Ulnar sided Wrist Pain

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1 Ulnar sided Wrist Pain 1 Susan Cross, 1 Anshul Rastogi, 2 Brian Cohen, 1 Rosy Jalan 1 Dept of Radiology, Barts Health NHS Trust, London, UK 2 London Orthopaedic Centre Contact: Abstract number: EE33 Pictorial Review

2 Purpose To review the complex anatomy of the ulnar side of the wrist To provide a comprehensive pictorial review of the varied diagnoses associated with Ulnar sided wrist pain using 3.0 Tesla (T) MRI with arthroscopic correlation where appropriate To illustrate and highlight pitfalls and misinterpretations on 3.0T MRI of the wrist

3 Anatomy Image from - K. Sachar, Ulnar-sided wrist pain: evaluation and treatment of TFCC tears, ulnocarpal impacation syndrome, lunotriquetral ligament tears, Current concepts JHS. Vol 33A November 2008

4 Causes of ulnar sided wrist pain Others including infection, AVM Extensor carpi ulnaris pathology Triangular fibrocartilage complex injuries Ganglion Ulnar sided wrist pain Ulnocarpal and inter carpal ligament injuries Inflammatory arthritis Ulnar impaction syndrome Fractures

5 One of the most common questions posed when a patient presents with ulnar sided wrist pain, is whether the TFCC is intact. The following six cases demonstrate unenhanced, non arthrographic 3 Tesla MRI appearances of the symptomatic wrist with direct arthroscopic correlation. Two MRIs were false positive for a TFCC tear which on review post arthroscopy demonstrate quite marked intrasubstance degeneration. When these findings are observed it may be prudent to further evaluate with an MR arthrogram

6 Case 1 54 yr old female complaining of left ulnar sided wrist pain and swelling

7 Pre operative MRI Perforating tear of radial attachment of the TFCC (blue arrow) Non united ulnar styloid fracture with 6mm loose body (red arrow) adjacent to the triquetrum and pisiform, likely secondary to a degree of ulnar carpal impaction

8 Arthroscopy findings: Radial side split of TFCC (blue arrow) 6 mm loose body, demonstrated on pre operative MRI, retrieved from ulnar side of wrist

9 Case 2 36 yr old female with ulnar sided wrist pain,?tfcc tear

10 Negative ulnar variance Full thickness tear of the radial attachment of the TFCC (blue arrow) with abnormal fluid signal within the gap of the tear and immediately deep to it (white arrows) Pre operative MRI

11 Arthroscopy confirmed MRI findings Tear of the radial attachment of the TFCC was confirmed at arthroscopy (red arrow) This was debrided.

12 Case 3 32 yr old female with painful wrist? cause

13 Pre operative MRI Findings: Intrasubstance tear of the TFCC (red arrow) with detachment of the distal ulnar attachment (blue arrow). The scapholunate and lunotriquetral ligaments appear intact. Normal articular surfaces of the distal radius, scaphoid, lunate and triquetrum.

14 Arthroscopy found intact TFCC despite the MRI appearances (false positive) : The TFCC was intact throughout but surrounded by synovitis. On review of the preoperative MRI, there was marked intermediate signal within the TFCC but no overt fluid signal component. In such cases it may be prudent to further evaluate with IV contrast or an MR arthrogram.

15 Case 4 17 yr old female with ulnar sided wrist pain

16 Pre operative MRI Findings: Partial tear of the scapholunate ligament (white arrow) TFCC intact (uniform low signal throughout) Lunotriquetral intact

17 Arthroscopy correlated with the MRI: Findings: Tear of the scapholunate ligament confirmed at arthroscopy TFCC intact Articulating surfaces of the distal radius, scaphoid, lunate and triquetrum intact

18 Case 5 22 yr old male with painful wrist? TFCC tear Preoperative MRI findings: Intrasubstance signal change in the ulnar aspect of TFCC ( blue arrow) with direct extension of hyperintense fluid signal into the distal radioulnar joint (red arrow), in keeping with a TFCC tear

19 Arthroscopy correlated with MRI Confirmed partial tear of the TFCC (arrow). This was debrided. SL and LT ligaments normal Articular surfaces of distal radius, scaphoid, lunate and triquetrum are normal

20 Case 6 44 yr old female with ulnar sided wrist pain?tfcc tear

21 MRI findings Complex tear of the TFC with extension to superior and inferior surfaces with direct extension of fluid into the distal radioulnar joint (red arrow) The meniscal homologue is oedematous (blue arrow) Subchondral oedema of the lunate with chondral cartilage thinning (white arrow) Tear of the Lunotriquetral ligament Palmar DRUJ ligamentous injury (black arrow)

22 Arthroscopy found intact TFC despite MRI appearances (false positive) There was some synovitis within the ulnar recess Chondral cartilage damage of the distal radius Intact TFC False positive for TFCC tear on the pre operative MRI. Again, there is intrasubstance intermediate signal within the TFC but no discrete overt fluid signal within the TFC. The fluid within the distal radioulnar joint may be attributable to the distal volar radioulnar ligamentous disruption.

23 Extensor Carpi Ulnaris Tendinopathy Coronal (left) and axial (right)t2w fat saturated images of the wrist: Demonstrates markedly thickened extensor carpi ulnaris tendon (red arrow) with intrinsic abnormal high signal, more than the usual high signal,in keeping with florid tendinopathy. There is also associated surrounding soft tissue odema and mild tenosynovitis. Note also ulnar attachment TFC tear (blue arrow)

24 Extensor carpi ulnaris tear Axial T2 Fat saturated image of the wrist : Demonstrates ulnar styloid fracture (blue arrow). This is relatively acute as quite marked bone marrow oedema persists within the distal ulna. There is extensor carpi ulnaris tenosynovitis with partial tears (red arrow). Oedema present within the related soft tissues is in keeping with post traumatic change

25 Distal volar radio-ulnar ligament injury Axial T2W fat saturated image of the wrist at the level of the distal radioulnar joint: Demonstrates disruption of distal volar radio-ulnar ligament following trauma (red arrow). There is also ulnar styloid undisplaced fracture (blue arrow). The ECU is intact.

26 Intercarpal ligament injury Axial T2W fat saturated images of the wrist at the mid carpal level: Demonstrate high signal with loss of congruity (red arrow) in the dorsal intercarpal ligaments in keeping with ligamentous disruption

27 TFCC Anatomy Left: TFCC disc (broad white arrow), proximal and distal laminae (thin arrows), meniscus homologue (open white arrow). Right: Ulnotriquetral ligament (open arrow head) ² ² Images from review article, P.S. Vezeridis et al, Ulnar-seded wrist pain. Part 1: anatomy and physical examination. Skeletal Radiol (2010) 39:

28 Triangulofibrocartilage (TFC) Tears Left: High signal on the ulnar styloid side of TFCC (red arrow). Right: Another patient with complete tear of distal lamina attachment to ulnar styloid (white arrow)

29 Traumatic TFC Tears Left: Coronal T2W Fat saturated image of the wrist Demonstrates traumatic TFC radial perforation with fluid extending into the distal radio-ulnar joint (white arrow). Also note is made of ulnar styloid fracture (red arrow). Right: Axial T2W fat saturated image of the wrist There is a full thickness TFC tear with fluid in distal radio-ulnar joint (blue arrow), with triquetral fracture (green arrow)

30 Ulnar impaction syndrome Coronal T2 Fatsaturated and T1W images: Demonstrate bone marrow oedema (red arrow) due to ulnar impaction. In addition there is also partial disruption of the scapholunate ligament (white arrow)

31 Ulnar impaction syndrome Coronal T2W fat saturated and T1W images of the wrist: Demonstrates subchondral cysts in the proximal lunate (blue arrows) suggestive of ulnarcarpal impaction. There is also TFCC strain and fluid around the meniscal homologue (white arrow)

32 Fractures Coronal T1W and T2W fat saturated images : Demonstrates a displaced ulnar styloid fracture, marrow oedema (red arrow), and small TFCC radial perforation with fluid in distal radio-ulnar joint (green arrow). Note is also made of fractures of base of 1 st 4 th metacarpals (blue arrows)

33 Fractures Full thickness TFCC tear with fluid in distal radio-ulnar joint (red arrow); triquetral fracture (green arrow)

34 Fractures Patient with known distal radial fracture (left) also had an occult pisiform fracture (green arrow)

35 Synovitis Axial T1W fat saturated post contrast images in a patient with swollen wrist show florid synovitis and enhancement post contrast (red arrow), there is also extensor carpi ulnaris tendinopathy (black arrow)

36 Ganglion Coronal and axial T2W fat saturated images demonstrate scapholunate ganglion with intraosseous extension into the lunate ( blue arrow)

37 Masses Left: Pre contrast T1W axial image shows a well defined low signal lesion (red arrow) Right: This shows avid enhancement with central low signal area, likely a nerve sheath tumour

38 Vascular malformations Images above show serpiginous (red arrow) lesion with avid enhancement in keeping with an arteriovenous malformation

39 Conclusion We have shown a number of common pathologies seen in patients presenting with ulnar sided wrist pain using 3T MRI, with arthroscopic correlation where appropriate. Contrast may be helpful in situations where fluid around TFCC makes diagnosis difficult

40 Conflict of Interest Susan Cross: None Anshul Rastogi: None Brian Cohen: None Rosy Jalan: None Acknowledgements: Nuada Medical Specialist Imaging, UK

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