Wrist Arthrography Research Articles

The Use of Cone-Beam Computed Tomography (CBCT) Arthrography for Wrist Ligamentous Injuries - A Diagnostic Test Accuracy Meta-analysis.

Background: Diagnosis of ligamentous wrist injuries can be challenging with the absence of dynamic instability on radiographs. Our aim was to evaluate the accuracy of cone-beam computed tomography (CBCT) arthrography in diagnosing scapholunate ligament (SLL), lunotriquetral ligament (LTL) and triangular fibrocartilage complex (TFCC) injuries. Methods: A systematic review and literature search were conducted in compliance with Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) and registered at the International Prospective Register of Systematic Reviews, PROSPERO (CRD42024517655). A mixed-effects logistic regression bivariate model was used to estimate summary sensitivity and specificity, and hierarchical summary receiver operating characteristic (HSROC) curves were constructed to determine diagnostic accuracy of CBCT arthrography. Results: We identified five studies assessing the accuracy of CBCT arthrography against wrist arthrography or intraoperative findings as reference standard. The pooled estimates for sensitivity and specificity of CBCT arthrography was 93% (95% CI 40-100) and 91% (95% CI 81-96) for SLL injuries, 83% (95% CI 37-98) and 64% (95% CI 42-81) for LTL injuries and 78% (95% CI 57-91) and 80% (95% CI 54-93) for TFCC injuries. The area under the curve was 0.91 (95% CI 0.89-0.94), showing an excellent diagnostic accuracy of CBCT arthrography in SLL injuries. CBCT arthrography had an estimated mean effective dose of 3.2 mSv (2.0-4.8). Conclusions: Our study confirms that CBCT arthrography has an excellent diagnostic accuracy for wrist ligamentous injuries with comparably high sensitivity to conventional arthrography and a better specificity. While further studies with more robust methodology are required to support its implementation in clinical practice, our analysis shows that it is a reliable option and has a promising future. Level of Evidence: Level III (Diagnostic).

Assessing the scapholunate and lunotriquetral interosseous ligament in MR arthrography: Diagnostic advantages of paraxial reformatting

PurposeThe scapholunate (SLIL) and lunotriquetral interosseous ligament (LTIL) function as the main stabilizers of the proximal carpal row. Even with MR arthrography, component assessability is often limited in orthogonal standard planes due to their horseshoe-like shape and resulting partial volume effects. This study aims to investigate the diagnostic value of reformatting isotropic 3D sequences with respect to the anatomical orientation of the intrinsic carpal ligaments. MethodIn 110 MR arthrograms of the wrist, we investigated the diagnostic accuracy of two radiologists (R1/R2) for SLIL and LTIL injuries in orthogonal standard planes vs. ancillary angulated reformatting of isotropic 3D dual echo steady state sequence. Component assessability and diagnostic confidence were compared between datasets. ResultsThe addition of paraxial reformations improved diagnostic accuracy for lesions of the palmar (R1: 0.87 vs. 0.93; R2: 0.86 vs. 0.93; all p < 0.05) and dorsal LTIL (R1: 0.85 vs. 0.93; R2: 0.82 vs. 0.90; all p < 0.05). No significant increase in accuracy could be ascertained for palmar (R1: 0.92 vs. 0.94, p = 0.50; R2: 0.86 vs. 0.92, p = 0.07) and dorsal (R1: 0.95 vs. 0.95, p = 1.00; R2: 0.90 vs. 0.94, p = 0.29) lesions of the SLIL. Interrater reliability was almost perfect with and without angulated planes for SLIL (κ = 0.88 vs. 0.82) and LTIL assessment (κ = 0.88 vs. 0.86). For the LTIL, observer confidence and component assessability were superior with anatomical reformations available (all p < 0.05). ConclusionsIn contrast to SLIL injuries, diagnosis of LTIL lesions benefits from ancillary paraxial reformations of 3D sequences in MR wrist arthrography.

How we decide when to immobilize the wrist after stable osteosynthesis of displaced distal radius fracture.

Fractures of the distal radius are frequently associated with injuries of the scapholunate (SL) and lunotriquetral (LT) ligaments. Our study is aimed at revealing their hidden lesions by employing a fast and accessible fluoroscopic identification. We investigated 40 patients who were indicated for plate osteosynthesis of distal radius fracture. After completing the osteosynthesis, the procedure was concluded with a wrist arthrography. The patients with SL and LT interval lesions had their wrists immobilized by a plaster splint while patients with normal findings with an elastic bandage. The patients were followed up for 12 months after the surgery. The functional results were evaluated by Mayo wrist score. The intra-operative examination identified 62.5 % of patients with lesions of SL and/or LT interval, and 37.5 % of patients were lesion-free. The Mayo wrist scores after 3, 6 and 12 months in patients whose wrists were not immobilized were 72, 86.3, and 86.3, respectively. The latter scores in the group of patients with external immobilization were 54.4, 82, and 84.8, respectively. The difference between the groups was significant three months after the surgery. After six and twelve months, the difference became negligible. The exclusion of hidden lesions allows earlier rehabilitation, while in patients with signs of lesions, it is appropriate to immobilize the wrist (Tab. 1, Fig. 3, Ref. 31). Text in PDF www.elis.sk Keywords: distal radius fractures, scapholunate ligament, lunotriquetral ligament, fluoroscopic, diagnosis.

The importance of radial multiplanar reconstructions for assessment of triangular fibrocartilage complex injury in CT arthrography of the wrist

BackgroundTriangular fibrocartilage complex (TFCC) lesions commonly cause ulnar-sided wrist pain and instability of the distal radioulnar joint. Due to its triangular shape, discontinuity of the TFCC is oftentimes difficult to visualize in radiological standard planes. Radial multiplanar reconstructions (MPR) may have the potential to simplify diagnosis in CT wrist arthrography. The objective of this study was to assess diagnostic advantages provided by radial MPR over standard planes for TFCC lesions in CT arthrography.MethodsOne hundred six patients (49 women, 57 men; mean age 44.2 ± 15.8 years) underwent CT imaging after wrist arthrography. Two radiologists (R1, R2) retrospectively analyzed three randomized datasets for each CT arthrography. One set contained axial, coronal and sagittal planes (MPRStandard), while the other two included an additional radial reconstruction with the rotating center either atop the ulnar styloid (MPRStyloid) or in the ulnar fovea (MPRFovea). Readers evaluated TFCC differentiability and condition. Suspected lesions were categorized using Palmer’s and Atzei’s classification and diagnostic confidence was stated on a five-point Likert scale.ResultsCompared to standard planes, differentiability of the superficial and deep TFCC layer was superior in radial reconstructions (R1/R2; MPRFovea: p < 0.001; MPRStyloid: p ≤ 0.007). Palmer and Atzei lesions were present in 86.8% (92/106) and 52.8% (56/106) of patients, respectively. Specificity, sensitivity and accuracy for central Palmer lesions did not differ in radial and standard MPR. For peripheral Atzei lesions, sensitivity (MPRStandard 78.6%/80.4%, MPRStyloid 94.6%/94.6%, MPRFovea 91.1%/89.3%) and accuracy (MPRStandard 86.8%/86.8%, MPRStyloid 96.2%/96.2%, MPRFovea 94.3%/93.4%) improved with additional styloid-centered (p = 0.004/0.008) and fovea-centered (p = 0.039/0.125) reconstructions. No substantial difference was observed between both radial MPR (p = 0.688/0.250). Interrater agreement was almost perfect for each dataset (κStandard = 0.876, κStyloid = 0.894, κFovea = 0.949). Diagnostic confidence increased with addition of either radial MPR (p < 0.001).ConclusionsAncillary radial planes improve accuracy and diagnostic confidence for detection of peripheral TFCC lesions in CT arthrography of the wrist.

The Relevance of Ulnar-Sided Contrast Extravasation During Radiocarpal Joint Wrist Arthrography.

Contrast material often extends from the radiocarpal joint into the proximal soft tissues adjacent to the ulnar aspect of the ulnar styloid during single-compartment radiocarpal joint MR arthrography of the wrist. The hypothesis of this study was that this is a common finding unrelated to symptoms or examination technique. Wrist MR arthrograms were retrospectively reviewed in consensus by two radiologists. The presence or absence of ulnar-sided contrast extravasation was documented, whether this extravasation appeared contained or dispersed, as was the overall degree of proximal extension of the extravasated contrast material. Patient age, sex, wrist sidedness, volume of contrast material administered, location of symptoms reported clinically, and aberrant contrast material also apparent within the midcarpal space or distal radioulnar joint on the MR images reviewed were documented to determine potential association with ulnar-sided contrast extravasation. Ninety-nine examinations met the inclusion criteria. Ulnar-sided contrast extravasation after single-compartment radiocarpal joint injection was present in 56 of the 99 wrists (57%). This finding was statistically more common in right versus left wrists. No other statistically significant associations were identified. Contrast extravasation along the ulnar aspect of the distal ulna after single-compartment radiocarpal joint injection is common. In this study it had no statistically significant association with the location of a patient's wrist pain or abnormal findings evaluated at MR arthrography.

Comparison of the sensitivity of wrist arthrography and subsequent MRA in the detection of inter-joint communications

Purpose: Plain film arthrography of the wrist (PFA) is often performed at time of injection prior to magnetic resonance arthrography (MRA). Controversy exists as to whether single or multiple injection sites confer optimal diagnostic sensitivity. We investigated the degree to which the time period between MRA and pre-MRA wrist arthrogram improves the detection of inter-joint communications. The improvement in sensitivity of MRA over PFA was compared with that previously reported for multiple-injection PFA.

SPECT/CT arthrography of the wrist in ulnocarpal impaction syndrome

Ulnar-sided wrist pain is a diagnostic challenge for hand surgeons and radiologists due to the complex anatomy of the involved small structures. Along with the clinical history and physical examination, imaging is important in the evaluation of ulnar-sided wrist pain [1–4]. Ulnocarpal impaction syndrome can lead to severe damage to the cartilage, triangular fibrocartilagecomplex (TFCC) and bone. The new generation of SPECT/CT devices allow SPECT and high-resolution CT imaging of the wrist with a spatial resolution of 0.33 mm in one imaging step [5]. CT arthrography of the wrist is a wellestablished investigation [6]. Combining wrist arthrography (arrowheads intraarticular contrast medium) and SPECT/CT (Arthro-SPECT/CT) offers a one-stop shop imaging approach for patients with ulnocarpal impaction. In our 63-year-old male patient with ulnar-sided wrist pain for 3 months, Arthro-SPECT/CT demonstrated severe osteoarthritis of the distal radioulnar joint (DRUJ), profound damage to the cartilage of the ulnotriquetral joint (short arrow) and a large defect in the central part of the TFCC (short arrow). Concomitant increased uptake was observed in the triquetral bone (long arrow )a nd DRUJ. Arthro-SPECT/CT of the wrist is feasible and offers unique anatomic and metabolic information to the hand surgeon in patients with ulnar-sided wrist pain. Arthro-SPECT/CTseems to be a promising alternative to wrist MRI. Conflicts of interest None.

Lateral Approach for Radiocarpal Wrist Arthrography

We describe a technique of radiocarpal arthrography using the lateral approach. This technique may be used as an alternative to conventional dorsal techniques. Radiocarpal injection using the lateral approach can be considered as an alternative to conventional dorsal approaches in the evaluation of wrist pain and instability.

Arthrographische Darstellung von Ganglien im Handbereich

In the genesis of ganglions synovial herniation is discussed with an existence of a valve mechanism which prevents the synovial fluid from returning into the joint space. Arthrography of the wrist was performed in 34 patients with suspicion of ganglions on the dorsal and volar aspect of the wrist. By injection of contrast medium in 6 cases directly into the ganglion no connection with the carpal joint cavity was seen. On the contrary, wrist arthrography with examination of the midcarpal and radiocarpal joint showed regularly a communication by a torturous narrow duct between the midcarpal joint and the dorsal ganglion and the radiocarpal joint and the volar ganglion. Other pathologic findings were seen, like tears of the scapholunate ligament and of the triangular fibrocartilage. The consequences for surgical therapy and conclusions for the aetiology of the ganglions are shown.

Axial oblique MR imaging of the intrinsic ligaments of the wrist: initial experience

To evaluate two separate MR sequences acquired in the axial oblique plane, parallel to the long axis of the scapholunate (SL) and lunotriquetral (LT) ligaments, to determine whether the addition of these sequences to the standard MR wrist examination improves visualization of the intrinsic ligaments, and the evaluation of their integrity. To our knowledge, this plane has not been described in the literature previously. In total we evaluated 26 patients with chronic wrist pain or instability, referred for MR imaging following assessment by an orthopedic surgeon or physiatrist. All patients underwent initial conventional tri-compartment wrist arthrography, which served as the reference standard. This was immediately followed by MR arthrography, in the standard coronal and true axial planes, as well as in the axial oblique plane. The SL and LT ligaments were initially assessed for the presence or absence of tear, using the standard coronal and true axial sequences, and subsequently re-evaluated with the addition of the axial oblique planes. A total of ten intrinsic ligament tears were identified with conventional arthrography: six SL and four LT tears. Five of the six SL tears were identified on the standard sequences. All six were diagnosed with the addition of the oblique sequences. There were three false-positive SL tears identified using standard MR imaging, and two false-positives with the addition of the oblique sequences. No LT tear was identified on standard sequences, whereas all four were confidently seen with the addition of oblique images. No false-positives of the LT ligament were recorded with either standard or axial oblique sequences. The study suggests that the addition of axial oblique MR sequences helps identify tears to the intrinsic ligaments of the wrist, particularly the LT ligament. In addition, the axial oblique images assist in localization of the tear.

Wrist arthrography: a simple method

A technique of wrist arthrography is presented using an adhesive marker-plate with radiopaque coordinates to identify precisely sites for puncture arthrography of the wrist and to obviate the need for fluoroscopic guidance. Radiocarpal joint arthrography was performed successfully in all 24 cases, 14 in the cadaveric wrists and 10 in the live patients. The arthrographic procedure described in this study is simple, safe, and rapid, and has the advantage of precise localisation of the site for puncture without need for fluoroscopic guidance.

Validation of the extensor carpi ulnaris groove as a predictor for the recognition of standard posteroanterior radiographs of the wrist

This study was designed to establish the extensor carpi ulnaris groove (ECUG) as a reliable radiographic criterion for recognition of true neutral posteroanterior (PA) radiographs and to verify precise measurements of ulnar variance in a large cohort of patients. In 197 patients 197 wrists were evaluated with a series of radiographic views obtained during routine wrist arthrography. Posteroanterior views were taken in all patients at 90 degrees, 45 degrees, and 0 degrees arm abduction and in 171 patients at 90 degrees elbow flexion and 90 degrees arm abduction with full elbow extension. The ECUG position was classified according to its profile with the ulnar styloid as excellent, acceptable, or unacceptable. Ulnar variance was measured on all x-ray films. Statistical analysis included interobserver reliability with 100 x-ray films measured by 2 evaluators. The ECUG was excellent or acceptable in 100% of the x-rays on standard PA views (arm abducted 90 degrees ), 87% excellent or acceptable and 13% unacceptable on 45 degrees arm abduction views, and 23% excellent or acceptable and 77% unacceptable on 0 degrees arm abduction (adducted) views (all with the elbow flexed at 90 degrees ). With the arm at 90 degrees abduction and full elbow extension the ECUG was excellent or acceptable in 91% of cases. These results show that the ECUG is a reliable criterion to verify arm position during PA wrist radiography and therefore provides a standard for making treatment decisions. The need for repeat radiographs should be reduced.

Carpal injuries associated with distal radius fractures. Diagnosis and therapy

The frequency of carpal injuries associated with distal radius fractures is often underestimated. Diagnosis of such lesions can be difficult. Important diagnostic steps include conventional X-rays, cinematography of the wrist, MRI, and arthroscopy. Different procedures such as wrist arthrography and CT are of secondary value. An early diagnosis of ligament injuries and instabilities can be obtained through cinematographic examination, whereas injuries to the TFCC are mainly diagnosed by MRI. Arthroscopy provides exact diagnosis as well as therapy, including arthroscopically controlled reposition of centrally depressed fragments of the articular surface of the radius and even treatment of TFCC lesions.

Wrist Arthrography Study of the Terry-Thomas Sign

Background. Chronic wrist pain is common. The Terry-Thomas sign indicates an interosseous ligament abnormality. The purpose of this study was to evaluate the usefulness of the Terry-Thomas sign for predicting the degree of interosseous ligament tears by means of wrist arthrography. Methods. Wrist arthrography with midcarpal compartment injection was performed on 48 patients with Terry-Thomas sign following its diagnosis by conventional radiography. Results. In our study, 41.7% of cases had tears of the interosseous ligament. However, when we included only patients whose gap between the lunate and the scaphoid bones measured 3 mm or more, the percentage of cases with tears increased to 63.2%. Finally, all patients whose gaps measured 4 mm or more had tears. Conclusions. From the above results, we conclude that the larger the gap between the lunate and scaphoid bones, the higher the incidence of interosseous ligament tears.

Dynamic axial carpal instability

I was intrigued by the recent article by Shin et al entitled “Dynamic Axial Carpal Instability: A Case Report” (J Hand Surg 1999;24A:781–785) and was surprised by statements the authors made that warrant clarification. Shin et al stated that the arthrogram done as part of the patient's evaluation showed “no abnormal dye passage between the scapholunate, lunotriquetral, or capitohamate joints.” How do they explain this finding in light of the fact that arthroscopy demonstrated “complete loss of integrity of the capitohamate interosseous ligaments”? Furthermore, the preoperative arthrogram showed a “slight leak” of dye through the triangular fibrocartilage complex (TFCC) and yet the authors reported that a tear of the TFCC was diagnosed arthroscopically that was large enough to mandate repair. These discrepancies raise 2 questions. First, how do the authors reconcile the differences between the negative arthrogram and the complete capitohamate ligament incompetence? The sensitivities and specificities of arthrograms for detecting intercarpal ligament tears range from 56% to 100% and 56% to 83%, respectively, in published reports. 1Chung KC Zimmerman NB Travis MT. Wrist arthrography versus arthroscopy: a comparative study of 150 cases.J Hand Surg. 1996; 21A: 591-594Abstract Full Text PDF Scopus (72) Google Scholar, 2Cooney WP. Evaluation of chronic wrist pain by arthrography, arthroscopy and arthrotomy.J Hand Surg. 1993; 18A: 815-822Abstract Full Text PDF Scopus (113) Google Scholar, 3Weiss A-PC Akelman E Lambiase R. Comparison of the findings of triple-injection cinearthrography of the wrist with those of arthroscopy.J Bone Joint Surg. 1996; 78A: 348-356Crossref Scopus (114) Google Scholar It surprised me that Shin et al did not comment on the importance of the negative arthrogram in evaluating their patient for this proposed new disorder of dynamic axial carpal instability. Is the arthrogram superfluous in the workup of patients with similar presentations? Second, why do the authors attribute the patient's symptoms to dynamic capitohamate instability rather than the TFCC tear? The case history and physical examination, which included ulnar-sided wrist tenderness and pain with ulnar deviation following a fall on the outstretched hand, are consistent with a TFCC tear, which is a common disorder that responds well to arthroscopic management.4Trumble TE Gilbert M Vedder N. Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair.J Hand Surg. 1997; 22A: 57-65Abstract Full Text PDF Scopus (133) Google Scholar Why did the authors discount the TFCC tear and its subsequent repair as the source of the patient's symptoms and recovery, respectively? Shin et al present their case as an example of dynamic carpal instability in which the energy of trauma disrupted the capitohamate and scapholunate joints. It is unclear why they conclude this if the scapholunate interosseous ligament was interpreted as being intact on arthrogram and magnetic resonance imaging and showed no tears arthroscopically (just a suggestion of slight stretching). Geissler grade 2 ligament changes do not equal joint disruption. An extensive battery of diagnostic tests was completed in the workup of the patient presented, including special view radiographs, an arthrogram, trispiral tomograms, a bone scan, a magnetic resonance imaging scan, diagnostic lidocaine injections, and arthroscopy. Are all these tests required to make the proposed diagnosis? In this time of increased cost consciousness among physicians and third-party payers alike, we should always strive to establish diagnoses as expeditiously and cost effectively as possible. The authors missed a chance to comment on their recommendations for evaluating similar patients in the future without ordering such an exhaustive and expensive array of diagnostic modalities. Finally, did the patient described in the report receive workers' compensation for his injury and treatment? Secondary gain or its absence may have affected the outcome one way or the other and it would be useful to know this when examining and counseling other patients suspected of having similar pathology in the future.

Techniques of Wrist Arthroscopy* **

Arthroscopy has revolutionized the practice of orthopaedics by providing the technical capability to examine and treat intra-articular abnormalities directly. The development of wrist arthroscopy was a natural evolutionary progression from the successful application of arthroscopy to other, larger joints. Wrist arthroscopy has seen considerable growth since Whipple et al. reported their original description of the techniques that they developed for viewing the anatomy of the wrist56. The wrist is a labyrinth of eight carpal bones, multiple articular surfaces with intrinsic and extrinsic ligaments, and a triangular fibrocartilage complex, all within a five-centimeter interval. This perplexing joint continues to challenge clinicians with an array of potential diagnoses and treatments. Wrist arthroscopy allows direct visualization of cartilage surfaces, synovial tissue, and ligaments under bright illumination and magnification. While most acute sprains of the wrist with normal radiographic findings resolve after temporary immobilization, how to further evaluate the patient who does not have improvement after such treatment is controversial. Tricompartmental wrist arthrography has historically been the so-called gold standard for the detection of intra-articular abnormalities9,10,43,54. However, the proved ability of wrist arthroscopy to enable detection and simultaneous treatment of wrist injuries, as well as the introduction of magnetic resonance imaging, has markedly altered this situation28,38,44. Adolfsson used arthroscopy to examine 144 patients who had posttraumatic wrist pain and normal findings on standard radiographs1. Ligamentous changes were observed in seventy-five patients; lesions of the triangular fibrocartilage complex, including lunotriquetral instability, in sixty-one patients; and varying degrees of scapholunate instability, in fourteen patients. The indications for wrist arthroscopy continue to expand as new techniques and instrumentation are developed. Diagnostic indications include assessment of tears of the interosseous ligaments and determination of whether they are partial or complete …

WRIST ARTHROGRAPHY TODAY

In recent years, wrist arthrography has been criticized for having low sensitivity and low specificity. This largely has been due to widely varying and less than rigorous technique and the reliance on criteria for abnormality that are now known to be invalid. Other criticisms have included the length of time needed to perform a three-compartment arthrogram with or without comparison to the contralateral side and the radiation dose to the patient. It is our belief, however, that with the use of the patient's history, symptoms and physical examination to develop a focused examination strategy, and with the use of digital equipment, the examination can be performed quickly and with minimal radiation dose to the patient. In order to improve the accuracy of arthrography, the radiologist must abandon the concept that simply identifying a communicating defect between the carpal compartments is a criterion for abnormality. He or she must utilize a meticulous approach to determine the site of communication to evaluate the features of the defects in order to determine the significance of the defect. As more is learned about the nature of traumatic and attritional defects and with further technologic advancements in cross-sectional imaging and three-dimensional rendering, it is quite possible that arthrographic imaging of the wrist will experience a resurgence of interest in the evaluation of posttraumatic wrist pain, avoiding the fate of such examinations as pneumoencephalography and oral cholecystography as many have predicted.

Arthrography is superior to magnetic resonance imaging for diagnosing injuries of the triangular fibrocartilage

The ability of single-injection radiocarpal arthrography and magnetic resonance imaging (MRI) to detect full-thickness tears of the triangular fibrocartilage were compared with wrist arthroscopy in 102 patients with wrist pain. The sensitivity of arthrography was 85%, and of MRI was 73%. Specificity was 100% for arthrography and 72% for MRI. Accuracy was 92% for arthrography, and 73% for MRI. Although future advances in MRI technology will probably improve its usefulness, single-injection wrist arthrography currently is superior to routine MRI for the detection of full-thickness triangular fibrocartilage tears.

Wrist arthrography after acute trauma to the distal radius: diagnostic accuracy, technique, and sources of diagnostic errors.

The objective of this investigation was to determine the diagnostic accuracy of wrist arthrography in the detection of interosseous ligament disruptions and of triangular fibrocartilage complex (TFCC) lesions in patients after acute wrist trauma and to define the sources of diagnostic error of wrist arthrography after recent trauma. Twenty-two patients with radial fractures after acute wrist trauma underwent arthrography and arthroscopy of the wrist. Arthrography was performed in a standardized manner by two- or three-compartment injection technique. Subsequently wrist arthroscopy was performed within the same session. Image analysis included the evaluation of interosseous carpal ligaments, the TFCC, and the osseous structures. In 22 patients, 11 injuries of the intrinsic ligaments and the TFCC were diagnosed by arthroscopy, of which 9 had been diagnosed correctly with arthrography before surgery. One scaphoid fracture previously missed on conventional radiographs also could be diagnosed by arthrography. Arthrography of the posttraumatic wrist is a valuable tool in the diagnostic evaluation of interosseous carpal ligaments and the TFCC.

Triple-injection wrist arthrography: Unidirectional communications are due to technical factors

One justification for triple-injection wrist arthrography is detection of unidirectional interjoint communication that might escape notice if only a single joint were injected. To determine whether the direction of 1-way communications is related to the choice of the first joint injected, the authors prospectively randomized 100 wrists undergoing consecutive single-contrast, fluoroscopically controlled arthrograms into 2 well-matched groups. One group received the initial injections into the midcarpal and distal radioulnar joints and the other group received the initial injection into the radiocarpal joint. Two unidirectional radial capsular communications with the radiocarpal joint were detected on delayed midcarpal joint injection. No other unidirectional communications were found. No statistically significant difference was found between the midcarpal and radiocarpal study groups. Thus, the first joint injected appears to be a major determinant in demonstrating unidirectional communications between wrist compartments.