpal joints, precise recognition of the carpal bones is challenging, although ultrasound is paramount for visualizing the wrist ligaments. In this regard, the current article for point of view aims to elaborate sonoanatomy of the carpal bones and to present a stepwise systematic approach for navigating the extrinsic and intrinsic wrist ligaments.

Ultrasonographic anatomy of the dorsal region of the carpus of the dog

The dorsal region of the canine carpus is anatomically complex and its normal ultrasonographic characteristics have not been published. The aims of this prospective, descriptive, anatomic study were (a) to describe the normal ultrasonographic appearance of the dorsal carpal structures in medium to large breed dogs, and (b) to describe a standardized protocol for evaluations. The final study, based on the methodology developed in a pilot study performed in twenty-two carpi, comprised two phases: (a) identification phase, in which a correlation between ultrasound and dissection and anatomic slices was performed in forty-eight cadaver carpi and the ultrasonographic protocol was developed; and (b) descriptive phase, in which the ultrasonographic characteristics of the examined structures in 23 carpi of 12 alive adult and healthy dogs were recorded. The tendons of the abductor pollicis longus and the extensor muscles of the carpus and digits, the dorsal ligaments of the carpus - including the medial and lateral collateral ligaments - the extensor retinaculum, a distal radioulnar fibrocartilage and the regional osseous surfaces were ultrasonographically identified and described. Findings from the current study can be used as a reference for ultrasonographic examinations in dogs with injuries or other diseases affecting the dorsal region of the carpus.

Feasibility of ultrasound-based measurement of dorsal scaphoid displacement: A 3D-model study

The present study aimed to develop a reliable dynamic measurement technique, which can be used directly in the outpatient setting, based on dorsal subluxation of the scaphoid on scaphoid shift test. This study was designed to evaluate feasibility and to quantify dorsal subluxation of the scaphoid in relation to the lunate. Based on a scaphoid shift test under ultrasonography, a standardized 3D test model was developed to measure subluxation. Sagittal subluxation ranged between 0 and 6 mm, as checked on the implemented scale. Four hand surgeons trained in ultrasonography (experience level II-V) performed blinded measurements (total of 52, n = 13 per investigator) with a standardized measurement protocol. Dorsal subluxation of the scaphoid was measured in relation to the lunate. Interobserver reliability on intraclass correlation coefficient (ICC) was excellent, at 0.97 (95% confidence interval, 0.930-0.992). Mean overall absolute measurement error was 0.27 mm ± 0.21. Dorsal subluxation of the scaphoid can thus be accurately measured on ultrasound with excellent interobserver reliability, quantifying and improving clinical assessment of scapholunate instability.

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.

Magnetic resonance imaging of the wrist and hand

The anatomy of the wrist and hand is complex and contains numerous small structures. Magnetic resonance imaging (MRI) is often an ideal imaging modality in the assessment of various traumatic and pathologic conditions of this region, and it is frequently performed after initial radiographs. In this manuscript we describe the normal anatomy, imaging techniques, and MRI findings of various traumatic and pathologic conditions of the wrist and hand including occult fractures, osteonecrosis, ligamentous and tendon injuries, and entrapment neuropathies.

The radial and ulnar collateral ligaments of the wrist are true ligaments

PURPOSE

Our hypothesis in this study is that the radial and ulnar collateral ligaments of the wrist exist and are true ligaments which can be visualized by high-resolution ultrasonography (US).

METHODS

High-resolution US examination of the radial and ulnar collateral ligaments of the wrist was performed on 56 fresh cadaveric wrists. The visibility of these ligaments was assessed by four observers who classified the ligaments in consensus as well seen, adequately seen, or not seen. Surgical dissections of 12 radial collateral ligaments and 12 ulnar collateral ligaments were then performed and the ligaments were classified as present or absent. The US and dissection results were then compared. To confirm that the dissected structures represent true ligaments a histologic examination of the ligaments was performed.

RESULTS

All examined radial and ulnar collateral ligaments were seen on the US examination. The radial collateral ligament was seen between the radial styloid and radial aspect of the scaphoid. The ulnar collateral ligament was seen between ulnar styloid process and the triquetrum. On all surgical dissections, the radial collateral ligament was present at the floor of the first extensor compartment and the ulnar collateral ligament was at the floor of the sixth extensor compartment. Both ligaments were proven to be true capsular ligaments on both dissection and histologic examinations.

CONCLUSION

The radial and ulnar collateral ligaments of the wrist are true ligaments and can be seen at the floor of the first and the sixth extensor compartments, respectively, using high-resolution US. Based on their anatomic location, they most likely provide static stability to the wrist joint.

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.

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.

Changes in Medicare Reimbursement for Advanced Upper Extremity Imaging

PURPOSE

Advanced noninvasive imaging of the upper extremity joints, including computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US) , has numerous applications in the evaluation of musculoskeletal pathology. Choice of modality is influenced by clinical and cost concerns, with US and CT traditionally considered less expensive than MRI. We analyzed the changes in Medicare reimbursement for these imaging modalities with the hypothesis that recent reimbursement decreases in MRI have made this modality more cost-competitive than other commonly used imaging modalities.

METHODS

Using the Medicare Fee Schedule Database, we reviewed the Medicare reimbursements fee schedule for CT, US, and MRI from 2000 to 2015 at the national, regional, and state levels. Charges were identified and queried by Common Procedural Terminology (CPT) codes for each modality. Changes in reimbursement were calculated for each of the modalities.

RESULTS

Total (technical and professional) reimbursement for MRI decreased from $516.93 to $237.16 between 2007 and 2015. Adjusted for inflation, this represents a 60% decrease in reimbursement. During the same time period, total (technical and professional) reimbursement for CT decreased from $256.95 to $180.03, a 39% decrease adjusted for inflation. Total (technical and professional) reimbursement for US increased over the same time period, from $98.91 to $118.22 in 2015, in conjunction with changes in the CPT coding for US. Total (technical and professional) MRI reimbursement decreased from 5.23 times the reimbursement of US in 2007 to 2.01 times in 2015.

CONCLUSIONS

In concordance with our hypothesis, these findings demonstrate that upper extremity MRI and CT reimbursements as scheduled by Medicare have declined significantly in recent years and that these modalities are approaching financial parity with wrist US. In spite of these decreases, MRI remains the most costly advanced imaging modality. Depending on each clinical scenario, the added cost may be justified by the value added by the type of information that can be garnered from each study. Cost-analysis studies evaluating the clinical application of MRI performed prior to the reimbursement decline should be evaluated with caution, and cost-benefit analyses based on these data are at risk of being out-of-date.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic Analysis IV.

The Quantitative Anatomy of the Dorsal Scapholunate Interosseous Ligament

BACKGROUND

The anatomy of the scapholunate interosseous ligament (SLIL) has been described qualitatively in great detail, with recognition of the dorsal component's importance for carpal stability. The purpose of this study was to define the quantitative anatomy of the dorsal SLIL and to assess the use of high-frequency ultrasound to image the dorsal SLIL.

METHODS

We used high-frequency ultrasound imaging to evaluate 40 wrists in 20 volunteers and recorded the radial-ulnar (length) and dorsal-volar (thickness) dimensions of the dorsal SLIL and the dimensions of the scapholunate interval. We assessed the use of high-frequency ultrasound by comparing the length and thickness of the dorsal SLIL on ultrasound evaluation and open dissection of 12 cadaveric wrists. Student's t test was used to assess the relationship between measurements obtained on cadaver ultrasound and open dissection.

RESULTS

In the volunteer wrists, the mean dorsal SLIL length was 7.5 ± 1.4 mm and thickness was 1.8 ± 0.4 mm; the mean scapholunate interval was 5.0 mm dorsally and 2.5 mm centrally. In the cadaver wrists, there was no difference in dorsal SLIL length or thickness between ultrasound and open dissection.

CONCLUSIONS

The dorsal SLIL is approximately 7.5 mm long and 1.8 mm thick. These parameters may be useful in treatment of SLIL injuries to restore the native anatomy. High-frequency ultrasound is a useful imaging technique to assess the dorsal SLIL, although further study is needed to assess the use of high-frequency ultrasound in detection of SLIL pathology.

Point-of-care wrist ultrasonography in trauma patients with ulnar-sided pain and instability

OBJECTIVE

We evaluated the effectiveness of point-of-care wrist ultrasonography compared with 3T-magnetic resonance imaging (MRI) for diagnosing triangular fibrocartilage complex (TFCC) injuries in trauma patients with ulnar-sided pain and instability. Moreover, we assessed the inter-observer variability between an emergency physician and a musculoskeletal radiology fellow.

MATERIAL AND METHODS

A prospective cross-sectional study was conducted in an emergency department; patients with ulnar-sided sprain and instability were recruited. An emergency physician and a musculoskeletal radiology fellow independently evaluated the TFC, meniscal homologue, volar and dorsal distal radioulnar ligaments, and extensor carpi ulnaris using point-of-care ultrasonography. Findings were classified as normal, partial rupture, or complete rupture. Wrist 3T-MRI was used as the reference standard. We compared the diagnostic values for point-of-care ultrasonography obtained by both reviewers using DeLong's test. Intra-class correlation coefficients (ICCs) were calculated for agreement between each reviewer and the reference standard, and directly between the two reviewers.

RESULTS

Sixty-five patients were enrolled. Point-of-care wrist ultrasonography showed acceptable sensitivity (97.2-99.1%), specificity (96.8-97.3%), and accuracy (96.9-97.9%); these diagnostic performance values did not differ significantly between reviewers (p=0.58-0.98). Agreement between each reviewer and the reference standard was excellent (emergency physician, ICC=0.964; musculoskeletal radiology fellow, ICC=0.976), as was the inter-observer agreement (ICC=0.968).

CONCLUSION

Point-of-care wrist ultrasonography is as precise as MRI for detecting TFCC injuries, and can be used for immediate diagnosis and further preoperative imaging. Moreover, it may shorten the interval from emergency department admission to surgical intervention while reducing costs.

Dynamic high-resolution ultrasound of intrinsic and extrinsic ligaments of the wrist: How to make it simple

Wrist ligaments are crucial structures for the maintenance of carpal stability. They are classified into extrinsic ligaments, connecting the carpus with the forearm bones or distal radioulnar ligaments, and intrinsic ligaments, entirely situated within the carpus. Lesions of intrinsic and extrinsic ligaments of the wrist have been demonstrated to occur largely, mostly in patients with history of trauma and carpal instability, or rheumatoid arthritis. Ultrasound allows for rapid, cost-effective, non-invasive and dynamic evaluation of the wrist, and may represent a valuable diagnostic tool. Although promising results have been published, ultrasound of wrist ligaments is not performed in routine clinical practice, maybe due to its technical feasibility regarded as quite complex. This review article aims to enlighten readers about the normal sonographic appearance of intrinsic and extrinsic carpal ligaments, and describe a systematic approach for their sonographic assessment with detailed anatomic landmarks, dynamic manoeuvres and scanning technique.

Optimal detection of scapholunate ligament tears with MRI

Background Scapholunate interosseous ligament (SLIL) injuries can often be difficult to detect using magnetic resonance imaging (MRI), especially with older 1.0 and 1.5 Tesla magnets. Wrist arthroscopy is the gold standard for diagnosis of SLIL injuries, but is an invasive procedure with associated risks. Purpose To assess whether SLIL injuries can be more accurately detected using axial MRI sequences instead of coronal sequences. Material and Methods An institutional review board approved retrospective analysis of arthroscopic wrist surgeries performed at our institution. Patients that had a preoperative MRI performed at our university center using a 1.5 Tesla scanner with a dedicated wrist coil were included in the study. Three fellowship-trained musculoskeletal radiologists reviewed the axial sequences and coronal sequences independently. The accuracy of the coronal and axial sequences was compared with the arthroscopic/surgical findings. Result Twenty-six patients met the inclusion criteria. The sensitivity for SLIL tears was 79% and 65% for the axial and coronal sequences, respectively. The specificity was 82% for the axial and 69% for the coronal sequences, respectively. The positive and negative predictive values for the axial sequences were 76% and 84% respectively, compared to 68% and 71% for the coronal sequences, a statistically significant difference. Conclusion SLIL tears are more readily detectable on axial MRI sequences than coronal. Clinically, patients with radial-sided wrist pain and suspicion for SLIL tears should have the axial sequences scrutinized carefully. An otherwise normal study with the axial sequence being degraded by motion or other MRI artifacts might need repeat imaging.

Normal Sonographic Anatomy of the Wrist With Emphasis on Assessment of Tendons, Nerves, and Ligaments

Sonography allows for rapid, cost-effective, noninvasive, and dynamic evaluation of soft tissue structures, thus representing a valuable tool for ruling out musculoskeletal disorders of the wrist. Because of the complexity of the wrist joint, sonographic training and familiarity with normal and variant anatomy are needed to avoid misdiagnosis and improper treatment. The aim of this article is to enlighten readers about the structures representing normal findings or common variants during sonographic evaluations of the wrist. The main text reviews the pertinent gross anatomy and procedures that are recommended to assess the soft tissue structures of the wrist, with particular emphasis given to tendons, nerves, and ligaments. Detailed explanations of the scanning techniques and sonographic appearance of the wrist structures are provided in the figure legends.

Dynamic high-resolution US of ankle and midfoot ligaments: normal anatomic structure and imaging technique

The ankle is the most frequently injured major joint in the body, and ankle sprains are frequently encountered in individuals playing football, basketball, and other team sports, in addition to occurring in the general population. Imaging plays a crucial role in the evaluation of ankle ligaments. Magnetic resonance imaging has been proven to provide excellent evaluation of ligaments around the ankle, with the ability to show associated intraarticular abnormalities, joint effusion, and bone marrow edema. Ultrasonography (US) performed with high-resolution broadband linear-array probes has become increasingly important in the assessment of ligaments around the ankle because it is low cost, fast, readily available, and free of ionizing radiation. US can provide a detailed depiction of normal anatomic structures and is effective for evaluating ligament integrity. In addition, US allows the performance of dynamic maneuvers, which may contribute to increased visibility of normal ligaments and improved detection of tears. In this article, the authors describe the US techniques for evaluation of the ankle and midfoot ligaments and include a brief review of the literature related to their basic anatomic structures and US of these structures. Short video clips showing dynamic maneuvers and dynamic real-time US of ankle and midfoot structures and their principal pathologic patterns are included as supplemental material. Use of a standardized imaging technique may help reduce the intrinsic operator dependence of US. Online supplemental material is available for this article.

Wrist ultrasound examination - scanning technique and ultrasound anatomy. Part 1: Dorsal wrist

Ultrasound imaging of the musculoskeletal system is superior to other imaging methods in many aspects, such as multidimensional character of imaging, possibility of dynamic evaluation and precise assessment of soft tissues. Moreover, it is a safe and relatively inexpensive method, broadly available and well-tolerated by patients. A correctly conducted ultrasound examination of the wrist delivers detailed information concerning the condition of tendons, muscles, ligaments, nerves and vessels. However, the knowledge of anatomy is crucial to establish a correct ultrasound diagnosis, also in wrist assessment. An ultrasound examination of the wrist is one of the most common US examinations conducted in patients with rheumatological diseases. Ultrasonographic signs depend on the advancement of the disease. The examination is equally frequently conducted in patients with pain or swelling of the wrist due to non-rheumatological causes. The aim of this publication was to present ultrasound images and anatomic schemes corresponding to them. The correct scanning technique of the dorsal part of the wrist was discussed and some practical tips, thanks to which highly diagnostic images can be obtained, were presented. The following anatomical structures should be visualized in an ultrasound examination of the dorsal wrist: distal radio-ulnar joint, radiocarpal joint, midcarpal joint, carpometacarpal joints, dorsal radiocarpal ligament, compartments of extensor tendons, radial artery, cephalic vein, two small branches of the radial nerve: superficial and deep, as well as certain midcarpal ligaments, particularly the scapholunate ligament and lunotriquetral ligament. The paper was distinguished in 2014 as the “poster of the month” (poster number C-1896) during the poster session of the European Congress of Radiology in Vienna.

Scapholunate advanced collapse: a pictorial review

Scapholunate advanced collapse (SLAC) is the most common cause of osteoarthritis involving the wrist. Along with clinical investigation, radiological studies play a vital role in the diagnosis of SLAC wrist. Given that the osteoarthritic changes that are seen with SLAC occur in a predictable progressive pattern, it is important to understand the pathological evolution of SLAC to be able to recognise the associated progressive imaging findings seen with this disease process. Focusing on radiological findings, this article provides a pictorial review of the anatomy of the scapholunate interosseous ligament as well as the common terminology and biomechanical alterations seen in the pathway leading to the development of SLAC arthropathy. We will then discuss two additional common causes of SLAC wrist and their imaging findings, namely scaphoid non-union advanced collapse and calcium pyrophosphate dehydrate disease. In addition, we will provide a brief overview of the current treatment options of these pathological entities.

• SLAC is the most common cause of osteoarthritis involving the wrist.

• Arthritic changes of SLAC occur in a predictable progressive pathological and radiographic pattern.

• Imaging is key for diagnosing, monitoring progression and assessing post-treatment changes of SLAC.

Acute short radiolunate ligament rupture in a rock climber

We report the occurrence of a short radiolunate ligament rupture in a rock climber. To our knowledge, an isolated traumatic rupture of this ligament has not been described in the literature, and awareness of this entity allows initiation of therapy. The magnetic resonance imaging and ultrasound appearances are reviewed and the mechanism of injury is discussed.

High-resolution ultrasound of the extrinsic carpal ligaments

Thanks to its intrinsic high spatial resolution, ultrasound is an ideal imaging modality for examining very thin, superficial structures, and this makes it very helpful in the evaluation of extrinsic carpal ligaments. These structures, which arise from the radius and ulna and insert on the carpal bones, are extremely important for wrist stability. Previous studies have assessed the use of ultrasound to study the extrinsic carpal ligaments in cadavers, healthy asymptomatic subjects, and patients with rheumatoid arthritis. In the present report, we review the normal anatomy, biomechanics, and ultrasound appearance of these ligaments.

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.

Anatomical study of the pisotriquetral joint ligaments using ultrasonography

OBJECTIVE

The aim of this study was to demonstrate that ultrasonography may allow a precise assessment of the primary stabilizers of pisotriquetral joint (pisohamate, pisometacarpal, and ulnar pisotriquetral ligaments).

METHODS AND MATERIALS

This study was initially undertaken in eight cadavers. Metal markers were placed in the ligaments using ultrasonographic guidance, followed by the dissection of the wrists. High-resolution ultrasonography was then performed in 15 volunteers (30 wrists) for the analysis of the presence, appearance, and thickness of the ligaments.

RESULTS

At dissection, the metal markers were located in the ligaments or immediately adjacent to them, confirming that they were correctly depicted using ultrasonography. The three ligaments could also be identified in each volunteer. The optimal positioning of the probe and the dynamic maneuvers of the wrist allowing the strain of these ligaments could be defined. No significant changes in the appearance and thickness of the ligaments could be observed.

CONCLUSIONS

The three ligaments stabilizing the pisotriquetral joint can be identified using ultrasonography. Further studies are now required to know whether this knowledge may be useful in the assessment of pain involving the ulnar part of the wrist.

High-resolution ultrasound evaluation of extrinsic wrist ligaments in patients affected by rheumatoid arthritis

OBJECTIVES

To evaluate the ultrasound features of the extrinsic wrist ligaments in rheumatoid arthritis (RA) patients in comparison with healthy volunteers.

METHODS

Twenty-one consecutive patients affected by RA (12 men, 9 women; mean age 57 ± 14.6 years) were compared with 21 controls (12, 9; 54 ± 12.1, respectively). Wrists were evaluated using ultrasound on both palmar and dorsal sides along each ligament, using carpal bones as references. The following ligaments were studied: radioscaphocapitate, radiolunotriquetral, palmar ulnolunate, palmar ulnotriquetral, dorsal radiotriquetral, dorsal ulnotriquetral, and radial collateral ligament. Ligament number and thickness were noted. Echotexture was rated as fibrillar, fragmented, or heterogeneous; the surface was rated as smooth or blurred.

RESULTS

The number of palmar ulnolunate and palmar ulnotriquetral ligaments detected by ultrasound in patients was significantly lower than in controls (P = 0.031 and P = 0.037, respectively). All ligaments had significantly more fragmented or heterogeneous echotexture and blurred surface and were significantly thinner in patients than in controls (P < 0.001). No correlation was found between ligament thickness and RA duration or clinical parameters.

CONCLUSIONS

Extrinsic wrist ligaments were less detectable and thinner in patients affected by RA compared with healthy volunteers matched for age and sex. Ligament thinning did not directly correlate with RA duration and clinical parameters.

KEY POINTS

• Ultrasound is increasingly used to evaluate normal anatomy of extrinsic wrist ligaments. • Extrinsic wrist ligaments are thinner in rheumatoid arthritis patients than in controls. • Extrinsic wrist ligaments are less easy to detect in rheumatoid arthritis patients. • Ligament thinning and detectability are not related to clinical parameters.

Sonographically guided distal radioulnar joint injection: technique and validation in a cadaveric model

Distal radioulnar joint (DRUJ) disorders are uncommon but important causes of ulnar-sided wrist pain and disability. Fluoroscopically guided injections may be performed to diagnose or treat DRUJ-related pain or as part of a diagnostic arthrogram. Sonographic guidance may provide a favorable alternative to fluoroscopic guidance for distal DRUJ injections. This report describes and validates a sonographically guided technique for DRUJ injections in an unembalmed cadaveric model. An experienced clinician used sonographic guidance to inject diluted colored latex into the DRUJs of 10 unembalmed cadaveric specimens. Subsequent dissection by a fellowship-trained hand surgeon confirmed accurate injections in all 10 specimens. Two cases of ulnocarpal flow, indicative of triangular fibrocartilage injury, were noted during injection and subsequently confirmed during dissection. Clinicians should consider using sonographic guidance to perform DRUJ injections when clinically indicated. Further research should explore the efficacy of sonographically guided DRUJ injections to treat patients with painful DRUJ syndromes or to evaluate the triangular fibrocartilage complex in patients with ulnar wrist pain syndromes.