Imaging of wrist joint

1. SOURAV TALUKDER
MBBS

2. WRIST JOINT
INCLUDES DRUJ,
RADIOCARPAL,
PISOTRIQUETRAL,
MIDCARPAL, 1ST CMC,
2ND -5TH CMC AND
ASSOCIATED
LIGAMENTS AND
TENDONS

3. RADIOGRAPHY
USG
CT SCAN
MRI

4.  P-A VIEW
CENTERING- MIDWAY
BETWEEN RADIUS AND
ULNAR STYLOID PROCESS

6.  ULNAR NEUTRAL- ULNA NO MORE THAN
2MM SHORTER THAN RADIUS
 ULNAR MINUS- KIENBOCK DISEASE
 ULNAR PLUS- ULNOLUNATE IMPACTION
SYNDROME AND TFC TEAR

7. . ARC OF GILULA
. GREATER AND
LESSER ARCS
. VULNERABLE ZONE

8.  CARPAL HEIGHT-
 Distance from 3rd metacarpal
base to distal radius articular
surface
 CARPAL HEIGHT
RATIO-
 Carpal height/3rd metacarpal
shaft length (nl-0.54)
 CARPAL HEIGHT
INDEX-
 Carpal height ratio of dominant
hand/ carpal height ratio of
non-dominant hand (nl- 1.0
±0.15)

9. Width of the lunate/
width of the radial
lunate fossa
(Nl.- Less than 50%
Lunate overhangs the
ulnar edge of the
radius)

11.  Bet. One line
connecting the radial
styloid tip and ulnar
aspect of the distal
radius and a second
line perpendicular
through the
longitudinal axis of
the radius

12.  Angle formed by
tangential lines to
proximal scaphoid-lunate
and proximal
triquetrum-lunate
Positive carpal sign-angle
is 117◦ or less

13.  Create a contour
reminiscent of an ‘m’

14. LATERAL VIEW
CENTERING- ON
STYLOID PROCESS
OF RADIUS

16.  Line drawn tangent to
ant and post . radial
margins intersects
line drawn
perpendicular to
radial long axis
 Nl- 2-20˚, average 11˚

18.  RADIO-LUNATE- <15˚
 SCAPHOLUNATE- 30-60˚
 CAPITO-LUNATE- 0-30˚
 LUNO-TRIQUETRAL- 14-16˚

20. OBLIQUE VIEW
CENTERING-BETWEEN
RADIUS
AND ULNAR
STYLOID PROCESS

22.  STAGE 1- SCAPHO-LUNATE
DISSOCIATION
 STAGE 2- PERILUNATE DISLOCATION
 STAGE 3-TRIQUETRO-LUNATE
DISSOCIATION
 STAGE 4- LUNATE DISLOCATION

24.  Lunate is centered over distal
radius and rest of the carpal
bones are tilted dorsally
 High energy trauma
 Trans-scaphoid perilunate
dislocation
 Tear of radioscapho-capitate
ligament

25.  CAUSES-
# Triquetrum
LT ligament injury with associated injury of Radioluno-triquetral
and dorsal radio-carpal ligament
NEITHER LUNATE OR CAPITATE IS IN ALIGNMENT WITH
DISTAL RADIUS

26.  High energy trauma
 A-p view- overlaps
capitate, hamate and
triquetrum, ▲ shape-”
piece of pie” sign
 Lat view- tilted volarly-
” spilled tea cup “
appearance
 Due to dorsal radio-carpal
ligament tear

27.  VISI
Volar rotation of
lunate and dorsal
rotation of capitate
and hamate
Due to tear of ulnar
sided radio-carpal
ligaments and L-T
Ligament
Capito-lunate angle-
>30˚

28.  DISI
 Dorsal tilt of lunate
 Capito-lunate angle-
>30˚
 Causes-
Scaphoid #
s-l ligament tear

29. # SCAPHOID BENNET’S #

30.  Distal metaphysis of
radius
 Dorsal angulation and
displacement
 Elderly, osteoporotic
patient

31.  Younger patient
 High energy trauma
 Volar displacement
and angulation

32. DORSAL TYPE
VOLAR TYPE (AKA-REVERSE
BARTON’S #)

33. Depression # of lunate
fossa of distal radius
May be asso. With
proximal subluxation
of lunate

35. A- EXTRA-ARTICULAR
#
A1- ulna, radius intact
A2- radius, simple
and impacted
A3- radius,
multifragmentary

36. B- PARTIALLY
ARTICULAR #
B1- radius, sagital
B2- radius, frontal,
dorsal rim
B3- radius, frontal,
ventral rim

37.  C- COMPLETELY
ARTICULAR
C1- articular, simple,
metaphyseal simple
C2- articular simple,
metaphyseal multi-fragmentary
C3- articular
multifragmentary

38. A. BENDING #- ONE CORTEX OF METAPHYSIS FAILS
DUE TO TENSILE STRESS AND THE OPPOSITE CORTEX
UNDERGOES SOME COMMINUTION
B. SHEARING #- FRACTURE OF JOINT SURFACE
C. COMPRESSION #- # WITH IMPACTION AND
COMMUNITION
D. AVULSION #- # OF THE LIGAMENTOUS
ATTACHMENTS
E. COMBINED #- COMBINATION OF TYPES, HIGH
ENERGY FORCES

39.  Stable- avulsion # of
tip of ulnar styloid or
stable # of the ulnar
neck

40.  Unstable- avulsion of
the base of the ulnar
styloid of tear of tfc

41.  Potentially unstable-intra-
articular # of the
sigmoid notch or
intraarticular # of the
ulnar head

42.  SYNOVIAL
A. DIFFUSE AND
SYMMETRIC JOINT SPACE
NARROWING
B. PERI-ARTICULAR
OSTEOPENIA
C. BONE EROSIN
D. SOFT TISSUE SWELLING
 CHONDROPATHIC
A. ASYMETRIC JOINT
SPACE NARROWING
B. GEODE FORMATION
C. OSTEOPHYTE
FORMATION
D. SUBCHONDRAL
SCLEROSIS

43. SYNOVIAL CHONDROPATHIC

44. Causes- untreated chronic
scapho-lunate dissociation
Scaphoid #
cppd deposition ds.
Watson’s staging-
Grade 1- radial styloid and
scaphoid
Grade 2-whole radio-scaphoid
articulation
Grade 3- radio-scaphoid +
capito-lunate
Grade 4- radio-carpal +other
intercarpal ± druj

45. ISOLATED- TRANSVERSE
LUNO-TRIQUETRAL
CAPITO-HAMATE
SYNDROMIC- PROXIMO-DISTAL
TRAUMA, INFECTION, RA

46.  Lunula- bet. TFC and triquetrum
 Os styloideum- on the dorsal surface of the 2nd/ 3rd
metacarpal base
 Os triangulare- just distal to ulnar fovea
 Trapezium secondarium- medial to tubercle of
trapezium on volar surface
 Os epilunate- dorsal to lunate
 Os hamuli proprium-at tip of hamate hook

47.  PATIENT POSITION
 PROBE SELECTION
 EXAMINATION PROTOCOL

48.  SIX GROUPS

61. SYNOVITIS

62.  Erosion

63.  Tenosynovitis

64.  Stenosing
tenosynovitis
involving 1st
extensor group
 Intertendinous
septum

65.  At the intersection of
1st and 2nd tendon
sheaths
 Approx. 4 cm prox to
lister tubercle

66.  Tenosynovitis of epl
when it crosses group
2 tendons

67. DIAMETER CRITERIA
‘NOTCH SIGN’
↑ DOPPLER SIGNAL
SECONDARY NV. CHANGES-Hypoechoic
swollen nv.
Loss of fascicular pattern
Flattening of the nv.
ASSOCIATED FACTORS-Persistent
median artery
Bifid median nv.

70.  MAGNET
 COIL
 POSITION
 ORIENTATION
 SEQUENCES

71.  T1WI
 T2WI/ PDWI
 FS PD FSE/ FS T2 FSE- Fluid sensitive
 T2*GRE- Ligament evaluation
 3D SPGR
TECHNICAL CONSIDERATIONS
CONTRAST ADMINISTRATION

72. DIRECT
UNICOMPARTMENTAL
MULTICOMPARETMENTAL
INDIRECT
PROCEDURE- 0.1 ml of gd diluted into 20 ml of
solution ( 10 ml of saline + 5 ml iodinated
contrast material + 5 ml of lidocaine 1%)

75.  GENERAL
CONSIDERATIONS
VOLAR RADIO-CARPAL
LIGAMENTS
Radio-scapho-capitate
Volar radio-luno-triquetral
Radio-scapho-lunate
(ligament of Testut)
Short Radio-lunate

76. VOLAR ULNO-CARPAL
LIGAMENT
 Ulno-lunate ligament
 Ulno-triquetral
ligament
 Ulno-capitate
ligament
 Arcuate ligament
(rsc+uc+tc)

77.  VOLAR
MIDCARPAL
Scapho-trapezium-trapezoid
Scapho-capitate
Triquetro-capitate
Triquetro-hamate
Piso-hamate
Deltoid (sc+tc)

78.  DORSAL RADIO-CARPAL
LIGAMENT
(radioluno-triquetral
ligament)
 Modified viegas
classification

79.  DORSAL
INTERCARPAL
LIGAMENT

80.  PROXIMAL
INTEROSSEUS
LIGAMENTS
Scapho-lunate
Ligament
Luno-triquetral
Ligament

81. DISTAL INTEROSSEUS LIGAMENTS
 Trapezio-trapezoid
 Trapezio-capitate
 Capito-hamate

82. CARPO-METACARPAL
LIGAMENTS
DISTAL RADIO-ULNAR
LIGAMENTS
Piso-metacarpal
Carpo-metacarpal
ligaments of thumb
Dorsal carpometacarpal
Volar carpometacarpal
 Dorsal radio-ulnar
 Volar radio-ulnar

84. S-L LIGAMENT L-T LIGAMENT

85.  Tfc proper
 Meniscus homolouge
 Ulnar collateral
ligament
 Dorsal and volar
radio-ulnar ligament
 Extensor carpi ulnaris
tendon
 Ulnocarpal ligament

86. BLOOD SUPPLY
Ulnar artery
Ant. Interosseus artery
FUNCTIONS
Stabilisation of DRUJ and
ulnar carpus
Load bearing structure
Prevention of volar
subluxation of ulnar
carpus

87.  PALMER
CLASSIFICATION
CLASS 1 (TRAUMATIC)
A. Central perforation
B. Ulnar avulsion with
or without distal
ulnar fracture
C. Distal avulsion
D. Radial avulsion with
or without sigmoid
notch fracture

88.  PALMER CLASSIFICATION
CLASS 2 (DEGENERATIVE)
A. TFCC wear
B.TFCC wear with lunate and/or
ulnar chondromalacia
C. TFCC perforation with lunate
and/or ulnar chondromalacia
D. C plus LT ligament perforation
E. D plus ulnocarpal arthritis

89.  PREDISPOSING
FACTORS
Congenital positive ulnar
variance
Essex-Lopresti #
Malunited distal radius #
Premature physeal
closure of radius
Surgically excised radial
head

90. ULNAR IMPACTION SYNDROME
PATHOLOGIC SPECTRA

91. PREDISPOSING
FACTORS
 Abnormally elongated
styloid (6 mm) or Ulnar
styloid process index >
0.21 ± 0.07
 Curved ulnar styloid
(parrot beak
appearance)
 Malunited # Styloid-
Type 1 and 2

92. USPI PATHOLOGIC SPECTRA

93. PREDISPOSING
FACTORS
 Congenital negative
ulnar variance
 Premature physeal
closure of ulna
 Surgical removal of
distal ulna

94. ULNAR IMPINGEMENT SYNDROME
PATHOLOGIC SPECTRA

95.  Chondromalacia of
proximal pole of
hamate
 Type 2 lunate
morphology

96.  EROSION
 EDEMA
 SYNOVITIS
 TENOSYNOVITIS

97. MARROW EDEMA SYNOVITIS

98.  VOLAR CARPAL LIGAMENT
 FLEXOR RETINACULUM
 EXTENSOR RETINACULUM

99.  ANATOMICAL SNUFFBOX
 CARPAL TUNNEL
 GUYON CANAL

101.  SIGNS
Swelling of nv.
Flattening/angulation of
nv.
Bowing of Flexor
retinaculum (Bowing
Ratio > 15%)
↑ T2 signal intensity of
nv.

102. NORMAL ABNORMAL

104.  Minnar de villers’
classification
Type 1-Proximal pseudo-arthrosis
Type 2- Proximal osseus
bridge with distal
notch
Type 3- Complete osseus
fusion
Type 4- Associated other
carpal abnormalities

105.  GROUP 1- Vessel entering only one surface or
large area dependent on single vessel
scaphoid, capitate, 8% of lunate
 GROUP 2- Absence of internal anastomosis
hamate, trapezoid
 GROUP 3- Rich internal anastomosis
trapezium, triquerum, pisiform, 92% of
lunate

106.  Proximal pole of
scaphoid
 Lunate
 Proximal pole of
capitate

107.  ENCHONDROMA
 INTRA-OSSEUS
GANGLION CYST

108. GANGLION CYST
COMPOUND PALMAR
GANGLION