The value of multi-detector CT arthrography of the ...

The Egyptian Journal of Radiology and Nuclear Medicine 49 (2018) 394–399

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Original Article

The value of multi-detector CT arthrography of the wrist joint in evaluation of ligamentous and capsular injuries in post-traumatic pain

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Mohammad Fouad Abdel-Baki Allama, , Mostafa Mohamed Mostafa Eliana, Ahmad Fouad Abdel-Baki Allamb a b

Department of Radiology, Faculty of Medicine, Minia University, 61111, Egypt Department of Orthopedics and Traumatology, Faculty of Medicine, Minia University, Egypt

A R T I C LE I N FO

A B S T R A C T

Keywords: Wrist pain Ligament tear Capsular tear MDCT arthrography

The wrist joint is a complex joint containing several intrinsic and extrinsic ligaments that contribute to carpal stability. There is increased incidence of ligamentous/capsular injury following trauma. Objective: The aim of this study was to assess the value of high resolution MDCT arthrography in detection of various ligamentous and capsular injuries of the wrist in post-traumatic writ pain. Patients and methods: From August 2016 to February 2017 Seventeen patients with posttraumatic wrist pain underwent MDCT arthrography primarily through radiocarpal injection and using high resolution study, all patients have negative MRI study of the wrist. Results: 59% of cases had ligamentous/capsular tear. The most frequent was the capsular tears. Incomplete intrinsic ligament tears were observed, the dorsal scaphotrapezio-trapezoid ligament was the commonest to be affected. Class IA traumatic TFC tear was found in 12%. There was significant high positive correlation between the VAS score for wrist pain and the presence of ligamentous/capsular tear in absence of bone fracture. Conclusion: MDCT arthrography of the wrist is an excellent imaging method that can detect MRI occult ligamentous tear in unexplained post traumatic pain.

1. Introduction The wrist joint is one of the most complex joints in the body; it is composed of articulations of eight carpal bones together and with the distal forearm bones as well as with the metacarpals. There are several ligaments connecting carpals to carpals; these are the intrinsic wrist ligaments that contribute to carpal stability and normal wrist joint alignment. Extrinsic ligaments are those connecting carpals to radius, ulna, metacarpals, retinacula, or to a tendon sheath. The intrinsic ligaments of the wrist include scapholunate, lunotriquetral, scaphotrapeziotrapezoid, scaphocapitate, triquetrohamate, capitathamate and pisohamate ligaments. Important extrinsic ligaments are radioscaphocapitate, long radiolunate, ulno-capitate, ulnolunate, dorsal radiocarpal, dorsal intercarpal, dorsal and volar radioulnar, and carpometacarpal ligaments [1–3]. Following wrist trauma, there is an increased incidence of ligamentous injury through either intrinsic or extrinsic ones; most clinical and imaging interests are focused on the most clinically significant ligamentous complexes; the scapholunate (SL), lunotriquetral ligaments

(LT), and the triangular fibrocartilage complex (TFCC). However, there are many other ligaments that are susceptible to injury and can contribute to subsequent post-traumatic chronic wrist pain and /or joint instability [4]. Arthroscopy is the gold standard tool to diagnose the intrinsic ligament tears; however it could not be applied as a reference standard for evaluation of extrinsic ligaments, and even with use of multi-portal wrist arthroscopy, the extrinsic ligaments attachments are not visualized [5]. Multi-detector row CT (MDCT) arthrography and MR arthrography are the best imaging tools in suspected intrinsic wrist ligament tears; both are equivocal in low grade injury, such as minimal sprain or minimal interstitial tear without definite fiber disruption, both tools can diagnose complete tears of the scapholunate and lunotriquetral ligaments. Despite that, MDCT arthrography could be considered superior to MR arthrography, it can provide excellent spatial resolution and directly visualizes the ligament tears even the small partial-thickness type, and thus is sometimes preferred in small joints such as the wrist when the primary consideration is a tiny ligament tear or articular

Peer review under responsibility of The Egyptian Society of Radiology and Nuclear Medicine. ⁎ Corresponding author. E-mail address: [email protected] (M.F.A.-B. Allam). https://doi.org/10.1016/j.ejrnm.2018.01.003 Received 5 May 2017; Accepted 7 January 2018 Available online 25 April 2018 0378-603X/ copyright 2018 The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).


M.F.A.-B. Allam et al.

– and supination lift test for detection of TFCC pathologies (d) Neurological examination of the wrist/hand was done to exclude any neurogenic source of pain.

cartilage defect [6]. The extrinsic ligaments are readily visualized on MDCT arthrography. The radioscaphocapitate and long radiolunate ligaments are invariably seen on sagittal images, separated by recess of Poirier. The capsular tear could be easily diagnosed by extraarticular passage of contrast. Cartilage abnormalities of the wrist are readily detected in MDCT arthrography given thin hyaline cartilage of this small joint [7,8]. Looks different from MRI in assessment of the wrist joint which always need high end closed magnet aided by arthrography to properly asses the small ligaments of the wrist that will add more costs on patients and heath care, High resolution MDCT will provide a cheap, relatively easy and rapid alternative method.

2.5. Study technique For logistic reasons, our musculoskeletal imaging group favors the single compartment injection technique of the radio-carpal (RC) joint under imaging guidance, however in some cases with primary ulnar sided pain and suspected TFCC injuries, additional DRUJ injection can be performed. Radio-carpal joint injection of non-ionic iodinated contrast medium (Ioversol; Optiray® 350) was done with careful sterile technique using 1:1 dilution with lidocaine HCl 1%. The utilized needle was 25-gauge 1.5 in. needle. The injection was performed under superficial ultrasonographic guidance, the 12 MHz linear transducer was placed longitudinally on the dorsal surface of the wrist, the entry point was just distal to the Lister's tubercle with mild cephalic angulation about 20°, when the tip of the needle was imaged in the radio-scaphoid interval, about 3 cc of contrast was injected, the injection was continued to firm resistance to achieve joint distension. Additional distal radio-ulnar joint (DRUJ) injection was performed in some ulnar sided pain cases; the injection was performed via dorsal approach after ultrasonographic localization of the joint with a marker, then placing the needle straight down into the joint, the average amount of contrast was 1 cc. Any joint effusion was aspirated prior to contrast injection. The patient was scanned in “superman” position in which the patient lie prone with his arm placed above the head and his hand is pronated and centered within machine gantry, generally; this position was not difficult for the patient, owing to short examination time. High resolution bone algorithm was used, the beam collimation was thin (0.6 mm), and the field of view was small (=100 mm), Exposure parameters were 120 kV and 200 mAs.

1.1. Aim of the work Being widely available, cheaper and does not need high end machine, the aim of this study was to assess the value of high resolution MDCT arthrography in detection of various ligamentous and capsular injuries of the wrist in post-traumatic writ pain. 2. Patients and methods 2.1. Study participants This study was conducted during August 2016 through February 2017 after being approved by the ethical committee of our institution. Seventeen patients, suffered from post-traumatic wrist pain, were referred from orthopaedic clinic, Minia University Hospital, and underwent MDCT arthrography using Philips 16 detector row CT machine. All patients had undergone conventional MRI (not more than 3 months ago), with equivocal examination as regarding the wrist ligaments. All patients were asked to score the severity of their wrist pain using visual analogue scale (VAS). Informed written consent was obtained from all participants prior to the study.

2.6. Image processing and analysis

2.2. Inclusion criteria Inclusion criteria for the patients were based on: 1- Post-traumatic wrist pain for at least one month duration with negative radiograph for fractures and negative conventional MRI for bone bruises or ligamentous tear. 2- Persistent wrist pain in different location other than the primary traumatic site in the context of properly managed united bone fracture and unremarkable conventional MRI.

Corrected axial, sagittal, and coronal reformatted images were obtained along the axis of the capitate. Overview of the entire wrist joint was obtained from the coronal cuts. The axial plane is the essential plane for direct visualization of the intrinsic ligaments and appreciating the joint capsule and many extrinsic ligaments as radio-scapho-capitate and long radio-lunate ligaments, the sagittal plane was the optimal plane for analysis of the TFCC, scapho-trapezio-trapeziod and carpometacarpal ligaments.

2.3. Exclusion criteria

2.7. Statistical analysis

Surrounding/overlying soft tissue infection was the only exclusion criterion.

Results of CT arthrography were recorded, tabulated and statistically analyzed using SPSS-16; the data were represented as number and percent. Inter-rater agreement was assessed for ligamentous and nonligamentous findings.

2.4. Clinical examination

3. Results

All patients were subjected to complete history taking and thorough clinical examination of wrist joints in the orthopaedic clinic with special concern of the following:

There were 10 males and 7 females in the study; their mean age was 36 ± 18 y (range 19–55y). The most frequent imaged wrist in the study was the right side (11 cases, 65%).

(a) Wrist palpation for exact location of the pain with exclusion of any painful disorders related to the tendon sheaths. (b) Passive and active range of motion testing (c) Instability testing including: – Watson test and scapholunate ballottement test for scapholunate instability. – lunotriquetral ballottement test (Reagan test) to evaluate the integrity of the lunotriquetral ligament. – dorsal capitate displacement apprehension test for determination of the stability of the capitate bone

3.1. MDCT arthroscopic findings Among 17 patients, there were 10 patients (59%) had ligamentous/ capsular tear with or without other non-ligamentous pathology, one other patient had pure non-ligamentous pathology, the rest of the patients (6 patients) had unremarkable CT arthrographic study. The most frequent pathological changes were the volar capsular tears (4 cases) three of which were isolated tear without other ligamentous injury, and 395



Fig. 1. Sagittal (A) and coronal (B) MDCT arthrography demonstrate volar capsular tear evidenced by the extra-articular passage of contrast volarly (white arrow) away from the site of contrast injection at dorsal wrist, long radio-lunate ligament tear (black arrow), and normal radioscaphocapitate ligament (notched black arrow). The contrast tracking along the dorsal tendon was due to mixed intra- and extra-articular contrast injection.

(class IA TFC tear), one of them was associated with chondral fissure through the scaphoid cartilage at the radio-scaphoid compartment. There was one case of synovial thickening associated the dorsal scapholunate ligament tear (Fig. 4) (Table 2). There were two minor complications happened post-arthrography, two patients developed vaso-vagal attack, both of them underwent the procedure while in sitting position, one patient developed mild soft tissue swelling about the dorsum of the wrist due to mixed intra- and extra- articular contrast injection. No major complications happened (Fig. 1) (Table 3).

Table 1 Percentage of capsular injury and extrinsic and intrinsic ligament tear in the study population. (*): Combined capsular and ligament tear in one patient. Ligament and capsular tear

Number (No.)

Percent (%)

Capsular

3

18

1

6

1 1 2

6 6 12

1 1 1

6 6 6

Extrinsic Intrinsic

Capsular tear in absence of ligamentous tears Capsular tear with other ligamentous tear* Long radiolunate* Carpo-metacarpal (Piso-metacarpal) Dorsal Scaphotrapeziotrapezoid ligament Dorsal Scapholunate ligament Volar Scapholunate ligament Volar luno-triquetral ligament

3.2. Correlation analysis There was significant high positive correlation between the severity of pain assessed with VAS scale and the presence of ligamentous/capsular tear in absence of bone fracture (Fig. 5). Most of patients with ligamentous/capsular tear were experienced moderate pain (VAS score 4-7).

the fourth one associated long radio-lunate ligament tear (Fig. 1) (Table 1). There were five cases had intrinsic ligament tears, all of which were incomplete tear, the affected ligaments were the dorsal scapho-trapezio-trapezoid ligament, the volar or dorsal scapho-lunate ligament, and the dorsal luno-triquetral ligament (Figs. 2 and 3) (Table 1). There were other non-ligamentous pathologies found in the study cases; the most significant was traumatic TFC tear (2 cases 12%) without associated regional chondromalacia, both cases showed radial sided central tear of TFC disc with intact radio-ulnar ligaments (RULs)

3.3. Inter-rater reliability The percent agreement was high; it was 90% for ligamentous injuries and 100% for non-ligamentous injuries.

Fig. 2. Sagittal (A) and coronal (B) MDCT arthrography show torn dorsal scapho-trapezio-trapezoid ligament (black arrow), with contrast passing into the scaphotrapezio-trapezoid joint (white arrow). 396



Fig. 3. Axial (A) and coronal (B) MDCT arthrography (RC and DRUJ injection), demonstrate incomplete tear through the volar scapho-lunate ligament (white arrow).

Fig. 4. Sagittal (A) and coronal (B) MDCT arthrography show radial sided central triangular fibrocartilage tear (black arrow), with passage of the contrast into the distal radio-ulnar joint (star), normal dorsal and volar radio-ulnar ligaments (white arrows), there is dorsal scapho-lunate ligament tear (notched arrow). Table 2 Percentage of other non-ligamentous joint injury. (*) One patient of TFC tear was associated with chondral injury. Other non-ligamentous injuries *

TFC tear Chondral injury* Synovial thickening

Number (No.)

Percent (%)

2 1 1

12 6 6

Table 3 Percentage of complications of the arthrographic procedure. Complication of arthrography

Number (No.)

Percent (%)

Vaso-vagal attack Mixed intra- and extra-articular injection Infection/Septic arthritis

2 1 0

12 6 0

Fig. 5. Correlation scatterplot demonstrate significant high correlation between the VAS pain scoring and the presence of ligamentous/capsular tear.

3.4. Management Because of lack of wrist joint instability, all cases with ligamentous/ capsular and/or TFCC tear had a trial of conservative treatment that consisted of 6 week immobilization cast, NSAIDS and post cast 6 week course of physiotherapy. Nine out of eleven patients (82%) improved and were able to return to work and/or sports at a pre-injury level with significant improvement of VAS for wrist pain. Two patients were still suffering from chronic pain at work, then a local steroid injection was administered, one patient who had synovial thickening and dorsal scapholunate ligament tear was improved, the other who had combined TFCC tear and chondral fissure had no significant improvement, he refused to undergo arthroscopic debridement and preferred to change his work style and life moderation.

The six cases with unremarkable study had responded completely to 6–8 weeks course of physiotherapy.

3.5. Cases presentation 3.5.1. Case 1 A female patient 29 years old complained of right post-traumatic wrist pain mainly at the radial side, no fractures or abnormality on wrist radiograph or MRI. MDCT arthrography shows tear of the volar wrist capsule with extra-articular passage of contrast, and long radio-lunate ligament tear (Fig. 1). 397



mechanical importance [10–12]. The ability of high resolution MDCT arthrography in delineation of such incomplete injuries should widen the scope of wrist imaging to be beyond the conventional MRI, even when aided by arthrography, as MRI has inherent low spatial resolution and detection of such injuries is a challenge point especially when imaging is made without using micro-coil or made on low field magent. Class IA TFC lesion is one of the most common types of TFC complex injuries, it involves the central avascular part of the TFC and leaves a small rim attached to the radius. This tear is usually full-thickness one, so radiocarpal joint communication with the DRUJ is readily detected on arthrography. Clinically, DRUJ instability usually absent especially with intact RULs. MDCT arthrography can precisely classify the TFCC tear, it can detect the location of the tear, measures the size of the defect and associated ligamentous and chondral pathologies, and differentiate the traumatic lesion from the degenerative one, and thus, MDCT affects the treatment option and arthroscopic decision. Generally, class IA TFC tear is not amenable to direct arthroscopic repair and the only treatment option is to remove any flap that may disturb the joint biomechanics [13]. The severity of pain was correlated with the presence of wrist ligament/capsular tear. Most patients with ligamentous/capsular tear suffered from moderately severe pain. This emphasizes the need for extended clinical/imaging approach examining the traumatized wrist for possible ligamentous/ capsular tear especially in sitting of absence of fracture and persistent clinically significant pain however.

3.5.2. Case 2 A male patient 40 years old complained of post-traumatic radial sided pain in the right wrist with limited range of thumb movement. Wrist MRI and radiograph were negative for fractures or ligamentous tear. MDCT arthrography shows partial tear involving the dorsal scaphotrapezio-trapezoid ligament, with contrast passing into the scapho-trapezio-trapezoid joint (Fig. 2). 3.5.3. Case 3 A female patient 45 years old complained of diffuse pain in the left wrist, she experienced trauma 2 months prior. No fractures or ligamentous injury was detected on radiograph and MRI of the wrist. MDCT arthrography, demonstrate incomplete tear through the volar scapho-lunate ligament (Fig. 3). 3.5.4. Case 4 A male patient 34 years old complained of ulnar and radial sided wrist pain, with history of old trauma. No abnormality detected at wrist radiograph or MRI. MDCT arthrography shows radial sided central triangular fibrocartilage tear, with contrast opacification of the distal radio-ulnar joint, and dorsal scapho-lunate ligament tear (Fig. 4). 4. Discussion The ligamentous/capsular structures of the wrist are numerous and complex, the scapholunate ligament, lunotriquetral ligament, and the TFCC are given the highest attention on diagnostic imaging when wrist ligaments are assessed. The purpose of the current study is to evaluate the role of high resolution MDCT arthrography in detection of intrinsic and extrinsic ligamentous/capsular injury as a source of post-traumatic wrist pain. The inherent high resolution in MDCT arthrography and higher image contrast allows for easy detection of even small ligamentous tear. In this study, there were 59% of the cases had ligamentous/capsular tear, this is a relatively high percentage that highlights the clinical importance of such injury as a possible source of post-traumatic wrist pain, and the clinical suspicion of the source of pain should be higher especially in absence of bone fracture. The most frequent injury in the study population was the volar capsular tear (24%) either with or without concurrent extrinsic ligament injury, the extrinsic ligaments/capsular tear was the major injury found (36%); these findings could provide a new paradigm when assessing the wrist ligaments for injury, and give an emphasis on the joint capsule and the extrinsic ligaments in addition to the intrinsic ligaments, rather than the traditional attention to the intrinsic ligament only. Among the partial intrinsic ligament tear cases in the study, the dorsal scapho-trapezio-trapezoid ligament was the most frequent intrinsic ligament tear, and was found in two cases (12%). This requires an insight into such an injury. The isolated scapho-trapezio-trapezoid ligament tear is not uncommon injury; it carries a diagnostic challenge, and should be suspected when radial sided wrist pain occurs at the base of the thenar eminence, with decreased strength of thumb-index-middle finger pinch. The radiological diagnosis can be made only using arthrography [9]. Incomplete scapho-lunate and luno-triquetral ligament tear are recognized among the study cases. MDCT arthrography can delineate precisely the extent of the tear within the SL and LT ligamentous complexes, and differentiate the complete from the incomplete tear; this is an important and clinically relevant point, as most patients who have incomplete tears (especially through the volar SL and dorsal LT ligaments) have no wrist instability and generally are treated conservatively. The dorsal part of the scapholunate ligament and the volar part of the lunotriquetral ligament are important for wrist stability, whereas the membranous proximal portions have virtually no

5. Study limitation There was a variety of directly visualized ligamentous pathologies in this study; all injuries were partial or incomplete. Although the arthroscopy is considered the reference standard in intrinsic ligament tear, the lack of associated wrist instability in all cases hinders its utility. 6. Conclusion We concluded that high resolution MDCT arthrography is an excellent imaging method, can detect MRI occult ligamentous tear, it directly visualize the ligamentous tear of the wrist as an etiology of unexplained post traumatic wrist pain with accurate classification of various intrinsic and extrinsic/capsular injury. Conflict of interest All authors state that there are no conflict of interests in the manuscript, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest. Funding source No disclosure of funding received for this work from any organization. References [1] Crim J, Andrews CL. Wrist ligaments. In: Manaster BJ, Crim J, editors. Imaging anatomy. Musculoskeletal. 2nd ed. Altona, Manitoba, Canada: Amirsys. Elsevier. Section 5; 2016. p. 388–90. [2] Morrison WB. Wrist anatomy. In: Crim J, Morrison WB, editors. Specialty imaging. Arthrography. 1st ed. Salt Lake City. Utah. USA: Amirsys, Section 4; 2009. p. 100. [3] Brown RR, Fliszar E, Cotten A, Trudell, Resnick RTD. Extrinsic and intrinsic ligaments of the wrist: normal and pathologic anatomy at MR arthrography with threecompartment enhancement. RadioGraphics 1998;18:667–74. [4] Bateni CP, Bartolotta R, Richardson ML, Mulcahy H, Allan CH. Imaging key wrist ligaments: what the surgeon needs the radiologist to know. AJR 2013;200:1089–95. [5] Yoshioka H. Wrist ligaments and the triangular fibrocartilage complex. In: Chung CB, Steibbach LS, editors. MRI of the upper extremity: shoulder, elbow, wrist and hand. 1st ed., vol. 15. Philadelphia, USA: LWW; 2010. p. 556. [6] Moser T, Dosch JC, Moussaoui A, Dietemann JL. Wrist ligament tears: evaluation of

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[10] Pappou IP, Basel J, Deal DN. Scapholunate ligament injuries: a review of current concepts. Hand 2013;8:146–56. [11] Berger RA. The gross and histologic anatomy of the scapholunate interosseous ligament. J Hand Surg [Am] 1996;21:170–8. [12] Nicoson NC, Moran SL. Diagnosis and treatment of acute lunotriquetral ligament injuries. Hand Clin 2015;31(3):467–76. [13] Cerezal L, Berná-Mestre JD, Canga A, Llopis E, et al. MR and CT arthrography of the wrist. Semin Musculoskelet Radiol 2012;16:27–41.

MRI and combined MDCT and MR arthrography. AJR 2007;188:1278–86. [7] Moser T, Dosch JC, Moussaoui A, et al. Multidetector CT arthrography of the wrist joint: how to do it. RadioGraphics 2008;28(3):787–800. [8] De Filippo M, Pogliacomi F, Bertellini A, et al. MDCT arthrography of the wrist: diagnostic accuracy and indications. Eur J Radiol 2010;74:221–5. [9] Masquelet AC, Strube F, Nordin JY. The isolated scapho-trapezio-trapezoid ligament injury. Diagnosis and surgical treatment in four cases. J Hand Surg Br 1993;18(6):730–5.

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