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Wrist Arthrography

- Discussion:
    - arthrography may be used in diagnosis of carpal instability because it is technically easy & is only minimally invasive;
    - normally there should be no communication between the radiocarpal, mid-carpal, and distal radial-ulnar joints;
    - it is noteworthy that in normal wrists there may be communications between different compartments & that these communications should not be assumed to be caused by trauma;
            - communications may indicate age-related degenerative changes;
            - patients in their twenties will be perforated 8% of the time;
            - communications may occur in upto 27 % of patients less than 35 years, w/ TFCC tears being the most common;
            - by age 50, more than half of patients will have at least one communction;
     - false negative results:
            - a complete tear may be masked by scarr tissue which has impeded the flow of the contrast material;

- Mid Carpal Joint:
    - arthrogram of normal mid-carpal joint shows contrast medium between scaphoid, lunate, triquetrum;
    - non dissociative carpal instability:
           - capitolunate instability
           - ulnar mid-carpal instability;

- Ligament Tears:
     - triquetrolunate interosseous ligament;
            - arthrography is most accurate for diagnosing this condition;
     - triangular fibrocartilage;
            - provides most useful information in younger patients, since degenerative changes are common in older patients;
            - may diagnose central TFCC tears and peripheral TFCC avulsions;
            - false positive result:
                    - normal the extension of dye, from the radiocarpal joint into the RU joint, is consistent w/ TFCC tear;
                    - note, however, tear of the ulnolunate ligament will also allow egress of dye between these spaces;
    - ulnolunate ligament:
            - this is a key ligament along w/ the TFC;
            - on occassion, may avulse from its insertion on the lunate, and this injury will allow dye extension both into the distal RU joint and into the mid-carpal joint;
    - scapholunate interosseous ligament;
            - injection of contrast into the radio-scaphoid joint, should allow contrast to flow into the scapholunate interval if the ligament is torn;
            - false negatives may occur due to redundancy of the scapho-lunate ligament which may allow the ligament to bunch up and obstruct the flow of contrast thru a ligament tear;
            - needle is introduced distally at STT or ulnarly at triquetrohamate joint so as to avoid injured area and possible errors in interpretation associated with extravasation;
            - dye is followed under the image intensifier to see where it flows;
            - both scapholunate & lunotriquetral penetrations are suggestive of respective injuries;
            - flow palmarly through the space of Poirier is indicative of this space having been injured in a PLD.

- Technique:
    - it is important that PA and lateral radiographs be taken with proper technique;
           - elbow is flexed in 90 deg w/ neutral rotation;
           - lateral radiograph is taken w/ arm at side
           - PA radiograph is taken w/ shoulder abducted;
    - arthrograms that are made by injecting all three major joints (radio-carpal, mid-carpal, and distal radio-ulnar) w/ contrast medium are helpful and sometimes obligatory;
    - contrast medium: non ionic contrast (such as Omnipaque 300)
    - greater sensitivity is achieved by first injecting contrast medium into mid-carpal row;
           - this allows diagnosis of tears of the scapholunate or lunotriquetral ligaments;
    - radiocarpal joint is next injected;
           - test is positive for TFCC perforation if contrast material leaks into the distal RU joint;
    - injection into the RU joint:
           - direct injection into the distal RU joint may show dye leakage into the radiocarpal joint;
    - important that the flow of opaque material be followed in an image intensifier to find leaks and abnormal communications;
           - digital fluoroscopy has been used advantageously for same purpose

Arthrography of the wrist. Assessment of the integrity of the ligaments in young asymptomatic adults.

Wrist pain: correlation of clinical and plain film findings with arthrographic results.

Arthrographic evaluation of the carpal triangular fibrocartilage complex.

Disruption of the ulnolunate ligament as a cause of chronic wrist pain.

The Triple Injection Wrist Arthrogram.

Arthrography of the wrist joint. An experimental study.

Arthrography of the contralateral, asymptomatic wrist in patients with unilateral wrist pain.

The relevance of ligament tears or perforations in the diagnosis of wrist pain: an arthrographic study.