|Year : 2015 | Volume
| Issue : 2 | Page : 503-507
Role of MRI in evaluation of painful wrist joint
Mohameed R El-Kholy, Mohameed A Maaly, Yasmin H Hemeeda MSc
Department of Radiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||19-May-2013|
|Date of Acceptance||08-Jul-2014|
|Date of Web Publication||31-Aug-2015|
Yasmin H Hemeeda
Department Radiodiagnosis, Faculty of Medicine, Menoufia University, Menoufia 32511
Source of Support: None, Conflict of Interest: None
The aim of this work was to show the value of MRI in evaluation of patients suffering from wrist pain.
Wrist pain is a common clinical complaint. The most common causes of wrist pain are traumatic and nontraumatic abnormalities involving avascular necrosis, ganglia, and triangular fibrocartilage lesions. MRI serves as a problem-solving technique to assess the cause of wrist pain. It also plays an important prognostic role.
Materials and methods
This study was conducted on 50 patients complaining of wrist pain. The patients were referred to the Radiology Department from the outpatient clinics and the Orthopedics Department of Menoufia University Hospital. All patients were examined by radiography and conventional MRI. Data of soft tissue and osseous lesions were collected, analyzed, and correlated with findings on laboratory and arthroscopic examination.
There were 32 male patients and 18 female patients; their ages ranged between 17 and 60 years (mean age, 38 years). The most affected age group was between 20 and 40 years (60%). Avascular necrosis was the commonest nontraumatic lesion found in 10 patients (26%).
MRI has a marked impact on the diagnosis and assessment of variety of wrist disorders. It is noninvasive and ideal modality to demonstrate the complex anatomy and pathological conditions of the wrist.
Keywords: avascular necrosis, MRI, wrist pain
|How to cite this article:|
El-Kholy MR, Maaly MA, Hemeeda YH. Role of MRI in evaluation of painful wrist joint. Menoufia Med J 2015;28:503-7
| Introduction|| |
Concerning the painful wrist, high-resolution MRI can be utilized to enhance detection and evaluation of several wrist disorders, allowing for discrimination of soft tissue structures, including marrow, ligaments, tendons, cartilage, muscles, nerves, and blood vessels. MRI can be of aid in evaluation of carpal instability, disorders of the triangular fibrocartilage (TFC), ulnar impaction syndrome, distal radioulnar joint (DRUJ) instability, fracture, avascular necrosis, tendinopathy, nerve entrapment syndromes, synovial abnormalities, and soft tissue masses  .
MRI for wrist pain is challenging. Correct assessment of the TFC, hyaline cartilage, ligaments, and tendons has become mandatory for comprehensive decision making in wrist surgery. MR arthrography with injection of gadolinium-containing contrast material into the DRUJ is suggested for evaluation of the TFC  .
The wrist is perhaps the most complicated joint in the body and the most important joint for today's human being in this computer and internet age. Evolutionary in concept where so many bones are constrained to work together, it is not surprising that where there is strain there is conflict. Pain is often the presenting symptom. It is not surprising, then, that the painful wrist presents the physician with a diagnostic challenge. The differential diagnosis is extensive and a definite diagnosis is only achieved in about 70% of cases  .
| Materials and methods|| |
This study was performed between August 2010 and December 2013 on 50 patients complaining of wrist pain. There were 32 male patients and 18 female patients; their ages ranged between 17 and 60 years (mean age, 38 years). The patients were referred to the Radiology Department from the outpatient clinics and the Orthopedics Department of Menoufia University Hospital for MRI examination of the wrist.
After approval from the local institutional ethical committee of Menoufia University Hospital and obtaining oral consent from each patient, all patients included in this study were subjected to plain radiographic examination of the wrist, using conventional radiographic unit in the following position: posteroanterior, lateral, and scaphoid (posteroanterior with 30° internal rotation) views.
The MRI machine used was Toshiba Exclart Vantage 1.5 T scanner. The examination protocol included coronal, sagittal, and axial planes. Coronal and axial fast spin-echo T1-weighted (TR/TE, 400/15), coronal axial and sagittal fast spin-echo T2-weighted (TR/TE, 2000/70), coronal gradient (TR/TE, 435/15), and coronal STIR (TR/TE, 20000/48) sequences with a field of view of 12 cm were used. Slice thickness was 2.5 mm with 2 mm interslice gap. All our patients were examined by conventional MRI. This was correlated with laboratory and arthroscopic findings.
| Results|| |
A total of 28 patients suffered from right wrist pain, whereas 22 had left side pain. Avascular necrosis (AVN) was the most common pathologic finding (10 patients) followed by intercarpal ligament tear (eight patients). Neoplasm (two patients) and arthritis (three patients) were the least common pathological findings. More than one finding were found in patients with fractures. In two cases, fracture waist of scaphoid bone was associated with AVN of their proximal pole; one case of trapezoid and hamate bones AVN was associated with fracture trapezoid bone and ulnar styloid process; two cases with actual tear of triangular fibrocartilage complex (TFCC) were associated with fracture ulnar and radial styloid process; and one case of aneurismal bone cyst was complicated with pathological fracture distal end shaft radius [Table 1].
|Table 1 Classification of the traumatic and nontraumatic lesions as detected by MRI and plain radiography in 50 patients|
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Ten patients with AVN affecting the lunate, scaphoid, trapezoid, and hamate bones were included in our study; the most common affected carpal bone with AVN was the lunate bone seen in six patients (60%) with high sensitivity of MRI to detect the early marrow changes in the cases with AVN compared with the plain radiography, which was seen normal in the two cases with lunate early avascular necrosis [Table 2].
On MRI, ganglions appeared as cystic lesions with the signal intensities as shown in [Table 3].
[Table 3] shows that four cases (57.1%) had scapholunate joint cyst at the dorsal side, One case (14.3%) had extensor digitorum tendon cyst, showing multiple internal septations and mural wall irregularity at the dorsal side, and two cases (28.6%) had intraosseous ganglion.
In our study, all the extraosseous cases arise at the dorsal side mostly from scapholunate joint.
The sensitivity of MRI to detect carpal tunnel syndrome (CTS) compared with nerve conduction study was 33.3% in mild cases, 50% in moderate cases, and 100% in severe cases. Three cases with CTS were seen negative with MRI and they were diagnosed by nerve conduction test; hence, the MRI has weak sensitivity in detection of mild cases of CTS [Table 4] [Figure 1], [Figure 2], [Figure 3], [Figure 4].
|Figure 1: Case 1 (a– d): MRI coronal T1-weighted image, coronal T2-weighted image, and short TI inversion recovery (STIR), respectively, show evidence of avascular necrosis of the lunate bone. (a) Altered marrow signal with hypointense signal in T1-weighted image (white arrow) associated with chondromalacia at the opposing surfaces of the capitates and hamate bones (blue arrows). (b, c) intermediate signal intensity is seen in the lunate bone in coronal T2-weighted image with residual normal marrow signal associated with subarticular cystic changes seen at the second carpometacarpal articulation involving the opposing articular surfaces (white arrows). (c) Synovitis is seen at the radiocarpal articulation with effusion and bulging synovial recess showing mild synovial thickening. (d) STIR-weighted image showing mixed signal intensity of the lunate bone and cystic nature of the subarticular second carpometacarpal joint lesion (white arrow).|
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|Figure 2: Case 2 (a– c): coronal T1, T2, and short TI inversion recovery (STIR)- weighted images showing hypointense signal in the lunate bone in T1-weighted image (a), T2-weighted image (b), and STIR-weighted image (c) (white arrows), associated with bone island (appearing as hypointense area in capitate bone in T2-weighted image) (arrow head)|
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|Figure 3: Case 3 (a– d): MRI coronal T1-weighted image, coronal T2-weighted image, and short TI inversion recovery (STIR), respectively, show ganglion cyst at the lateral aspect of scaphoid bone showing hypointense signal in T1-weighted image (a) and hyperintense signal in T2-weighted image and STIR (b, c) and extending into its dorsal aspect. It shows multiple septations and mild mural irregularity indicating infl ammatory process (white arrow in c). (d) Minimal effusion is seen at distal radioulnar joint (white arrow).|
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|Figure 4: Case 4 (a– e): coronal T1, T2, short TI inversion recovery (STIR), and sagittal T2-weighted image showing (a) comminuted fracture of distal radius reaching the articular surface (white arrow). (b, c) Partial tear of the TFCC is evidenced by intrasubstance fl uid hyperintense signal in T2 and STIR-weighted image associated with marrow edema seen in STIR-weighted image (white arrows). (d) Volar dislocation of the lunate bone with dorsal tilt of the capitates and consequent VISI deformity seen in sagittal T2-weighted image (white arrow). TFCC, triangular fibrocartilage complex; VISI, volar intercalated segmental instability.|
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|Table 4 Sensitivity of MRI in comparison with NCS (gold standard) in differentiation of different degrees of CTS|
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| Discussion|| |
The anatomy of the wrist is complex and its structures are small, with ligaments and cartilage measuring few millimeters. Evaluation of wrist pain begins with a review of findings from medical history, a detailed physical examination, and plain radiograph. If a diagnosis is not forthcoming, additional diagnostic studies such as ultrasound, computed tomography, and MRI may be obtained  .
MRI is a useful tool in the imaging of the wrist because of its multiplanar, multisequence capability and its excellent resolution of soft tissue structures  .
Our study included 50 patients; this is close to those in the study by Anderson et al.  , which was carried out on 34 patients to determine whether MRI can differentiate between occult ganglion and synovitis in chronic painful wrist. The study included 67.6% female patients and 32.3% male patients, whereas in our study male patients represented 64% of all cases and female patients represented 36%, with age ranging from 17 to 60 years.
According to the study by Van Vugt et al.  , different imaging studies were used systematically to determine the cause of wrist pain, which was subdivided into pain of traumatic or nontraumatic origin. This is in agreement with the aim of our study to evaluate the role of MRI in diagnosis of painful wrist causes, which was subdivided into traumatic and nontraumatic categories that included AVN, ganglia, TFC lesions, ligament lesions, DRUJ subluxation, arthritis, fractures, neoplasm, tendinopathy, and neuropathy.
In our study, all patients showed painful wrist (100%) and other symptoms such as limitation of movement (28%), swellings (18%), and tingling and numbness (10%); history of trauma was recorded in 40% of patients, whereas 60% were without history of trauma. However, in the study by Van Vugt et al.  , patients with wrist pain during activity represented 24%, paresthesia 14%, burning pain at rest 29%, and swellings 57%. History of trauma represented in 10 and 90% were without history of trauma.
In our study, patients with Kienböck disease had ages ranging between 17 and 40 years; similarly, in a study by Horch et al.  mentioned that patients with Kienböck disease had ages ranging between 20 and 35 years.
Cases with AVN of lunate bone appeared normal in plain radiographs in early cases and appeared with increased bone density in advanced cases. This is similar to the study by Seymour and White  , which stated that sclerosis of lunate bone appeared in late cases of AVN.
There was total agreement between our study and Seymour and White  study, reporting that, in MRI, AVN of the lunate (Kienbööck's disease) is manifested in its earliest stage by marrow edema. In advanced stage, the lunate bone had low signal in all pulse sequences. AVN of the scaphoid (Preiser's disease) also showed similar features.
In the study conducted by Hoglund et al.  , ganglion cysts were more common in female patients between the ages 30 and 40 years. This is similar to patients with ganglion cysts who were included in our study; women recorded five patients, whereas men recorded two and their ages ranged between 20 and 60 years. With respect to the study by Hoglund et al.  , the commonest location of ganglion cysts was adjacent to scapholunate ligament representing 60-70%, but they may also occur adjacent to radioscaphoid ligament and the less common sites in the carpal tunnel. However, in our study, four cases were adjacent to scapholunate ligament representing 57.1% of all cases with ganglion cysts, one case related to the tendon of extensor digitorum tendon, and two patients were suggested as intraosseous ganglion cyst in the capitate bone.
In the study conducted by Anderson et al.  concluded that all radiographs of the patients with ganglia in their study were normal in appearance. There was no evidence of soft tissue shadow, calcification, or bone or joint abnormality. This is the same finding in our study.
Tham  , study stated that intraosseous ganglion cysts appeared as a radiolucent area in the carpal bones, whereas in our study the radiograph of the two patients with intraosseous ganglion cyst appeared normal.
Finlay et al.  added that radiographs were used to assess the ulnar variance and to exclude other possible osseous or ligamentous pathology in patients with suspected TFC lesions. This coincides with our study, as the radiograph of our patients with TFC tear showed either ulnar minus, fracture ulnar styloid, distorted scaphoid, abnormal position of distal radius overlapping of DRUJ, or widening space between scaphoid and lunate bones in different cases as mentioned in our results.
Onesen et al.  reported in their study that TFC tears had a linear focus of high signal intensity crossing the low-signal TFC in T2-weighted image, whereas in our study TFC tears had intermediate signal intensity in T2-weighted image crossing low-signal TFC in three cases of degeneration and high signal intensity in T2 in two cases with actual tear approved by arthroscopy.
| Conclusion|| |
MRI has become the preferred modality for imaging patients with internal derangement of the wrist, which includes lesions of the TFCC, scapholunate, and lunotriquetral ligaments.
Results of plain radiographs had been normal or inconclusive in most of nontraumatic wrist pathological lesions in comparison with other modalities. The plain radiography may detect the earliest sign of rheumatoid arthritis in the form of periarticular soft tissue swelling with a fusiform appearance and the late signs in the form of narrowing joint space, bony erosion, and joint deformities and also may help in diagnosis of carpal fractures.
MRI provides unique anatomic information making it an effective modality to determine the cause of the common pathologic lesions of the wrist - for example, AVN, ganglion cysts, TFCC tears, ligamentous tears, DRUJ subluxation, rheumatoid arthritis, fractures, soft tissue masses, tenosynovitis, and CTS.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]