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MRI of the Wrist
David W. Stoller, MD, FACR Director, California Advanced Imaging and MRI
California Pacific Medical Center
Director, National Orthopaedic Imaging Associates
San Francisco, California
Adjunct Clinical Professor,
Johns Hopkins University School of Medicine
DAVID W. STOLLER, MD Director of MRI,
California Pacific Medical Center San Francisco, CA Medical Director,
National Orthopaedic Imaging Associates Adjunct Professor of Radiology
Johns Hopkins University School of Medicine,
Baltimore, MD
DISCLOSURE INFORMATION
WESTERN OCCUPATIONAL HEALTH
CONFERENCE 2012
I have nothing to disclose. I will not discuss off label use and/or
investigational use in my presentation.
Wrist Checklist
Coronal
1. Intrinsic Ligaments (SL, LT)
2. Extrinsic Ligaments (volar
radiocarpal)
3. TFC
4. Lunate fossa
5. Radial and ulnar styloid
6. Evaluate for triscaphe and SLAC
arthritis
Axial
1. Carpal Tunnel
2. First to sixth extensor
compartments
3. Sigmoid Notch
Sagittal
1. Carpal alignment
(capitolunate angle)
2. Scaphoid deformity
(humpback)
2
Wrist Sample Dictation
Coronal
1. Intrinsic Ligaments (SL, LT)
2. Extrinsic Ligaments (volar radiocarpal)
3. TFC
4. Lunate fossa
5. Radial and ulnar styloid
6. Evaluate for triscaphe and SLAC arthritis
• The intrinsic scapholunate and lunotriquetral ligaments are intact. The triangular fibrocartilage is normal. The triscaphe and radioscaphoid articulation are normal.
• The volar radiocarpal extrinsic ligaments are normal.
Wrist Dictation
Axial
1.Carpal Tunnel
2.First to sixth extensor compartments
3.Sigmoid Notch
• The carpal tunnel, including the median nerve, is normal. The extensor carpi ulnaris shows normal morphology without tenosynovitis. There is normal congruity of the sigmoid notch at the level of the distal radioulnar joint.
Wrist Dictation
Sagittal
1.Carpal alignment
(capitolunate angle)
2.Scaphoid deformity
(humpback)
• The capitolunate angle
is normal. There is no
flexion deformity of
the scaphoid. The
lunate fossa is intact.
3
Wrist Dictation
Impression:
1. Normal intrinsic scapholunate and lunotriquetral
ligaments. Intact triangular fibrocartilage.
2. Normal carpal alignment and carpal tunnel.
Overview
• Protocols
• Arc Injuries
• Ligaments (Intrinsic and Extrisic)
• Fractures, AVN
• Carpal Tunnel
• Arthritis
Wrist - MR Routine Protocol
• Coronal
– T1 or PD FSE
– FS PD FSE
• Axial
– T1 or PD FSE
– FS PD FSE • STIR or T2* for heterogenous
fat suppresion
• Sagittal
– FS PD FSE
4
Wrist MR Arthrography
• FS PD FSE
coronal
• FS PD FSE axial
• Fat-suppressed
T1 axial, coronal,
and sagittal
images vs fluid
sensitive
sequences using
FS PD FSE
1.5T vs. 3T MRI
Coronal PD Fat Sat Wrist
1.5T voxel size is 247% larger than the
3T voxel size.
FOV (cm) Freq. Matrix Phase Matrix Slice Width (mm) Voxel (mm3) Cor PD FS Wrist
1.5T 8 268 177 3 0.37
Cor PD FS Wrist
3T 7 304 213 1.25 0.15
3T Wrist Coronal PD FS Protocols High Resolution
Resolution (mm)
0.23f x 0.3p x 1.25sl mm
FOV (cm) 7
Matrix (Freq. x Ph.)* 304 x 213
Phase Direction AP
# of slices 22
TE/TR (msec.) 27 / 3742
Echo Train (ETL/TF) 13
Echo Spacing 9.0
WFS (BW) 1.8
Parallel Imaging*****1.3
Foldover Supp. (NPW) No
DRIVE*** Yes
Fat Sat** SPAIR
NSA (NEX) 3
Scan Time 5:32
SPEED
Resolution (mm)
0.3f x 0.4p x 2sl mm
FOV (cm) 7
Matrix (Freq. x Ph.)* 232 x 141
Phase Direction AP
# of slices 14
TE/TR (msec.) 27 / 1937
Echo Train (ETL/TF) 13
Echo Spacing 6.8
WFS (BW) 1.14
Parallel Imaging***** 1.3
Foldover Supp. (NPW) No
DRIVE*** No
Fat Sat** SPAIR
NSA (NEX) 1
Scan Time 0:57
Isotropic 3D Vista****
Resolution (mm)
0.35f x 0.35p x 0.35sl mm
FOV (cm) 7
Matrix (Freq. x Ph.)* 200 x 198
Phase Direction AP
# of slices 150
TE/TR (msec.) 28 /1400
Echo Train (ETL/TF) 66
Echo Spacing N/A
WFS (BW) 1.2
Parallel Imaging***** 2 Ph., 1.4 Slice
Foldover Supp. (NPW) No
DRIVE*** Yes
Fat Sat** SPAIR
NSA (NEX) 2
Scan Time 6:41
* Matrix is defined by number of frequency and phase voxels.
**SPAIR is a fat selective, adiabatic, suppression pre-pulse.
SPAIR is incremental with varying degrees of fat suppression.
***Drive (Driven Equilibrium) or Fast Recovery FSE (FR-FSE).
****Vista (Volume ISotrpic Tse Acquisition) 3D TSE or 3D FSE.
*****Parallel Imaging acceleration or “Speed Up”
values are chosen in incremental factors.
Note: TE values were chosen as a balance for image
sharpness, contrast, and SNR.
Note: Echo Spacing values were chosen for optimal
image sharpness and SNR.
5
Comparative Voxels
High Resolution 3D Vista
0.35f x 0.35p x 0.35sl mm
NSA (NEX) 2
0.23f x 0.3p x 1.25sl mm
NSA (NEX) 3
0.3f x 0.4p x 2.0sl mm
NSA (NEX) 1
SPEED
Scan Time 5:32 Scan Time 0:57 Scan Time 6:41
Wrist Images
SPEED High Resolution 3D Vista
Scan Time 5:32 Scan Time 0:57 Scan Time 6:41
3D Multi Planar Reconstructions
Resolution (mm) 0.35f x 0.35p x 0.2sl recon
FOV (cm) 7
Matrix (Freq. x Ph.)* 200 x 198
# of slices 150
TE/TR (msec.) 28 /1400
Echo Train (ETL/TF) 66
Fat Sat** SPAIR
NSA (NEX) 2
Phase Direction AP
Parallel Imaging 2 Ph., 1.4 Slice
Scan Time 6:41
6
Wrist Images
High Resolution
Scan Time 5:32
3D Vista
Scan Time 6:41
UNKNOWN CASE
CASE
FS PD FSE PD FSE
7
CASE
GRE FS PD FSE
CASE
FS PD FSE LAST
SLIDE
CASE:
SCAPHOLUNATE LIGAMENT SPRAIN AND DORSAL GANGLION
AND TRABECULAR INJURY TO DISTAL RADIUS
DIAGNOSIS
8
CASE
DORSAL GANGLION
SPRAIN
DORSAL
FIBERS
Greater and Lesser Arc Injuries
• Lesser Arc
(Ligamentous injuries)
• Greater Arc (Osseous
fractures: Occur in radial
deviation with force
transmitted through
scaphoid creating
osseous perilunate
instability)
Ligaments
• Intrinsic ligaments
SL, LT
• Extrinsic ligaments
RSC, RLT, RSL
9
Volar or Palmar
Radiocarpal Ligaments
• Radioscaphocapitate
(RSC)
• Radiolunotriquetral (RLT)
= long radiolunate (LRL)
• Radioscapholunate (RSL)
(serves as a vascular
conduit supplying the SL
ligament)
• Radiocarpal ligament
stronger volarly
RSC
RLT
Volar Radiocarpal Ligaments
• RSC
• RLT
• RSL
Volar Radiocarpal
Ligaments
10
Long Radiolunate
• Long radiolunate
or
radiolunotriquetral
ligament
• Acts as a volar
sling for lunate
Dorsal Intercarpal
Ligament
• Triquetroscaphoid
fascicle
• Triquetrotrapezial
fascicle
Dorsal Capsule and
Radiotriquetral Ligament
11
Arcuate or Deltoid Ligament
Intrinsic
Scapholunate
Complex
• Dorsal component
(strongest)
• Membranous
component
• Volar component
v
M
D
Scapholunate Ligament
Dorsal component
Volar component
Membranous
component
Radioscapholunate
ligament
Radiocarpal joint
Dorsal radiocarpal
joint capsule
• Normal scapholunate ligament complex
12
Volar Component
Membranous Component
Dorsal Component
coronal
axial
13
Scapholunate
Interosseous
Ligament
• Fibers shorter,
thicker and stronger
in dorsal portion
• Cross-section
ligament C-shaped,
open distally
UNKNOWN CASE
CASE
FS PD FSE PD
14
CASE
FS PD FSE
CASE
PD LAST
SLIDE
CASE:
SL DIASTASIS AND FLEXED
SCAPHOID
DIAGNOSIS
15
CASE
SL DIASTASIS
DISRUPTION OF
DORSAL FIBERS
FLEXED SCAPHOID
Scapholunate
Ligament
Tear
Scapholunate Ligament Tear MR Findings
• Discontinuity of scapholunate ligament
• Scapholunate interval diastasis > 3 mm
• Volar of plamar flexion of scaphoid on
sagittal
• Dorsal intercalated segment instability
(DISI) with dorsal tilting of lunate, ↑
capitolunate angle > 30°, ↑ scapholunate
angle > 80°
• Pearl: DISI associated with SL
dissociation, unstable scaphoid fracture,
and Kienbock’s disease
16
Scapholunate Ligament Tear
• Complete scapholunate ligament disruption
• Dorsal tilting of lunate in DISI deformity. Capitolunate angle is > 30 degrees
• DISI does not occur with isolated SL ligament tear but is usually associated
with strain of other ligaments (volar radiocarpal ligaments)
• Normal SL angle = 30-60 degrees; normal CL angle = 0-15 degrees
Dorsal Component Sprain
Dorsal component is biomechanically strongest
Partial Tear SL Ligament
Dorsal Component
17
Ganglion Cyst, Wrist
• Cystic mucinous soft tissue masses occurring about the wrist & hand in predictable locations
• Oval with narrow stalk extending from origin
• Dorsal ganglion cysts (70-80%) associated with scapholunate ligament disruption
• Volar ganglion cysts (20-30%) associated with radiocarpal and STT joints
Perilunate Patterns of Instability
• Stage I –
Scapholunate interval
disruption
• Stage II – Disruption
of scapholunate joint
and capitolunate
failure
• Stage III - Disruption
of scapholunate,
capitolunate, and
lunotriquetral joints
• Stage IV – Disruption
of dorsal radiocarpal
ligament with volar
rotation of the lunate
LT Ligament
Volar (strongest)
Membranous
Dorsal
18
Lunotriquetral Instability
• Discontinuity of normally hypointense LT
ligament across LT interval
• Flap tears or complete absence of ligament
• Focal membranous injuries with ulnocarpal
impaction – positive ulnar variance
• VISI (volar intercalated segmental
instability) associated with LT and dorsal
radiotriquetral ligament disruption
LT Ligament:
Flap Tear
Membraneous
LT Ligament Tear: Volar
Lunotriquetral offset
19
TFC
• Articular disc
• Volar radioulnar
ligament
• Dorsal radioulnar
ligament
TFCC
• TFC
• Meniscus homologue
• Ulnar collateral
ligament
• Sheath of the ECU
• Ulnolunate ligament
• Ulnotriquetral ligament
Ulnolunate and
Ulnotriquetral
Ligaments
• From volar aspect
volar radioulnar
ligament to lunate
and triquetrum
20
Radioulnar Ligament
volar
dorsal
Dorsal and Volar
Margins TFC
TFCC Insertion
• Proximal and distal
to styloid
• One broad based
attachment to
styloid (less
common)
21
Spectrum of TFC Injuries
Palmer Class I Palmer Class II
TFC Tear
Palmer Classification 1
• Class 1: traumatic
– A = central perforation
– B = ulnar avulsion + distal ulnar fracture
– C = distal avulsion
– D = radial avulsion + sigmoid notch fracture
Class 1 Tear
22
TFC Tear
Palmer Classification 2
• Class 2: degenerative (ulnocarpal abutment syndrome / ulnar positive variance)
– A = TFCC wear (degeneration)
– B = TFCC wear + lunate, triquetral, +/-ulnar chondromalacia
– C = TFCC perforation + lunate, triquetral, ulnar chondromalacia
– D = TFCC perforation + lunate, triquetral, ulnar chondromalacia, LT ligament tear & ulnocarpal arthritis
Class 2 Tear
Ulnocarpal abutment syndrome
TFC Tear
Central perforation of the TFC (Palmer Class I)
Radial avulsion of the TFC (Class I)
Palmer class II degenerative wear
of the initial stage of ulnocarpal
(ulnolunate) abutment syndrome
23
TFC Tear
• Advanced changes of ulnocarpal (ulnolunate)
abutment (Palmer class II) with TFC tear, lunate,
triquetral and ulnar chondromalacia and
lunotriquetral ligament tear
Lunate and
triquetral edema LT ligament
perforation
TFC disruption Distal ulna
chondromalacia
and subchondral
edema
TFC Tear
• Degenerative TFC
lesion with
horizontal tear and
chondromalacia of
distal ulna, lunate
and triquetrum
TFC Tear
• TFC tear/perforation plus dorsal or volar
radioulnar ligament involvement is associated with
distal radioulnar joint instability (DRUJ)
24
TFC Tear
Traumatic TFC tear
with clinical DRUJ
Central defect of TFCC at
junction of disk and dorsal
radioulnar ligament
UNKNOWN CASE
CASE
GRE PD
25
CASE
FS PD FSE LAST
SLIDE
CASE:
ULNOCARPAL ABUTMENT
DIAGNOSIS
CASE
LUNATE ECCENTRIC
SCLEROSIS
ECCENTRIC LUNATE EDEMA
26
Ulnocarpal Impaction Syndrome
Triad of LT, TFCC tear, chondromalacia of proximal
ulnar lunate & proximal radial aspect triquetrum
Stabilizing Forces on DRUJ
• Pronation - dorsal
radioulnar ligament
taut
• Supination - volar
radioulnar ligament
taut
Scaphoid Fractures
• Transverse fx line most commonly in middle third or waist of scaphoid
• Dorsiflexion 2° fall
• Most common carpus fx
• Pain over anatomic snuffbox
• Limited ROM
• Decreased grip strength
• Exclude associated perilunate dislocation and capitate fracture
27
Scaphoid Fractures Fx line, Edema
T1WI FS PD FSE
Acute vs. Chronic
• Fx extension to
cortex
differentiates
acute from
chronic fx
– Intact cortex
implies
chronic
Scaphoid Fractures Pearl
• Evaluate scaphoid flexion deformity – Humpback deformity
– Foreshortening of carpus
• Assess presence of scapholunate advanced collapse (SLAC) – Proximal capitate
migration, radioscaphoid & capitolunate arthrosis in untreated SL dissociation
28
• Post internal
fixation with
Herbert screw
• Associated with
DISI
• Intact SL
Scaphoid Flexion
Scaphoid Flexion
Mild rotation in rotatory
instability
Fx from scaphoid
attachment of SL
Scaphoid
Avulsion Fx
UNKNOWN CASE
29
CASE
FS PD FSE PD
CASE
PD LAST
SLIDE
CASE:
SCAPHOID FRACTURE AND
AVN
DIAGNOSIS
30
CASE
SCLEROSIS OF PROXIMAL POLE
PROXIMAL
POLE
FRACTURE
UNKNOWN CASE
CASE
FS PD FSE PD
31
CASE
PD LAST
SLIDE
CASE:
SNAC
DIAGNOSIS
CASE
NONUNION
SLAC
FLEXED SCAPHOID
32
Scaphoid Non-Union
• Scaphoid fx fails to
unite within 6 mos
• Loss of proximal
fragment blood supply
• Proximal third fx
• Wrist pain
• Preiser’s disease =
AVN of the scaphoid
without fracture
Radial artery
Scaphoid Non-Union
MR Findings
• Displacement
– Cortical offset ≥ 1mm
• Instability
• Avascular necrosis
Scaphoid Non-Union
T1WI FS PD FSE
33
Scaphoid Non-Union
AVN of proximal pole and fx diastasis
Double fx of proximal,
distal poles
Scaphoid Non-Union
• Type 1: simple – Nondisplaced & no degenerative changes
• Type 2: unstable – Displacement (>1 mm) or DISI (SL angle >70°), no
degenerative changes
• Type 3: early arthritic – Radioscaphoid arthritis
• Type 4: scaphoid non-union advanced collapse (SNAC wrist)
• Type 5: SNAC plus – Arthritis throughout wrist
Scaphoid Non-Union
• Avascular necrosis
• 2° proximal pole fx
• Radioscaphoid
sclerosis
• Stage I SLAC
• SNAC represents
SLAC + scaphoid
non-union
34
Scaphoid Non-Union
• SNAC as greater
arc injury
– Late degenerative
change with DISI
• Radial styloid-
scaphoid sclerosis
UNKNOWN CASE
CASE
FS PD FSE PD LAST
SLIDE
35
CASE:
KIENBOCKS
DIAGNOSIS
CASE
LUNATE EDEMA
Kienböck’s Disease • Avascular necrosis of
lunate
• Acute trauma
• Repeated minor trauma - 2° to excessive shear force
• Interruption of blood supply to anatomically susceptible lunate
• Dorsal tenderness about lunate
• Associated with negative ulnar variance and common in young men ages 20-40
36
Lunate Blood Supply
• 3 patterns of
lunate’s
intraosseous
vascular supply
I X Y
Kienböck’s Disease MR Findings
• Marrow
involvement
• Fx to complete
lunate collapse
• Fx- linear or
compression
• Degenerative
changes at carpus
Kienböck’s Disease
• Stage I: normal radiographs ± fx
• Stage II: sclerosis without collapse
• Stage III: fragmentation + collapse
– A = no instability
– B = instability
• Stage IV: perilunate arthritis
37
Stage I Kienböck’s Disease
Stages of Lunate Collapse
Stage III Kienböck’s Disease
• Elongation of
anteroposterior
dimension of
lunate collapse
38
UNKNOWN CASE
CASE
GRE PD FSE
CASE
FS PD FSE
39
CASE
PD FSE LAST
SLIDE
CASE:
DISTAL RADIUS FRACTURE
DIAGNOSIS
CASE
ULNAR STYLOID FRACTURE DISTAL RADIUS FRACTURE
LUNATE FOSSA
FRACTURE OF
DISTAL RADIUS
40
Die Punch Fx, Distal Radius
• Intraarticular comminuted
distal radius fx
• 2° to axial lunate
compression
• Splitting distal radius
Unstable Melone type II
Lunate impaction on dorsal
medial fragment
Die Punch Fx, Distal Radius
• Melone fracture classification – four
primary fx fragments
– Metaphyseal
– Radial styloid
– Dorsal medial
– Palmar medial
Die Punch Fracture
Dorsal medial fragment
Ulnar styloid fracture
Palmar medial fragment
Radial styloid fragment
Volar spike fragment
41
Ulnar styloid fracture at its base
Gymnast’s Wrist
• Distal radial physis and
metaphysis with stress
fracture (widening of the
distal physis)
• Cystic changes and
irregularity of the
metaphyseal margin of the
physis
• Beak effect of the distal
aspect of the epiphysis
• Haziness of the physis
Median Nerve in Carpal Tunnel
• Deep to flexor retinaculum
• Superficial to profundus and flexor pollicis longus tendons
• Borders of the carpal tunnel are: Scaphoid tubercle and hamate
• Contents of the carpal tunnel are: 9 flexor tendons (FDSx4, FDPx4, FPL, median nerve)
Flexor
retinaculum
42
Carpal Tunnel Syndrome
Inflammatory tenosynovitis Enlarged median nerve
Carpal Tunnel
Median nerve
Flexor
pollicis
longus
Flexor
digitorum
superficialis
Carpal tunnel syndrome with
enlarged nerve fascicles
Epineurium
Perineurium
Thenar Denervation
43
Carpal Tunnel Syndrome
Volar ganglion Median N. edema
Carpal Tunnel Syndrome
Benign peripheral N
sheath tumor Edematous median N.
Carpal tunnel syndrome with enlarged, hyperintense
median nerve with thenar muscle atrophy and denervation
44
Fibrolipoma median nerve with
denervation
Guyon’s Canal
Deep branch
ulnar nerve
Ulnar nerve
Motor
Branch
Sensory
Branches
Ulnar
artery
De Quervain’s
Tenosynovitis
• Tenosynovitis & tendonitis of 1st dorsal
extensor compartment
• Abductor pollicis longus (APL) located
volar to EPB at level of radial styloid
• Normal tendons of 1st extensor
compartment at level of radial
styloid
• Extensor pollicis brevis (EPB)
associated with a separate
subcompartment
45
De Quervain’s Tenosynovitis
• Tenosynovitis and tendon enlargement; APL demonstrates a striated appearance secondary to enlargement of multiple slips
Extensor carpi ulnaris tendinopathy
Ulnar Collateral Ligament Tear, Thumb
• UCL rupture,
gamekeeper’s thumb,
skier’s thumb
• Discontinuity of ulnar
collateral ligament
attachment to
proximal phalanx
• Pain greatest on ulnar
side of MCP joint
46
UCL Tear, Thumb
• UCL retraction deep to or superficial (Stener
lesion) to adductor aponeurosis
• UCL tear generally avulse distally
• Thickened, foreshortened UCL with proximal
retraction
• Mass-like tissue vs. horizontally directed
UCL in Stener lesion
Rupture without a Stener Lesion
Rupture with a Stener Lesion
47
Stener Lesion
“yo-yo on a string”
Stener Lesion
Flexor Digitorum
Superficialis
Single terminal slip
Lateral partial slips
Medial partial slips
Ulnar slip
Radial slip
Single tendon
Tendinous
Chiasm
Divided
Tendon
Single
Tendon
48
Flexor Tendon Pulley System
A5 C3 A4 C2 A3 C1 A2 A1
A2 pulley rupture
A2 pulley A1 pulley
Ruptured A2 pulley Ruptured A2 pulley
A4 Pulley
Partial Tear
Tear Widened gap
Normal A4
Pulley
49
A1 Pulley Asymmetric Disruption
(Radial side)
Degenerative Arthritis, Wrist
• Scaphoradial joint space narrowing in
scapholunate advanced collapse (SLAC) &
sclerosis of triscaphe articulation
• High shear stresses over small contact
surfaces
• SLAC wrist = most common pattern
comprising 55% of degenerative arthritis of
wrist
Watson Stages of SLAC Wrist
• Stage I: arthrosis limited to radial styloid –
scaphoid articulation
• Stage II: arthrosis of entire radioscaphoid
articulation
• Stage III: periscaphoid arthrosis with
radioscaphoid & capitolunate joints
50
SLAC Wrist
• Stage I • Stage III
SLAC Wrist Etiology
• Rotary subluxation scaphoid (RSS)
• Scapholunate or periscaphoid dissociation
• Predynamic to dynamic to static RSS
• Progression ot radioscaphoid/SLAC or triscaphe
arthrosis
• SLAC also caused by abnormal articular loading
in scaphoid fracture, non-union, Kienböck’s &
capal fractures
SLAC Wrist
• Normal radioscaphoid congruous joint surfaces
• Rotational instability secondary to rotatory subluxation of scaphoid with abnormal load transfer to volar and dorsal margins of distal radius
51
SLAC Wrist
• Widening of scapholunate interval and proximal migration of capitate in SLAC arthritis
• Scaphoid non union advanced collapse; sclerosis in AVN of proximal pole of scaphoid
Triscaphe Arthrosis
• Load changes and articular pathology analogous to
SLAC wrist
• Disruption in ligamentous support of scaphoid
distally
• SLAC & triscaphe arthritis may coexist
• Scaphotrapezial involvement twice as common as
isolated scaphotrapezoidal
• Trapezium & trapezoid migrate proximally
Triscaphe Arthrosis
• Degeneration of scaphotrapeziotrapezoid articulation
• Sclerosis with loss of articular cartilage in triscaphe joint
52
Hamato-Lunate Impingement
• Degenerative arthritis between a type II lunate with an extra facet and proximal hamate
• Type I lunate has no extra or medial facet
• Type II lunate = alteration of normal uniform loading
Hamato-Lunate Impingement
• Early chondral erosions between medial lunate facet and proximal pole of hamate
• Altered biomechanics leads to chondromalacia
• Chondromalacia secondary to impingement & abrasion of hamate & lunate
Hamato-Lunate Impingement Histology of chondral degeneration
• Release of chondral debris into joint space
• Exposed surface of subchondral bone with full thickness chondral loss
53
Hamato-Lunate Impingement
• Early chondral loss of medial lunate facet and fibrillation of proximal pole of hamate
• Full thickness chondral loss of medial lunate facet with subchondral sclerosis of proximal pole of hamate
Rheumatoid Arthritis, Wrist and Hand
• Inflammatory synovial/pannus tissue
• Erosions, joint space narrowing, soft tissue swelling & ulnar translocation
• Bilateral, symmetrical joint involvement
Rheumatoid Arthritis
• Inflammation divided into
acute (perfusion MRI),
subacute (inflammatory,
stromal cells and
capillaries), seen with
contrast MRI, and chronic
(fibrous tissue), seen with
conventional MRI
• Rheumatoid osteitis
involves inflammatory cell
replacement of fat cells
and correlates with
subsequent bone
destruction
54
Rheumatoid Arthritis, Wrist and Hand
• Ulnar deviation of metacarpal phalangeal joints
• Proximal migration of the capitate
• Scapholuate dissociation
• Ulnar and carpal erosions
• Carpal erosion
Rheumatoid Arthritis, Wrist and Hand
• Synovitis
• Scapholunate dissociation with carpal erosions and marrow edema
• Subchondral erosions and carpal cyst
Rheumatoid Arthritis, Wrist and Hand
55
• Tenosynovitis of flexor carpi radialis in association with scapholunate dissociation
• Osteopenia of carpus
Rheumatoid Arthritis, Wrist and Hand
Giant cell tumor
Summary
• Intrinsic and extrinsic ligaments – anatomy,
tear and ganglion
• Scaphoid fracture and non-union
• Keinbock’s disease
• Distal radius fracture
• Carpal tunnel
• Stener lesion
• Degenerative and rheumatoid arthritis
56
Summary
• Wrist MRI requires the use of a 4 or 8 channel
dedicated wrist coil
• Fluid sensitive sequences (FS PD FSE) are
used for articular cartilage and intrinsic
ligament injuries
• Use axial images to secondarily identify
components of the SL and LT ligament
complexes
• T2* gradient echo increases conspicuity for
the triangular fibrocartilage when required
MRI of the Wrist
Thank you
