Pain, limitation of motion or instability are the usual clinical indications for wrist arthrography. Ligamentous tears, tears of the triangular fibrocartilage, and synovitis found by arthrography, even in the presence of normal plain roentgenograms, have been well described in the literature.1"5 In patients in whom carpal instability is suspected, fluoroscopy of the wrist motion with videotaping prior to contrast injection is obtained, as subluxation may be transient. We have found several modifications of standard arthrography techniques to be helpful in detecting many of our patients' abnormalities.
Material and Methods
Twenty-five patients underwent 27 arthrograms between February 1979 and August 1981. Most had a history of trauma with symptoms of two weeks to two years. Nine patients underwent surgery and another was scheduled. One patient with juvenile rheumatoid arthritis refused surgery. Two patients were lost to followup.
The patient is seated at the head of a fluoroscopy table wearing a lead apron. The arm is extended until the wrist is visible under the fluoroscopy tablé. As an alternative, the patient may be in the prone position on the fluoroscopic table with the arm extended cephalad. The image intensifier is placed about 16" (40.5 cm) above the table top for magnification. The 0.6 mm focal spot is used without photo timing. With the Alpha 8 screens™ and XDL film™ (400 speed), between 42 and 46 KVP is used at 2.5 mas. This would vary according to the particular film screen combinations available. No grid is used.
A paper clip is taped to the index finger of the patient's opposite hand, and the patient is asked to point to the area of maximum pain or discomfort. Often the patient will rub an area several seconds before pointing the metal to a specific spot. An AP film, and sometimes an oblique or lateral film, is obtained both for technique and to document the area of greatest pain. Stress magnification views are then obtained in radial and ulnar deviation with a tight fist. Lateral views in flexion and extension are also obtained with a tight fist. Making a fist requires contraction of both wrist flexors and extensors. This action puts a longitudinal compression on the wirst, which may magnify any instability or joint space widening from ligamentous tears.6
The dorsal surface of the wrist is then prepared and draped, and an injection is made in the radiocarpal joint near the ulnar side of the scaphoid, taking care to avoid the scapholunate ligament. An alternative is to inject between the scaphoid and the radius in the area of the snuff box. Care must be taken to avoid the dorsal branch of the radial artery. The needle is angled about 45° cephalad. If the scapholunate ligament is the area of greatest pain or the area of interest, this has the relative advantage of not obscuring the area of pathology if extravasation occurs. Also, there is less likelihood of injecting the midcarpal and radiocarpal joints simultaneously. This would make it more difficult to detect ligamentous tears because communication between the radiocarpal and midcarpal joints is the most important roentgenographic sign. A 25 gauge W needle or 22 gauge IW needle may be used. Aspiration is attempted, and then contrast is injected via syringe and extension tubing that has been previously filled with contrast and emptied of air bubbles. As the contrast is injected, slight stress in radial or ulnar deviation may be obtained, taking care not to dislodge the needle. The paper clip view alerts us as to which type of stress may be more useful. In six patients, we have seen contrast shoot into the midcarpal joint from the radiocarpal joint, and have been able to localize the tear to the transverse ligament between the lunate and triquetrum (Table 1) (Fig. 1). Early films of the communication are obtained, and the joint is filled, using 2 to 4 cm of 60% contrast. We then take one or several paper clip views using four on one spot films in views similar to the precontrast films. In addition, at least one traction film is obtained in the AP projection. This may show ligamentous ,laxity in the longitudinally oriented ligaments (Fig. 2).6
RESULTS OF ARTHR0GRAMS-25 PATIENTS (Some had more than one diagnosis)
The magnification aspect of the technique has the advantage of showing small irregularities in the articular cartilage. We have found overhead films to be superfluous. If there is an initial question of widening of the joint space on the initial films, the opposite wrist may be fluoroscoped to assess the patient's inherent ligamentous laxity.
This 44-year-old policeman sustained injury to his wrist during the apprehension of an alleged robber. The pain had persisted for about three weeks. The paper clip view localized the pain at the lunatetriquetral area (Fig. IA) and a tear was demonstrated (Fig. 1 B, C).
A 15-year-old girl experienced seven months of pain, locking and cracking of the wrist following injury. A plain magnification view in ulnar deviation showed scapholunate dissociation (Fig. 2A). Arthrography showed beaking of contrast at that level, which was felt to be consistent with a partial or healed tear of the scapholunate ligament (Fig. 2B). On traction, the scaphoid was pulled distally, consistent with a tear of the radioscaphoid ligament (Fig. 2C).
This 30-year-old man injured his shoulder, elbow and wrist IVi years previously. A small volar wrist mass was palpated two months prior to arthrography. This information was not conveyed to the arthrographer until after the arthrogram had been interpreted. A paper clip view (Fig. 3A), after contrast injections, pointed to a small collection felt to be a communicating ganglion. The patient also had a tear of the scapholunate ligament (Fig. 3B). Since symptoms were not referable to this latter area, the patient was managed without surgery.
A 24-year-old man presented with chronic localized pain exacerbated by active dorsiflexion. The pain was over the radial wrist extensors. The examination was technically limited because of poor film exposure and light fog. The arthrography was initially interpreted as normal; however, in retrospect, there are multiple lucencies that correspond to the area of the patient's indicated pain (Fig. 4). These were persistent. At surgery, the patient had a multilocular ganglion arising from the capitate-lunate ligament in the exact location of the lucencies.
A 16-year-old girl with longstanding juvenile rheumatoid arthritis and wrist subluxation at the midcarpal joint presented for evaluation for surgery (Fig. 5). The films showed synovitis and volar perilunate dislocation of the wrist. The arthrogram demonstrated a reasonable amount of radial articular cartilage so that proximal carpectomy was an alternative to fusion, or if fusion was performed, the radiocarpal joint would be spared. However, the patient did not return and was lost to followup.
There were 27 arthrograms in 25 patients (Table I). The diagnoses ranged from postoperative adhesions, ligamentous tears, ganglia synovitis, Madelung's deformity and juvenile rheumatoid arthritis.
The paper clip view proved helpful for localized proximal carpal ligamentous tears, two patients with ganglia, and triangular fibrocartilage tears. Before the injection of contrast, the paper clip (or any metallic pointer) alerts the examiner to the area of pathology. Gentle traction and stress were used during injection under fluoroscopy. Care was taken not to dislodge the needle. In this way we can usually tell whether communication between the radiocarpal and midcarpal joints was secondary to scapholunate or triquetrolunate ligamentous tears. A partially healed tear could be demonstrated by pooling of contrast without communication (Fig. 2B).
One tiny volar ganglion was not seen at fluoroscopy but was seen on reviewing the spot films (Fig. 3). Another patient with an arthrogram initially interpreted as normal, underwent exploration in the area of indicated pain. What was initially felt to be air bubbles turned out to be an intraligamentous ganglion (Fig. 4), The person performing the arthrogram was less experienced than the usual examiner, and some of the films were underexposed. In retrospect, this cluster of Iucencies was present on all films. Nine patients underwent surgery, and in six the arthrogram correlated well with the findings (five prospectively and one retrospectively as noted above). A tenth patient with juvenile rheumatoid arthritis was scheduled for surgery but failed to return. The arthrogram showed a reasonable amount of radial articular cartilage, so that a proximal carpectomy was an alternative to wrist fusion. The patient had subluxation of the distal carpal row (Fig. 5).
There were three patients in whom the preoperative arthrogram was not particularly helpful. The first was a 32-year-old woman, a practical nurse, who had a one year history of pain following lifting a patient. Arthrography showed a triangular fib roca rtilage tear, but her pain was more distal. Conservative therapy failed. At surgery she had tenosynovitis of the extensor carpi ulnaris tendon. Postoperatively, she developed Sudeck's atrophy. A second patient had a two year history of pain with a normal wrist arthrogram. At surgery there appeared to be injury to the ligament between the lunate and capitate. One year later she still experienced pain with a click over the capitate. In fairness to the arthrogram, the midcarpal joint was not visualized because the proximal ligamentous row was intact. Possibly an injection into the midcarpal joint may have shown the loss of cartilage around the capitate or another abnormality. The third postsurgical patient in whom the arthrogram was not helpful had a two year history of pain following injury. The arthrogram was negative except for a question of mild synovitis with irregular synovial contours. At surgery instability of the triquetral-hamate joint was found, and fusion between the triquetrum, lunate and hamate was performed. This patient did well. Though the numbers are small, one can speculate that wrist arthrography is not as helpful in diagnosing tears of the longitudinally oriented ligaments as tears of the proximal transversely oriented ligaments and triangular fibroca rtilage, which show communication between different compartments.
Wrist arthrography has also been useful in the selection of patients for conservative therapy. Having the patient make a tight fist to increase longitudinal compression increases the likelihood of demonstrating abnnormal intercarpal relationships. Gentle stress during injection with fluoroscopy may pinpoint the exact ligamentous injury. The traction view nicely shows the articular cartilage of the radiocarpal joint and may be helpful in diagnosing the gross longitudinal ligamentous tears, though experience is limited at this time (Fig, 2C). To date, we have had no serious complications and with careful attention to technique, the study has proved simple to perform.
1. Goldman AB: The wrist, in Freiberger RH. Kay JJ, Spiller J. Arthrography, ed 1. New York, Appleton-Century-Crofts, 1979, pp 277-290.
2. Resnick D: Rheumatoid arthritis of the wrist; The compartmental approach, Med Radiogr Photogr 1976; 52:50-88.
3. Resnick D: Arthrography in the evaluation of arthritic disorders of the wrist. Radiology 1974; 113:331-340.
4. Dalinka MK, Turner ML, Osterman AL, et al: Wrist arthrography. Radici CUn North Am 1981; 1 9(2 ):2 17-226.
5. Protas JM, Jackson WT: Evaluating carpal instabilities with fluoroscopy. A]R 1980; 135:137-140.
6. Mayfield JK, Johnson RP, Kilcoyne RK: Carpal dislocations: Pathomechânïcs and processive perilunar instability, j Hand Surg 1980; 5:226-241.
RESULTS OF ARTHR0GRAMS-25 PATIENTS (Some had more than one diagnosis)