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Imaging 15:180-192 (2003)
© 2003 The British Institute of Radiology

Imaging of the wrist

P S McAlinden, MRCP, FRCR and J Teh, MRCP, FRCR

Department of Radiology, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7LD, UK

Correspondence: Dr James Teh


   Summary
Top
 Summary
Acute trauma
 Chronic focal pain
 Nerve entrapment
 Diffuse wrist pain
 Masses
 References
 

The wrist is complex both anatomically and functionally. Plain radiographs, combined with a careful physical examination are often sufficient to elucidate the cause of a painful wrist or hand. However, further imaging by ultrasound (US), arthrography, MRI or CT, or a combination of these, may be required to reach a diagnosis. This article aims to outline the commonly encountered pathological conditions affecting the wrist, according to the clinical presentation.


   Acute trauma
Top
 Summary
 Acute trauma
Chronic focal pain
 Nerve entrapment
 Diffuse wrist pain
 Masses
 References
 
Bony injury
Injuries around the wrist are common and usually occur as a result of falling on the outstretched hand. The pattern of injury depends on the distribution of forces and position of the hand when injured, as well as the age of the patient. Typically, in the elderly patient, a fall on the outstretched hand will cause a Colles' fracture, whereas in the young adult a scaphoid fracture is more common. In the child metaphyseal and physeal injuries predominate and carpal injuries are extremely rare [1]. Most fractures in the wrist and hand are easily detected on plain radiography.

Occult fractures
Following trauma, if plain radiographs are normal and a fracture is suspected, a repeat examination 7–10 days later may reveal early callus formation. Bone scintigraphy has also been used to detect radiographically occult fractures but involves a relatively large radiation dose and does not give the anatomical detail of cross sectional modalities. Multislice CT is a valuable technique for diagnosing fractures, especially when three-dimensional (3D) data sets are acquired, allowing 2D and 3D reformats [2] (Figure 1Go). MRI is also extremely sensitive [3] for detecting fractures, especially when T1 weighted images are coupled with coronal short tau inversion recovery (STIR) images which are highly sensitive for bone marrow oedema [4, 5] (Figure 2Go). MRI has been shown to be more sensitive and specific than bone scintigraphy [6, 7].



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  		Figure 1. Axial CT scan demonstrating a fracture of the hook of the hamate (white arrow) that was not seen on plain radiography. An incidental intraosseous ganglion (black arrow) is present.

 


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  		Figure 2. (a) Coronal T1 weighted image demonstrating a low signal fracture line (arrows) of the distal radius that was radiographically occult. (b) Same patient as (a). Coronal short tau inversion recovery image demonstrating high signal surrounding the distal radius fracture indicating marrow oedema and haemorrhage.

 
The scaphoid is the most frequently fractured carpal bone [8], usually occurring as a result of a fall on the outstretched hand. Patients typically complain of anatomical snuffbox tenderness on examination. Due to the high incidence of complications such as non-union and avascular necrosis (AVN), and the difficulty in detecting scaphoid fractures on plain radiographs, the early use of MRI has been advocated [3, 9] so that appropriate treatment can be instituted (Figure 3Go).



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  		Figure 3. Coronal short tau inversion recovery image demonstrating high signal throughout the scaphoid (arrow) indicating a fracture.

 
Acute soft tissue trauma
Acute injury to the triangular fibrocartilage complex (TFCC) and intrinsic ligaments of the wrist is often demonstrated when MRI is used for the detection of occult bony injury (Figure 4Go). Usually however, these injuries present with chronic focal symptoms, and they will therefore be discussed later in this article.



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  		Figure 4. Coronal gradient echo image demonstrating acute disruption of the triangular fibrocartilage (black arrow) with dislocation of the distal radioulnar joint (white arrow).

 
Tendon ruptures may occur as a result of penetrating and non-penetrating injuries, as well as in patients with inflammatory arthropathies. In the latter group the extensor tendons are more commonly ruptured [10]. Both MRI and US have been advocated for diagnosing tendon ruptures [11–13]. On both imaging modalities the key feature is loss of continuity of the tendon, with variable retraction of the torn ends. There may be fluid/haemorrhage within the tendon sheath in acute injury. The authors' preferred technique is US as it easily accessible, rapid and allows accurate assessment of the position of the tendon ends (Figure 5Go).



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  		Figure 5. Longitudinal ultrasound image demonstrating a rupture of the flexor digitorum profundus tendon with retraction of the tendon ends (arrow). The distal, middle and proximal phalanges are marked (DP, MP and PP, respectively).

 

   Chronic focal pain
Top
 Summary
 Acute trauma
 Chronic focal pain
Nerve entrapment
 Diffuse wrist pain
 Masses
 References
 
Chronic focal pain is usually the result of previous trauma, but may also be related to a variety of overuse injuries.

Scaphoid non-union
70% of scaphoid fractures occur at the waist, with 20% occurring at the proximal pole [14]. As the blood supply enters distally, fractures may result in AVN of the proximal pole. This becomes much more likely if there is non-union of the fracture, which occurs in up to 40% of cases. Distal scaphoid fractures involving the tubercle are much less likely to develop complications. The two main modalities used for demonstrating non-union are CT and MRI. CT allows detailed assessment of bony architecture, and may be less susceptible to metallic artefact than MRI (Figure 6Go). The ability of CT to assess viability of the proximal fragment is however, limited.



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  		Figure 6. Axial CT image demonstrating non-union of a scaphoid fracture with a Herbert screw in situ.

 
On MRI non-union is easily recognised by a low signal line running through the scaphoid on both T1 and T2 weighted images [5, 15].

AVN
Abnormal marrow signal in the proximal pole with loss of the normal high signal fatty marrow on T1 weighted and T2 weighted sequences may indicate AVN [16]. This however is not always the case as granulation tissue or impacted bone may have similar appearances. The use of contrast enhancement has been shown to improve the accuracy of detecting AVN [1, 17] (Figure 7Go). By comparing the rate of enhancement of the proximal pole with that of normal bone, the relative vascularity of the proximal pole can be calculated.



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  		Figure 7. Coronal (a) T1 and (b) T2 weighted images, respectively, demonstrating low signal in the proximal pole fragment of the scaphoid consistent with avascular necrosis.

 
Kienbock's disease
AVN of the lunate, or Keinbock's disease, is a condition that usually affects the dominant hand of male manual workers, probably as a result of repetitive trauma [18]. It is also related to negative ulnar variance [15, 19]. In the late stages of disease, there is sclerosis and collapse of the lunate on plain radiographs. Early diagnosis is the key to preventing progression, which may be achieved by immobilization or surgery. MRI detects marrow oedema before any change is seen on plain radiographs [20]. There may also be an associated effusion or synovitis within the wrist joint (Figure 8Go).



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  		Figure 8. Coronal short tau inversion recovery image demonstrating bone marrow oedema in the lunate consistent with early Kienbock's disease.

 
Ligamentous disruption
Intercalated segment instability
The ligaments of the wrist are arranged in into superficial, extrinsic and intrinsic group.

The extrinsic and superficial ligaments of the wrist are difficult to visualize as discrete structures on MRI. Arthrography improves visualization [21], but assessment remains problematic. The best clue to extrinsic ligament disruption or laxity is static carpal instability, with either dorsal rotation of the lunate (dorsal intercalated segment instability, DISI), or volar rotation (VISI) [22]. DISI occurs in association with deficiency of the scapholunate ligament whereas VISI occurs with deficiency of the lunotriquetral ligament. These may be recognised on plain radiographs or sagittal MRI by measuring the scapholunate angle and also the capitolunate angle (Figure 9Go).



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  		Figure 9. (a) Lateral radiograph of the wrist demonstrating dorsal intercalated segmental instability (DISI). The scapholunate angle is typically greater than 60 degrees. (b) Lateral radiograph of the wrist demonstrating volar intercalated segmental instability (VISI). The scapholunate angle is typically less than 30 degrees.

 
Intrinsic ligament disruption
Scapholunate and lunotriquetral ligament disruptions are a common cause of chronic wrist pain and instability. Before the advent of MRI, the diagnosis of intrinsic ligament disruption was usually made on plain radiographs (Terry Thomas sign) or arthrography, typically performed as a radiocarpal joint injection (Figure 10Go). Contrast should remain within the compartment into which it has been injected. Arthrography however does not allow direct visualization of the ligaments.



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  		Figure 10. Anteroposterior radiograph of the wrist demonstrating widening of the scapholunate gap to >2 mm (this has been likened to a diastema, hence the Terry Thomas sign).

 
Using conventional MRI, the sensitivity for scapholunate tears has been reported at between 50% and 93%. For the lunotriquetral ligament the sensitivity has been reported at between 40% and 56% [23–25]. A recent meta-analysis has shown that without intra-articular contrast medium, MRI cannot reliably exclude tears of the intrinsic carpal ligaments [26]. In our current practice, MR arthrography is therefore routinely used to assess the wrist if there is a specific question about intrinsic ligament disruption. The scapholunate ligament has a linear or delta shape [23, 27] which is of low signal on T1 and T2 weighted images. The lunotriquetral ligament is more linear in appearance (Figure 11Go). A tear is denoted by contrast extending through the ligament (Figure 12Go). Tears occurring in the central portion of the ligament are not thought to be as biomechanically significant as dorsal or volar tears [24, 28].



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  		Figure 11. Coronal T1 fat saturated MR arthrogram demonstrating the normal scapholunate ligament (long white arrow), the lunotriquetral ligament (short white arrow) and the triangular fibrocartilage disc (arrowhead).

 


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  		Figure 12. Coronal T1 fat saturated MR arthrogram demonstrating contrast extending between the scaphoid and lunate (arrow) consistent with a tear.

 
TFCC disruption
The TFCC is a complex structure composed of the triangular fibrocartilage disc (TFC) with numerous supporting ligaments. TFC disruption is a common cause of ulnar sided wrist pain. Degenerative changes and perforations of the TFC are very common and often asymptomatic. The imaging findings must therefore always be closely correlated with the patient's symptoms. Using arthroscopy as the gold standard, MRI has been shown to have an accuracy of 64–95% for perforations or tears [29–32]. The inhomogeneous signal intensity and striated appearance of the ulnar portion of some normal TFCs [33, 34] may make these disruptions more difficult to detect [32]. Radial aspect perforations tend to be traumatic, whilst ulnar aspect lesions are more often degenerative and commonly seen in older patients [35].

If a TFC perforation is present, contrast is seen to enter the distal radioulnar joint (DRUJ) following a radiocarpal arthrogram (Figure 13Go). On MRI full thickness tears or perforations are diagnosed when fluid signal extends completely across the TFC on T2 weighted spin echo or gradient echo images, or if there is disruption of the normal architecture. With degeneration there may be increased signal intensity within the disc on T2 weighted spin echo or gradient echo images, which does not extend to an articular surface. There is good evidence that radiocarpal arthrography improves diagnostic accuracy [31, 36, 37] although some authors argue that this may be unnecessary [26, 30, 38] (Figure 14Go).



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  		Figure 13. Radiocarpal arthrogram with contrast seen to enter the distal radioulnar joint (arrow) consistent with a triangular fibrocartilage disc perforation (arrowhead).

 


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  		Figure 14. Coronal T1 fat saturated MR arthrogram demonstrating contrast extending across the triangular fibrocartilage disc which is ruptured on the ulnar aspect (arrow).

 
Distal radioulnar joint (DRUJ) dysfunction
The DRUJ is a highly evolved and complex structure, which in combination with the TFCC permits pronation and supination of the wrist. Dysfunction may be due to fractures, TFCC or ligamentous injury, arthropathies or developmental disorders [39]. Radiographic assessment of DRUJ subluxation is problematic, as a true lateral radiograph must be obtained. As little as 10° of rotation may lead to an inaccurate diagnosis [40], and therefore, either CT or MRI has been advocated for its diagnosis (Figure 15Go). The wrist should ideally be examined in both prone and supine positions as instability may only manifest in one position.



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  		Figure 15. Axial T2 fat saturated image demonstrating subluxation of the distal radioulnar joint. The ulna should lie between the subtended lines.

 
Tendon pathology
Tendon pathology is often encountered in the wrist and hand, which may be the result of overuse, trauma or inflammation. Patients typically present with focal pain and swelling.

The term "tendinitis" is an inaccurate term for describing tendon abnormality, as pathologically there is usually no significant inflammatory change. A better term is tendinosis, which describes a degenerative process with "microtears", healing and vascular in-growth. The term "tendinopathy" encompasses both degenerative and inflammatory conditions. Tenosynovitis refers to inflammatory change within the tendon sheath, with or without tendon morphological changes.

Tendons have a characteristic fibrillar echotexture on US which is the authors' modality of choice for examining the tendons of the hand and wrist. With MRI normal tendons appear as low signal structures on both T1 and T2 weighted images. With tendinosis thickening of the tendon is seen on both MRI and US. On US there may focal areas of decreased echogenicity reflecting myxoid degeneration and on MRI there may be increased signal on T2 weighted images. Tenosynovitis is manifest as fluid within the tendon sheath, with possible thickening of the sheath itself. The tendon may appear morphologically normal (Figure 16Go). On imaging grounds alone, it may be difficult to distinguish inflammatory from infective tenosynovitis.



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  		Figure 16. Longitudinal ultrasound image demonstrating flexor tenosynovitis at the wrist. The normal fibrillar echotexture of the tendon is preserved (arrowheads), with low echogenicity fluid seen surrounding the tendon (arrows).

 
Chronic tenosynovitis may lead to fibrosis within the tendon sheath which appears as low signal [41]. De Quervain's tenosynovitis is a repetitive strain injury more often seen in women [42]. It predominantly affects extensor compartment 1 which comprises extensor pollicis longus and abductor pollicis brevis. The disease may be seen to progress from oedema and inflammation to fibrosis and compartmental stenosis. The key sign on US or MRI is tendon and tendon sheath thickening. Synovial fluid and subcutaneous oedema may also be seen. With chronicity, fibrosis occurs leading to low signal material on T1 and T2 weighted images surrounding the tendon [43] (Figure 17Go).



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  		Figure 17. Coronal T1 weighted image demonstrating fusiform low signal thickening of extensor compartment 1 indicating de Quervain's tenosynovitis.

 

   Nerve entrapment
Top
 Summary
 Acute trauma
 Chronic focal pain
 Nerve entrapment
Diffuse wrist pain
 Masses
 References
 
Carpal tunnel syndrome is the most common of the nerve entrapment neuropathies. It is much more common in women and is thought to arise secondary to wide variety of conditions including repetitive strain, tenosynovitis or space-occupying lesions [44]. The diagnosis is usually made clinically, the patient complaining of paraesthesia in the median nerve distribution. Tapping the volar aspect of the wrist over the flexor retinaculum may reproduce symptoms (Tinel's sign). Imaging is seldom required to make the diagnosis unless a space-occupying lesion such as a ganglion is suspected (Figure 18Go).



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  		Figure 18. Transverse ultrasound scan of the carpal tunnel demonstrating a ganglion (long arrow) which compresses the median nerve (arrowhead).

 
On US the most reliable sign of median nerve neuropathy is swelling of the nerve just before entering the carpal tunnel [44, 45] (Figure 19Go). Bowing of the flexor retinaculum may also be seen but is less specific [45]. On MRI similar features may be present, but in addition the nerve may be of increased signal on T2 weighted sequences [42]. Deep palmar bursitis is a sign which has high specificity in diagnosing the condition [27].



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  		Figure 19. Longitudinal ultrasound scan of the median nerve demonstrating relative swelling of the median nerve (large arrow) prior to entering the carpal tunnel (indicated by small arrow).

 
Guyon's canal is a fibro-osseous tunnel in the anteromedial portion of the wrist through which pass the ulnar nerve and artery. Hook of hamate fractures and space occupying lesions in Guyon's canal, such as ulnar artery aneurysms and ganglions, may result in ulnar nerve entrapment [42].


   Diffuse wrist pain
Top
 Summary
 Acute trauma
 Chronic focal pain
 Nerve entrapment
 Diffuse wrist pain
Masses
 References
 
Inflammatory joint conditions
Synovitis of the wrist may be due to inflammatory arthropathies or infection. Bone erosions seen on plain radiography are usually a late finding.

With non-infective inflammatory arthropathies such as rheumatoid arthritis there is improved long-term outcome with the early use of disease modifying agents. As a result there is great interest in the early detection of synovitis by US or MRI [10, 46, 47]. In the case of acutely painful tender wrist with a joint effusion present, US has the advantage of allowing image guided aspiration at the time of scanning to confirm diagnosis. The use of Doppler is very helpful in determining the presence of synovitis [48] (Figures 20 and 21GoGo).



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  		Figure 20. Longitudinal ultrasound scan of the dorsum of the wrist demonstrating synovial hypertrophy and increased flow on Doppler interrogation in a patient with psoriatic arthritis.

 


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  		Figure 21. Longitudinal ultrasound scan of the index metacarpophalangeal joint demonstrating synovial hypertrophy and increased flow on power Doppler in a patient with rheumatoid arthritis.

 
MRI has been shown to be more sensitive than plain radiography at detecting erosions [10, 49–51]. Synovial hypertrophy is hyperintense on T2 weighted and STIR images, and may be indistinguishable from joint fluid (Figure 22Go). It may be necessary to administer gadolinium to differentiate between these [52–54] but in practice this is not essential. Serial MRI to quantify synovial volume has been used to follow up response to treatment [55].



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  		Figure 22. Coronal short tau inversion recovery image demonstrating early synovitis of the hands (arrows) in a rheumatoid patient with a normal plain radiograph.

 

   Masses
Top
 Summary
 Acute trauma
 Chronic focal pain
 Nerve entrapment
 Diffuse wrist pain
 Masses
References
 
Benign masses of the wrist are much more common than malignant lesions [56, 57]. Most benign lesions are cystic [57].

Cystic lesions
Ganglia are the most common masses that occur in the wrist. They are indistinguishable from synovial cysts on imaging and so the terms are used interchangeably [56]. They usually present as masses but not infrequently occult, presenting with pain only [8]. The majority occur on the dorsum of the wrist and are related to the dorsal scapholunate ligament. On the volar aspect of the wrist ganglia arise from the radial side of the wrist and communicate with the scaphotrapezial joint [42]. On US ganglia are typically well defined cystic masses with posterior acoustic enhancement. Their relationship to structures such as vessels, tendons and nerves should be assessed [42] (Figure 23Go). US aspiration and injection may provide symptomatic relief. On MRI ganglia are well defined rounded or lobulated lesions that are typically hyperintense on T2 weighted imaging and hypointense on T1 weighted imaging (Figure 24Go). MRI may detect associated intrinsic ligament tears [58].



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  		Figure 23. Longitudinal ultrasound scan of the dorsum of the wrist demonstrating a well defined low echogenicity mass (arrows) with posterior acoustic enhancement consistent with a ganglion.

 


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  		Figure 24. Axial T2 fat saturated image demonstrating a well defined high/fluid signal mass with deep to the extensor tendons consistent with a ganglion.

 
Solid lesions
With the exception of superficial lipomas neither MRI [57, 59] or US [60] have the capability of differentiating benign from malignant neoplasms. Their main use is in determining the site and size of the lesion, as well as its relationship to other structures. It may also be possible to specify the tissue of origin of the mass from its location.

Lipomas are benign fatty lesions that are usually located in the subcutaneous tissues. On US they are typically of increased echogenicity and are well defined. On MRI they are of high signal on T1 weighted images and should be of homogeneous low signal on fat suppressed and STIR images [57] (Figure 25Go). Fatty lesions that are deep, large and heterogeneous [60] are suspicious for liposarcomas.



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  		Figure 25. (a) Coronal T1 weighted image demonstrating a homogeneous high signal mass in the hypothenar eminence consistent with a benign lipoma. (b) Same patient as (a). Coronal short tau inversion recovery image demonstrating homogeneous low signal throughout the lipoma.

 
Peripheral nerve sheath tumours commonly occur around the wrist, most often arising from the median nerve. They usually present as slowly growing tender masses and may be associated with paraesthesia. On US nerve sheath tumours are usually well defined hypoechoeic lesions, often diagnosed by the presence of a dural tail. The nerve may be seen to taper as it enters the mass. On MRI peripheral nerve sheath tumours should be considered if a mass is related to a nerve or has a "target" appearance characterized by a low signal centre surrounded by high signal on T2 weighted images [57].

The fibrolipomatous hamartoma is classically seen in patients with syndactly or macrodactyly of the index or middle finger [42]. The lesion is a hamartomatous mass of fibrofatty tissue that splays the median nerve in the wrist. The MRI appearances are characteristic, with a fibroadipose mass which separates but does not invade the fasiculi of the median neve [61] (Figure 26Go).



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  		Figure 26. Coronal T1 weighted image demonstrating the classic appearances of a fibrolipomatous hamartoma. There is fatty tissue interspersed between the splayed fibres of the median nerve (arrows).

 
Vascular lesions such as capillary haemangiomas and arteriovenous malformations are often seen in the wrist. Clinically, patients present with long-standing masses that are often compressible and may vary in size. Capillary haemangiomas are composed of fatty and vascular tissue. On US they typically demonstrate increased echogenicity with numerous low flow vessels seen within them. On MRI they are often lobulated with high signal areas seen on T1 weighted images consistent with fat. Phleboliths may also be identified [57]. Arteriovenous malformations may be seen secondary to trauma. They appear vascular on ultrasound and feeding vessels are frequently identifiable [42]. On MRI a soft tissue mass with flow voids due to high flow vessels is seen [57].

Anomalous flexor and extensor muscles of the wrist present with a mass or with neural compression. On imaging they may not be recognised as abnormalities since they are indistinguishable from normal muscle. A good knowledge of anatomy is therefore required. US shows the typical striated appearance of muscle and has the benefit of allowing dynamic imaging of muscle contraction with movement [42, 57]. Comparative imaging with the contralateral side is therefore very useful (Figure 27Go).



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  		Figure 27. Transverse ultrasound images of both wrists obtained through Guyon's canal demonstrating an anomalous abductor digitus minimus muscle (arrowheads) displacing the ulnar nerve (long arrow). Compare with the normal image on the left.

 
Giant cell tumours of the tendon sheath are amongst the most common solid masses seen in the hand. They are sometimes referred to as focal pigmented villonodular synovitis due to their histological appearance. Patients usually present with a slow growing lump, either in the palm or digits. On MRI they are well defined masses which typically demonstrate low signal areas on both T1 and T2 weighted images indicating haemosiderin deposition and fibrosis [57] (Figure 28Go).



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  		Figure 28. Axial (a) T1 weighted and (b) T2 fat saturated images demonstrating a well defined solid mass in the middle finger adjacent to the flexor tendon consistent with a giant cell tumour of the tendon sheath. Note small low signal foci on both sequences indicating haemosiderin deposition.

 


   References
Top
 Summary
 Acute trauma
 Chronic focal pain
 Nerve entrapment
 Diffuse wrist pain
 Masses
 References
 

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