Radiographic Evaluation of the Wrist: A Vanishing Art

Rebecca A. Loredo, MD,* David G. Sorge, MD, Lt. Colonel, and Glenn Garcia, MD

he intricate anatomy and compartmentalization of structures in the wrist are somewhat daunting. As in other joints, the radiographic appearance of disease processes affecting the wrist is very much dependent on the articular and periarticular soft tissue and osseous anatomy. Therefore, abbreviated discussions of the pertinent anatomy are included within the introduction with more specic anatomic discussions within the text as a prelude to certain conditions affecting the wrist.

interpretation of standard or MR arthrograms and for identifying various patterns of arthritic involvement.2 The compartments are as follows: 1. 2. 3. 4. 5. 6. 7. Radiocarpal compartment Midcarpal compartment Pisiform-triquetral compartment Common carpometacarpal compartment First carpometacarpal compartment Intermetacarpal compartments Inferior (distal) radioulnar compartment

Anatomy of the Wrist

Osseous Anatomy
The osseous structures of the wrist are the distal portions of the radius and ulna, the proximal and distal rows of carpal bones, and the bases of the metacarpals (Fig. 1). The proximal row of carpal bones consists of the scaphoid, lunate, triquetrum, and the pisiform. The distal row of carpal bones contains the trapezium, trapezoid, capitate, and hamate bones. The distal row of bones articulates with the metacarpal bases. The bases of the metacarpals articulate with the distal row of carpal bones and with each other. The proximal carpal row is termed an intercalated segment because forces acting on its proximal and distal articulations determine its position.1 This aspect of the osseus anatomy becomes important when considering the pattern of collapse that occurs in the different types of wrist instability.

Articular Compartmental Anatomy

The wrist joint is separated into a number of compartments by the many ligaments that attach to the carpal bones (Fig. 2). These compartments are of considerable signicance for the
*Department of Radiology, University of Texas Health Science Center, San Antonio, TX. Department of Radiology, Wilford Hall Medical Center, Lackland AFB, TX. Department of Radiology, University of Texas Health Science Center, San Antonio, TX. The opinions and assertions expressed herein are the private views of the authors and are not to be construed as ofcial or as representing the views of the Air Force or the Department of Defense. Address reprint requests to Rebecca A. Loredo, MD, Associate Professor and Chief of Musculoskeletal Imaging, Department of Radiology, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, Texas 78284. E-mail: loredo@uthscsa.edu

In daily clinical practice, the most important compartments are the radiocarpal, midcarpal, and distal radioulnar compartments. The radiocarpal compartment (Fig. 2) lies between the proximal carpal row and the distal radius and the triangular brocartilage, which is brocartilaginous tissue that extends from the ulnar side of the distal aspect of the radius to the base of the ulnar styloid. A meniscus attaches to the triquetrum and is located between the radiocarpal and pisiform-triquetral compartments, in most cases. In the coronal plane, the radiocarpal compartment forms a C-shaped cavity bordered by the radial collateral ligament on the radial side and the point at which the meniscus is attached to the triquetrum on the ulnar side.2 On its ulnar side, two projections are noted from the joint space, a proximal prestyloid recess between the meniscus and the triangular brocartilage and a distal recess that extends to the triquetrum; these latter projections form a Y-shaped area toward the ulnar wrist. The prestyloid recess abuts the ulnar styloid and, on its radial aspect, the radiocarpal compartment contacts the bare area (area unprotected by articular cartilage) of the scaphoid and the radial styloid.2 These relationships become important when articular diseases such as rheumatoid arthritis affect the wrist.2 The midcarpal compartment (Fig. 2) includes articulations between the proximal and the distal carpal rows. The distal pole of the scaphoid articulates with the two trapezial bones, termed the trapezioscaphoid space. The proximal end of the scaphoid combines with the lunate and triquetrum to form a concavity that articulates with the combined capitate and hamate.2 The inferior radioulnar compartment (Fig. 2) lies between

248

0037-198X/05/$-see front matter 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.ro.2005.01.014

Radiographic evaluation of the wrist

249 extrinsic ligaments because they connect the distal portion of the radius and the carpal bones. Two intrinsic ligaments join the bones of the proximal carpal row, the scapholunate interosseous ligament (joining the proximal surfaces of the scaphoid and lunate) and the lunotriquetral interosseous ligament (joining the proximal surfaces of the lunate and triquetrum) (Fig. 3).1 These ligaments connect the bones from their palmar to dorsal surfaces. The intrinsic scapholunate ligament complex and the lunotriquetral complex each consist of dorsal, palmar, and proximal (membranous) components.3 When intact, they separate the radiocarpal and midcarpal compartments of the wrist. The ulnar ligamentous complex (ulnocarpal ligaments) is largely synonymous with the triangular brocartilage complex (TFCC), comprising the triangular brocartilage (TFC) proper (the articular disk) and the dorsal radioulnar ligament, volar radioulnar ligament, ulnolunate ligament, ulnotriquetral ligament, ulnar collateral ligament, and the meniscus homologue.4 The literature includes the sheath of the extensor carpi ulnaris tendon in the description of the TFCC.5 The distal radioulnar joint is stabilized by the TFCC.5 The complex arises from the medial margin of the distal radius to insert in the fovea at the base of the ulnar styloid process. From the ulnar side, the ulnocarpal ligaments arise and insert strongly on the triquetrum (the ulnotriquetral ligament) and weakly on the lunotriquetral interosseous ligament and on the lunate (the ulnolunate ligament). Further ulnarly, the TFCC becomes thickened again as it is joined by bers of the ulnar collateral ligament to form the meniscus homologue, and it courses distally to insert on the triquetrum, hamate, and base of the fth metacarpal bone (meniscus reection). On its dorsolateral side, the TFCC is incorporated into the oor of the sheath of the extensor carpi ulnaris tendon. The

Figure 1 Gross anatomic section through the wrist illustrating the osseous anatomy. The proximal row consists of the scaphoid (S), lunate (L), triquetrum (tq), and pisiform (not shown). The distal row includes the trapezium (tm), trapezoid (tz), capitate (C) and hamate (H). R radius, U ulna, 1st base of thumb metacarpal, 5th base of small nger metacarpal. (Color version of gure is available online.)

the cartilage-covered surfaces of the radius (sigmoid notch) and the ulnar head, surrounded by a loose capsule. When the articulating surface between the ulna and the sigmoid notch is intact, the radius translates on the seat of the ulnar head. The synovial cavity of this compartment is described as Lshaped in coronal section, as it extends between the distal radius and ulna and then across the distal ulna.2 This compartment is separated from the radiocarpal joint by the triangular brocartilage.

Ligamentous Anatomy
Detailed review of the ligamentous anatomy of the wrist is beyond the scope of this article. Rather, the discussion will be limited to the scapholunate ligament, lunotriquetral ligament, and the triangular brocartilage complex. The ligaments of the wrist have been classied into intrinsic ligaments because they arise and insert on carpal bones and

Figure 2 Articular compartmental anatomy. The wrist is separated into compartments by ligaments that attach to carpal bones. The radiocarpal, midcarpal, pisiform-triquetral, common carpometacarpal, rst carpometacarpal, intermetacarpal, and inferior radioulnar compartments are shown. (Reproduced with permission.19)

Figure 3 Intrinsic ligaments. Joining the proximal surfaces of the scaphoid (S) and lunate (L) is the scapholunate interosseous ligament; and, joining the proximal surfaces of the lunate (L) and triquetrum (T) is the lunotriquetral interosseous ligament. They separate the radiocarpal and midcarpal compartments. In the distal carpal row, three intrinsic ligaments unite the trapezium (TR) and trapezoid (TZ) bones, the trapezoid and capitate bones, and the capitate with the hamate bones. These distal interosseous ligaments do not prohibit midcarpal and common carpometacarpal compartment communication. (Reproduced with permission.1)

250

R.A. Loredo, D.G. Sorge, and G. Garcia

Figure 4 Standard radiographic evaluation of the wrist. The routine radiographic evaluation includes (from left to right) posteroanterior, lateral, and oblique radiographs.

TFC may be fenestrated centrally, especially in middle-aged and elderly persons. It functions as a cushion between the ulna proximally and the carpus, primarily the triquetrum, distally. It is a major stabilizer of the distal radioulnar joint.2,5

Imaging of Osseous and Articular Structures

Radiographic Views
In most situations, standard radiographic evaluation of the wrist includes posteroanterior, oblique, and lateral radiographs (Fig. 4). Additional exams may include radial or ulnar deviation views, carpal tunnel view, carpal bridge view, special scaphoid views, or other specialized techniques.1,6 To avoid diagnostic errors, the routine and specialized techniques and signicant points of plain lm evaluation are reviewed.

at 90 to the arm.6 With the forearm in this pronated position, the ulnar styloid is seen in prole. When views are taken in supination, the ulnar styloid overlaps the central portion of the distal ulna. With the wrist in the neutral position, onehalf or more of the lunate should contact the distal radial articular surface.1 Normal Arcs of the Wrist Three smooth carpal arcs are formed on the neutral PA view along the radiocarpal and midcarpal joints (Fig. 6). Arc 1 follows the proximal surfaces of the scaphoid, lunate, and triquetrum; arc 2 is along the distal surfaces of these same carpal bones, and arc 3 follows the curvature of the proximal surfaces of the capitate and hamate.7 In the normal situation, on a neutral PA view, these curvilinear arcs are roughly parallel, without disruption, and the interosseous spaces are nearly equal in size. Disruption of these arcs or abnormal overlapping of adjacent bones on the PA view commonly indicates carpal subluxation or dislocation. There are, however, two common normal variants that mimic step-offs within the carpal arcs (Fig. 7): (1) a triquetrum shorter in its proximal-distal dimension than the adjacent lunate creates a

Posteroanterior Projection
The posteroanterior (PA) projection (Fig. 5) is obtained with the arm abducted 90 from the trunk and the forearm exed

Radiographic evaluation of the wrist

251

Figure 5 Posteroanterior (PA) views. (A) With the forearm in a pronated position, the ulnar styloid is seen in prole. (B) When views are taken in supination, the ulnar styloid overlaps the central portion of the distal ulna. With the wrist in a neutral position, one-half or more of the lunate (L) should contact the distal radial articular surface.

Figure 7 Two common normal variants that mimic step-offs within the carpal arcs: (A) a triquetrum (tq) shorter in its proximal-distal dimension than the adjacent lunate (L) creating a lunotriquetral step-off (arrow) of the rst carpal arc and a normal second carpal arc, and (B) a proximally prominent hamate (H) with an apposing hamate facet on the lunate (L type II lunate) that produces a bilobate second and third carpal arc using the capitate (C) facet and hamate (H) facet along the distal lunate articular surface to create the second carpal arc and the proximal capitate and hamate facets to create the third carpal arc (shown).

lunotriquetral step-off of the rst carpal arc and a normal second carpal arc and (2) a proximally prominent hamate with an apposing hamate facet on the lunate (type II lunate) that produces a bilobate third carpal arc and a smooth second carpal arc if the radial portion (capitate facet), rather than the hamate facet, of the distal lunate articular surface is used to create the second carpal arc.7,8 Normal Scapholunate Joint Space The normal scapholunate joint space width is the same as the width between pairs of the other carpal bones. It is measured at the center of the scapholunate joint with the beam angled from the dorsal ulnar aspect of the wrist approximately 10.9 In its midportion, this space normally measures 2 mm or less and usually remains constant even within the normal range of radial or ulnar deviation of the wrist.9

Ulnar Variance Changes in the length of the ulna relative to the length of the radius, designated ulnar variance (Fig. 8), alter the distribution of compressive forces across the wrist. Ulnar variance is found by extending a line along the distal articular surface of the radius toward the ulna and measuring the distance from this line to the distal ulna2 (Fig. 8A). Normally, the radius and ulna are almost the same length, although wrist and forearm position and centering of the x-ray tube have been noted to inuence the measurements obtained.1 When the ulna is shorter than the radius, the term negative ulnar variance is

Figure 6 PA view illustrating the normal three arcs of the wrist. Arc 1 spans the proximal articular surfaces of the scaphoid (S), lunate (L), and triquetrum (tq). Arc 2 connects the distal concave surfaces of these same bones. Arc 3 outlines the proximal articular surfaces of the capitate (C) and hamate (H).

Figure 8 Ulnar variance on PA wrist views. (A) Normal or neutral variance. Perpendicular to the long axis of the radius, tangential lines are drawn along the ulnar-most extent of the subchondral white line of the distal radius and the distal-most extent of the articular surface of the ulnar dome. The shortest distance between these two lines is the measure of ulnar variance. (B) Negative ulnar variance or ulna minus variance (measurement of dotted line). (C) Positive ulnar variance (measurement of dotted line).

252

R.A. Loredo, D.G. Sorge, and G. Garcia

Figure 9 Carpal height relative measurements in the left and right hands of the same patient. (A) Left hand carpal height is shown as a line (a) that spans the distance between the base of the third metacarpal and the distal radial articular surface on a PA radiograph. (B) In the right hand, the carpal height (b) is comparatively shorter than that measured in the left hand due to chronic arthritis affecting the right left hand.

used (Fig. 8B). The consequences of negative ulnar variance are increased force applied to the radial side of the wrist and to the lunate bone, which may explain the association of negative ulnar variance and Kienbcks disease.2 With such variance, the TFC is thicker, and abnormalities of the TFCC are uncommon. A consequence of a long ulna, or positive ulnar variance, is the ulnar impaction or ulnar abutment syndrome, with resulting limitation of rotation. The TFC is thinner in instances of positive ulnar variance, and degenerative perforation of this structure (as well as disruption of the lunotriquetral interosseous ligament) may be observed.2 Carpal Height Carpal height is the distance between the base of the third metacarpal and the distal radial articular surface as determined on a PA radiograph of the wrist (Fig. 9). Measurement of carpal height allows comparative quantication of carpal collapse in an individual patient over time.7 The carpal height ratio allows comparison between individuals and it is the carpal height divided by the length of the third metacarpal. Similarly, a carpal height index may be obtained by dividing the carpal height ratio of the diseased wrist by that of the normal hand. Some investigators believe the carpal height index to be the most sensitive for detection of abnormal carpal height in a specic hand.7

Figure 10 Normal lateral views of the wrist. (A) Normal. The distal pole of the scaphoid (S) is seen. (B) Example of parallelism of the long axis of the radius with the long axis of the third metacarpal. The pisiform (P) is overlying the distal pole of the scaphoid.

Lateral Projection
On a true lateral view of a normal wrist (Fig. 10), the long axis of the third metacarpal should be coaxial (parallel) with the long axis of the radius. Another clue to a true lateral view is that the pisiform projects directly over the dorsal pole of the scaphoid.5 Longitudinal Axes of the Radius, Lunate, and Capitate In neutral position, the longitudinal axes through the third metacarpal, the capitate, the lunate, and the radius all fall on the same line (Fig. 11A). This ideal situation is actually uncommon, but in most cases the axes are within 10 of this line. The axis of the radius is constructed as a line parallel to
Figure 11 Normal lateral views illustrating measurements. (A) The axes of the radius, lunate, and capitate should superimpose, with 0 to 30 described as the capitate-lunate angle in normal patients. The axis of the capitate (C) is drawn from the center of its head to the center of its distal articular surface. The lunate axis (L) is drawn as perpendicular to a line through the center of its proximal and distal poles. (B) The scapholunate angle formed between the long axis of the lunate and that of the scaphoid (the scapholunate angle) ranges between 30 and 60. The axis of the scaphoid (S) is shown as a line connecting the proximal and distal convex margins. The lunate (L) axis is shown as a perpendicular to a line through the center of the proximal and distal poles.

Radiographic evaluation of the wrist

253

Oblique View
The standard oblique view (Fig. 13) is taken in the PA position, with the hand in partial pronation. This view is helpful in detection of scaphoid tuberosity and waist fractures and dorsal margin triquetral fractures. It proles the scaphotrapezial, trapeziotrapezoidal, and capitolunate joints and will show the rst carpometacarpal and the scaphotrapezoidal joints to best advantage.12

Radial and Ulnar Deviation Views

Figure 12 Normal measurements of the distal radius. (A) Palmar or volar tilt of the radius can be measured by obtaining the angle of intersection between a line drawn tangentially across the most distal points of the radial articular surface and a perpendicular to the midshaft of the radius. Normal range is 11 of volar tilt to 4 of dorsal tilt. (B) Radial inclination is measured on PA radiographs and averages 22 (range 13 to 30). (C) Radial length is the distance between the tip of the radial styloid and the ulnar head articular surface. Radial length averages 11 to 22 mm.

the center of the radial shaft (Fig. 11A). The axis of the lunate can be drawn through the midpoints of its proximal and distal articular surfaces (Fig. 11A). The axis of the capitate is drawn through the centers of its head and its distal articular surface (Fig. 11A). The axes of the radius, lunate, and capitate should superimpose, with 0 to 30 described as the capitolunate angle in normal patients.1 Longitudinal Axis of the Scaphoid The long axis of the scaphoid is represented by a line drawn through the midpoints of its proximal and distal poles (Fig. 11B).1 Another method, proposed by Gilula and Weeks, consists of connecting the ventral convexities of the scaphoid that are visible on the lateral view.10 Normally, the angle formed between the long axis of the radius, the lunate, and the capitate and that of the scaphoid (the scapholunate angle) ranges between 30 and 60 and averages 47.1 Distal Radial Measurements on Lateral and Posteroanterior Views There are three radiographic measurements that are commonly used to assess the anatomy of the distal radius, namely, palmar tilt, radial inclination, and radial length (Fig. 12).1,11 The normal palmar or volar tilt of the radius can be measured on lateral views by noting the angle of intersection between a line drawn tangentially across the most distal points of the radial articular surface and a perpendicular to the midshaft of the radius (Fig. 12A). This normally ranges from 11 of volar tilt to 4 of dorsal tilt.1 Radial inclination (Fig. 12B) is measured on PA radiographs and averages 22 (range 13 to 30). Radial length (Fig. 12C) can be measured along the longitudinal axis of the radius. It is the distance between the tip of the radial styloid and the ulnar head articular surface. Radial length averages 11 to 22 mm.11

Radiographs obtained with radial and ulnar deviation of the wrist (Fig. 14) are useful for visualizing the carpal bones, particularly the scaphoid, and for assessing carpal mobility. As the wrist is radially deviated, palmar exion of the proximal carpal row occurs and the distal pole of the distal scaphoid rotates into the palm. This causes the normal scaphoid to appear foreshortened and exhibit a ring-like appearance of its distal pole as the distal aspect of the scaphoid is seen end-on. As the wrist is placed in ulnar deviation, the scaphoid rotates its distal pole dorsally and ulnarly and it appears to elongate.1 The distances between the carpal bones are normally equal throughout and are unchanged by radial or ulnar deviation. Although widening of the scapholunate distance to between 2 and 4 mm may be abnormal, more than 4 mm is denitely abnormal.1,6

Radiocarpal Joint View

Radiographs obtained by angulating the beam along the axis of the radiocarpal joint (Fig. 15) allow better visualization of

Figure 13 Normal semipronated oblique radiograph: this view allows examination of the radial aspect of the wrist, particularly the scaphoid (S) and radial styloid (RS).

254

R.A. Loredo, D.G. Sorge, and G. Garcia

Figure 14 Normal radial and ulnar deviation views. (A) Radial and (B) ulnar deviation. In radial deviation, the scaphoid (S) rotates toward the palm and appears foreshortened. The distal scaphoid is projected end-on and appears as a circular density (asterisk). The scapholunate distance remains normal (less than 2 mm). In ulnar deviation, the scaphoid is seen in full length. The scaphoid rotates (its distal pole moving dorsally and toward the ulna) and appears to elongate (arrows). The scapholunate interval may increase slightly.

Figure 16 Normal oblique views. (A) Normal AP semisupinated oblique radiograph: in this view, the pisiform bone is separated from the remaining carpal bones. The hamate (H), pisiform (P), triquetrum (tq), and pisiform-triquetral joint (arrow) are specically seen on this view when evaluating for inammatory disease. (B) Normal semipronated oblique radiograph: This view allows examination of the radial aspect of the wrist, particularly the scaphoid (S) and radial styloid (arrow).

this articulation; a PA roentgenogram may be obtained with the beam angulated 10 proximally, and a lateral radiograph from the radial side of the joint may be obtained with the beam angulated 15 proximally. The PA view elongates the scaphoid and shortens the capitate, and it may provide better visualization of abnormalities of the scaphoid.12

AP Projection
To more reliably prole the scapholunate and lunotriquetral interspaces, an AP view can be obtained. The dorsum of the hand and wrist are at against the cassette and the central beam is perpendicular to the cassette, centered over the head of the capitate. The ulnar styloid projects over the ulnar head on an adequate examination.6,9

Semisupinated Oblique View

In some cases, oblique projections are taken in both a semipronated oblique and a semisupinated oblique position (Fig. 16). The latter is an anteroposterior oblique view that is taken in partial supination. Synonymous names for this view include the Norgaard view, the ball-catchers or Youre in good hands with Allstate view. It shows the pisiform, palmar aspect of the triquetrum, palmar ulnar surface of the hamate, and it proles the pisiform-triquetral joint. The Norgaard view is optimal for evaluation of early erosive changes in the hands and wrists of patients with inammatory arthritides.1,12,13

Lateral Flexion and Extension Views

These views demonstrate extension and exion at the radiocarpal and midcarpal joints in normal wrists (Fig. 17). They can be used in evaluation of carpal instability patterns. In particular, these views can assist in distinguishing between a true instability pattern versus normal variance.12 Extension and exion of the wrist is recognized by observation of the long axis of the third metacarpal extended dorsally and exed volarly, respectively, relative to the long axis of the radius and ulna. In extension, the pisiform remains closely apposed to the triquetrum and projects over the scaphoid as in the neu-

Figure 15 Normal radiocarpal joint view. (A) The wrist and palm are placed at on the cassette, as in the PA view. The central beam is angled 25 to 30 toward the elbow and is centered just distal to Listers tubercle.12 (B) This view elongates the scaphoid and shortens the capitate. The radiocarpal (R-C) joint should demonstrate minimum bony overlap with parallelism at the (R-C) joint still visible. (Reproduced with permission.12)

Radiographic evaluation of the wrist

255

Figure 17 (A) Normal lateral volar exion and (B) dorsiexion (extension) of the wrist occur with motion at the radiocarpal and the midcarpal joints. The distal pole of the scaphoid (S) rotates toward the palm in volar exion.

Figure 19 Normal carpal tunnel view. (A) The long axis of the hand is placed in a vertical direction (hyperextended) and the central ray is directed along the volar aspect at an angle of 25 to 30 to the long axis.6 (B) and (C) In the normal situation, the trapezium (tm), scaphoid (S), triquetrum (tq), pisiform (P), and the hook of the hamate (h) can be delineated. (Reproduced with permission.1)

tral lateral view. In exion, the pisiform moves away from the triquetrum, projecting anterior to the scaphoid.12

Carpal Boss View or Off-Lateral View

A slightly supinated off-lateral view (Fig. 18) shows the dorsal carpal boss on a tangent and enables distinction of (1) a separate os styloideum, (2) a bony prominence attached to the second or third metacarpal base or apposing surface of the trapezoid or capitate bones, (3) degenerative osteophytes, or (4) a fracture of the dorsal prominence.12

The view is taken with the ulnar side of the wrist on the cassette, in slight ulnar deviation and with approximately 30 supination. The central beam passes tangent to the dorsal prominence.12

Scaphoid Views
The standard pronated oblique view generally shows fractures of the scaphoid tubercle. However, the detection of non-displaced scaphoid fractures can be signicantly improved with the use of dedicated scaphoid views. These may include magnication views or any combination of the following: PA or AP ulnar deviation view, semipronated oblique view with ulnar deviation, lateral scaphoid view, stecher position view, ulnar oblique scaphoid view, 30-degree semipronated oblique PA view, 60-degree semipronated oblique PA view, and elongated oblique view.12 For a more detailed technical discussion of these projections, the reader is referred to standard imaging texts that detail the position and technique for obtaining these views.12

Carpal Tunnel View

The carpal tunnel view (Fig. 19) is obtained with the wrist dorsiexed and either the ventral aspect of the wrist (inferosuperior view) or the palm (superoinferior view) placed on the lm cassette. The x-ray beam is angled to prole the carpal tunnel. This view shows the palmar soft tissues and the palmar aspects of the trapezium, scaphoid tuberosity, capitate, hook of the hamate, triquetrum, and the entire pisiform.6,12 It should be noted that the carpal tunnel view obtained using the inferosuperior projection, the GaynorHart method, may create a confusing ring artifact representing an end-on view of the fth metacarpal

Figure 18 Carpal boss view. (A) The wrist is slightly ulnar-deviated with the ulnar side of the wrist on the cassette. Approximately 30 supination of the wrist is performed to place the dorsal prominence of the second to third CMC joints tangent to a vertical central ray. The central beam is passed through or tangent to the dorsal prominence. (Reproduced with permission.12) (B) In this case, the dorsal prominence is proled to show a separate bone, the carpal boss (arrow), in tangent.

256

R.A. Loredo, D.G. Sorge, and G. Garcia

Figure 20 Normal carpal bridge view. (A) The wrist is exed to approximately 90 and the central ray is angled at 45 in a superoinferior direction (Reproduced with permission.12) (B) This view demonstrates the scaphoid (S) and lunate (L) and triquetrum (tq) and is useful for diagnosing fractures, foreign bodies, and soft-tissue swelling within the dorsum of the wrist.

Figure 21 Normal clenched st view. With a tight st, the contracting tendons and muscles create a force within the wrist that drives the capitate (C) proximally toward the scapholunate joint. In wrists with a lax or disrupted scapholunate ligament, the joint will widen. In this case, the S-L interval did not abnormally widen.

superimposed on the carpal bones, with the central radiolucent area corresponding to the medullary canal.6

First Carpometacarpal Joint View

A dedicated anteroposterior projection with beam angulation has been used to dene changes in the rst carpometacarpal joint (Fig. 23).12 Coned frontal and lateral views of the rst carpometacarpal joint allow a more precise analysis of arthritis and traumatic lesions, such as the Bennetts fracture.6

Carpal Bridge View

This view proles dorsal surface fractures of the scaphoid, chip fractures of the dorsum of other carpal bones, and it demonstrates calcications and foreign bodies in the dorsal soft tissues. On an adequate examination, there is tangential view of the dorsal aspect of the scaphoid, lunate, and triquetrum (Fig. 20). The superimposed capitate should be visible.12

Clenched Fist View

The clenched st view (Fig. 21) is used to widen the scapholunate joint in cases of scapholunate joint diastasis. It can be obtained in a PA or AP position as the central beam passes through the center of the capitate head. With a tight st, the contracting tendons and muscles create a force within the wrist that drives the capitate proximally toward the scapholunate joint.3,12 In wrists with a lax or disrupted scapholunate ligament, the joint will widen.

Distal Tilt View

If there is suspicion of a capitate waist fracture that is not demonstrated on the standard PA view, the distal tilt view (Fig. 22) may be utilized. It is a PA projection with the central beam angled 25 to 30 toward the ngers, centered on the capitate.12

Figure 22 Normal distal tilt view. (A) The wrist is placed at on the cassette, as it is for a PA view. The central beam is angled 25 to 30 toward the ngers, centered on the capitate. (B) This view is used for optimal evaluation of the capitate waist. The capitate (C) is elongated and the scaphoid (S) is foreshortened. (Reproduced with permission.12)

Radiographic evaluation of the wrist

257

Figure 23 Normal rst carpometacarpal joint: specialized view. (A) The hand is hyperextended and the thumb is placed in a horizontal position. The central ray is angled approximately 45 toward the elbow. (Reproduced with permission.6) (B) The radiograph shows that the axis of the thumb differs from the other digits.

Figure 24 The pronator quadratus fat pad. The pronator quadratus fat stripe is seen on the lateral radiograph of the wrist as a linear or crescent-shaped lucency just anterior to the distal radius and ulna (arrowheads). Fractures involving the distal radius or ulna often show volar displacement (arrows), blurring, irregularity, or obliteration of this fat plane.

Radiographic Evaluation of Soft Tissues

Deep and Supercial Fat Planes
There are two deep fat planes that are useful in the radiographic evaluation of wrist trauma: the pronator quadratus fat pad and the scaphoid fat pad. The pronator quadratus fat pad (Fig. 24) lies between the pronator quadratus muscle and the volar tendon sheaths. It is seen on the lateral radiograph of the wrist as a linear or crescentshaped lucency just anterior to the distal radius and ulna. Fractures involving the distal radius or ulna often show volar displacement, blurring, irregularity, or obliteration of this fat plane. The scaphoid fat plane or fat stripe (Fig. 25) is a triangular or linear collection of fat that is bounded by tendons of the abductor pollicis longus and the extensor pollicis brevis and by the radial collateral ligament.1 This fat plane is seen on the PA radiograph as a lucent stripe extending from the radial styloid to the trapezium and almost paralleling the radial aspect of the scaphoid. Fractures of the scaphoid, the radial styloid, and the rst metacarpal often result in displacement or obliteration of this fat stripe. On the ulnar aspect of the wrist, fat along the extensor carpi ulnaris tendon is often visible. Inammatory processes such as rheumatoid arthritis may obliterate this fat stripe and thicken the tendon shadow, increasing the amount of softtissue density along the ulnar styloid.1

Wrist Pain Differential Diagnosis

Many wrist disorders are readily identied during the initial clinical evaluation. Alternatively, the patients history may be pathognomonic of a certain injury, such as acute volar ulnar wrist pain in a golfer after a dubbed swing; this being a history that is typically associated with fracture of the hook of the hamate. However, some disorders such as carpal instabil-

Figure 25 Scaphoid fat stripe. (A) The normal fat stripe is seen paralleling the lateral aspect of the scaphoid (arrows). (B) A non-displaced fracture of the scaphoid is associated with obliteration of the fat stripe (circle).

258

R.A. Loredo, D.G. Sorge, and G. Garcia

ponents or parts of an articular fracture: (1) the radial shaft, (2) the radial styloid, (3) a dorsal medial fragment, and (4) a palmar medial fragment (Fig. 26). The two medial fragments, along with their ligamentous attachments to the carpus and the ulnar styloid, are termed the medial complex. Anatomic preservation of this medial complex is recognized as an absolute requirement for optimal fracture reduction and management. Displacement of these strategically positioned medial fragments also forms the basis for categorizing articular fractures into a classication system (type I, II, III, IV), taking into account features of previous classication systems.15 Type I fractures are minimally displaced, stable after closed reduction, and effectively treated by a short period of cast immobilization (Fig. 27). More commonly, an articular fracture is Type II, which is the dorsally displaced die-punch fracture. In such a fracture, the lunate selectively impacts the dorsal medial component, resulting in an unstable fracture characterized by varying degrees of comminution of the dorsal metaphysis, marked dorsal tilting, and considerable shortening of the radius.15 In the majority of type II fractures, the medial complex components are neither widely separated nor rotated (Type IIA), and they are generally amenable to closed reduction and skeletal xation (Fig. 28). Less commonly, a more comminuted and displaced pattern of dorsal or palmar displacement, the type IIB fracture (Fig. 29), is seen, irreducible by closed methods.15 A third type of pattern, the type III spike fracture, demonstrates articular disruption similar to that in type II injuries with added displacement of a spike fragment, from the volar metaphysis (Fig. 30). Displacement of the spike fragment may occur at the time of injury or during fracture ma-

Figure 26 Basic components of an articular fracture of the radius. The basic fracture parts are (1) the radial shaft, (2) the radial styloid, (3) a dorsal medial fragment, and (4) a palmar medial fragment.

ity and ulnar-sided wrist pain are less specic; and these conditions are conclusively diagnosed only after careful examination supported by appropriate imaging studies. There are many varied causes of wrist pain and methods of radiographic evaluation, as will be discussed throughout the following pages of this writing.

Traumatic
Fractures of the Radius and UlnaPatterns of Injury
Fractures of the distal aspect of the radius are one of the most common skeletal injuries treated by orthopedic surgeons and they account for 17% of all fractures seen in emergency departments.14 A multitude of classication systems have been devised based on extraarticular or intraarticular involvement, fracture complexity (degree of displacement and angulation), management issues, mechanism of injury, and treatment options.15 Intraarticular fractures of the distal portion of the radius have been described as two-, three-, four-, or ve-part (or more) fractures. Based on stability and reducibility of the fracture, consistent radiographic observations have led to a more universally accepted description of articular injuries (discussion of fracture parts), whereby analysis of the fracture pattern and creation of a subset of articular injury classication has facilitated their treatment.15 Despite frequent comminution, there are four basic com-

Figure 27 Type I fractures are minimally displaced and stable after closed reduction.

Radiographic evaluation of the wrist

259

Figure 28 Type IIA die-punch fracture. The medial complex components are neither widely separated nor rotated and are generally amenable to closed reduction and/or skeletal external xation.

nipulation, which worsens fracture stability and may cause injury to adjacent nerves and tendons.15 The type IV fracture pattern is characterized by wide separation or rotation of the dorsal and palmar medial fragments with severe disruption of the distal radius articulations15 (Fig. 31). A more violent injury accounts for the occurrence of the type V explosion fracture. This severe injury results from an enormous force, composed of both axial compression and direct crush, with resultant severe comminution often extending from the articular surface of the radius to the diaphysis.15 The latter two patterns usually occur in association with severe surrounding soft-tissue trauma.

Figure 30 Type III spike fracture. The articular disruption is similar to that in type II injuries with the added displacement of a spike fragment (arrow), from the volar metaphysis.

Figure 29 Type IIB die-punch fracture. (A) PA view and (B) oblique view show a more comminuted and displaced pattern of dorsal displacement.

Figure 31 Type IV fracture. (A) PA view and (B) lateral view show wide separation or rotation of the dorsal and palmar medial fragments with severe disruption of the distal radius articulation.

260

R.A. Loredo, D.G. Sorge, and G. Garcia

impaction (Fig. 33); (2) angulation or tilting of the radial articular surface exceeding 20 in the sagittal plane, which causes a serious disturbance of radiocarpal collinear alignment as well as incongruity of the distal radioulnar joint; and (3) metaphyseal comminution involving both the volar and the dorsal radial cortices as this eliminates an intact bony buttress on which a stable reduction must hinge. Recognition of these radiographic signs of instability is essential for satisfactory management of these injuries.15

Smiths Fracture
The less common Smiths fracture is a fracture of the distal radial metaphysis or epiphysis, with or without articular involvement, demonstrating palmar displacement or angulation. The mechanism of injury is hyperexion from a fall on the palmar-exed wrist (Fig. 34). Complications of Smiths fractures are similar to those of Colles fractures and may include injury to the extensor tendons.16

Figure 32 Colles fracture. (A) PA oblique and (B) lateral views show a metaphyseal fracture of the radius (arrows) in mild dorsal angulation with associated ulna styloid tip avulsion fracture (arrowhead).

The classication system described above is not meant to replace the common fracture descriptions and use of their eponyms; it is a method of discussion that increases understanding of fracture reducibility, stability, and ultimate management. Common eponyms are consistently used to describe fractures of the distal end of the radius. Examples include Colles fracture (fracture of the distal aspect of the radius with dorsal displacement), Smiths fracture (fracture of the distal portion of the radius with palmar displacement), Bartons fracture (fracture of the dorsal rim of the radius), palmar or reverse Bartons fracture (fracture of the palmar rim of the radius), and Hutchinsons or chauffeurs fracture (fracture of the radial styloid process).

Bartons Fracture
A Bartons fracture is a marginal fracture of the dorsal rim of the radius that displaces along with the carpus, producing a fracture-subluxation (Fig. 35). The fracture results from a fall causing dorsiexion and forearm pronation on a xed wrist. A variant of the Bartons fracture involves the palmar rim of the distal end of the radius (Fig. 36) and may be more common than its dorsal counterpart. It is sometimes referred to as a reverse Bartons or a palmar Bartons fracture. Complications of fractures of the dorsal or palmar rim of the radius are

Colles Fracture
The well-known Colles fracture (Fig. 32) is the most common injury to the wrist caused by a fall on an outstretched hand causing axial compression together with a bending moment. The combination leads to dorsiexion of the joint.16 The frequency of this fracture increases with advancing age of the patient. The classic Colles fracture is a transverse fracture, with or without comminution, with or without intraarticular extension, accompanied by impaction and dorsal displacement of the distal surface of the radius.16 Complications of Colles fractures are diverse and fairly common. Such complications include unstable reduction, articular incongruity, subluxation or dislocation of the distal radioulnar joint, median nerve compression resulting in carpal tunnel syndrome, ulnar nerve injury, entrapment of exor tendons, reex sympathetic dystrophy, carpal malalignment or fracture, posttraumatic osteolysis of the ulna, and malunion, delayed union, or nonunion.16 Therefore, measurement of such parameters as radial tilt, radial inclination, and ulnar variance on routine radiographs assumes some importance17 in evaluation of fracture stability. Markers of fracture instability are (1) radial shortening in excess of 6 to 10 mm, as this predisposes to further collapse, resulting in distal radioulnar instability and ulnocarpal joint

Figure 33 Result of Colles fracture instability. A PA view demonstrates radial shortening resulting in both disabling distal radioulnar instability and ulnocarpal joint impaction (ellipse).

Radiographic evaluation of the wrist

261

Figure 34 Smiths fracture. (A) PA view and (B) lateral view of a fracture of the distal radial metaphysis that is angulated in the palmar direction.

Figure 36 Reverse Bartons fracture. (A) Lateral and (B) PA views demonstrate a volar rim fracture with palmar displacement of the carpus with the rim fragment (arrow), consistent with a fracture subluxation pattern.

similar to those of a Colles fracture with increased difculty in maintaining stable reduction.15

Hutchinsons or Chauffeurs Fracture

Fracture of the styloid process of the radius is often referred to as a Hutchinsons fracture or a chauffeurs fracture (originally described as a fracture that occurred when the starting crank of an engine suddenly reversed during an engine backre) (Fig. 37). It is an avulsion injury related to the sites of attachment of the radiocarpal ligaments or the radial collateral ligament. It may also result from a direct blow.18 Because the fragment is most often non-displaced, this fracture is often difcult to visualize. The fracture is best identied on a PA radiograph and may not be apparent on a lateral radiograph. On the PA view, it should not be confused with the normal irregularity along the lateral surface of the radius at the expected site of previous physeal closure. The fracture

line may enter the space between the scaphoid and lunate fossae, thereby causing scapholunate dissociation and lesser arc injury of the wrist.16 It is critical to restore the articular surface to anatomic congruency following the described various fracture patterns

Figure 35 Bartons fracture. (A) Lateral and (B) AP oblique views show a marginal fracture of the dorsal rim of the radius that is displaced along with the carpus, producing a fracture-subluxation.

Figure 37 Hutchinsons fracture or chauffeurs fracture. (A) PA and (B) PA oblique views demonstrate a fracture through the base of the radial styloid (arrows). The fracture approaches the space between the scaphoid and lunate fossae (arrowheads).

262

R.A. Loredo, D.G. Sorge, and G. Garcia

Figure 38 Ulna styloid fractures. (A) PA view shows a fracture of the ulna styloid (arrow). This fracture is associated with a scaphoid fracture (arrowheads). (B) Oblique view demonstrating hypertrophy of the ulna fragment with ulna fracture nonunion.

Figure 39 Torus fracture. (A) PA view and (B) lateral views show a unicortical fracture of the metaphysis of the radius (arrow).

to prevent the development of instability and late posttraumatic arthritis. In addition to diagnostic PA, lateral and oblique plain x-rays, thin-section computed tomography (CT) scans with multiplanar reconstruction of images can be used to assess the intraarticular extent and fracture fragment morphology in preparation for percutaneous pinning and other methods of reduction. In particular, coronal and sagittal images are especially helpful in measuring cortical depression or offset. MR imaging has been useful in evaluation of ligamentous, nerve, tendon, and surrounding soft-tissue pathology associated with wrist fractures.

tures commonly occur (Fig. 39). The radiographs of children should be inspected carefully in at least two orthogonal planes in an effort to avoid misdiagnosis or incomplete diagnosis of fractures. Physeal fractures are usually SalterHarris type II (Fig. 40).

Occult Wrist Fractures

There are a number of common and not-so-common carpal bone fractures that are more often missed than others. Increasing awareness of these injuries and more consistent use of CT scanning and MR imaging have improved their diagnosis.

Ulna Styloid Fracture

When an ulnar styloid fracture is present, another fracture should be sought (Fig. 38A), because only 6% of ulnar styloid fractures occur alone.19 In isolation, an ulna styloid fracture is perhaps related to an avulsion produced by the ulnar collateral ligament or triangular brocartilage complex. The resulting ossic fragment should not be confused with the anatomic variant appearance of the normal ossication center (lunula) that may appear in the meniscus homologue of the wrist. The irregular contour of the fracture fragment, as well as the irregularity of the donor site along the styloid process, generally allows accurate diagnosis of the fracture. Hypertrophy of the fragment with fracture nonunion is encountered infrequently and may be a source of chronic wrist pain16 (Fig. 38B).

Childhood Fractures
In children, injuries may result from acute trauma or chronic overuse. Due to the fact that the capsule and ligaments are two to ve times stronger than the growth plate, the growth plate is more often involved. Acute fractures typically involve the radial and ulnar physes; in younger children, torus fracFigure 40 Salter Harris, type II fracture of the radius. (A) PA and (B) lateral views of the wrist demonstrate fracture of the metaphysis (arrows) that extends into the physis (arrowhead) with dorsal displacement of the epiphysis with the dorsal metaphyseal fragment.

Radiographic evaluation of the wrist

263 that the entire blood supply to the scaphoid enters through its distal pole, avascular necrosis (AVN) may occur following fractures through the waist of the scaphoid and it is an expected sequela of proximal pole fractures. Increased density of the proximal fragment, indicating avascular necrosis, has been noted on radiographs in about 30% of patients.1 However, sclerosis alone does not indicate inevitable nonunion, and both the fracture and the avascular area may go on to heal. Nonunion of scaphoid fractures is due primarily to a delay in diagnosis or lack of adequate immobilization, or both.21 Contributing factors include anatomical features such as the presence of articular cartilage covering ve of the six scaphoid surfaces, healing by endosteal reaction only, failure to achieve anatomical reduction, and a tenuous blood supply in some cases.21,22 Radiographic abnormalities of scaphoid nonunion include bone sclerosis, cyst formation, widening of the scapholunate space, bone resorption, and, subsequently, osteoarthritis. Tendon ruptures may occur as a complication of scaphoid nonunion, and CT may reveal hypertrophy of Listers tubercle in the dorsum of the radius, which may predispose to tendon disruption.16

Figure 41 Scaphoid fracture avascular necrosis (AVN) and nonunion. (A) Avascular necrosis of the proximal fragment (arrow) is more prevalent in fractures that involve the proximal third of the scaphoid and less frequent with fractures that involve the middle third. (B) A PA view of the wrist demonstrates a chronic fracture through the waist of the scaphoid, consistent with nonunion (arrow).

Scaphoid Fracture
The majority of fractures of the wrist involve the scaphoid (65%). However, radiographic diagnosis may be difcult. Seventy percent of these fractures occur through the waist; 20% involve the proximal third, and 10% occur in the distal pole. In children, avulsion fractures of the distal portion of the scaphoid are typical. Unusual patterns of scaphoid injury include dorsal avulsion fractures and fractures of the osteochondral interface in young children.16 Radiographically, multiple views of the wrist are indicated in patients with suspected scaphoid fractures. In addition to PA, lateral and oblique projections, angled and magnication views, and views with the wrist in ulnar deviation will show the waist of the scaphoid to best advantage. Soft-tissue signs of fracture include dorsal swelling and scaphoid fat pad changes. Obliteration, distortion, or displacement of the scaphoid fat stripe may occur (Fig. 25B). In the case of a displaced scaphoid fracture or suboptimal healing, there may be dorsal tilting of the lunate (humpback deformity) simulating that occurring in dorsal segmental instability.16 The major factor leading to nonunion of scaphoid fractures is delayed or inadequate immobilization. Therefore, treatment is often begun even when radiographic conrmation is lacking. Individuals without radiographically demonstrable fractures who are clinically suspected of having non-displaced scaphoid fractures are immobilized in a cast for several weeks and then reexamined. Ganel and coworkers, who noted that a negative bone scan 24 to 72 hours after injury excludes fracture at this site, have suggested an alternative course.20 In clinically suspicious cases with negative radiographs, a bone scan (with the cast on) is performed and, if this is negative, immobilization is discontinued. Complications of a scaphoid fracture (Fig. 41) include avascular necrosis of the proximal pole, delayed or nonunion, and an unusual form of osteoarthritis, termed scaphoid nonunion advanced collapse16 (SNAC). Due to the fact

Figure 42 Triquetral dorsal avulsion fracture. A lateral view shows a dorsal-avulsion fracture of the triquetrum (ellipse).

264

R.A. Loredo, D.G. Sorge, and G. Garcia

Figure 43 Fracture of the body of the triquetrum. (A) A conventional lateral x-ray may not show this rare type of triquetral injury. It is better diagnosed with (B), computed tomography (arrow).

Figure 44 Hamate fracture. (A) A pronated oblique view of the wrist demonstrates a fracture of the hook of the hamate (arrow). (B) Corresponding CT scan image shows the fracture to best advantage (arrow). (Courtesy of Donald Resnick, MD, San Diego, CA.)

Fractures of Other Carpal Bones

The triquetrum is the second most commonly injured carpal bone (3 to 4% of all carpal bone injuries). The dorsal fracture (Fig. 42) may be caused by forceful contact of the triquetral with the hamate or ulnar styloid process or to avulsion of the dorsal radiotriquetral ligaments.16 The dorsal-avulsion type of injury is not often missed on the lateral or oblique projections. However, a less common triquetral fracture that is often missed involves the body of the triquetrum (Fig. 43), caused by a direct blow in most cases.16 This rare type of triquetral injury may be missed on conventional radiography and better diagnosed with CT. Fractures of the hamate make up 2 to 4% of all carpal fractures.16 Sagittal or coronal fractures through the body may occur and these may be detected on plain x-ray or with CT. CT scans are often necessary to dene the fracture plane. It is more difcult to clinically and radiographically detect the more common fracture involving the hook of the hamate (Fig. 44). Therefore, this injury deserves attention. Fractures of the hook often occur in association with a dubbed golf swing or in sports that use rackets or bats. The grip may place the end of the club handle or bat against the hook, thereby predisposing the hook to direct trauma. These injuries may also result from a fall on a dorsiexed wrist, with the force transmitted through the transverse carpal and pisohamate ligaments.16 Aside from standard radiographs, a carpal tunnel view, computed tomography, or a bone scan may be helpful in detecting fractures of the hook of the hamate, as is MR imaging (Fig. 45). Complications of these fractures include nonunion, osteonecrosis, injuries to the ulnar or median nerve, tenosynovitis or tendon rupture, and chronic pain. A bipartite hook or os hamuli proprium (incomplete fusion of the ossication center of the hook) may mimic a fracture.16 On an MR imaging study, it is recommended that the axial and sagittal images be completely reviewed before excluding a fracture of the hamate.23 Fractures of the pisiform (Fig. 46) are usually the result of

a direct blow to the volar surface of the wrist. The fracture may be transverse (usually a chip fracture of the distal end of the bone) or longitudinal. Occasionally, the fracture is comminuted. The fracture is best visualized on a 30 supinated AP view, carpal tunnel view, lateral oblique view, or a radial deviation PA view. When no other soft-tissue swelling is seen, paraulnar fat pad swelling suggests a pisiform fracture. A complication of fractures involving the pisiform is ulnar nerve damage.16,24 Isolated fractures of the capitate, trapezium, and trapezoid are infrequent. Capitate fractures (Fig. 47) usually involve the neck of the bone and may be associated with metacarpal fractures, scaphoid fractures, and trans-scaphoid perilunate dislocations, at times resulting in the scaphocapitate syndrome (Fig. 48).16 In scaphocapitate syndrome, the head of

Figure 45 Hamate hook fracture. (A) Sagittal T1-weighted MR image of a hamate hook fracture (arrows). (B) T1-weighted axial image and (C) T2-weighted axial image show the fracture line (circle and arrow).

Radiographic evaluation of the wrist

265

Figure 46 Pisiform fracture. A 30 supinated AP view demonstrates a transverse fracture (chip fracture) of the distal end of the bone (arrows).

Figure 48 Scaphocapitate syndrome status post transscaphoid, transcapitate perilunate fracture dislocation. (A) The squared-off appearance of the proximal end of the capitate, best seen on a PA view, is the key to making the proper diagnosis of the syndrome. C capitate. (B) A lateral view shows the perilunate fracture dislocation pattern. The lunate (L), capitate (C), and two scaphoid fragments (S) are labeled.

the capitate is fractured and rotated 180. Difculty interpreting the radiographs in this situation can result in improper treatment of a fracture fragment that is considerably displaced or a fracture fragment that is markedly rotated. Proper radiographic interpretation often requires multiple projections, including PA, lateral, and oblique views, often supplemented with CT scan images. When interpreting the lms, the squared-off appearance of the proximal end of the

capitate, best seen on a PA view, is the key to making the proper diagnosis.24 The trapezium may fracture in various places, the vertical body, dorsoradial tubercle, dorsoulnar tubercle, and anterior (palmar) ridge.25,26 The vertical split fracture of the body of the trapezium is associated with lateral subluxation of the rst metacarpal, which remains attached to the lateral trapezial fragment. The fracture of the palmar trapezial ridge, although rare, is important to recognize as these fractures are prone to nonunion27 if not promptly diagnosed and treated. The anatomy is such that a portion of the transverse carpal ligament attaches to this ridge and extends across the carpal tunnel to the hook of the hamate. In a setting of trauma, an avulsion fracture of the trapezial ridge may be produced26 (Fig. 49). Because the ridge is not well visualized on routine radiographs, the diagnosis can be easily overlooked. Trapezial ridge fractures can best be seen on the carpal tunnel view (Fig. 49B). CT scans also are very useful in evaluation of these fractures.

Carpometacarpal Injuries
Anatomically, the osseous structures of the wrist include the bases of the metacarpals. Within the rst carpometacarpal compartment of the wrist, relatively common injuries include the Bennetts fracture-dislocation and Rolandos fracture that occur at the base of the thumb metacarpal (Fig. 50). The Bennetts fracture and Rolandos fracture are two-part and three-part (or comminuted) fractures, respectively, and they are usually well recognized on radiographs. A more challenging diagnosis is that of a beak ligament avulsion fracture. The beak ligament avulsion fracture (Fig. 51) occurs at the level of the thumb carpometacarpal joint. At this articulation,

Figure 47 Capitate fracture. (A) A Capitate (C) neck fracture is not well seen on a PA view. (B) An axial T1-weighted MR image illustrates a low signal intensity fracture line within the capitate (arrows). (C) In the same patient, a coronal T2-weighted MR image demonstrates high marrow signal intensity within the capitate (circle) and a subtle high signal intensity fracture line within the waist of the capitate (arrow).

266

R.A. Loredo, D.G. Sorge, and G. Garcia

Figure 49 Trapezial ridge fracture. (A) A PA wrist view does not clearly demonstrate the fracture of the trapezium (circle). (B) A carpal tunnel view clearly illustrates a trapezial ridge fracture (arrow). The trapezium (tm), scaphoid (S), and hamate hook (h) are labeled.

Figure 51 Beak ligament avulsion fracture. (A) The rst carpometacarpal (CMC) joint is subluxed (circle) and an adjacent bone fragment is seen (arrow). (B) Pinning of the rst CMC joint is necessary for adequate reduction and prevention of instability.

there is a major strong ligament that connects the beak of the metacarpal base to the anterior tubercle of the trapezium. This ligament has been referred to as the anterior oblique, the ulnar, the ulnar-volar, and the beak ligament.28 Two other ligaments in the capsule include the lateral ligament beneath the abductor pollicis longus tendon insertion, and the posterior oblique ligament that is under the extensor pollicis longus.2 Although rare, pure dislocation of the rst metacarpal without fracture can occur. The dislocations are always dorsal and the beak ligament strips subperiosteally along the metacarpal. The ligament is lax in the dislocated position, but it becomes tight again if the thumb is reduced. Chronic instability can result if unrecognized and not treated with rigid reduction (pinning) for a 6- to 8-week time interval.2 Careful radiographic examination may demonstrate the tiny avulsed

fragment(s) adjacent to the metacarpal base unless there is pure ligamentous avulsion.

Stress Fracture of the Radial Epiphyseal Plate

In the skeletally immature, a stress reaction can develop primarily at the distal radial growth plate and to a lesser degree in the distal end of the ulna. Gymnastics is the major cause of this injury; hence it bears the name, gymnasts wrist29 (Figs. 52 and 53). The condition is due to chronic compression and rotational forces that are applied as the upper extremity becomes the weight-bearing limb during this sport activity. Radiographically, the changes at the physis resemble those seen in rickets. The physeal plate shows irregularity, cystic change, and widening, consistent with a SalterHarris type I or II injury. There may be adjacent bone fragmentation. If not treated, the condition can lead to early physeal closure and positive ulnar variance with dysfunction of the distal radio-

Figure 50 Fracture of the base of the thumb metacarpal. (A) A Bennetts fracture is consistent with a two-part fracture-dislocation (circle). (B) A Rolandos fracture is consistent with a comminuted (three-part) fracture (circle).

Figure 52 Gymnasts wrist (SH I injury). (A) PA and (B) lateral wrist views demonstrate widening of the physis of the radius (arrows) secondary to chronic stress reaction in a gymnast.

Radiographic evaluation of the wrist

267

Figure 53 Gymnasts wristSH II injury of radius and ulna. (A) A PA view shows mild widening of the physes of the ulna and radius (arrows) with possible minimal metaphyseal sclerosis. (B) The corresponding coronal T2-weighted image shows high signal intensity metaphyseal bands that are consistent with stress reaction or stress fractures of the radius and ulna (arrows).

Figure 54 Perilunate dislocation. (A and B) Widening of the scapholunate joint (arrow) secondary to ligamentous injury and dorsal perilunate dislocation (arrows) are shown. The anterior-most line depicts the lunate (L) sitting within the radial (R) articular surface with the second line spanning the dorsally displaced carpus.

ulnar joint and abnormalities of the triangular brocartilage complex.29

ligaments.24 The nal stage IV injury is associated with disruption of the dorsal radiocarpal ligaments, which frees the lunate and allows it to become volarly displaced (lunate dis-

Wrist Instability
Carpal instability occurs when there is symptomatic malalignment between the rows of carpal bones and between the carpal bones and the radius. Figuratively speaking, the proximal carpal row is termed an intercalated segment because forces acting on its proximal and distal articulations determine its position.30 Collapse is normally prevented by linkage of the proximal and the distal carpal rows by the scaphoid and its connecting ligaments.1 When the system is compressed, a zigzag pattern of collapse occurs, analogous to what happens to cars in a train if the rst car stops short. The resultant instability may be due to traumatic injuries (fractures or ligamentous disruption) or to inammatory conditions such as rheumatoid arthritis. When the term carpal instability was rst coined, it was almost synonymous with scapholunate instability. Since then, descriptions of progressive perilunate instabilities have evolved with scapholunate instability representing the rst stage of perilunate injuries.3

Perilunate Dislocation
Most wrist injuries, including dislocations, result from forced dorsiexion of the wrist. The resultant lesions are predictable as they are all progressive stages of the same injury pattern. A stage I injury is secondary to scapholunate ligamentous failure and dissociation with rotatory subluxation of the scaphoid.16 Stage II injury is characterized by perilunar instability resulting from capitolunate failure of the palmar radioscaphocapitate ligament or a fracture of the radial styloid process, leading to perilunate dislocation16 (Fig. 54). The stage III injury results from lunotriquetral partial or complete failure or avulsion of the volar and dorsal radiotriquetral

Figure 55 A lateral x-ray depicts palmar lunate dislocation (arrow) with minimal dorsal tilt of the capitate (lines drawn).

268

R.A. Loredo, D.G. Sorge, and G. Garcia

1. A wide scapholunate distance (Terry Thomas sign). Normally, the scapholunate distance is less than 2 mm. Ligamentous disruption is suggested when the distance between the scaphoid and lunate is greater than 2 mm and can be diagnosed almost unequivocally when this distance is 4 mm or more.1,16 2. Foreshortened appearance of the scaphoid. On a PA view, this appearance is due to rotation of the distal pole of the scaphoid toward the palm. In contrast to the normal wrist, this foreshortening does not appear on ulnar deviation. 3. Ring sign. This sign refers to the density produced by the cortex of the distal pole of the scaphoid seen end-on because of the abnormal scaphoid rotation. Normal individuals may exhibit this nding on PA views taken with the hand in radial deviation; however, this appearance should not persist when the hand is in ulnar deviation.1 4. Dorsiexion instability. On a continuum of progressive severity of scapholunate injury or dissociation is the occurrence of secondary changes such as capsular contracture, scaphoid and midcarpal xation, dorsal intercalary segment instability (DISI), scapholunate advanced collapse (SLAC), and pancarpal degenerative arthritis.1,16 Radiographic ndings of DISI include (1) on a PA view, overlap of the lunate and the capitate and (2) on a lateral view (Fig. 57), scapholunate angle 80

Figure 56 A PA view demonstrates marked scapholunate joint space widening (double arrow), a foreshortened scaphoid with a ring sign (circle) due to palmar rotary subluxation of the scaphoid, consistent with scapholunate dissociation. Incidentally noted is rst carpometacarpal osteoarthritis.

location)16 (Fig. 55). When the perilunate dislocation pattern is associated with fractures, these injuries are then called greater arc injuries as the arc of injury passes through the scaphoid, capitate, hamate, and/or triquetrum. The lesser arc injuries affect the ligaments and joint spaces about the circumference of the lunate and begin with scapholunate injury.16

Scapholunate (SL) Instability

Scapholunate instability or scapholunate dissociation may accompany tears of the palmar radiocarpal ligaments and scapholunate interosseous ligament complex. Scapholunate dissociation (rotatory subluxation of the scaphoid) may occur as a complication of lunate or perilunate dislocation, rheumatoid arthritis, and other articular diseases, or as an isolated injury.16 Although characteristic abnormalities are typically identied on routine radiographic examination, patients who are suspected of having ligamentous instability may require additional views. The full series may include (1) PA views in neutral, ulnar deviation, and radial deviation; (2) AP clenched st view; (3) an oblique view; (4) lateral views with the wrist in neutral, exion, and extension; and (5) lateral view in neutral position with the st clenched.1 The views in exion and extension and in radial and ulnar deviation help to demonstrate the dynamics of wrist motion. The clenched-st views compress the wrist, tending to force the capitate into the space between the scaphoid and the lunate, and to rotate the scaphoid toward the palm, thus revealing any tendency for abnormal scaphoid rotation or scapholunate separation.1,3 Abnormal ndings on standard radiographic views or on the additional views include the following1 (Fig. 56):

Figure 57 A lateral view demonstrates dorsal tilt of the lunate and a widened scapholunate angle to near 90 (normal 30 to 60) suggesting disruption of the scapholunate ligament resulting in a DISI deformity.

Radiographic evaluation of the wrist

(normal 30 to 60), lunate dorsally tilted, and scaphoid exed toward the palm.1,16 A wrist with SLAC has a pattern of osteoarthritis, characterized by narrowing of both the radioscaphoid and the capitolunate spaces.1 During videouoroscopy, widening of the scapholunate space may be demonstrated, as the wrist is observed during a range of motion.30 Conventional arthrography can conrm disruption of the scapholunate ligament by demonstrating extension of contrast medium into the midcarpal joint space following radiocarpal joint injection. CT scanning and MR imaging can be useful for the diagnosis of scapholunate dissociation. Aside from the expected observations that can be extrapolated from radiographs (scapholunate gap 2 mm, palmar exion of scaphoid, dorsal tilting of lunate), abnormalities of the intrinsic and extrinsic components of the scapholunate ligament can be visualized with the use of specic MR imaging parameters. T2weighted image ndings include hyperintense linear signal intensity in partial or complete ligament tears, complete ligamentous disruption with a hyperintense uid-lled gap, hyperintense synovial uid communication between the radiocarpal and midcarpal compartments, disruption of the dorsal component of the SL ligament, synovitis of the extrinsic volar radiocarpal ligaments, and degenerative perforations in the membranous (proximal) ligamentous portion. MR arthrography has been successful in identication of ap tears, perforation, and assessment of the integrity of the dorsal component of the SL ligament.23 With all methods of assessment for instability, caution must be exercised as improper positioning of the wrist during routine radiography, CT scanning, or MR imaging may simulate the instability patterns.16

269

Figure 58 A lateral view demonstrates capitolunate angle 30 (normal 0 to 30), lunate tilted volarly, capitate directed dorsally, volar tilting of the lunate most consistent with a VISI (volar intercalated segment instability) often due to disruption of the lunotriquetral ligament.

Lunotriquetral Instability
Lunotriquetral instability may be seen after sprain or disruption of the lunotriquetral interosseous ligament, with perilunate injury, excision of the triquetrum, sprains of the midcarpal joint that attenuate the extrinsic ligaments, with ulnar positive variance associated with degenerative lunotriquetal membranous tears, and in patients using wheelchairs.16,23 Patients with this injury usually progress from minimal symptoms to ulnar wrist pain and the sensation of instability. They develop ulnar nerve paresthesias and eventual midcarpal instability. A similar pattern of instability is seen as a normal variant in persons with ligamentous laxity and in those with various articular disorders, including rheumatoid arthritis and calcium pyrophosphate dihydrate crystal deposition disease.14 Standard radiographs may appear normal in patients with lunotriquetral tears or sprains and in those with lunotriquetral dissociation and dynamic instability.16 Stress radiographs, ie, clenched-st AP view in pronation or ulnar deviation or the clenched-st lateral view, may be necessary to elicit the abnormality in patients with dynamic instability. The abnormalities encountered include disruption of the normal smooth convexity of the proximal carpal row with the triquetrum displaced proximally on the AP radiograph. Disruption of the normal arc is particularly pronounced with

ulnar deviation, producing overlapping of the lunate and triquetrum.31 On the lateral view, the lunate is tilted volarly, capitate directed dorsally, and the triquetrum dorsiexed in relation to the lunate compared with the other wrist.1,18,31 With progressive instability, volar intercalated segmental instability (VISI) deformity occurs and radiographic ndings include the following: (1) PA views show that the lunate overlaps the capitate and (2) lateral views (Fig. 58) demonstrate a scapholunate angle 30 (normal 30 to 60), increased capitolunate angle to 30 (normal 0 to 30), lunate tilted volarly, capitate directed dorsally, and the triquetrum dorsiexed in relation to the lunate compared with the other wrist.1,16,30 Standard arthrography is probably the most helpful diagnostic aid in the evaluation of lunotriquetral tears30 (sprains). Sequential injection of the midcarpal and radiocarpal spaces has been shown to be the best method of evaluation.16 A positive study demonstrates communication between the midcarpal and radiocarpal joints through the lunotriquetral space. Patients with isolated lunotriquetral tears need to be differentiated from those with ulnar impaction syndrome. Ulnar impaction syndrome is discussed more extensively elsewhere in this writing.

Midcarpal InstabilityIntrinsic to Carpus

In midcarpal instability, laxity of certain carpal ligaments results in lack of support for the proximal carpal row and

270 midcarpal joint, which in turn leads to a loss of the normal joint reactive forces between the proximal and distal carpal rows. The proposed etiology is injury to or laxity ofthe ulnar arm of the arcuate ligament (a major stabilizer of the midcarpal joint) and laxity of the dorsal radiolunotriquetral (RLT) ligament.32 A dynamic exion deformity (VISI) occurs in the proximal row as the distal row translates palmarly owing to the lax ligament. As the wrist moves from radial to ulnar deviation, there is no longer the normal coupled rotation of the carpus and smooth transition from exion (VISI) to extension (DISI). Instead, the proximal row remains exed in a VISI-like pattern for a period with the head of the capitate [subluxed] volarly into the space of Poirier.32,33 As the distal row/capitate abruptly reduces, the proximal row snaps into extension in a DISI-like pattern creating the clinical nding called the catch-up clunk. This is accentuated by increasing the load on the capitolunate joint when the st is clenched and relieved by either splints which apply pressure in a dorsal direction to the pisiform or by surgery to strengthen the volar arcuate ligament and dorsal ligaments or by fusion of the lunate-triquetrum-capitate-hamate bones.33 The dynamic pattern of instability described above is named palmar midcarpal instability (PMCI) because of the palmar translation of the distal row. In earlier reports, this entity was termed ulnar midcarpal instability.34 Dorsiexion injury, compression, rotation, and distraction injuries and ulnar minus variance have been associated with PMCI.35 PMCI is the most common pattern of midcarpal instability.36 A much less common variant of midcarpal instability, in which the proximal carpal row is extended (DISI) and the distal carpal row is subluxed dorsally when the wrist is in neutral, is termed dorsal midcarpal instability (DMCI).32 The radiographs may be normal as PMCI is a dynamic condition. Lateral radiographs in neutral, radial, and ulnar deviation may demonstrate VISI deformity and mild palmar translation of the distal carpal row. Videouoroscopy in PA and lateral planes may show the dynamic palmar exion instability (VISI) with wrist motions from radial to ulnar deviation.32 CT scan and MR image ndings include VISI deformity with volar tilt of the scaphoid and the lunate, palmar translocation of the distal row, sclerosis between the distal lunate and proximal capitate, and dorsal tilting of the distal pole of the capitate. The T2-weighted MR images show an attenuated or disrupted lunotriquetral ligament with hyperintense uid extending across the lunotriquetral (LT) or scapholunate (SL) interval. There may be hyperintense synovitis versus ligament attenuation associated with the ulnar arm of the arcuate ligament and the dorsal radiotriquetral (or radiolunotriquetral) ligament. MR arthrography will show contrast directly communicating across the SL or LT interval.32 The natural history of midcarpal instability is that the dynamic instability becomes a xed VISI deformity with loss of the normal physiologic VISI to DISI wrist motion with wrist motion from radial to ulnar deviation. Louis and associates37 have described the capitolunate instability pattern (CLIP wrist) where there is laxity of the palmar radioscaphocapitate ligament in patients in whom dorsal subluxation of the cap-

R.A. Loredo, D.G. Sorge, and G. Garcia

itate on the lunate and the scaphoid on the scaphoid fossa of the radius could be demonstrated. These patients have features similar to those of patients with DMCI.17

Midcarpal InstabilityExtrinsic to Carpus

Extrinsic midcarpal instability is often associated with reversal of the normal volar tilt of the distal articulating surface of the radius. This is most often observed in patients with malunion of a distal radial fracture. Subsequently, the lunate and capitate are tilted dorsally; however, they maintain a collinear relationship with each other on neutral lateral views. With ulnar deviation, the capitate rotates volarly and becomes parallel and slightly dorsally displaced, relative to the shaft of the radius on the lateral view. However, the lunate remains dorsally tilted. The inability of the lunate to rotate volarly with the capitate is thought to cause the pain and clunk associated with extrinsic midcarpal instability.32

Radiocarpal or Proximal Carpal Instabilities

Although a rare occurrence, proximal carpal instabilities are characterized by subluxation or dislocation of the entire carpus in a dorsal, palmar, ulnar, or radial direction relative to the distal radius. Dorsal and palmar instabilities are most commonly related to trauma and ulnar dislocations are related to ligamentous laxity. Radial translocations have not been reported.32 Dorsal carpal instabilities may appear as an isolated nding or in association with Colles or Bartons fractures, which result in either dorsal tilt of the distal radial articular surface or dorsal displacement of the dorsal lip. Palmar carpal instabilities are less common, as one might expect, given their association with the rare palmar or reverse Bartons fracture. This results in increased palmar tilt or displacement of the articular surface. Both are treated with osteotomy to correct the malalignment.18,38 Ulnar carpal instabilities are generally from capsular injury or any type of synovitis, such as rheumatoid arthritis resulting in weakening and laxity of the extrinsic ligaments.32 This allows the carpus to migrate down the inclined plane of the distal radius in an ulnar direction33 (Fig. 59). A diagnostic feature is an abnormally wide space between the radial styloid process and the scaphoid29 as the carpus begins to slide ulnarly along the radius. The scapholunate angle is less than 30. PA views show that the lunate overlaps the capitate. Shift of the entire carpus dorsal to the midpoint of the distal radial articular surface is seen.1

Distal Radioulnar Joint Instability

Anatomically, in full supination, the ulnar head rests on the palmar aspect of the notch, and in full pronation, it rests against the dorsal lip of the notch.2 Acute injuries of the distal radioulnar joint (DRUJ) frequently go undiagnosed or misdiagnosed. Early recognition of DRUJ injury is crucial to effective treatment because chronic DRUJ conditions are much more difcult to manage.39 Injuries to the DRUJ can involve trauma to the bone, joint, and the surrounding soft tissues.

Radiographic evaluation of the wrist

271 PA radiograph; (2) widening of the radioulnar distance on the PA view in ulna dorsal dislocations; (3) superimposition of the radius and ulna on the PA view in ulna ventral dislocations; and (4) posterior or anterior (less common) displacement of the ulna on lateral radiographs.27 Unfortunately, detection of subluxation on radiographs may be quite difcult because slight variations in wrist position alter the relationship of the radius and ulna. Because of the difculty in demonstrating the anatomy of the distal radioulnar joint on routine radiographs, the associated complex injuries that occur, and the infrequent occurrence of isolated subluxations or dislocations, CT of the bilateral wrists in neutral, pronated, and supinated positions may be utilized to conrm the diagnosis.46 Due to the fact that DRUJ dislocation or subluxation may not occur until the patient reaches the extremes of pronation or supination, most institutions study the DRUJ in full pronation, neutral position, and in full supination. The asymptomatic wrist is included in the same positions.5 On transax-

Figure 59 A coronal T1-weighted MR image with scapholunate widening, proximal migration of the capitate (C), and ulnar translocation of the carpus.

DRUJ Dislocation/Subluxation
DRUJ dislocations have been reported as isolated injuries as well as with Galleazzi fractures, Essex-Lopresti injuries, both bone forearm fractures, distal radius fractures, fracture-dislocation of the elbow, and in plastic deformation of the forearm.39 DRUJ dislocation can be categorized as simple (reduces spontaneously or with minimal manipulation), or complex (irreducible, incomplete reduction, or interposition of soft tissue or bone). Isolated dislocations of the inferior radioulnar joint are uncommon, usually resulting from signicant rotatory force applied to the forearm about a xed hand, as in a fall or twisting injury. At the distal radioulnar articulation, dislocations of the ulna most often occur in a distal, dorsal, and medial direction; volar dislocation is less frequent.16 Most dislocations of this articulation occur in conjunction with Galeazzi fractures, short oblique, or transverse fractures that occur at the junction of the middle and distal third of the radius accompanied by dislocation of the DRUJ. An Essex-Lopresti injury is a fracture or fracture-dislocation of the radial head associated with disruption of the interosseous membrane between the radius and ulna and dislocation of the DRUJ.40 DRUJ injuries also occur with distal radius fractures. Poor results following treatment of distal radius fractures with symptoms at the distal radioulnar joint are typically from chronic disruption of the TFCC, ulnar abutment due to radial shortening, posttraumatic arthritis of the distal radioulnar joint, and/or persistent instability or dislocation of the DRUJ.39 Radiographic ndings of distal radioulnar dislocation (Fig. 60) include (1) abnormal rotation of the ulna with the ulnar styloid overlying the central portion of the distal ulna on the

Figure 60 Distal radioulnar joint (DRUJ) dorsal dislocation. A PA view demonstrates widening of the radioulnar distance (diamond), abnormal rotation of the ulna with the ulnar styloid (arrow) overlying the central portion of the distal ulna. Incidentally noted is softtissue calcication in the expected location of the ex carpi ulnaris tendon (asterisk).

272

R.A. Loredo, D.G. Sorge, and G. Garcia

Figure 61 Objective methods of evaluation of normal DRUJ on CT. (A) With the forearm in neutral rotation, the congruent ulnar head should lie between the two divergent lines drawn.46 (B) In supination, a perpendicular line drawn from the midpoint between the center of the ulnar head and the ulnar styloid (center of DRUJ rotation) to the chord of the sigmoid notch falls in the center of the sigmoid notch. (C) With the arm in pronation, the arcs of the sigmoid notch and the ulnar head should be congruous. (Reprinted with permission.5)

Figure 62 A coronal T1-weighted fat suppressed postgadolinium MR image following radiocarpal contrast injection demonstrating a tear (arrow) just ulnar to the cartilaginous attachment of the TFC (triangular bro-cartilage) onto the radius with contrast spilling into the distal radioulnar joint from a radiocarpal injection.

contrast opacication of the radiocarpal joint will be associated with lling of the inferior radioulnar joint as a result of perforation or detachment of the intervening articular cartilage (Fig. 62).

ial images, there are methods of objective CT or MR evaluation of the position of the ulna relative to the radius. The methods (Fig. 61) require construction of a number of lines that are drawn along the radius and ulna. In one method, a line is drawn through the dorsoulnar and dorsoradial aspects of the radius and another line is drawn through the palmoulnar and palmoradial aspects of the radius; the congruent ulnar head should lie between these two divergent lines5,46 (Fig. 61A). If the ulnar head crosses the respective dorsal or palmar line, subluxation in a dorsal or palmar direction is diagnosed. Another method is the epicenter method.41 In this method, with the DRUJ in supination, a perpendicular line is drawn from the midpoint between the center of the ulnar head and the ulnar styloid (center of DRUJ rotation) to the chord of the sigmoid notch (Fig. 61B). If this line is in the center of the sigmoid notch, the joint is considered congruous.5 With the arm in pronation, the arcs of the sigmoid notch and the ulnar head should be congruous (Fig. 61C). CT and MR imaging share diagnostic advantages in assessment of this joint. However, MR imaging has the added advantage of evaluation of the surrounding soft-tissue structures. In equivocal cases, arthrography of the radiocarpal joint can be helpful in establishing the diagnosis, as disruption of the inferior radioulnar joint requires injury to one or more components of the TFCC, the major stabilizing structure of the distal portion of the ulna.16 On arthrographic images,

Triangular Fibrocartilage Complex Tears

Pathologic conditions affecting the TFCC can be categorized as traumatic or degenerative and Palmer has devised a system for categorizing the abnormalities42 (Table 1). Lesions of the TFCC are variable in location; they may be conned to the horizontal, or at, portion of the TFCC (referred to as the TFC or articular disc) or involve one or more components of the TFCC with or without instability of the distal radioulnar
Table 1 Palmer Classication of TFCC Abnormalities42 Class 1. Traumatic A. Central perforation B. Ulnar avulsion C. Distal avulsion D. Radial avulsion Class 2. Degenerative (ulnocarpal abutment syndrome) A. TFCC wear B. TFCC wear (lunate /or ulnar chondromalacia) C. TFCC perforation (lunate /or ulnar chondromalacia) D. TFCC perforation (chondromalacia lunotriquetral ligament perforation) E. TFCC perforation (chondromalacia, ligament perforation, ulnocarpal arthritis)
Traumatic and degenerative TFCC abnormalities/tears exist and are listed according to the most often used classication system described by Palmer.42

Radiographic evaluation of the wrist

joint.2 Degenerative lesions of the TFCC are more common than traumatic lesions and are thought of as chronic injuries resulting from load on the ulnar side of the wrist. Anatomic studies have shown that perforation of the TFCC occurs in approximately one-third to one-half of cadaveric specimens, perhaps due to degenerative changes.1 Radiography is not useful in characterization of TFCC abnormalities. However, there are radiographic ndings that are associated with abnormalities of the complex, such as positive ulnar variance, the presence of an ulnar base fracture associated with proximal detachment of the TFCC, and avulsion fracture of the fovea of the ulna indicating injury at the site of attachment of the proximal lamina of the TFCC.43 The role of arthrography in the diagnosis of TFCC defects is well established, although there is some disagreement regarding the optimal technique for compartmental injection. Nonetheless, the terms communicating (full-thickness) and noncommunicating (partial thickness) defects are used in discussion of TFCC abnormalities. The presence of contrast material in the DRUJ after radiocarpal opacication or in the radiocarpal compartment after DRUJ injection is diagnostic of a communicating defect in the TFC (articular disc) (see Fig. 62). Noncommunicating, or partial, defects involving the proximal and distal aspects of the TFC can be demonstrated following injection of the DRUJ and radiocarpal joint, respectively. Other traumatic abnormalities that involve the TFCC attachments, as described by Palmer, may be associated with distinctive arthrographic ndings.42 At this time, arthrography and state-of-the-art MR imaging can be considered equally accurate in assessment of defects of the TFCC.2

273

Figure 64 A coronal T2-weighted fat suppressed MR image demonstrates negative ulnar variance and cystic degenerative changes at the distal radioulnar joint consistent with distal radioulnar impingement.

Ulnar Abutment Syndrome

The ulna abutment syndrome, also termed ulnocarpal abutment, ulnar impaction syndrome, and ulnolunate impaction syndrome, is a degenerative condition related to excessive load-bearing across the ulnar side of the wrist.44 It is most

Figure 63 A PA x-ray demonstrates positive ulnar variance and cystic changes of the radial aspect of the distal ulna and ulnar aspect of the proximal lunate consistent with ulnolunate abutment or impaction (see arrows).

often due to altered mechanics from ulnar elongation relative to the radius (positive ulnar variance). Patients present with ulnar wrist pain, swelling, crepitus, and limited wrist motion. The condition is caused by chronic impaction of the ulnar head against the TFCC and ulnar-sided carpal bones resulting in progressive deterioration of the TFCC, chondromalacia of the lunate and ulna, and attrition of the lunotriquetral interosseous ligament.44 The ulnar impaction syndrome is almost always associated with a positive ulnar variance. Positive ulnar variance is often idiopathic but can be caused by malunion of a distal radial fracture, premature physeal arrest of the distal radius, or an Essex-Lopresti injury.31 Although the ulnar impaction syndrome has been identied in patients with neutral or positive ulnar variance, it is not associated with negative ulnar variance.31 A routine PA radiograph may demonstrate positive ulnar variance (Fig. 63) and degenerative changes such as joint space narrowing, subchondral sclerosis, or cystic changes in the ulnar head, sigmoid notch, lunate, or triquetrum.45 An excellent radiographic study for ulnar abutment is to obtain a PA view with the st clenched in addition to the routine PA view. With a load across the wrist, the ulna moves distal relative to the radius, and this change is often quite noticeable on plain radiographs.5 Videouoroscopy can be used to determine whether there truly is an abutment between the distal ulna and the carpus in ulnar impaction syndrome.5 MR imaging may demonstrate chondromalacia or degenerative arthritis of the ulnar head or carpus, and the lunotriquetral ligament may be perforated.37,45 The syndrome of ulnar abutment or impaction should

274

R.A. Loredo, D.G. Sorge, and G. Garcia

wrist. The destruction of the trapezioscaphoid and trapezoidoscaphoid joints results from disruptions in the ligamentous support of the scaphoid distally. The radial column collapse allows the trapezium and trapezoid to migrate proximally and come to rest on the nonarticular dorsum of the distal scaphoid, immediately proximal to the distal articular cartilage. This, along with any rotational changes and lateral displacement of the distal scaphoid, leads to abnormal shear stresses that result in the degeneration observed.

Congenital/Developmental Conditions
The following topics are congenital or developmental conditions that may lead to wrist pain. The discussion of each entity is brief, and interested readers may consult standard reference textbooks for more detailed information.

Figure 65 A PA view shows a more advanced case of SLAC wrist (circle).

Carpal Coalition
Coalition, or carpal fusion, is relatively common and may occur as an isolated phenomenon or as part of a generalized congenital malformation syndrome. As a rule, isolated fusions involve bones in the same carpal row (proximal or distal); fusions related to syndromes may affect bones in different rows (proximal and distal) and massive carpal fusion is usually associated with congenital malformations and anomalies.31 Coalition may be brous (Fig. 67) or bony (Fig. 68). The most common type of isolated fusion is between the triquetrum and the lunate bones, occurring in 0.1 to 1.6% of the general population. The condition is bilateral in approximately 60% of cases.31 The scapholunate interosseous space is frequently widened in cases of lunotriquetral coalition, and, although the SL ligament is generally intact,31 abnormal

be differentiated from the syndrome of ulna impingement, which is generally associated with negative ulnar variance (Fig. 64). Impingement at the level of the DRUJ can occur following surgical resection of the distal ulna, following fracture of the ulnar head or secondary to a malunited sigmoid notch as a sequela of a distal radius fracture.5 The syndrome of impingement may be seen in chronic instability of the DRUJ, infection, inammatory arthritis, crystalline disease, and primary osteoarthritis.7,46 Ulna impingement syndrome is a degenerative process that leads to DRUJ pathology and pain with supination.

Posttraumatic/Postinstability Arthrosis (SLAC)

A wrist with scapholunate advanced collapse (Fig. 65) has a pattern of osteoarthritis, occurring either spontaneously or after trauma, characterized by narrowing of both the radioscaphoid and the capitolunate spaces. Some investigators believe that it is one of the most common patterns of degenerative joint disease in the wrist. The most common etiology of SLAC wrist is rotary subluxation of the scaphoid (RSS) due to scapholunate or periscaphoid dissociation. In addition to RSS, SLAC wrist may be caused by other conditions such as Kienbocks disease, scaphoid fracture nonunion or malunion, radioscaphoid and capitolunate intraarticular fractures, Preisers disease (spontaneous osteonecrosis of the scaphoid), and crystalline pyrophosphate deposition disease (CPPD).5 The presence of chondrocalcinosis or other types of intraarticular calcication, the absence of a history of injury, or the presence of radiolunate joint space narrowing, alone or in combination, strongly suggests the diagnosis of CPPD crystal deposition disease.

Triscaphe Arthritis
Triscaphe arthritis (Fig. 66) occurs as a result of load changes and articular abnormalities analogous to those in the SLAC

Figure 66 PA x-ray with variant of triscaphe arthritis (arrows) in addition to distal radioulnar fractures and trapezium-trapezoid-capitate coalition.

Radiographic evaluation of the wrist

275

Figure 69 A PA radiograph shows slight increased density of the lunate (arrow) suggestive of early Kienbocks disease. Figure 67 A coronal T2-weighted fat suppressed MR image conrms partial brous lunotriquetral coalition (arrows) with surrounding marrow edema suggesting minimal motion at the partial coalition site.

such as juvenile chronic arthritis, and rheumatoid arthritis, trauma, and surgery.31

Osteonecrosis and Osteochondrosis

widening to more than 3 to 4 mm suggests a scapholunate ligament tear or laxity.7 Less common isolated fusions have been described in almost all possible combinations, including two or more bones. Bone cysts adjacent to the coalition are sometimes seen. The changes can usually be differentiated from the acquired ankylosis that may accompany infection, certain arthritides Kienbchs Disease The various synonyms used for this condition (lunatomalacia, aseptic necrosis, avascular necrosis, osteochondritis, traumatic osteoporosis, osteitis) are most likely a reection of the fact that its exact etiology remains unclear. Early descriptions of Peste and, later on, Kienbck, supported the belief that the lesion is a fracture with a traumatic etiology.36,38 Kienbck believed that repeated sprains, contusions, or subluxations led to ligamentous and vascular injury resulting in loss of blood supply to the lunate.36 Since then, numerous authorities have described the pathologic changes as avascular necrosis. The exact cause and pathogenesis is not denitely known. However, there is the nding of ulna minus variance that has been associated with Kienbocks disease. Theoretically, a short ulna causes increased shear forces on the ulnar side of wrist and particularly on the lunate. This is thought to be a contributing factor in the development of avascular necrosis.35 Early in the course of Kienbcks disease, the radiographs may appear normal to slightly dense (Fig. 69). However, a linear or compression fracture can be delineated with CT scanning and MR imaging. Subsequently, increased density of the lunate is noted, followed by altered shape and diminished size of the bone. Eventually, the lunate may collapse and fragment. Later on, complications may develop such as disruption of carpal architecture, scapholunate separation, or dissociation, with disruption of the scapholunate interosseous ligament, ulnar deviation of the triquetrum, and secondary degenerative joint disease in the radiocarpal and midcarpal compartments of the wrist.35 Tendon rupture resulting from erosion by the irregular and collapsed lunate has been reported.47 Many classication systems of Kienbcks disease have

Figure 68 A coronal T1-weighted MR image shows osseous lunotriquetral coalition. tq triquetrum, L lunate.

276

R.A. Loredo, D.G. Sorge, and G. Garcia

steosis, enchondromatosis, hereditary multiple exostoses (HME) (Fig. 70), mesomelic dwarsm, and Turner syndrome.

Degenerative
Osteoarthritis Osteoarthritis (OA) is the most common arthropathy seen today. In primary osteoarthritis, the radiographic features include normal mineralization, nonuniform loss of joint space, subchondral new bone formation, osteophyte formation, cysts, subluxation, absence of erosions, and unilateral or bilateral asymmetrical distribution.15 Primary OA is virtually limited to the rst carpometacarpal and the trapezioscaphoid joints. Characteristic ndings are seen (Fig. 71) as follows: (1) at the rst carpometacarpal joint, there is radial subluxation of the metacarpal base; (2) osteophyte formation occurs between the base of the rst and second metacarpals; and (3) at the trapezioscaphoid area, joint space narrowing and eburnation may be the only ndings.13,50 Osteoarthritic changes involving any other joint in the wrist should be considered secondary to another arthropathy or to accidental or occupational trauma. In the posttraumatic setting, more widespread involvement of the wrist may be observed. Abnormalities of the radiocarpal and midcarpal compartments can follow a scaphoid fracture or Kienbocks disease; changes at the DRUJ can appear following subluxation or dislocation, and abnormalities of the radiocarpal and midcarpal areas can be observed in pneumatic tool operators or professional athletes.50 As the degenerative joint disease worsens and becomes more widespread, there may be eventual development of SLAC. In secondary osteoarthritis, the joint space loss is uniform as this type of arthritis develops secondary to an underlying cartilage problem. The uniform involvement distinguishes

Figure 70 Madelung deformity in a patient with HME.

been proposed. The most popular is a four-stage system described by Lichtman and coworkers that is based on radiographic abnormalities.48 In stage I, radiographs are usually normal except for possible visualization of a fracture. Unless a compression fracture is visible, this stage is clinically indistinguishable from a wrist sprain. Stage II is when there are abnormalities of radiodensity that are not accompanied by changes in size, shape, and relationships of the carpal bones. In stage III, the lunate bone is collapsed on the PA or AP view and is elongated in the lateral view with abnormalities in carpal bone relationships. The capitate migrates proximally secondary to scapholunate dissociation. To assess the extent of collapse in stage III, the carpal height ratio can be measured (normal ratio 0.54 0.03). Carpal height ratio is becoming more important, because the results of treatment in stage III are related to the extent of collapse. Stage III is divided into stage IIIA (lunate collapse without xed rotation of the scaphoid) and stage IIIB (lunate collapse with xed rotation of the scaphoid and other secondary derangements). Stage IV is when there are changes of osteoarthritis.49

Madelung Deformity
Madelung deformity is a developmental growth disturbance of the distal radial physis that manifests clinically during adolescence. The primary deformity is a bowing of the distal end of the radius typically in a volar direction while the ulna continues to grow in a straight fashion. The result is a short radius and a long ulna. It predominantly affects females and is usually bilateral, although one side may be symptomatic. Clinically, the carpus and hand appear to be displaced anterior to the forearm and the distal ulna is dorsally subluxed, forming a prominence that is most marked in pronation. Potential causes of Madelung deformity include dyschondro-

Figure 71 Osteoarthritis of the wrist. Characteristic areas of involvement (arrows) are well demonstrated on this PA view.

Radiographic evaluation of the wrist

277 wrist through the hand. Three routes of wrist extension of infection are via tendon sheaths, fascial planes, or lymphatics, with the tendon sheaths being the primary route of contamination.19 Particularly in the rst and fth digits, the synovial sheaths surrounding the exor tendons of the hand allow extension of infection to the radial and ulnar bursae. As a result of contamination of the fth nger, ulnar bursa, radial bursa, and rst nger, a characteristic horseshoe abscess may develop.19 In the dorsum of the wrist, infection usually occurs in the subcutaneous or subaponeurotic space. However, the less frequent occurrence of infected extensor tenosynovitis can contaminate the wrist19 (Fig. 72). On radiographs, diffuse soft-tissue swelling (Fig. 73), osteoporosis, and articular and osseous destruction are evident. Infections in the fascial planes of the hand are numerous. However, they result in wrist joint or bone alterations less frequently than those via the synovial sheaths.19 Lymphangitis may result from supercial injuries with rapid extension producing widespread swelling. In some cases, tenosynovitis, septicemia, osteomyelitis, and septic arthritis may result.

Figure 72 Abscess and tenosynovitis demonstrated with MR imaging. (A) Coronal T2-weighted MR image of the hand and wrist demonstrating heterogeneous high signal intensity tenosynovitis (circle) with synovial sheath extension of synovitis and infection from the hand into the wrist (arrows). (B) Sagittal T1-weighted MR image following intravenous administration of a gadolinium compound shows rim-enhancing exor synovial sheath and adjacent abscess (box).

Bacterial Osseous Infection

In acute hematogenous osteomyelitis, males are affected more commonly, and a history of trauma or recent infection is often obtained.51 In the neonate or infant, Staphylococcus aureus, group B streptococcus, and Escherichia coli are the bone isolates recovered most frequently; in children older than 1 year of age, S. aureus, Streptococcus pyogenes, and Haemophilus inuenzae are responsible for most cases of hematogenous osteomyelitis. Gram-negative organisms assume importance as pathogens in bone and joint infections in adults and in intravenous drug abusers. An acute or chronic

secondary osteoarthritis from primary OA where there is nonuniform joint space loss.

Infectious Diseases
Bacteria Soft-Tissue Infection
Infection may be derived from hematogenous seeding, spread from a contiguous source, direct implantation, or operative contamination. An infection can gain access to the

Figure 73 Dorsal hand infection. (A) Lateral view of the hand in a patient with dorsal soft-tissue cellulitis demonstrated as dorsal softtissue swelling (asterisks). (B) In a different patient, an infection has progressed to involve the extensor carpi ulnaris with associated soft-tissue swelling (asterisks) identied on a PA view. Osteopenia of the ulnar styloid is consistent with early osseous destruction (arrow).

Figure 74 Radiographic ndings in osteomyelitis and septic arthritis. A PA wrist view shows soft-tissue swelling and obliteration of tissue planes. Joint space loss, osteolysis, and marginal and central osseous erosions involve the distal aspect of the radius and ulna and multiple carpal bones.

278

R.A. Loredo, D.G. Sorge, and G. Garcia

than adults. The usual presentation is as a chronic extensor or exor tenosynovitis, with joint involvement in some cases. There is a rm or boggy swelling with minimal tenderness and inammation. Diagnosis may be delayed for several months.52,53 Infection with Mycobacterium fortuitum can occur following penetrating wounds and steroid injections,54 whereas infection with Mycobacterium marinum or Mycobacterium terrae may occur following exposure to a marine or farm environment, respectively.53 Mycobacterium kansasii and Mycobacterium aviumintracellulare appear to be the most commonly isolated pathogens in deep mycobacterial infections.54,55 Mycobacterium tuberculosis infection occurs less commonly at the wrist than at other sites, such as the spine and hip, although the clinical presentation is similar. In cases of wrist involvement, dactylitis involving the metacarpals may present as a swollen wrist. Successful treatment of mycobacterial infection consists of surgical debridement in conjunction with long-term antibiotic therapy. Besides atypical mycobacterial infections, cutaneous, tendon sheath, and joint infection may be caused by Sporothrix schenckii.56 Bacteroides infection may follow a human bite wound.57 In the immunocompromised patient, a variety of unusual bacterial, myocobacterial, and fungal infections may occur and are often difcult to eradicate (Fig. 75). Chronic recurrent multifocal osteomyelitis is an inammatory disorder of unknown origin affecting the skeletally immature. It is characterized by repeated episodes of fever, local pain, and swelling over the metaphyseal region of tubular bones and the clavicle. The radiographic appearance is similar to that of osteomyelitis (Fig. 77). Antibiotics produce no response. The condition is treated with anti-inammatory agents and it usually shows eventual spontaneous remission.58

Figure 75 Septic arthritis and osteomyelitis. (A) Early and (B) late disease radiographs. The PA wrist views show pancompartmental narrowing of the wrist joints with progressive periarticular erosions (arrows).

respiratory tract infection is important in the pathogenesis of tuberculous, fungal, and pneumococcal osteomyelitis.19 The route of hematogenous bacterial seeding very much depends on the age of the patient. In a child, a metaphyseal focus is frequent as the growth plate acts as a barrier. From this site, cortical penetration can result in a subperiosteal abscess in those locations in which the growth plate is extraarticular or in a septic joint in those locations in which the growth plate is intraarticular. Because the distal radial and ulnar metaphyses are extraarticular, secondary joint involvement does not occur as a rule. In children, the radius and ulna are affected in 5 to 9% of cases. In the infant (1-yearold), a metaphyseal focus may be complicated by epiphyseal extension owing to the vascular anatomy in this age group. In the adult, a subchondral focus in an epiphysis is not unusual owing to the vascular anatomy in this older age group19 (Fig. 74). In general, carpal bone osteomyelitis is extremely rare. The radiographic ndings of osteomyelitis (Figs. 74 and 75) (including abscess, involucrum, and sequestration), septic arthritis (including joint space loss and marginal and central osseous erosions), and soft-tissue suppuration (including swelling, radiolucent streaks, and periostitis) are generally delayed for a variable period after the clinical onset of infection. Radiographs are nonspecic in the early stages, showing soft-tissue swelling and obliteration of tissue planes. After 10 days or so, diffuse or focal osteopenia, periosteal elevation, and new bone formation are seen. Localized cortical and medullary abscesses may be seen as single or multiple radiolucent cortical or medullary lesions with surrounding sclerosis. Cortical necrosis and sequestra formation may occur followed by sinus tract formation. Other diagnostic techniques, including scintigraphy and MR imaging (Fig. 76), allow accurate diagnosis at an earlier stage of the process.

Atypical Infections
The wrist is the most commonly affected site in atypical mycobacterial infections. Children are affected less frequently

Figure 76 MR image ndings in osteomyelitis and septic arthritis. (A) T1-weighted coronal image shows abnormal intermediate signal intensity within the epiphysis of the ulna (U) and radius (R) and in multiple carpal bones (C). (B) The corresponding T2-weighted coronal image shows abnormal increased signal intensity in the same areas within the ulna (U) and radius (R) and in the carpus. (C) A T1-weighted coronal image following intravenous administration of a gadolinium compound illustrates enhancement within these same areas of involvement.

Radiographic evaluation of the wrist

279

Figure 77 Chronic recurrent multifocal osteomyelitis. (A) A PA wrist view in a skeletally immature patient shows focal osteolysis of the metaphysis of the radius (arrow). (B) In the same patient, an AP radiograph of the knee demonstrates focal areas of tibial osteomyelitis (arrows).

Tumors and Tumor-like Diseases

With the exception of ganglion cysts, tumors and tumor-like conditions of the wrist are uncommon. As is true of the hand, most tumors that occur in or about the wrist are benign, although malignancies do appear on occasion. All ages may be affected and the size of the lesion is not a clue as to whether the lesion is benign or malignant. Tumor-like lesions may be associated with a generalized metabolic disorder, such as in gout or xanthomatosis; or may develop following trauma as in a foreign body reaction or granuloma.59

Figure 78 Enchondroma. (A) Magnication view of the ulna shows a lucent lesion with a well-circumscribed nonsclerotic margin (arrow). The matrix appears nonmineralized. (B) A coronal uid-sensitive MR image illustrates a homogeneously bright matrix (arrow). (C) The corresponding axial T1-weighted image following administration of a gadolinium compound shows a rim-enhancing margin and intermediate signal intensity matrix (arrow).

Osteoblastic lesions vary from the benign bone island or osteoma to aggressive, fortunately rare, osteosarcoma. Bone islands (enostoses) are common, can occur in any carpal bone, are usually asymptomatic, and are picked up as incidental ndings. Occasionally, one may show increased radiopharmaceutical uptake on a bone scan. However, more commonly, increased uptake represents a more active process, such as an osteoid osteoma. Osteoid osteoma (Fig. 81) is not an infrequent nding in the wrist area. It usually manifests as pain that is relieved by salicylates. Conventional radiography, CT scanning, or MR

OsseousBenign
Lytic lesions are very common in the carpal bones. If cystic, radiographically, they usually appear as rounded lucencies that are sharply demarcated by a thin margin of sclerosis. They usually contain mucinous material and probably represent degenerative cysts. Occasionally, they are called intraosseous ganglia because they originate in the same location as the routine ganglia and represent remodeling of the bone and capsular tissues.60 Cartilaginous lesions, such as enchondromas, are relatively common (Fig. 78) and are often seen in conjunction with enchondromas in the hand. A variety of bone lesions occur in the radius and ulna. The distal aspect of the radius is one of the more common locations for occurrence of a giant cell tumor; the ulna is somewhat less common. Radiographically, extensive osteoclastic resorption and remodeling is seen with an irregular, thin shell of expanded bone and periosteum (Fig. 79). Osteochondromas can occur in the wrist and may involve the radius, ulna, or carpal bones. Multiple osteochondromas may be seen in the hereditable condition of osteochondromatosis (Fig. 70). Rarely, epiphyseal osteochondromas (Trevors disease) may be a source of wrist pain (Fig. 80).

Figure 79 Giant cell tumor. (A) PA view illustrating an expansile, lytic lesion within the radius (arrow) that spans the metaphysis and the epiphysis in this skeletally mature patient. (B) A lateral view shows extensive osteoclastic resorption and remodeling with an irregular, thin shell of expanded bone and periosteum.

280

R.A. Loredo, D.G. Sorge, and G. Garcia

Figure 80 Trevors disease. PA wrist view shows enlargement and sclerosis/calcication of the radial epiphysis due to the presence of an osteochondroma (arrow).

imaging may delineate the nidus. It is not unusual for symptoms to be present for a year or more before a diagnosis is made. Radiothermal ablation of the nidus is curative.

Figure 81 Osteoid osteoma. A PA view illustrates a focal sclerotic nidus of an osteoid osteoma within the capitate (arrow), surrounded by dense-appearing bone. C capitate, H hamate.

OsseousMalignant
Primary skeletal malignancies of the carpus are rare. As in malignancies elsewhere, control of the primary tumor is usually surgical. However, due to the central location of the wrist, in terms of structures passing from the forearm to the hand, a localized limb-sparing resection is seldom feasible.59 MR imaging has become essential in staging of primary malignancies to determine whether the tumor is retained within a compartment or if metastasis is present. Although reports of metastatic tumors of the bones of the wrist and hand are quite uncommon, a large number of malignant tumors of the wrist are metastatic.61 There is no specic predilection for any given primary tumor to metastasize to the bones of the wrist. The incidence of any type tends to match that of the tumors that metastasize to bone (ie, breast, lung, kidney). When tumors do metastasize to the carpus, they tend to cause destruction in several bones simultaneously, which is often a clue to the aggressive nature of the process. Generally, the tumor is treated systemically, although occasionally, a local approach may be necessary for diagnostic reasons and for stabilization or pain relief.59 mass in patients of any age; however, it tends to occur during the third to fth decades. Women are more commonly affected and there may be a history of prior trauma. On the volar side, most ganglia originate from the joint capsule (Fig. 82) and some originate from the trapezioscaphoid joint. Fre-

Soft TissueBenign
In all reported series, the dorsal wrist ganglion cyst arising from the capsule over the scapholunate joint is the most common tumor of the hand/wrist. It may appear as a painless
Figure 82 Volar soft-tissue ganglion cyst. (A) Lateral and (B) PA views of the wrist depict a volar, radial side soft tissue mass (arrows).

Radiographic evaluation of the wrist

281

Figure 83 Lipoma. (A) A T1-weighted coronal image of the wrist demonstrates extension of a high signal intensity soft-tissue mass from the hand into the wrist (arrows). The mass follows fat signal intensity (asterisk) on the (B) T1-weighted axial and (C) T2weighted fat suppressed axial images (asterisk).

Figure 84 Giant cell tumor of the tendon sheath. (A) Within the dorsum of the ulnar wrist, there is an inhomogeneous mildly increased signal intensity mass that is shown on a T2-weighted sagittal MR image (arrow). (B) The mass appears as inhomogeneous intermediate signal intensity (asterisk) on a corresponding T1-weighted axial image. (C) The T1-weighted axial fat-suppressed image shows bright homogeneous enhancement of the lesion (asterisk).

quently, they appear near the radial artery and cause compression of the artery or distort its path. These lesions may be found in the carpal tunnel or in Guyons canal.59 The exact etiology of ganglia is still unknown. The most commonly accepted theory involves remodeling of the brous capsular tissue of the joint. Collagen ber breakdown products and intercellular mucin collect and as these collections coalesce, expand, and dissect their way toward the subcutaneous tissues, a brous pseudocapsule is created.63 Lipomas may involve the wrist by way of extension from the hand or the forearm and appear as deep or supercial lesions (Fig. 83). Not uncommonly they may be found during carpal tunnel release procedures. There are reports of large lipomas in the median nerve.64 Radiographically, lipomas in the wrist have the typical density of fat, unless they undergo metaplastic change and appear as a mixture of fat and myxoid material, or undergo osseous metaplasia following trauma.59 Giant cell tumors of the tendon sheath are slow growing, painless masses that may arise in association with synovial tissue of the joints or tendon sheaths on the exor or extensor side of the wrist (Fig. 84). These benign growths contain numerous histiocytes and foreign body giant cells adjacent to hemosiderin deposits from minor bleeding episodes secondary to trauma.59 Vascular lesions more commonly include hemangiomas (Fig. 85), arteriovenous shunts (congenital or acquired), thromboses (after intravenous infusions or following trauma), or aneurysms (following repetitive trauma).59 Glomus tumors have been described in the carpal area.62 One of the more common lesions in the wrist is a neuroma caused by trauma following operative section of a nerve, presenting as a tender mass. Neuromas of the supercial radial and palmar cutaneous branch of the median nerve are particularly problematic.59 A neurobroma or a neurilemoma may occur in any of the nerves at the wrist. Neurilemomas arise from Schwann cells and are composed of two types of tissue, a cellular

type and a myxomatous or cystic type, and they are easily removed. On the other hand, neurobromas originate from the brous tissue of the epineurium or endoneurium, are more inltrative between nerve bundles, and are difcult to remove without causing damage to the nerve of origin.59 Fibrous lesions can occur in the skin or subdermal soft tissues. They are relatively common lesions, may be single or multiple, and are locally invasive. They may or may not have ne stippled calcications.59 A not-so-common, but interesting le-

Figure 85 Venous hemangioma. (A) A serpiginous intermediate inhomogeneous signal intensity mass is seen on a T1-weighted coronal MR image of the wrist (circle). (B) The axial T2-weighted fatsuppressed image shows the mass to be inhomogeneous increased signal intensity (arrows). (C) Following gadolinium administration, the mass (arrows) shows inhomogeneous enhancement on an axial T1-weighted MR image.

282

R.A. Loredo, D.G. Sorge, and G. Garcia

inammatory problem. On the PA view, early erosions in the wrist may be seen in specic locations, namely, the waist of the navicular, the waist of the capitate, the articulation of the hamate with the base of the small nger metacarpal, the articulation of the thumb metacarpal with the trapezium, the radial styloid, and the ulnar styloid.13 As the disease progresses (Fig. 87), there is pancompartmental loss of cartilage and joint spaces of the wrist; the soft-tissue swelling decreases, and the juxta-articular osteoporosis becomes diffuse. The initial subtle marginal erosions eventually become large subchondral erosions. Subcutaneous rheumatoid nodules may develop in 25% of the patients, without bone destruction.13 As arthritis mutilans develops (Fig. 88), there is lack of any recognizable joint space as bone ankylosis occurs. One interesting nding that occurs at the wrist in patients with rheumatoid arthritis is the caput ulnae syndrome. The syndrome consists of pain, limited motion, and dorsal prominence of the distal end of an eroded ulna. The eroded and abnormally located ulnar head impinges into the extensor tendon compartments on the dorsum of the wrist. This produces fraying of the surfaces of the tendons in association with tenosynovitis, a situation that leads to weakening of the tendons with subsequent rupture of the tendons beginning on the ulnar side of the wrist.67 In evaluation of the wrist, MR imaging has not yet replaced quality conventional radiography, although rheumatoid ar-

Figure 86 Fibrolipomatous hamartoma in a 22-year-old male. (A) A T1-weighted axial MR image shows marked enlargement of the median nerve with multiple intermediate and low signal intensity longitudinal tubular regions (arrows), creating the appearance of a cable. (B) The corresponding T2-weighted axial image demonstrates the tubular regions as high signal intensity (arrows) with interspersed areas of low signal intensity. (C) A gadolinium enhanced axial image shows inhomogeneous bright enhancement of the lesion (arrows). (Courtesy of Donald Resnick, MD San Diego, CA.)

sion, called a brolipoma (Fig. 86), is a hamartomatous enlargement of the median nerve. It has been associated with macrodactyly of the ngers or overgrowth of portions of the hand, a condition known as, macrodystrophia lipomatosa.65,66

Synovial/Inammatory Diseases: Arthritis

Imaging modalities that may be utilized for the evaluation of articular disease include conventional radiography, computed tomography, scintigraphy, ultrasonography, and magnetic resonance imaging. Evaluation of articular disease should always begin with conventional radiography. If quality lms are obtained (appropriate patient positioning in at least two orthogonal planes), the extent and severity of joint involvement, and the disease progression or regression may be documented. In some cases, special views may be utilized to evaluate for specic joint involvement. Although PA and AP oblique (Norgaard) radiographs of the hands are the most informative for evaluation of arthritis, the wrist may show characteristic changes on these views as well. The PA view provides for evaluation of mineralization and soft-tissue involvement. In the Norgaard view of the wrist, the pisiform and the hamate are well demonstrated, and this view proles the triquetrum-pisiform joint.13,50

Rheumatoid Arthritis
In rheumatoid arthritis, the earliest radiographic changes are symmetric periarticular soft-tissue swelling and juxta-articular osteoporosis. Although these changes are nonspecic, they help support any clinical suspicion of an underlying
Figure 87 Progressive changes in rheumatoid arthritis. A PA view of the wrist in a patient with RA shows progressive marginal erosions that progressively involved more and more of the articular surface to become large subchondral erosions.

Radiographic evaluation of the wrist

283

Figure 89 Psoriatic arthritis. An AP oblique (Norgaard) view of the wrist illustrates a few hallmarks of this disorder: joint space loss, bone proliferation, and erosions (ellipse) in each bone that is outlined above. Figure 88 Arthritis mutilans. There is lack of any recognizable radiocarpal and intercarpal joints as bone ankylosis (box) has occurred. Similar changes involve multiple carpometacarpal joints (within box).

thritis has been the arthropathy most extensively studied by MR imaging. MR imaging can demonstrate synovitis, tenosynovitis, erosion, synovial cyst formation, bursitis, tendon rupture, and brocartilaginous degeneration associated with rheumatoid arthritis.15 The literature states that MR imaging may show erosions earlier than plain lms and offers the potential of directly demonstrating the extent of synovial hypertrophy and cartilage destruction.68 The MR image demonstration of the synovium may be very important to the rheumatologist, if the physical examination is equivocal in determining the effect of a particular treatment regimen. Synovium may demonstrate intermediate signal intensity on T1-weighted images relative to the low signal intensity of adjacent uid and show intermediate signal intensity on T2weighted images compared with the relatively high signal of an effusion.68 However, frequently, synovium cannot be differentiated from effusion without use of intravenous gadolinium. Active synovitis enhances following the administration of gadolinium. However, the affected joint must be imaged immediately, as gadolinium will diffuse into the joint if imaging is delayed.68

other features will distinguish psoriatic arthritis from rheumatoid arthritis (ie, usually DIP and/or PIP involvement and/or evidence of bone proliferation in psoriatic arthropathy).13

Reiters Disease
The classic radiographic features of Reiters disease (Fig. 90) are identical to those of psoriatic arthritis with the erosive disease and bone formation being the predominant ndings. However, the hands and wrists are less frequently involved in Reiters than in psoriatic arthropathy. When the upper extremity is affected, the hand is the most common area of involvement.13

Psoriatic Arthritis
In the hands or wrists, the hallmarks of this disorder are bilateral asymmetrical distribution of soft-tissue swelling, normal mineralization (following the initial stage of the disease), joint space loss (sometimes dramatic), bone proliferation (adjacent to erosions, along shafts, across joints, and at tendon and ligament insertions), and erosions (usually DIP or PIP joints) (Fig. 89).13 In the wrist, psoriatic arthritis may appear in the carpal bones in conjunction with ray involvement or it may appear only in the wrist in a pattern similar to that observed in rheumatoid arthritis. In the latter pattern,

Figure 90 Reiters disease. A PA wrist view shows multiple erosive defects (arrows) along the ulnar head and styloid and at the level of the distal radioulnar joint.

284

R.A. Loredo, D.G. Sorge, and G. Garcia

Figure 91 Chondrocalcinosis in CPPD. Chondrocalcinosis is most frequently encountered in the triangular brocartilage (arrow) and/or the hyaline cartilage between the lunate and the triquetrum (double arrow) and that between the scaphoid and lunate (hatched arrow). scaphoid S, lunate L, triquetrum tq, capitate C.

Crystal-Induced and Related Diseases

CPPD crystal deposition disease is a common disorder and the most common crystal arthropathy. CPPD crystals deposit in hyaline and brous cartilage, producing a radiographic picture of calcied cartilage (chondrocalcinosis). It is seen most frequently in the knee, pubic symphysis, and wrist, with the hips, shoulder, and elbow involved in decreasing order of frequency.13 The radiographic diagnosis can be made when two or more different joints (one wrist and one knee, not two wrists or two knees) in the skeleton demonstrate chondrocalcinosis.13 The radiographic picture varies from chondrocalcinosis alone to severe arthropathy (Figs. 91 and 92). When arthropathy occurs, the radiographic picture of CPPD crystal deposition disease resembles that of osteoarthritis. The arthropathy of the wrist most commonly affects the radiocarpal joint. There is typically uniform joint space loss, subchondral new bone formation, and cyst formation, with the changes in distribution different from that of primary OA. Normal mineralization, variable osteophyte formation, cyst formation (more prominent than in OA), and bilateral distribution are other typical features of the arthropathy. The wrist arthropathy is found in 70% of patients with the disease and chondrocalcinosis is found in 65% of the patients.13 Chondrocalcinosis is most frequently encountered in the triangular brocartilage and/or the hyaline cartilage between the lunate and the triquetrum and between the navicular and the lunate. This may lead to SL ligamentous disruption with subsequent SL disassociation.13 If there is SL dissociation, there may be associated narrowing of the capitolunate joint space. The characteristic appearance of these latter ndings has been described as a stepladder conguration.13 The only other two diseases known to cause deposition of CPPD crystals in cartilage, other than idiopathic CPPD crystal deposition disease, are hyperparathyroidism and hemochromatosis.13

Figure 92 Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease. There is typically uniform joint space loss, subchondral new bone formation, and cyst formation (arrows), with the changes in a distribution different from that of primary OA.

In the wrist, gout affects the bone, joint, or soft tissue in a sporadic, asymmetrical fashion. The radiographic changes of the disease occur in response to urate crystals that deposit in tissues such as cartilage, tendon sheaths, and bursa. If the urate crystals deposit in cartilage, the primary radiographic picture is that of osteoarthritis. Mineralization is maintained. There may be pancompartmental involvement of the wrist; however, frequently there is preferential involvement of the carpometacarpal joints with erosive change (Fig. 93). Many of the erosions have sclerotic borders and often there are overhanging edges of cortex (Fig. 94). The joint space may or may not be preserved, although gout is one of the few arthropathies that is known for causing signicant changes around the joint while maintaining the joint space.69 One

Figure 93 Gout. There is preferential involvement of the carpometacarpal joints with erosive changes (arrows) seen in this patient with longstanding gout.

Radiographic evaluation of the wrist

285

Figure 94 Erosion and gouty tophi. Dense soft-tissue swelling (calcied tophus) about the ulna styloid (arrow) and thumb (hatched arrow) are noted. The thumb metacarpal shows a large para-articular erosion (arrowhead) with an overhanging edge of cortex. Note the enlarged ends of the thumb metacarpal and proximal phalanx.

Figure 96 Extensive hydroxyapatite deposition in a patient with renal osteodystrophy.

may see irregular bone spicules at sites of tendon and ligamentous attachment. Enlargement of ends of bones may also occur. If urate deposits in soft tissue, chronic tophaceous gout will result (Fig. 94). A tophus deposited on the extensor aspect of a joint may cause signicant erosive change of the dorsal aspect of the joint while preserving the exor side.13 Hydroxyapatite depositional disease is an extremely common disorder that primarily causes periarticular disease. The wrist is involved more frequently than the hand. There may be bilateral, polyarticular involvement. Calcium hydroxyapatite crystals may deposit in bursae, tendons, musculotendinous junctions, ligaments, and within soft tissues of the wrist producing bursitis, tendinopathy, or carpal tunnel syndrome.70,71 Calcic deposits may be seen, most commonly, in or about the tendon of the exor carpi ulnaris (adjacent to the pisiform) (Fig. 95).72 Deposits also occur in or near the tendons of the exor carpi radialis (on the volar side of the radiocarpal joint), common exors (near the volar aspect of the wrist), and the extensor carpi ulnaris (adjacent to the distal end of the ulna).70 The crystals may be poorly dened or well dened. Calcic deposits are often described in vari-

Figure 95 Hydroxyapatite deposition on the radial aspect of the wrist. (A) A lateral view shows calcication (arrows) adjacent to the pisiform within the tendon of the exor carpi ulnaris muscle. (B) Calcication (arrow) on the radial side of the wrist is seen on a PA oblique view.

ous systemic diseases, such as scleroderma, dermatomyositis, renal osteodystrophy (Fig. 96), hypervitaminosis D, and milk-alkali syndrome.13 When there is no underlying systemic disease, the entity is known as hydroxyapatite deposition disease (HADD). In the triangular brocartilage complex, hydroxyapatite deposition may simulate the appearance of CPPD crystal deposition.70 Possible complications of calcium hydroxyapatite deposition within the tendon sheaths or tendons include tendon rupture and intraarticular extension of the calcication, resulting in articular disease, on rare occasion.13 Rare deposition diseases that may affect the wrist are hemochromatosis and Wilsons disease. These disorders have all been associated with chondrocalcinosis. Whether or not it is true that CPPD crystal deposits in the hyaline or brous cartilage or some other substance, degeneration and secondary osteoarthritis occur.13 Radiographically, each of the diseases has distinguishing features. Hemochromatosis, a rare disease leading to marked iron deposition throughout the body, is almost identical to that of CPPD crystal deposition in that there is osteoarthritis in atypical sites compared with primary OA. Characteristic ndings in the hand specically involve the second and third metacarpophalangeal joints. There may or may not be involvement of the wrist. However, if the wrist is involved (Fig. 97), there is usually involvement of the common carpometacarpal, midcarpal, and/or the rst carpometacarpal compartments, with sparing of the radiocarpal compartment.13 The changes observed are those of atypical OA or CPPD crystal deposition disease. Wilsons disease is extremely rare. Copper is the substance that is abnormally deposited in various tissues. Radiographically, chondrocalcinosis may be observed. However, it remains unclear whether the calcication seen is secondary to true CPPD crystals or bone fragmentation in the joint.13 In approximately 50% of patients, an arthropathy occurs. The arthropathy is distinctive as there is marked irregularity of

286

R.A. Loredo, D.G. Sorge, and G. Garcia

(during the acute phase) and central gull wing erosions. Eventual ankylosis may ensue.

Connective Tissue Disorders

The collagen vascular diseases (connective tissue diseases) are a group of conditions that have multisystem involvement. For the most part, the articular symptoms play a minor role in each condition. However, there are distinctive features in each disease.

Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is the most common of the collagen vascular diseases and it is associated with articular symptoms in 75 to 90% of affected individuals.13,73 Most often, this disease is described as a bilateral deforming nonerosive arthritis (Fig. 99). Soft-tissue swelling may be seen early in the disease, followed by soft-tissue atrophy. Juxtaarticular osteoporosis is observed with eventual diffuse demineralization. Reducible subluxation and/or dislocation without erosions are the hallmark of SLE.13,73 Osteonecrosis is a feature of SLE, whether or not the patient is receiving or has received steroid treatment. It usually occurs bilaterally and asymmetrically.13 As in osteonecrosis secondary to other etiologies, the radiographic ndings are similar. Initial osteoporosis may or may not be appreciated radiographically. The rst radiographic change that may be observed is an ill-dened increased bone density surrounded by osteoporosis creating a smudgy appearance.13 As the condition progresses, a subchondral lucency is seen due to subchondral fragmentation. This is followed by articular sur-

Figure 97 Hemochromatosis affecting the hand and wrist. The metacarpophalangeal joints show osteoarthritic changes with characteristic hook osteophytes (arrows).

the cortex and subchondral bone giving a paint brush appearance.15 Due to signicant subchondral bone fragmentation, the condition may appear as osteochondritis dissecans. Ossicles may be seen in the joint (Fig. 98).13 The arthropathy otherwise resembles primary osteoarthritis in an atypical distribution.

Erosive Osteoarthritis
Erosive osteoarthritis (OA) is an inammatory condition that is superimposed on underlying osteoarthritic changes. It is most often described in postmenopausal females. Radiographically, erosive osteoarthritis is similar to primary OA in distribution in the wrist. However, the inammatory component of erosive OA causes periarticular soft-tissue swelling

Figure 98 Wilsons disease. Ossicles (arrows) are seen within, and adjacent to, multiple joints.

Figure 99 Systemic lupus erythematosus. A deforming, nonerosive arthritis is shown on a lateral view.

Radiographic evaluation of the wrist

287 disease, juvenile-onset adult-type (seropositive) rheumatoid arthritis, and Stills disease (seronegative chronic arthritis).74 All of these disorders, except for Stills disease, tend to occur in older children and therefore usually behave like their adult counterpart. Juvenile-onset adult-type (seropositive) rheumatoid arthritis differs from adult rheumatoid arthritis in two ways. First, a periostitis is frequently present in the metaphyses of the phalanges, metacarpals, and metatarsals. Second, there is signicant erosive disease without joint space loss.13,74 Stills disease (seronegative chronic arthritis) makes up 70% of the cases of JCA. The radiographic changes are those of chronic inammation and hyperemia in a joint that is undergoing growth and change; the radiographic changes are as follows:13 1. Periarticular soft-tissue swelling 2. Osteoporosisjuxta-articular, metaphyseal lucent bands, and/or diffuse. 3. Periostitis 4. Overgrown or ballooned epiphyses 5. Advanced skeletal maturationpremature fusion 6. Late joint space loss 7. Late erosive disease 8. Ankylosis 9. Bilateral and symmetrical distribution in polyarticular disease; sporadic in pauciarticular or monoarticular disease 10. Distribution in hand and wrist, foot, knee, ankle, hip, cervical spine, and mandible, in decreasing order, in polyarticular disease; distribution in knee, ankle, elbow, and wrist in pauciarticular or monoarticular disease. The wrist is more often involved than the hand. Early in the disease there is juxta-articular osteoporosis, soft-tissue swelling secondary to synovitis, and a loss of complete wrist extension.74 With persistence of the disease process, there is acceleration of growth maturation in the wrist, as seen by increase in the number and size of the carpal bones. The carpal bones become irregular in their contour secondary to erosions occurring at a young age and repairing with growth. Nineteen percent of patients demonstrate ankylosis at the wrist with relative sparing of one of the three compartments. Most frequently the common carpometacarpal and midcarpal compartments are ankylosed, with total sparing of the radiocarpal compartment. Spontaneous intercarpal or radiocarpal fusion occurs more commonly in children with JRA than in adults. Secondary changes may occur in the distal radial epiphysis consisting of wedging and fragmentation (Fig. 101). With time, an ulnar deviation of the wrist and radial deviation of the digits appear.51,74 The wrist deformity is in contrast to the usual pattern of radial deviation seen in adults. It may be related in part to shortening of the ulna secondary to premature physeal arrest. This, in conjunction with attenuation of the volar wrist ligaments, results in ulnar and volar translocation of the carpus, leading to a bayonet deformity.51 Involvement of the basal joint of the thumb may lead to dorsal

Figure 100 Scleroderma. Amorphous subcutaneous calcication (arrows) within the ulnar side soft tissues is demonstrated on a PA view.

face deformity, collapse, and eventual secondary osteoarthritis. Calcication is the third typical but nonspecic feature of SLE. It may be present in the subcutaneous tissues and may appear as linear and streaky density.

Scleroderma and Dermatomyositis

Approximately 46% of patients with scleroderma have articular symptoms.13 The radiographic ndings appear to be limited primarily to the hands and secondarily to the wrist. In the wrist, the ndings are resorption of soft tissue and amorphous subcutaneous calcication (Fig. 100). Dermatomyositis is most commonly associated with the radiographic abnormality of soft-tissue calcication. The calcication is usually along the intermuscular fascial planes and may be seen within the subcutaneous tissues and about joints. At times, transient osteoporosis may be seen.13

Mixed Connective Tissue Disease

Mixed connective tissue disease (MCTD) is a disease that is made up by a combination of collagen vascular diseases, such as SLE, scleroderma, and/or rheumatoid arthritis. The radiographic features of this combined disorder are an overlap of ndings observed in each condition. To make the radiographic diagnosis, one should identify at least one feature of a specic arthritis and one feature of another type of arthritis. Some patients display a unique feature of preferential ankylosis of the capitate to the trapezoid.13

Juvenile Chronic Arthritis

Juvenile chronic arthritis (JCA) includes juvenile-onset ankylosing spondylitis, psoriatic arthritis of inammatory bowel

288

R.A. Loredo, D.G. Sorge, and G. Garcia

2. Resnick D: Internal derangements of joints, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, vol 4 (ed 4). Philadelphia, PA, Saunders, 2002, pp 3019-3053 3. Blatt G, Tobias B, Lichtman DM: Scapholunate injuries, in Lichtman DM, Alexander AH (eds): The Wrist and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1997, pp 268-306 4. Brody GA, Stoller DW: The wrist and hand, in Stoller DW (ed): Magnetic Resonance Imaging in Orthopaedics and Sports Medicine. Philadelphia, PA, Lippincott, 1993, pp 686-688 5. Loftus JB, Palmer AK: Disorders of the distal radioulnar joint and triangular brocartilage complex: An overview, in Lichtman DM, Alexander AH (eds): The Wrist and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1997, pp 385-414 6. Sartoris D, Resnick D: Plain lm radiography: Routine and specialized techniques and projections, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, vol 1 (ed 4). Philadelphia, PA, Saunders, 2002, pp 3-7 7. Mann FA, Gilula LA: Post-traumatic wrist pain and instability: A radiographic approach to diagnosis, in Lichtman DM, Alexander AH (eds): The Wrist and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1997, pp 91-108 8. Viegas SF, Wagner K, Patterson R, Peterson P: Medial (hamate) facet of the lunate. J Hand Surg Am 15A:564-571, 1990 9. Kindynis P, Resnick D, Kang HS, et al: Demonstration of the scapholunate space with radiography. Radiology 175:278-280, 1990 10. Gilula LA, Weeks PM: Post-traumatic ligamentous instabilities of the wrist. Radiology 129:641-651, 1978 11. Novotny SR, Lichtman DM: Distal radius malunion, in Lichtman DM, Alexander AH (eds): The Wrist and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1997, pp 373-384 12. Yin Y, Mann FA, Gilula LA: Positions and techniques, in Gilula LA, Yin Y (eds): Imaging of the Wrist and Hand. Philadelphia, WB Saunders, 1996, pp 93-158 13. Brower AC, Flemming DJ: Imaging techniques and modalities, in Arthritis in Black and White (ed 2). Philadelphia, PA, Saunders, 1997 14. Jupiter JB: Fractures of the distal end of the radius. J Bone Joint Surg Am 73:461-469, 1991 15. Rettig ME, Baskin KB, Melone CP: Fractures of the distal radius, in Lichtman DM, Alexander AH (eds): The Wrist and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1997, pp 347-372 16. Resnick D: Physical injury: Extraspinal sites, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, vol 3 (ed 4). Philadelphia, PA, Saunders, 2002, pp 2832-2848 17. Porter M, Stockley I. Fractures of the distal radius: intermediate and end results in relation to radiologic parameters. Clin Orthop 220:241, 1987 18. Alexander CE, Lichtman DM: Triquetrolunate instability, in Lichtman DM, Alexander AH (eds): The Wrist and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1997, pp 307-315 19. Resnick D: Osteomyelitis, septic arthritis, and soft tissue infection: Mechanisms and situations, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, vol 3 (ed 4). Philadelphia, PA, Saunders, 2002, pp 2377-2480. 20. Ganel A, Engel J, Oster Z, et al: Bone scanning in the assessment of fractures of the scaphoid. J Hand Surg 4:540-543, 1979 21. Verdan C, Narakas A: Fractures and pseudarthrosis of the scaphoid. Surg Clin North Am 48:1083-1095, 1968 22. Osterman AL, Bora FW: Injuries of the wrist, in Heppenstall RB (ed): Fracture Treatment and Healing. Saunders, Philadelphia, 1980 23. Stoller DW, Tirman PFJ, Bredella MA, et al (eds): Diagnostic Imaging Orthopaedics, Salt Lake City, UT, Amirsys, 2004, sec 3, pp 2-53 24. Markiewitz AD, Ruby LK, OBrien ET: Carpal fractures and dislocations, in Lichtman DM, Alexander AH (eds): The Wrist and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1997, pp 189-233 25. Griffen AC, Gilula LA, Young VL, et al: Fracture of the dorsoulnar tubercle of the trapezium. J Hand Surg Am 13:622, 1988 26. Botte MJ, von Schroeder HP, Gellman H, et al: Fracture of the trapezial ridge. Clin Orthop 276:202, 1992 27. Dameron TB Jr: Traumatic dislocation of the distal radio-ulnar joint. Clin Orthop 83:55-63, 1972

Figure 101 Secondary changes of JCA. The radial epiphysis shows wedging and fragmentation (arrow).

subluxation and adduction contracture of the rst web space.13,51

Other Disorders Entrapment Syndromes

Carpal or ulnar tunnel syndrome is due to compression of the median or ulnar nerve as it passes through the carpal tunnel or ulnar tunnel (Guyons canal), respectively. In most cases, accurate diagnosis is based on the clinical history, physical examination, and electromyographic studies. Diagnostic imaging plays a minor role in the diagnosis of either tunnel syndrome. Radiography is often obtained to exclude potential underlying causes, such as fractures, bone lesion, or softtissue mass. Ultrasonography, CT, and MR imaging may be used for additional assessment of either condition.

Conclusion
This review of conditions affecting the wrist has focused on common and not-so-common disease processes that affect the wrist. This was accomplished by primarily emphasizing radiographic analysis of each condition, often enhanced by advanced diagnostic imaging. Particular attention was paid to anatomy, as it is necessary to do so to advance to the oftendifcult discussion of the abnormal conditions that affect the wrist.

References
1. Weissman BNW, Sledge CB: Orthopedic Radiology. Philadelphia, PA, Saunders, 1986, pp 111-167

Radiographic evaluation of the wrist

28. Strauch RJ, Behrman MJ, Rosenwasser MP: Acute dislocation of the carpometacarpal joint of the thumb: an anatomic and cadaver study. J Hand Surg 19:93-98, 1994 29. Resnick D, Goergen TG: Physical injury: concepts and terminology, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, vol 3 (ed 4). Philadelphia, PA, Saunders, 2002, pp 2745-2746 30. Dobyns JH, Linscheid RL, Chao EYS, et al: Traumatic instability of the wrist. AAOS Instructional Course Lectures 11:182-199, 1975 31. Resnick D: Additional congenital or heritable anomalies and syndromes, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, vol 5 (ed 4). Philadelphia, PA, Saunders, 2002, pp 4561-4631 32. Lichtman DM, Gaenslen ES, Pollock GR: Midcarpal and proximal carpal instabilities, in Lichtman DM, Alexander AH (eds): The Wrist and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1997, pp 316-328 33. Stoller DW: Magnetic Resonance Imaging in Orthopaedics and Sports Medicine. Philadelphia, PA, Lippincott, Williams & Wilkins, 1997, pp 914-915 34. Alexander CE, Lichtman DM: Ulnar carpal instabilities. Orthop Clin North Am 15:307-320, 1984 35. Resnick D: Osteochondroses, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, vol 4 (ed 4). Philadelphia, PA, Saunders, 2002, pp 3686-3741 36. Kienbck R: Concerning traumatic malacia of the lunate and its consequences: degeneration and compression fractures. Clin Orthop 149: 4-8, 1980 37. Louis DS, Hankin FM, Greene TL, et al: Central carpal instabilitycapitate lunate instability pattern: Diagnosis by dynamic displacement. Orthopedics 7:1693-1696, 1984 38. Peste. [Discussion]. Bull Soc Anat Paris 18:169-170, 1843 39. Alexander CE, Lichtman DM: Treatment of acute injuries of the distal radioulnar joint, in Lichtman DM, Alexander AH (eds): The Wrist and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1997, pp 420-428 40. Essex-Lopresti P: Fractures of the radial head with distal radioulnar joint dislocation. J Bone Joint Surg 33B:244, 1951 41. Burk DL Jr, Karasick D, Wechsler RJ: Imaging of the distal radial ulnar joint. Hand Clin 7:263-275, 1991 42. Palmer AK: Triangular brocartilage complex lesions: a classication. J Hand Surg 14A:594-606, 1989 43. Kikuchi Y, Nakamura T: Avulsion fracture at the fovea of the ulna: A report of two cases. J Hand Surg Br 23:176, 1998 44. Friedman SL, Palmer AK: The ulnar impaction syndrome. Hand Clin 7:295, 1991 45. Gross SC, Watson HK, Strickland JW, et al: Triquetrolunate arthritis secondary to synostosis. J Hand Surg 14A:95-102, 1989 46. Mino DE, Palmer AK, Levinsohn EM: The role of radiography and computerized tomography in the diagnosis of subluxation and dislocation of the distal radioulnar joint. J Hand Surg 8:23-31, 1983 47. Hallett JP, Motta GR: Tendon ruptures in the hand with particular reference to attrition ruptures in the carpal canal. Hand 14:283, 1982 48. Lichtman DM, Alexander AH, Mack GR, et al: Kienbcks disease update on silicone replacement arthroplasty. J Hand Surg 7:343-347, 1982 49. Alexander CE, Alexander AH, Lichtman DM: Kienbcks disease and idiopathic necrosis of carpal bones, in Lichtman DM, Alexander AH (eds): The Wrist and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1997, pp 329-346 50. Resnick D: Target area approach to articular disorders: a synopsis, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, vol 2 (ed 4). Philadelphia, PA, Saunders, 2002, pp 1757-1779 51. Rao SB, Crawford AH: Traumatic and acquired wrist disorders in chil-

289
dren, in Lichtman DM, Alexander AH (eds): The Wrist and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1997, pp 540-561 Dixon JH: Non-tuberculous mycobacterial infection of the tendon sheaths in the hand. J Bone Joint Surg 63B:542-544, 1981 Kozin Sh, Bishop AT: Atypical mycobacterium infections of the upper extremity. J Hand Surg 19A:480-487, 1994 Ip FK, Chow SP: Mycobacterium fortuitum infections of the hand J Bone Joint Surg 17B:675-677, 1992 Sutker WL, Lankford LL, Tompsett R: Granulomatous synovitis: the role of atypical mycobacteria. Rev Infect Dis 1:729-735, 1979 Bayer AS, Scott VJ, Guze LB: Fungal arthritis III: sporotrichal arthritis. Semin Arthritis Rheum 9:66-74, 1979 Raff MJ, Melo JC: Anaerobic osteomyelitis. Medicine 57:83-103, 1978 Bjorksten B, Boquist L: Histopathological aspect of chronic recurrent multifocal osteomyelitis. J Bone Joint Surg 62B:376-380, 1980 Bogumill GP: Tumors of the wrist, in Lichtman DM, Alexander AH (eds): The Wrist and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1997, pp 563-581 Kambolis C, Bullough PG, Jaffe HL: Ganglionic cystic defects of bone. J Bone Joint Surg 55A:496-505, 1973 Kerin R: Metastatic tumors of the hand: a review of the literature. J Bone Joint Surg 65A:1331-1335, 1983 Joseph FR, Posner MA: Glomus tumors of the wrist. J Hand Surg 8:918920, 1983 Angelides AC, Wallace PF: The dorsal ganglion of the wrist: Its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg 1:228-235, 1976 Friedlander HL, Rosenberg NJ. Graubard DJ. Intraneural lipoma of the median nerve. J Bone Joint Surg 51A:352-362, 1969 Rowland SA. Case report: ten year follow-up of lipobroma of the median nerve in the palm. J Hand Surg 2:316-317, 1977 Goldman AB: Heritable diseases of connective tissue, epiphyseal dysplasias, and related conditions, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, vol 5 (ed 4). Philadelphia, PA, Saunders, 2002, pp 4382-4448 Backdahl M: The caput ulnae syndrome in rheumatoid arthritis: a study of the morphology, abnormal anatomy and clinical picture. Acta Rheumatol Scand Suppl 5:5, 1963 Resnick D: Rheumatoid arthritis, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, vol 2 (ed 4). Philadelphia, PA, Saunders, 2002, pp 891-987 Resnick D: Gouty arthritis, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, vol 2 (ed 4). Philadelphia, PA, Saunders, 2002, pp 1519-1559 Resnick D: Calcium hydroxyapatite crystal deposition disease, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, vol 2 (ed 4). Philadelphia, PA, Saunders, 2002, pp 1619-1657 Ametewee K: Carpal tunnel syndrome produced by a post traumatic calcied mass. Hand 15:212, 1983 Grandee RW, Harrison RB, Dee PM: Peritendinitis calcarea of exor carpi ulnaris. AJR Am J Roentgenol 133:1139, 1979 Resnick D: Systemic lupus erythematosus, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, vol 2 (ed 4). Philadelphia, PA, Saunders, 2002, pp 1171-1193 Resnick D: Juvenile chronic arthritis, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, vol 2 (ed 4). Philadelphia, PA, Saunders, 2002, pp 988-1022 Rao SB, Esposito PW, Crawford AH: Developmental and degenerative disorders in children, in Lichtman DM, Alexander AH (eds): The Wrist and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1997, pp 509-539

52. 53. 54. 55. 56. 57. 58. 59.

60. 61. 62. 63.

64. 65. 66.

67.

68.

69.

70.

71. 72. 73.

74.

75.