CT Arthrography Research Articles

Evaluation of Rotator Cuff Tendon Tears: Comparison of Multidetector CT Arthrography and 1.5-T MR Arthrography

To compare the diagnostic performance of multidetector computed tomographic (CT) arthrography and 1.5-T magnetic resonance (MR) arthrography in the evaluation of rotator cuff lesions, with arthroscopic correlation. This study was approved by the institutional ethical committee, and informed consent was obtained from all patients. CT and MR arthrographic images prospectively obtained in 56 consecutive patients, following the same arthrographic procedure, were independently evaluated by two radiologists. Arthroscopy, performed within 1 month of the imaging, was used as the reference standard. Sensitivity and specificity of CT and MR arthrography were compared by using the McNemar test. Interobserver and intertechnique agreement for detecting rotator cuff lesions were measured and compared with κ and Z statistics. The Bland-Altman method was used to determine interobserver and intertechnique agreement for measuring tendon tears. For grading fatty infiltration of rotator cuff muscles, κ and Z statistics were used. There was no statistically significant difference in sensitivity and specificity between CT arthrography and MR arthrography in depiction of rotator cuff lesions. The respective sensitivity and specificity of CT arthrography were 92% and 93%-97% for the supraspinatus, 100% and 77%-79% for the infraspinatus, 75%-88% and 85%-90% for the subscapularis, and 55%-65% and 100% for the biceps tendon. The respective sensitivity and specificity of MR arthrography were 96% and 83%-93% for the supraspinatus, 88%-100% and 81%-83% for the infraspinatus, 75%-88% and 90%-100% for the subscapularis, and 65%-85% and 100% for the biceps tendon. Interobserver agreement was substantial to almost perfect (κ = 0.744-0.964 for CT arthrography; κ = 0.641-0.893 for MR arthrography), and intertechnique agreement was almost perfect (κ > 0.819). CT and MR arthrography both yielded moderate interobserver and intertechnique agreement for measuring rotator cuff tears and grading muscle fatty infiltration. Data suggest that CT and MR arthrography have similar diagnostic performance for the evaluation of rotator cuff tendon tears.

Paper 28: The Usefulness of Multidetector CT Arthrography in the Diagnosis of Shoulder Pathology

The Usefulness of Multidetector CT Arthrography in the Diagnosis of Shoulder Pathology

Immediate passive motion versus immobilization after endoscopic supraspinatus tendon repair: A prospective randomized study

Rehabilitation programs after rotator cuff repair should allow recovery of shoulder function without preventing tendon healing. The aim of this randomized prospective study was to compare the clinical results after two types of postoperative management: immediate passive motion versus immobilization. We followed 100 patients, mean age 55 years old, who underwent arthroscopic repair of a non-retracted supraspinatus tear. Patients were randomized to receive postoperative management of immediate passive motion or strict immobilization for 6 weeks. A clinical evaluation was performed in 92 patients, and CT arthrography in 82. Mean follow-up was 15 months. The mean preoperative Constant score improved significantly from 46.1 points to 73.9 at the final follow-up. The rate of intact cuffs was 58.5%. Functional results were statistically better after immediate passive motion with a mean passive external rotation of 58.7° at the final follow-up versus 49.1° after immobilization (P=0.011), a passive anterior elevation of 172.4° versus 163.3° (P=0.094) respectively, a Constant score of 77.6 points versus 69.7 (P=0.045) respectively, and a lower rate of adhesive capsulitis and complex regional pain syndrome. Results for healing seemed to be slightly better with immobilization, but this was not statistically significant: the cuff had a normal appearance in 35.9% of cases after immobilization compared to 25.6% after passive motion, an image of intratendinous addition was found in 25.6% versus 30.2%, punctiform leaks in 23.1% versus 20.9%, and recurrent tears in 15.4% versus 23.3% respectively. The rehabilitation program that results in better tendon healing by preventing postoperative stiffness has not yet been identified. Our results suggest that early passive motion should be authorized: the functional results were better with no significant difference in healing.

C-arm flat-panel CT arthrography of the wrist and elbow: first experiences in human cadavers

To determine the optimal intra-articular iodine concentration for C-arm flat-panel computed tomography (FPCT) arthrography using advanced joint phantoms and to evaluate its application in human cadaveric wrists and elbows. Multi-detector (MD) CT served as the standard of reference. Joint phantoms and 10 human cadaveric wrist and elbow joints were scanned with C-arm FPCT (5-s, 8-s, and 20-s runs) and standard MDCT using different and optimal concentrations of iodinated contrast material. CT numbers of contrast material, tissue, and noise were measured and contrast-to-noise ratios (CNR) calculated for quantitative analysis. Image and depiction of cartilage, bone, and soft tissues were rated. Radiation doses were compared. In FPCT, iodine concentrations positively correlated with CT numbers and noise of contrast material and with radiation dose (r = 0.713-0.996, p < 0.05 each). At an iodine concentration of 45 mg/ml, CNR of cartilage and soft tissues were highest for all FPCT acquisitions and higher than in MDCT. The 20-s FPCT run performed best for image quality and depiction of anatomical structures and was rated overall equal to MDCT (p = 0.857). The optimal iodine concentration for C-arm FPCT arthrography in this study is 45 mg/ml, leading to superior CNR and image quality for an optimal FPCT protocol compared with standard MDCT arthrography in human cadaveric joints.

Usefulness of intra-articular bupivacain and lidocain adjunction in MR or CT arthrography: A prospective study in 148 patients

PurposeTo evaluate the influence of shorter- and longer-acting intra-articular anaesthetics on post-arthrographic pain. Materials and methods154 consecutive patients investigated by MR or CT arthrographies were randomly assigned to one of the following groups: 1 – intra-articular contrast injection only; 2 – lidocain 1% adjunction; or 3 – bupivacain 0.25% adjunction. Pain was assessed before injection, at 15min, 4h, 1 day and 1 week after injection by visual analogue scale (VAS). ResultsAt 15min, early mean pain score increased by 0.96, 0.24 and 0 in groups 1, 2 and 3, respectively. Differences between groups 1 & 3 and 1 & 2 were statistically significant (p=0.003 and 0.03, respectively), but not between groups 2 & 3 (p=0.54). Delayed mean pain score increase was maximal at 4h, reaching 1.60, 1.22 and 0.29 in groups 1, 2 and 3, respectively. Differences between groups 1 & 2 and 2 & 3 were statistically significant (p=0.002 and 0.02, respectively), but not between groups 1 & 2 (p=0.46). At 24h and 1 week, the interaction of local anaesthetics with increase in pain score was no longer significant. Results were independent of age, gender and baseline VAS. ConclusionIntra-articular anaesthesia may significantly reduce post-arthrographic pain. Bupivacain seems to be more effective than lidocain to reduce both early and delayed pain.

Interobserver and Intraobserver Reliability of the Goutallier Classification Using Magnetic Resonance Imaging

Background: The Goutallier classification of fatty infiltration of the rotator cuff was developed for use in axial computed tomography arthrography. Now the Goutallier classification is being used with magnetic resonance imaging (MRI). Not only is there debate on the validity of the use of this system in MRI, but current literature is unclear as to the clinical use of the Goutallier classification. Hypothesis: There will be significant inter- and intraobserver variability of the Goutallier classification grading system for patients with chronic rotator cuff tears. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: An online database consisting of 35 single MRI images from 35 patients with chronic rotator cuff tears was designed and sent to members of the American Shoulder and Elbow Society. Surgeons were asked to identify the stage of rotator cuff fatty infiltration using the Goutallier classification system. Thirty surgeons responded and completed the survey in its entirety. At a minimum of 2 months later, 28 of the 30 initial respondents completed evaluations of the same online database. The responding surgeons were divided dichotomously according to their demographics and the interobserver reliability of the groups compared. A kappa analysis was performed to determine inter- and intraobserver reliability using 95% confidence intervals (95% CIs). A simplified 3-tiered classification was proposed combining Goutallier grades 0 and 1 as well as grades 2 and 3. Results: Statistical analysis of all respondent data demonstrated moderate intraobserver variability with a κ value of 0.56 (95% CI, 0.53-0.60). In addition, moderate interobserver variability was shown with a κ value of 0.43 (range, 0.16-0.74). With the simplified classification, intraobserver reliability was 0.70 (95% CI, 0.66-0.74) and interobserver reliability was 0.61 (range, 0.21-0.87). Correlation analysis showed no correlation with the presence or absence of fellowship training or board certification with either the Goutallier classification or the proposed modification (P > .05). Sports versus shoulder/elbow fellows had statistically better intraobserver variability (κ = 0.63 vs 0.50) with the Goutallier classification. Years in practice was negatively correlated with the level of agreement for both classifications (–r value, P < .05). The number of rotator cuff repairs performed per year negatively correlated with the level of agreement in the proposed modification only (r = −0.44, P = .022). Percent of practice dedicated to the shoulder did not correlate significantly with either classification (P > .05). Conclusion: There is significant inter- and intraobserver variability observed among experienced shoulder surgeons using the Goutallier classification for assessing fatty infiltration of the rotator cuff muscles after chronic rotator cuff tears. Respondents were more likely to agree with themselves than with other respondents. A simplification of the MRI classification system is proposed that takes into consideration the variability determined by this study.

Change in labrum height after arthroscopic Bankart repair: correlation with preoperative tissue quality and clinical outcome

Arthroscopic factors, such as labral and capsular tissue quality or anterior labral periosteal sleeve avulsion (ALPSA) lesion, affect postoperative labral height stability. Labral height stability has a correlation with clinical outcome. The study included 40 patients who underwent arthroscopic surgery for a Bankart lesion between August 2005 and May 2009. The mean follow-up and patient age were 29.1 ± 10.9 months (range, 15-60 months) and 24.7 ± 8.4 years (range, 12-55 years), respectively. Labral and capsular tissue quality, ALPSA lesions, Hill-Sachs lesions, glenoid erosion, and superior labrum anterior-posterior tears were identified by arthroscopic examination. Stepwise postoperative computed tomography arthrography to estimate the labral height was performed at 3 months and 1 year. Correlation of postoperative 1 year Rowe scores with labral height maintenance was statistically significant (P < .01). Correlation of Rowe scores at 1 year postoperatively with labral height at 1 year postoperatively was also statistically significant (P < .01). The mean postoperative labral height at 3 months and at 1 year was 5.13 ± 1.56 mm (range, 2.9-8.8 mm) and 4.69 ± 1.75 mm (range, 1.6-8.5 mm), respectively (P < .01). The decrease in labral height at 1 year after surgery was significant in those patients with ALPSA lesions, Hill-Sachs lesions, and a poor labrum along with a poor capsule (P < .01). The patients with less labral height decrease between 3 months and 1 year or higher labral height at 1 year postoperatively showed higher Rowe scores at 1 year postoperatively. Shoulders with ALPSA lesions, Hill-Sachs lesions, and a poor labrum with poor capsular tissue quality correlated more strongly with postoperative labral height decrease.

Measuring cartilage quality with CT arthrography

Measuring cartilage quality with CT arthrography

Delayed Computed Tomography Arthrography of Human Knee Cartilage In Vivo.

Objective:We investigated the feasibility of delayed computed tomography (CT) arthrography for evaluation of human knee cartilage in vivo. Especially, the diffusion of contrast agent out of the joint space and the optimal time points for imaging were determined.Design:Two patients were imaged using delayed CT arthrography and delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) techniques.Results:Two hours after injection, the concentration of contrast agent in the joint space was still high enough (20% to 24.5% of the initial concentration at 0 minutes) to allow delayed CT arthrography. The half-life of the contrast agent in the joint space varied from 30 to 60 minutes. The contrast agent concentration in patellar and femoral cartilage reached the maximum after 30 and 60 minutes, respectively. According to dGEMRIC, there were no differences between patients. However, in delayed CT arthrography, the penetration of the contrast agent was higher in the osteoarthritic knee cartilage.Conclusions:Contrast agent remained in the joint space long enough to enable delayed CT arthrography of cartilage. After 30 minutes, the normalized contrast agent concentration was higher in the cartilage of the osteoarthritic knee in comparison with the healthy knee. To conclude, delayed CT arthrography exhibited potential for use in the clinical evaluation of cartilage integrity.

Synovial fluid dynamics with small disc perforation in temporomandibular joint

The articular disc plays an important role as a stress absorber in joint movement, resulting in stress reduction and redistribution in the temporomandibular joint (TMJ). The flow of synovial fluid in the TMJ may follow a regular pattern during movement of the jaw. We hypothesised that the regular pattern is disrupted when the TMJ disc is perforated. By computed tomography arthrography, we studied the upper TMJ compartment in patients with small disc perforation during jaw opening-closing at positions from 0 to 3 cm. Finite element fluid dynamic modelling was accomplished to analyse the pattern of fluid flow and pressure distribution during the movements. The results showed that the fluid flow in the upper compartment generally formed an anticlockwise circulation but with local vortexes with the jaw opening up to 2 cm. However, when the jaw opening-closing reached 3 cm, an abnormal flow field and the fluid pressure change associated with the perforation may increase the risk of perforation expansion or rupture and is unfavourable for self-repair of the perforated disc.

Computational synovial dynamics of a normal temporomandibular joint during jaw opening

Synovial fluid in the temporomandibular joint (TMJ) acts as a lubricant and shock absorber, facilitating smooth jaw movements by reducing friction and cushioning the articular cartilage and other tissues in the TMJ. This study investigated the flow pattern of synovial fluid in the articular cavity during jaw opening. The upper TMJ compartment in a healthy individual was studied by computed tomography arthrography, and the intra-articular pressures were measured during jaw opening. The compartment was reconstructed in three dimensions, and finite volume fluid dynamic modeling was used to analyze the pattern of fluid flow and pressure distribution during jaw movements. In a closed-jaw position, the upper joint compartment assumed a dumbbell shape. During the jaw opening process, the anterior portion of the upper compartment decreased gradually until it disappeared completely when the jaw was opened. As the jaw opened, the posterior space enlarged gradually. During jaw opening, the pressure in the anterior space of the upper compartment was higher than that in the posterior space. The model indicated that synovial fluid circulated anticlockwise, forming local vortices in both anterior and posterior spaces. During jaw opening processes, the three dimensional configuration of a normal upper TMJ compartment changed as the joint disc moved, with the synovial fluid circulating in an anticlockwise direction and local vortices forming.

Unusual cause of internal knee derangement.

A 25-year-old man was referred to our department by the orthopaedic surgeon for intermittent pain at the medial compartment of his knee after a rugby match. There was no history of direct trauma. At clinical examination the internal compartment was tender. There was no instability or blockage at clinical tests. A computed tomo - graphy arthrography (CTA) examination was performed in order to rule out a lesion at the medial knee compartment.

Flat-Panel CT Arthrography

To show the feasibility of flat-panel computed tomography (FPCT) arthrography and quantitatively and qualitatively compare different FPCT protocols with standard multidetector computed tomography (MDCT). First, a phantom simulating joint space with increasing iodine concentrations was scanned using a standard MDCT and 3 different FPCT protocols. Quantitative analyses were performed by measuring CT numbers of iodine dilutions, radiation dose, and image noise as well as signal-to-noise ratio and contrast-to-noise ratio. Second, FPCT arthrographies of 4 animal joint specimens were performed and analyzed qualitatively by 2 independent readers who evaluated image artifacts, image noise, overall image quality and anatomic depiction of bone, cartilage, and soft tissue. Kappa values were calculated for inter-reader agreement. Pearson's correlation coefficient (r) and Wilcoxon signed-ranks test with Bonferroni corrections for multiple comparisons were used to compare MDCT and FPCT. In phantoms, all CT scans showed a linear correlation between increasing iodine concentrations and mean HU values of contrast media and radiation dose, respectively (r = 0.98-0.99, P < 0.01). Dose-length product remained constant for MDCT scans. Signal-to-noise ratio for phantom water linearly decreased in all FPCT scans with increasing iodine concentrations. Contrast-to-noise ratio curves showed reduced slope at iodine concentrations higher than 75 mg/mL. FPCT arthrography after intra-articular administration of 5 to 6 mL of a 25% dilution of iopromide (Ultravist 300 mg/mL, Bayer HealthCare, Berlin, Germany) was successfully performed in all 4 animal joint specimens. Kappa values for inter-reader agreement of qualitative image analyses were 0.62 to 0.91. Image and depiction quality of 20-s FPCT scans were similar or superior compared with standard MDCT (P < 0.005). FPCT arthrography is feasible and may allow similar image quality compared with standard MDCT arthrography.

The diagnostic test accuracy of magnetic resonance imaging, magnetic resonance arthrography and computer tomography in the detection of chondral lesions of the hip

The purpose of this study was to assess the diagnostic test accuracy of magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA) and multidetector arrays in CT arthrography (MDCT) for assessing chondral lesions in the hip joint. A review of the published and unpublished literature databases was performed to identify all studies reporting the diagnostic test accuracy (sensitivity/specificity) of MRI, MRA or MDCT for the assessment of adults with chondral (cartilage) lesions of the hip with surgical comparison (arthroscopic or open) as the reference test. All included studies were reviewed using the quality assessment of diagnostic accuracy studies appraisal tool. Pooled sensitivity, specificity, likelihood ratios and diagnostic odds ratios were calculated with 95% confidence intervals using a random-effects meta-analysis for MRI, MRA and MDCT imaging. Eighteen studies satisfied the eligibility criteria. These included 648 hips from 637 patients. MRI indicated a pooled sensitivity of 0.59 (95% CI: 0.49-0.70) and specificity of 0.94 (95% CI: 0.90-0.97), and MRA sensitivity and specificity values were 0.62 (95% CI: 0.57-0.66) and 0.86 (95% CI: 0.83-0.89), respectively. The diagnostic test accuracy for the detection of hip joint cartilage lesions is currently superior for MRI compared with MRA. There were insufficient data to perform meta-analysis for MDCT or CTA protocols. Based on the current limited diagnostic test accuracy of the use of magnetic resonance or CT, arthroscopy remains the most accurate method of assessing chondral lesions in the hip joint.

Three-dimensional patterns of early acetabular cartilage damage in hip dysplasia; a high-resolutional CT arthrography study

The purpose of this study was to examine the three-dimensional (3D) progression patterns of early acetabular cartilage damage in hip dysplasia using high-resolutional computed tomography (CT) arthrography. Thirty-two dysplastic hips of 26 Japanese symptomatic females including 21 hips in pre-stage of osteoarthritis (Kellgren-Lawrence (K-L) grade 0; mean patient age, 32.0 years) and 11 hips in early stage of osteoarthritis (K-L grade 1 or 2; mean patient age, 32.8 years) were examined. Isotropic high-resolutional CT arthrography with an image resolution of 0.5 mm in any orthogonal direction was performed. A 3D acetabular cartilage model was generated and we evaluated distribution of cartilage thickness in 12 zones after dividing the weight-bearing area of the hip joint in radial and lateral/medial directions. In pre-stage of osteoarthritis, significant differences in cartilage thickness were observed between the lateral and medial zones in all radial regions, most prominently in the antero-superior region. In early stage of osteoarthritis, no significant differences in cartilage thickness were observed, except in the most posterior region. The lateral-medial (LM) ratio was defined as cartilage thickness in the lateral zone divided by that in the medial zone, and hips with the LM ratio in the antero-superior region of <1.4 had significantly more extensive involvement of labral tears than hips with the LM ratio of ≥1.4. In hip dysplasia, acetabular cartilage damage was probably occurred in the antero-superior lateral area. The LM ratio may be a sensitive index to quantify early cartilage damage associated with extent of labral disorders.

Associations of hip dysplasia and FAI on modes of acetabular labral tears -3 dimensional analysis by high-resolution CT arthrography-

s / Osteoarthritis and Cartilage 20 (2012) S54–S296 S214 men and 19% inwomen. In men the mean (SD) extrusion of the medial and lateral meniscus body was 3.0 (1.7) mm and 2.1 (1.3) mm, respectively. In women corresponding mean values were 2.9 (1.6) mm and 1.9 (1.3) mm. The absolute value of medial meniscal extrusionwas associatedwith TF OA and meniscal damage (Tables and Figure). In the multivariable regression models, medial meniscal damage was strongly associated with higher absolute value for medial meniscal extrusion in both men and women irrespective of TF OA status (p<0.001). In men without OA older age was associated with higher value of extrusion (p<0.004). In men and women with OA, higher BMI was associated with more medial meniscal extrusion (p<0.02).

CT arthrography of the human knee to measure cartilage quality with low radiation dose

Recently, CT arthrography (CTa) was introduced as a non-destructive technique to quantitatively measure cartilage quality in human knees. This study investigated whether this is also possible using lower radiation dose CT protocols. Furthermore, we studied the ability of (lower radiation) CTa to distinguish between local sulphated glycosaminoglycan (sGAG) content differences. Of ten human cadaveric knee joints, six CT scans using different radiation doses (81.33-8.13 mGy) were acquired after intra-articular ioxaglate injection. The capability of CTa to measure overall cartilage quality was determined in seven anatomical regions of interest (ROIs), using equilibrium partitioning of an ionic contrast agent using (EPIC)-microCT (μCT) as reference standard for sGAG content. To test the capability of CTa to spatially distinguish between local differences in sGAG content, we calculated the percentage of pixels incorrectly predicted as having high or low sGAG content by the different CTa protocols. Low radiation dose CTa correlated well with EPIC-μCT in large ROIs (R = 0.78; R(2) = 0.61; P < 0.0001). CTa can also distinguish between high and low sGAG content within a single slice. However, the percentage of incorrectly predicted quality pixels increases (from 35% to 41%) when less radiation is used. This makes is hard or even impossible to differentiate between spatial differences in sGAG content in the lowest radiation scans. CTa acquired using low radiation exposure, comparable to a regular knee CT, is able to measure overall cartilage quality. Spatial sGAG distribution can also be determined using CTa, however for this purpose a higher radiation dose is necessary. Nevertheless, radiation dose reduction makes CTa suitable for quantitative analysis of cartilage in clinical research.

Superior Labral Anterior-to-Posterior Lesions: Comparison of External Rotation and Active Supination CT Arthrography with Neutral CT Arthrography

To compare the diagnostic performance of computed tomographic (CT) arthrography performed with external rotation and active supination (ERAS) with that of CT angiography performed in the neutral position for superior labral anterior-to-posterior (SLAP) lesions. Institutional review board approval and informed consent were obtained. CT arthrography in neutral and ERAS positions was performed in 49 shoulders of 47 patients, with subsequent arthroscopic confirmation of the status of the superior labrum. Two musculoskeletal radiologists (1 and 8 years of experience) reviewed images and expressed the likelihood of SLAP lesions by using a continuous scale; they also measured gap widths and depths of labral detachment. Overall performances for the detection of SLAP lesions were determined with receiver-operating characteristic (ROC) analysis. Gap widths and depths measured with the two types of CT arthrography were also compared. For reader 1, area under the ROC curve increased insignificantly from 0.932 in the neutral position to 0.974 in the ERAS position (P = .210), whereas for reader 2, it increased significantly from 0.914 to 0.984 (P = .032). Mean gap width of SLAP lesion was significantly greater according to ERAS CT arthrography (3.98 mm ± 2.48 [standard deviation] vs 1.61 mm ± 1.11), whereas mean gap depth was not significantly different. Gap width and depth cutoff values for the detection of a SLAP lesion with ERAS CT arthrography were 1.7 mm and 1.6 mm, respectively. ERAS CT arthrography might improve the detection of SLAP lesions compared with neutral-position CT arthrography.

MR and CT Arthrography of the Hip

CT arthrography (CTa) and MR arthrography (MRa) are useful tools for the investigation of intra-articular hip disease. They are minimally invasive techniques with a very low rate of complications and can be performed safely. CTa or MRa can be performed after an intra-articular injection of diluted contrast, but both techniques can also be performed after a single injection. As radiologists we should be able to address the surgeon's questions and work together to standardize terminology and classifications systems for accurate reporting. This update emphasizes radiological findings with a clinical perspective. CTa and MRa allow the precise diagnosis of labral tears, loose bodies, and intra-articular ligaments (capsular and ligamentum teres). The use of careful technique and a tailored protocol has improved our ability to detect and describe cartilage lesions. This is essential because knowledge of the status of the cartilage may dictate a specific surgical approach, and when cartilage lesions are extensive, they are a negative prognostic indicator for arthroscopic treatment.

MR and CT Arthrography of the Wrist

The study of the wrist represents a major diagnostic challenge because of its complex anatomy and the small size of individual structures. Recent advances in imaging techniques have increased our diagnostic capabilities. However, 3T magnets, multichannel specific wrist coils, and new MRI sequences have not restricted the indications of arthrographic imaging techniques (CT arthrography and MR arthrography). Distension of the different wrist compartments at CT arthrography and MR arthrography significantly improves the diagnostic accuracy for triangular fibrocartilage (TFC) complex injuries and carpal instability. Dedicated multichannel wrist coils are essential for an adequate study of the wrist, but the placement of these coils and the positioning of the wrist are also important for proper diagnosis. The development of dynamic multislice CT studies allows a diagnostic approach that combines dynamic information and the accurate assessment of ligaments and the TFC complex. New advances in arthroscopy have changed the anatomical description of the TFC with a functional division in the proximal and distal TFC complex, and they have allowed a better characterization of lesions of the TFC complex with subclassification of Palmer 1B and 1D lesions and description of new lesions not included in the Palmer classification, such as capsular injuries.