Ulnar sided Wrist Pain
1
Susan Cross,
1
Anshul Rastogi,
2
Brian Cohen,
1
Rosy Jalan
1
Dept of Radiology, Barts Health NHS Trust, London, UK
2
London Orthopaedic Centre
Contact: susan.cross@bartshealth.nhs.uk
Abstract number: EE33
Purpose
• To review the complex anatomy of the ulnar
side of the wrist
• To provide a comprehensive pictorial review of
the varied diagnoses associated with Ulnar
sided wrist pain using 3.0 Tesla (T) MRI with
arthroscopic correlation where appropriate
• To illustrate and highlight pitfalls and
Anatomy
Image from - K. Sachar, Ulnar-sided wrist pain: evaluation and treatment of TFCC tears, ulnocarpal impacation syndrome, lunotriquetral ligament tears, Current concepts JHS. Vol 33A November 2008
Causes of ulnar sided wrist pain
Ulnar sided wrist pain Extensor carpi ulnaris pathology Triangular fibrocartilage complex injuries Ulnocarpal and inter carpal ligament injuries Ulnar impaction syndrome Fractures Inflammatory arthritis Ganglion Others including infection, AVMOne of the most common questions posed when a
patient presents with ulnar sided wrist pain, is whether
the TFCC is intact.
The following six cases demonstrate unenhanced, non
arthrographic 3 Tesla MRI appearances of the
symptomatic wrist with direct arthroscopic correlation.
Two MRIs were false positive for a TFCC tear which on
review post arthroscopy demonstrate quite marked
intrasubstance degeneration. When these findings are
observed it may be prudent to further evaluate with an
MR arthrogram
Case 1
• 54 yr old female complaining of left ulnar
sided wrist pain and swelling
Pre operative MRI
• Perforating tear of radial
attachment of the TFCC
(blue arrow)
• Non united ulnar styloid
fracture with 6mm loose
body (red arrow)
adjacent to the
triquetrum and pisiform,
likely secondary to a
degree of ulnar carpal
impaction
Arthroscopy findings:
•Radial side split of
TFCC (blue arrow)
•6 mm loose body,
demonstrated on
pre operative MRI,
retrieved from ulnar
side of wrist
Case 2
• 36 yr old female with ulnar sided wrist pain,
?TFCC tear
Pre operative MRI
• Negative ulnar
variance
• Full thickness
tear of the radial
attachment of the
TFCC (blue arrow)
with abnormal
fluid signal within
the gap of the tear
and immediately
deep to it (white
arrows)
Arthroscopy confirmed MRI findings
• Tear of the radial
attachment of the
TFCC was confirmed at
arthroscopy (red
arrow)
Case 3
Pre operative MRI
Findings:
• Intrasubstance tear of the TFCC
(red arrow) with detachment of
the distal ulnar attachment (blue
arrow).
• The scapholunate and
lunotriquetral ligaments appear
intact.
• Normal articular surfaces of the
distal radius, scaphoid, lunate and
triquetrum.
Arthroscopy found intact TFCC despite
the MRI appearances (false positive) :
• The TFCC was intact
throughout but surrounded by
synovitis.
• On review of the
preoperative MRI, there was
marked intermediate signal
within the TFCC but no overt
fluid signal component.
•In such cases it may be
prudent to further evaluate
with IV contrast or an MR
arthrogram .
Case 4
Pre operative MRI
Findings:
• Partial tear of the
scapholunate
ligament (white
arrow)
• TFCC intact
(uniform low signal
throughout)
• Lunotriquetral
intact
Arthroscopy correlated with the MRI:
Findings:
•Tear of the scapholunate
ligament confirmed at
arthroscopy
• TFCC intact
• Articulating surfaces of
the distal radius, scaphoid,
lunate and triquetrum
Preoperative MRI findings:
• Intrasubstance signal
change in the ulnar aspect
of TFCC ( blue arrow) with
direct extension of
hyperintense fluid signal
into the distal radioulnar
joint (red arrow), in
keeping with a TFCC tear
Case 5
Arthroscopy correlated with MRI
• Confirmed partial tear
of the TFCC (arrow). This
was debrided.
• SL and LT ligaments
normal
• Articular surfaces of
distal radius, scaphoid,
lunate and triquetrum
are normal
Case 6
• 44 yr old female with ulnar sided wrist pain
?TFCC tear
MRI findings
• Complex tear of the TFC with
extension to superior and inferior
surfaces with direct extension of fluid
into the distal radioulnar joint (red
arrow)
• The meniscal homologue is
oedematous (blue arrow)
• Subchondral oedema of the lunate
with chondral cartilage thinning
(white arrow)
•Tear of the Lunotriquetral ligament
• Palmar DRUJ ligamentous injury
(black arrow)
Arthroscopy found intact TFC despite
MRI appearances (false positive)
• There was some synovitis within the ulnar recess
• Chondral cartilage damage of the distal radius
• Intact TFC
False positive for TFCC tear on the pre operative MRI.
Again, there is intrasubstance intermediate signal
within the TFC but no discrete overt fluid signal within
the TFC. The fluid within the distal radioulnar joint
may be attributable to the distal volar radioulnar
ligamentous disruption.
Extensor Carpi Ulnaris Tendinopathy
Coronal (left) and axial (right)T2W fat saturated images of the wrist:
Demonstrates markedly thickened extensor carpi ulnaris tendon (red arrow) with intrinsic
abnormal high signal , more than the usual high signal,in keeping with florid tendinopathy. There
is also associated surrounding soft tissue odema and mild tenosynovitis. Note also ulnar
Extensor carpi ulnaris tear
Axial T2 Fat saturated image of the wrist :
Demonstrates ulnar styloid fracture (blue arrow). This is relatively acute as quite marked bone marrow oedema persists within the distal ulna. There is extensor carpi ulnaris tenosynovitis with partial tears (red arrow). Oedema present within the related soft tissues is in keeping with post traumatic change
Distal volar radio-ulnar ligament injury
Axial T2W fat saturated image of the wrist at the level of the distal radioulnar joint:
Demonstrates disruption of distal volar radio-ulnar ligament following trauma (red arrow). There is also ulnar styloid undisplaced fracture (blue arrow). The ECU is intact.
Intercarpal ligament injury
Axial T2W fat saturated images of the wrist at the mid carpal level:
Demonstrate high signal with loss of congruity (red arrow) in the dorsal intercarpal ligaments in keeping with ligamentous disruption
TFCC Anatomy
Left: TFCC disc (broad white arrow), proximal and distal laminae (thin arrows), meniscus homologue (open white arrow). Right: Ulnotriquetral ligament (open arrow head) ² ² Images from review article, P.S. Vezeridis et al, Ulnar-seded wrist pain. Part 1: anatomy and physical examination. Skeletal
Triangulofibrocartilage (TFC) Tears
Left: High signal on the ulnar styloid side of TFCC (red arrow).
Traumatic TFC Tears
Left: Coronal T2W Fat saturated image of the wrist
Demonstrates traumatic TFC radial perforation with fluid extending into the distal radio-ulnar joint (white arrow). Also note is made of ulnar styloid fracture (red arrow).
Right: Axial T2W fat saturated image of the wrist
There is a full thickness TFC tear with fluid in distal radio-ulnar joint (blue arrow), with triquetral fracture (green arrow)
Ulnar impaction syndrome
Coronal T2 Fatsaturated and T1W images:
Demonstrate bone marrow oedema (red arrow) due to ulnar impaction. In addition there is also partial disruption of the scapholunate ligament (white arrow)
Ulnar impaction syndrome
Coronal T2W fat saturated and T1W images of the wrist:
Demonstrates subchondral cysts in the proximal lunate (blue arrows) suggestive of ulnarcarpal impaction. There is also TFCC strain and fluid around the meniscal homologue (white arrow)
Fractures
Coronal T1W and T2W fat saturated images :
Demonstrates a displaced ulnar styloid fracture, marrow oedema (red arrow), and small TFCC radial perforation with fluid in distal radio-ulnar joint (green arrow). Note is also made of
Fractures
Full thickness TFCC tear with fluid in distal
radio-ulnar joint (red arrow); triquetral
fracture (green arrow)
Fractures
Patient with known distal radial fracture (left) also had an occult pisiform fracture
(green arrow)
Synovitis
Axial T1W fat saturated post contrast images in a patient with swollen wrist show florid synovitis and enhancement post contrast (red arrow), there is also extensor carpi ulnaris tendinopathy (black arrow)
Ganglion
Coronal and axial T2W fat saturated images demonstrate scapholunate ganglion with intra-osseous extension into the lunate ( blue arrow)
Masses
Left: Pre contrast T1W axial image shows a well defined low signal lesion (red arrow)
Vascular malformations
Images above show serpiginous (red arrow) lesion with avid enhancement in keeping with an arteriovenous