MRI of the Wrist: Algorithmic Approach for Evaluating Wrist Pain

HomeRadioGraphicsVol. 39, No. 2 PreviousNext Musculoskeletal ImagingFree AccessRadioGraphics Fundamentals | Online PresentationMRI of the Wrist: Algorithmic Approach for Evaluating Wrist PainGreg S. Matthews, Bahram Kiani, Scott D. Wuertzer, Jason A. Powell, Brandon L. Roller, Leon Lenchik, Maha Torabi Greg S. Matthews, Bahram Kiani, Scott D. Wuertzer, Jason A. Powell, Brandon L. Roller, Leon Lenchik, Maha Torabi Author AffiliationsFrom the Department of Radiology, Division of Musculoskeletal Imaging, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, One Medical Center Blvd, Winston-Salem, NC 27156.Address correspondence to M.T. (e-mail: [email protected]).Greg S. MatthewsBahram KianiScott D. WuertzerJason A. PowellBrandon L. RollerLeon LenchikMaha Torabi Published Online:Mar 7 2019https://doi.org/10.1148/rg.2019180157MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In AbstractThe full digital presentation is available online.Wrist MRI plays a key role in the evaluation of patients with subacute or chronic wrist pain. To determine whether a surgical approach or conservative management is needed, the surgeon needs to know not only the cause of the pain but also its severity. Information provided at MRI is used to help plan the surgical approach. The goals of this online presentation are to (a) describe an algorithmic approach that helps radiologists provide clinically relevant reports when interpreting wrist MR images; (b) review important surgical classification systems used for assessing common wrist conditions, which facilitates understanding of surgical management; and (c) evaluate common and some uncommon causes of wrist pain through the review of several cases.As the source of wrist pain can be difficult to determine on the basis of clinical evaluation, an algorithmic approach to MRI interpretation is helpful to determine the correct diagnosis and appropriate patient management. Determining if the cause of wrist pain is intra-articular or extra-articular helps the surgeon plan for an arthroscopic surgery, an open surgery, or a combined procedure.The intra-articular causes of wrist pain can be divided into osseous or soft-tissue conditions. Osseous intra-articular conditions include fractures, avascular necrosis (such as Kienböck disease), ulnocarpal impaction, and stylocarpal impaction. Historically, for the assessment and staging of Kienböck disease, different classification systems such as the Lichtman classification system have been used. However, many surgeons are using the arthroscopic classification system in assessing the wrist in symptomatic patients. Familiarity with the surgical classification of Kienböck disease can help with MR image interpretation and surgical planning.Soft-tissue intra-articular conditions include triangular fibrocartilage complex (TFCC) lesions, scapholunate ligament tears (Figure), lunotriquetral ligament tears, chondral lesions, and synovial conditions, including septic arthritis, inflammatory arthropathies, synovial osteochondromatosis, and pigmented villonodular synovitis. Appreciating surgical classification systems used for lesions of the intrinsic ligaments of the wrist improves communication between the radiologist and referring surgeon. The online presentation reviews the Palmer classification system for TFCC lesions and the Geissler classification system for scapholunate and lunotriquetral ligament lesions. While soft-tissue intra-articular conditions are usually treated with arthroscopic surgery, osseous conditions may require treatment with open surgery.Figure a. Grade 3 scapholunate ligament tear, graded according to the Geissler arthroscopic classification system, in a 51-year-old woman with a 2-year history of wrist stiffness, weakness, and pain. (a) Coronal T1-weighted fat-saturated MR arthrogram shows a contrast-material–filled linear defect (arrow) through the scapholunate ligament. (b) Arthroscopic image from the radiocarpal view shows the tear (arrow) and an associated hemorrhage in the scapholunate ligament, which was debrided.Figure a.Download as PowerPointOpen in Image Viewer Figure b. Grade 3 scapholunate ligament tear, graded according to the Geissler arthroscopic classification system, in a 51-year-old woman with a 2-year history of wrist stiffness, weakness, and pain. (a) Coronal T1-weighted fat-saturated MR arthrogram shows a contrast-material–filled linear defect (arrow) through the scapholunate ligament. (b) Arthroscopic image from the radiocarpal view shows the tear (arrow) and an associated hemorrhage in the scapholunate ligament, which was debrided.Figure b.Download as PowerPointOpen in Image Viewer Additional common and uncommon causes of extra-articular wrist pain may be related to tendon and tendon sheath injuries (eg, tears or tenosynovitis), vascular lesions (eg, aneurysms and vascular malformations), neuromas, nerve sheath tumors, or accessory muscles.Using an algorithmic approach when evaluating wrist pain can help with condition categorization and assessment and guide surgical planning. Familiarity with common wrist abnormalities, their appropriate surgical classification systems, and their methods of management may improve the radiologist's recognition of pertinent imaging findings to aid in appropriate communication of these findings to referring clinicians, improving patient care.Presented as an education exhibit at the 2017 RSNA Annual Meeting.All authors have disclosed no relevant relationships.Suggested ReadingsArnaiz J, Piedra T, Cerezal L, et al. Imaging of Kienböck disease. AJR Am J Roentgenol 2014;203(1):131–139. Crossref, Medline, Google ScholarBain GI, Begg M. Arthroscopic assessment and classification of Kienbock's disease. Tech Hand Up Extrem Surg 2006;10(1):8–13. Crossref, Medline, Google ScholarChloros GD, Wiesler ER, Poehling GG. Current concepts in wrist arthroscopy. Arthroscopy 2008;24(3):343–354. Crossref, Medline, Google ScholarRominger MB, Bernreuter WK, Kenney PJ, Lee DH. MR imaging of anatomy and tears of wrist ligaments. RadioGraphics 1993;13(6):1233–1246; discussion 1247–1248. Link, Google ScholarTorabi M, Martell B, Tuohy C, Lenchik L. MRI-arthroscopy correlation of the wrist: a primer for radiologists. Current Radiology Reports. 2016;4(2):1-3. Google ScholarZanetti M, Saupe N, Nagy L. Role of MR imaging in chronic wrist pain. Eur Radiol 2007;17(4):927–938. Crossref, Medline, Google ScholarArticle HistoryReceived: Apr 16 2018Revision requested: May 21 2018Revision received: June 15 2018Accepted: June 21 2018Published online: Mar 07 2019Published in print: Mar 2019 FiguresReferencesRelatedDetailsAccompanying This ArticleMRI of the Wrist: Algorithmic Approach for Evaluating Wrist PainMar 7 2019Default Digital Object SeriesRecommended Articles Imaging of Sports-related Hand and Wrist Injuries: Sports Imaging SeriesRadiology2016Volume: 279Issue: 3pp. 674-692Distal Radioulnar Joint: Normal Anatomy, Imaging of Common Disorders, and Injury ClassificationRadioGraphics2022Volume: 43Issue: 1Clinical Application of Ultrahigh-Field-Strength Wrist MRI: A Multireader 3-T and 7-T Comparison StudyRadiology2023Volume: 307Issue: 2Avulsion Injuries of the Hand and WristRadioGraphics2020Volume: 40Issue: 1pp. 163-180Four-dimensional CT Analysis of Wrist Kinematics during Radioulnar DeviationRadiology2018Volume: 289Issue: 3pp. 750-758See More RSNA Education Exhibits It's All in the Wrist: The Classification, Repair, and Postoperative Appearance of Intrinsic Wrist Ligament TearsDigital Posters2019Triangular Fibrocartilage Complex (TFCC) Injury Made SimpleDigital Posters2021The Other Side Of The Wrist: Ulnar Wrist Pain.Digital Posters2021 RSNA Case Collection Ulnocarpal Impaction SyndromeRSNA Case Collection2022Dysplasia Epiphysealis HemimelicaRSNA Case Collection2022Pyrophosphate ArthropathyRSNA Case Collection2020 Vol. 39, No. 2 Slide PresentationMetrics Altmetric Score PDF download