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PubMed1995

Wrist arthroscopy.

Major advancement in arthroscopic equipment and techniques has extended the ability of large joint arthroscopy to be performed in smaller joints. Although wrist arthroscopy is performed in small numbers, the same advantages are afforded as in large joint procedures. It provides important diagnostic information and therapeutic intervention, while avoiding the significant morbidity of open techniques. Patients with mechanical wrist pain are the best candidates for arthroscopy to evaluate ligamentous injuries or triangular fibrocartilage complex injuries. Arthroscopy is also an effective tool in the evaluation and treatment of intra-articular distal radius fractures and is particularly useful in radial styloid fractures. Wrist arthroscopy is a technically demanding procedure. However, it remains a safe and effective method for diagnosis and treatment if performed using a precise technique and if the surgeon has a precise understanding of the anatomy of the wrist.

Arthroscopy↗

PubMed2001

Histopathological analysis of Leri-Weill dyschondrosteosis: disordered growth plate.

Leri-Weill syndrome (LWS) is a dominant (pseudoautosomal) skeletal dysplasia with mesomelic short stature and bilateral Madelung deformity, due to dyschondrosteosis of the distal radius. It results from the loss of one copy of the Short Stature Homeobox Gene (SHOX) from the tip of the short arm of the X or Y chromosome. SHOX molecular testing enabled us to evaluate the histopathology of the radial physis in LWS patients with a documented SHOX abnormality. A widespread disorganisation of physeal anatomy was revealed with disruption of the normal parallel columnar arrangement of chondrocytes. Tandem stacking of maturing chondrocytes within columns was replaced by a side-by-side arrangement. The presence of hypertrophic osteoid with micro-enchondromata in the radial metaphysis suggests abnormal endochondral ossification. The Vickers' ligament was confirmed to blend with the triangular fibrocartilage complex (TFCC). This histopathological study demonstrates that the zone of dyschondrosteosis in LWS is characterised by marked disruption of normal physeal chondrocyte processes and that a generalised physeal abnormality is present.

Adolescent↗

PubMed2001

Arthroscopically-assisted reduction of intra-articular fractures and soft tissue management of distal radius.

Arthroscopy was used to help to reduce intra-articular fractures of the distal radius and treat soft tissue injuries in 33 acute cases. The fractures were treated by reduction under arthroscopic control and percutaneous fixation either with or without external fixation. The triangular fibrocartilage complex (TFCC) was torn in 18 of 33 patients (54%). All tears were peripheral and were repaired with arthroscopic procedures. Scapholunate (SL) ligament injuries prevailed in six (18%) patients; most of them exhibited instability in the SL joint. They received SL ligament debrided and transfixed with K-wires. Four (12%) of the patients suffered lunotriquetral (LT) ligament injuries; three of them also received transfixation with K-wires. Six (18%) of the patients exhibited chondral fractures. All fractures healed without measurable incongruity of joint surface and at follow-up (24 to 36 months), 11 patients displayed excellent results and 22 patients displayed good results according to the Mayo modified wrist score.

Adult↗

PubMed2003

An anatomical study of the ligaments of the ulnar compartment of the wrist.

The ligamentous structures of the triangular fibrocartilage complex (TFCC) and their attachments were examined anatomically and histologically using fresh and embalmed cadavers. The TFCC was observed to have a three-dimensional structure consisting of three palmar ligaments--the short radiolunate (SRL), ulnolunate (UL), and ulnotriquetral (UT) ligaments. In addition, the attachment site of the ulnocarpal ligament (UC), which had been previously unknown, was identified. The dorsal components of the TFCC have been previously reported to consist solely of the extensor carpi ulnaris (ECU) subsheath; however, the ligamentous components running from the ulnar styloid process to the triquetrum were found at a layer deeper than the floor of the ECU subsheath. The UC has been reported previously as a two-dimensional structure, but there has been some disagreement as to its attachment sites.(2-6,14,15) It is suggested that the dorsal UT ligament should be considered as a separate ligament, based on its different direction and distal attachment site as compared with those of the ulnar collateral ligament (UCL) and ECU subsheath.

Aged↗

PubMed2004

Distal radioulnar joint dorsal instability treated with dorsal capsular reconstruction.

Six patients with post-traumatic distal radioulnar joint dorsal instability were treated with dorsal capsular reconstruction. This new technique of reconstruction requires less extensive dissection than the previously described methods in the literature and requires no tendon graft. A total of six patients treated from 1999 to 2001 were included in this study. Two were males and four were females. The average age of patients was 30 years and all the instabilities were secondary to trauma. One of them had associated minimally displaced distal radius fracture. All patients had arthrogram and arthroscopy done before the reconstruction and had no significant triangular fibrocartilage complex injury. The surgery consisted of duplication capsulorrhaphy of the dorsal capsular structures of the distal radioulnar joint. All patients had satisfactory results after the operations in terms of pain relief, range of motion and stability.

Adult↗

PubMed1999

Anatomical Study of the Distal Radioulnar Joint: Degenerative Changes and Morphological Measurement.

A study of the degenerative changes in the distal radioulnar joint compared with morphological measurement of that joint using 91 joints of the hand from 51 systemic anatomy cadavers was conducted. X-ray images of the joints of the hand were taken followed by measurement of radial inclination, ulnar variance, volar tilt, sigmoid notch inclination and ulnar seat inclination. Macroscopic observations of the ulnar notch of the radius and surface of the distal radioulnar joint of the ulnar head were made by dividing them into six and nine areas, respectively. These were then used to classify the degree of cartilage degeneration. In addition, the status of the triangular fibrocartilage complex (TFCC) was also observed. Arthropathic changes of the distal radioulnar joint were associated with factors including TFC degeneration and UV(+), SNI(-) and USI(+).

Journal Article↗

PubMed1996

MR imaging of the wrist: normal findings that may simulate disease.

Twenty-six normal wrists in young adults were studied with magnetic resonance (MR) imaging. The following conclusions were drawn regarding normal anatomic features: (a) Multiple slips of the abductor pollicis longus tendon simulate longitudinal tears; (b) the extensor pollicis longus and extensor carpi ulnaris tendons normally demonstrate increased signal intensity simulating tendinitis; (c) small quantities of fluid in the extensor tendon sheaths may be normal and not indicative of tenosynovitis; (d) the triangular fibrocartilage normally demonstrates increased signal intensity simulating tears at its radial and ulnar attachment sites; (e) the volar ulnocarpal ligaments are often indistinct, thereby simulating injury; and (f) the median nerve has signal intensity equivalent to that of fat, nor of muscle as commonly believed. Awareness of these normal features is critical in making the correct interpretation of MR images of the wrist.

Adult↗

PubMedDate not supplied

Imaging findings in ulnar-sided wrist impaction syndromes.

Impaction syndromes related to ulnar-sided pain include ulnar impaction syndrome, ulnar impingement syndrome, ulnocarpal impaction syndrome secondary to nonunion of the ulnar styloid process, ulnar styloid impaction syndrome, and hamatolunate impingement syndrome. The most common of these, ulnar impaction syndrome, is a degenerative condition of the ulnar side of the wrist related to excessive load bearing across the ulnar carpus, triangular fibrocartilage (TFC) complex, and ulnar head. In an adequate clinical setting, characteristic osseous findings at radiography include positive ulnar variance in ulnar impaction syndrome, a short ulna in ulnar impingement syndrome, nonunion of the ulnar styloid process in ulnar impaction syndrome secondary to ulnar styloid nonunion, an excessively long ulnar styloid process in ulnar styloid impaction syndrome, and type II lunate bone in hamatolunate impingement syndrome. Nevertheless, confirmation of clinical and conventional radiographic findings with magnetic resonance (MR) imaging is often necessary to exclude other entities with similar clinical manifestations. MR imaging allows earlier detection of an abnormality in the TFC complex, cartilage, or bone marrow of carpal bones and is helpful in formulating the extensive differential diagnosis in patients with ulnar wrist pain and limitation of motion.

Carpal Bones↗

PubMedDate not supplied

Special focus session. MR arthrography.

Direct magnetic resonance (MR) arthrography with injection of saline solution or diluted gadolinium can be useful for evaluating certain pathologic conditions in the joints. It is most helpful for outlining labral-ligamentous abnormalities in the shoulder and distinguishing partial-thickness from full-thickness tears in the rotator cuff, demonstrating labral tears in the hip, showing partial- and full-thickness tears of the collateral ligament of the elbow and delineating bands in the elbow, identifying residual or recurrent tears in the knee following meniscectomy, increasing the certainty of perforations of the ligaments and triangular fibrocartilage in the wrist, correctly identifying ligament tears in the ankle and increasing the sensitivity for ankle impingement syndromes, assessing the stability of osteochondral lesions in the articular surface of joints, and delineating loose bodies in joints. Indirect MR arthrography with intravenous administration of diluted gadolinium may be performed when direct arthrography is inconvenient or not logistically feasible. Although indirect MR arthrography has some disadvantages vis-à-vis direct MR arthrography, it does not require fluoroscopic guidance or joint injection and it is superior to conventional MR imaging in delineating structures when there is minimal joint fluid. In addition, vascularized or inflamed tissue will enhance with this method. Indirect MR arthrography can be used to rule in or diagnose abnormalities and to exclude abnormalities.

Humans↗

PubMed2003

Internal derangement of the wrist: indirect MR arthrography versus unenhanced MR imaging.

PURPOSE: To compare indirect magnetic resonance (MR) arthrography with unenhanced MR imaging of the wrist for evaluation of the central disk of the triangular fibrocartilage complex (TFCC) and the scapholunate and lunotriquetral interosseous ligaments. MATERIALS AND METHODS: Eighty-six wrists were evaluated at MR imaging (41 indirect MR arthrography and 45 unenhanced MR imaging examinations). Three musculoskeletal radiologists independently evaluated the central disk of the TFCC and scapholunate and lunotriquetral ligaments and compared the results with those of wrist arthroscopy. Sensitivity and specificity were calculated for each of the readers, and the means were obtained. Sensitivities and specificities were compared with the Student t test. RESULTS: Thirty-three tears of the central disk of the TFCC and 13 scapholunate and 18 lunotriquetral ligament tears were identified at arthroscopy. Sensitivities and specificities were 54%-73% and 83%-91%, respectively, in the evaluation of the central disk of the TFCC, with no significant difference between indirect MR arthrography (P =.666) and unenhanced MR imaging (P =.559). Sensitivities and specificities in the evaluation of the scapholunate ligament were 38%-69% and 75%-99%, respectively, with a significant improvement in sensitivity at indirect MR arthrography (P =.017) and no significant difference in specificity (P =.876). Sensitivities in the evaluation of the lunotriquetral ligament were poor, 0%-22%, though the specificities were 88%-99%, with no significant difference between indirect MR arthrography and unenhanced MR imaging (P =.592 and P =.354, respectively, for sensitivity and specificity. CONCLUSION: Indirect MR arthrography significantly improves sensitivity in the evaluation of the scapholunate ligament when compared with unenhanced MR imaging of the wrist but does not significantly improve the ability to evaluate the central disk of the TFCC or the lunotriquetral ligament.

Adult↗

PubMed2006

Association between extrinsic and intrinsic carpal ligament injuries at MR arthrography and carpal instability at radiography: initial observations.

PURPOSE: To retrospectively compare the presence or absence of carpal instability on radiographs with the findings of magnetic resonance (MR) arthrographic evaluation of intrinsic and extrinsic ligament tears in patients with chronic wrist pain. MATERIALS AND METHODS: The institutional review board approved this study and did not require informed consent. Signs of carpal instability were assessed on static and dynamic radiographs of the wrist obtained in 72 patients (24 female, 48 male; mean age, 36 years; age range, 14-59 years) with posttraumatic wrist pain. MR arthrography was subsequently performed. Two musculoskeletal radiologists independently analyzed the radiographs and MR images. Each intrinsic and extrinsic ligament was individually evaluated for the presence of a ligament tear. The extent of the tear also was recorded. Interobserver agreement regarding MR arthrographic findings was tested by calculating kappa statistics. Statistical comparison between radiography and MR arthrography was performed by using the Fisher exact test. RESULTS: Twenty-five triangular fibrocartilage complex, 18 (five partial, 13 complete) scapholunate ligament, and 25 (10 partial, 15 complete) lunotriquetral ligament tears were visualized. Twenty-two (all complete) extrinsic ligament tears were detected: two radial collateral ligament, 10 radioscaphocapitate ligament, and 10 radiolunotriquetral ligament tears. Interobserver agreement regarding intrinsic and extrinsic ligament tear detection at MR arthrography was excellent (kappa = 0.80). Nineteen patients had evidence of carpal instability on radiographs. Fourteen (52%) of 27 patients with at least one complete intrinsic lesion had no sign of carpal instability. On the other hand, the association of scapholunate ligament and/or lunotriquetral ligament and extrinsic ligament tears was significantly correlated (P < .001) with carpal instability at radiography. CONCLUSION: The presence or absence of carpal instability on radiographs depends on the association between intrinsic and extrinsic ligament tears-even partial ones-rather than on the presence of intrinsic ligament tears alone, even when the tears are complete.

Adolescent↗

PubMed1989

Carpal tunnel: MR imaging. Part I. Normal anatomy.

To correlate the important structures of the carpal tunnel demonstrated on magnetic resonance (MR) images with gross anatomy, the authors imaged the wrists of 20 normal volunteers and nine cadavers. The cadaver specimens were sectioned in the same planes in which they were imaged, and three other specimens were dissected. The anatomy was directly correlated with the imaged morphology. Axial images delineated well the bone and ligament walls of the carpal tunnel. The median nerve was well delimited and of moderate signal intensity. It was surrounded in some cases by fat but was consistently bound by specific tendons. The ulnar nerve and artery were visualized as they traversed the Guyon canal to their division into superficial and deep branches. Coronal images permitted optimal visualization of the triangular fibrocartilage and the radial and ulnar collateral ligaments. Quantitative studies indicated that the normal median nerve does not significantly increase in size within the carpal tunnel but does become more flattened at the level of the pisiform bone. The normal flexor retinaculum may have a slight palmar bowing.

Arteries↗

PubMed1990

Scapholunate advanced collapse: a common wrist abnormality in calcium pyrophosphate dihydrate crystal deposition disease.

Scapholunate advanced collapse (SLAC) is a pattern of wrist malalignment that has been attributed to posttraumatic or spontaneous osteoarthritis of the wrist. Its features, however, also have been observed in patients with idiopathic calcium pyrophosphate dihydrate (CPPD) crystal deposition disease. To determine the frequency and characteristics of SLAC in this disease, the authors reviewed wrist radiographs in 168 well-documented cases of this disorder. Forty-four of the cases (26%) revealed wrist abnormalities typical of SLAC. Associated findings included bilateral involvement (63%); calcification in or near the triangular fibrocartilage (70%); scapholunate widening or dissociation (70%); and arthropathies of the trapezioscaphoid (57%), metacarpophalangeal (second through fifth) (52%), first carpometacarpal (40%), and radiolunate (14%) joints. Results strongly suggest that CPPD crystal deposition disease is one of the major causes of SLAC. Furthermore, radiolunate arthropathy was found in 14% of the patients with SLAC and CPPD crystal deposition disease, which is different from other observations.

Aged↗

PubMed1991

Wrist arthrography: value of the three-compartment injection method.

Arthrography of the wrist was performed on 300 consecutive patients by injecting contrast material separately into the radiocarpal (RCJ), midcarpal (MCJ), and distal radioulnar (DRUJ) joints. The addition of MCJ and DRUJ injections to the standard RCJ injection significantly improved diagnostic yield. In 78 (26%) of the 300 cases, the abnormality was found after MCJ or DRUJ injections alone. Of the 103 triangular fibrocartilage complex (TFCC) abnormalities identified, 27 (26%) could be demonstrated after DRUJ injection alone. Of the 145 abnormal RCJ and MCJ communications, 42 (29%) could be seen after MCJ injection alone. Similarly, 22 (15%) of the 145 abnormal RCJ and MCJ communications were seen after RCJ injection alone and would have been missed if only MCJ injection had been performed. Thus, three separate injections into the RCJ, MCJ, and DRUJ are necessary for complete arthrographic evaluation.

Adolescent↗

PubMedDate not supplied

Normal sonographic anatomy of the wrist and hand.

The advent of ultra-high-frequency sonographic transducers has significantly enhanced our ability to image superficial structures. As a result, sonography now can be used to assess injuries of the tendons in the wrist and hand. A clear understanding of normal sonographic anatomy is required to prevent misdiagnosis and ensure optimal patient care. The anatomy of the wrist and hand is best described by considering the extensor and flexor surfaces separately. The carpal extensor retinaculum divides the dorsal extensor tendons into six separate synovial compartments, which are demarcated by the points of its attachment to the radius and ulna. The course of these tendons from the wrist to the sites of their insertion can be traced by using sonography. The intrinsic wrist ligaments, triangular fibrocartilage, and dorsal finger extensor hood also can be assessed sonographically. The anatomy of the flexor surface of the wrist is defined principally by the flexor retinaculum. The median nerve, which is located deep to the retinaculum in the carpal tunnel, and the ulnar nerve, which is superficial to the retinaculum in the Guyon canal, can be easily detected. The long flexor tendons in the wrist and hand are also clearly depicted at sonography. The flexor annular pulley system is formed by five foci of thickening along the long flexor finger tendon synovial sheath, and the second and fourth annular pulleys can be identified sonographically in most patients. Sonography provides a rapid, cheap, noninvasive, and dynamic method for examination of the soft-tissue structures of the wrist and hand. Familiarity with the appearance of normal anatomic structures is a prerequisite for reliable interpretation of the resultant sonograms.

Hand↗

PubMed2005

Ulnar wrist pain in athletes caused by erosion of the floor of the sixth dorsal compartment: a case series.

BACKGROUND: Ulnar-side wrist pain can be disabling for athletes because of limitation of pronation-supination during sports such as tennis and golf. Erosion of the floor of the sixth dorsal space should be considered for unresponsive ulnar-side wrist pain. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Four athletes with severe unresponsive ulnar-side wrist pain were identified. Because the usual treatment regimens were ineffective in all cases, surgery was indicated to attempt mitigation of symptoms. During surgical exploration, all patients had inflammatory tendon changes and erosions in the floor of the sixth dorsal space, deep to the extensor carpi ulnaris. A soft tissue interposition flap fashioned from the roof of the sixth compartment was used to cover the defect. RESULTS: Patients were evaluated by reexamination for range of motion, ability to perform daily and sports activities, strength, and residual pain. All patients had relief of their symptoms, had normal range of motion with no residual pain, and returned to tennis and golf. Strength improved a mean of 15 lb after surgery. The follow-up was 19 to 40 months (mean, 33 months). CONCLUSION: Erosion of the sixth compartment floor has been given very little attention in the literature. It should be suspected when severe ulnar-side pain persists in athletes after the usual methods of treatment. The interposition surgery described herein has been effective in 4 cases previously unresponsive to the usual methods of treatment for chronic tendinitis of the extensor carpi ulnaris or triangular fibrocartilage rupture.

Aged↗

PubMedDate not supplied

Wrist pain syndrome in the gymnast. Pathogenetic, diagnostic, and therapeutic considerations.

Gymnast wrist pain syndrome presents a difficult diagnostic and therapeutic challenge. It is common and debilitating among gymnasts, resulting in a reduction in training and performance, and may be the result of a response to repetitive trauma during the period of growth and development. This study was undertaken to define and characterize factors contributing to the causes and development of gymnast wrist pain and to establish an effective means of systematic and comprehensive evaluation and treatment. Thirty-eight collegiate gymnasts (20 UCLA: 9 female, 11 male; 18 NCAA: all male) were evaluated by radiograph and questionnaire. Seventy-five percent (22) of the males and 33% (3) of the females had had wrist pain for at least 4 months. The UCLA males averaged 2.82 +/- 1.94 mm positive ulnar variance; this was significantly greater than that of the NCAA males, who averaged 1.28 +/- 1.02 mm (P less than 0.02). The UCLA females averaged 1.44 +/- 1.88 mm positive ulnar variance. All of the gymnasts had significantly greater variance than had the controls, who averaged -0.52 mm (P less than 0.0001). The pommel horse routine was consistently responsible for wrist pain among the males. Anatomical and histological correlation of cryosections with magnetic resonance imaging (MRI) was performed to establish the usefulness of MRI in the diagnosis of wrist pain. MRI was able to differentiate the complex transitions between cortical and trabecular bone, articular surfaces, the ligaments, and the triangular fibrocartilage (TFC) complex of the wrist joint. A therapeutic algorithm was established to facilitate the evaluation and management of gymnast wrist pain. Arthroscopic surgery was successful, and arthroscopic findings correlated well with those of MRI and arthrography. Prospective studies are now underway in the pediatric and adolescent population to define further the causes and development of wrist pain problems in gymnasts.

Adolescent↗

PubMed2006

Sensory innervation of temporomandibular joint disk.

PURPOSE: To investigate the nerve endings of the adult temporomandibular joint disk, in particular the presence and configuration of the sensory nerve endings by silver staining and electron microscopy. METHODS: 20 cadaveric temporomandibular joints impregnated with silver stain were studied using an optical microscope; 2 other joints were studied using a transmission electron microscope. RESULTS: Free nerve endings were found in the disk parenchyma of all joints. Golgi-Mazzoni corpuscles, Ruffini corpuscles, and articular corpuscles were also observed as sensory nerve end organs. Myelinated and nonmyelinated nerve fibres were visualised in the disk parenchyma using the transmission electron microscope. CONCLUSION: Free nerve endings and sensory nerve end organs are present in the disk parenchyma of the human temporomandibular joint and are associated with sensation and proprioception, just as they are in the acetabular labrum, glenoid labrum, triangular fibrocartilage complex, and meniscus.

Adult↗