Imaging of the Wrist and Hand

, Royal Victoria Hospital, McGill University, Montrèal, Canada.

Disclosures

Medscape General Medicine. 1999;1(1) 

In This Article

Arthrography

Wrist arthrography is an invasive technique performed by a radiologist requiring the use of ionizing radiation. It allows evaluation of the integrity of the intercarpal and capsular wrist ligaments and of the triangular fibrocartilage (TFC). Wrist arthrography consists of the intra-articular placement of ionic contrast, air, or air and contrast into the radiocarpal joint (RCJ), midcarpal (MCJ), and/or distal radioulnar (DRUJ) compartments (Fig. 13).

Figure 13. Right wrist arthrogram with the hand in the posteroanterior position, digital subtraction technique. Ionic contrast is identified within the midcarpal compartment of the wrist.

In the trauma setting, wrist arthrography is most often performed for assessment of the intercarpal or capsular ligaments. Indeed, some investigators have shown that intrinsic ligament damage may occur in up to 25% of patients with distal radial fractures.[10] Infrequently, wrist arthrography is requested to exclude adhesive capsulitis, detect the presence of osseous or cartilaginous joint bodies, or to assess for nonunion of an intra-articular carpal fracture.[11]

In the case of adhesive capsulitis, arthrography may be more than a diagnostic intervention. It may be employed therapeutically by allowing joint distention and confirming the intra-articular placement of corticosteroids. Arthrography may also be used for localization and treatment of symptomatology. Relief of patient wrist pain following the intra-articular administration of lidocaine and/or corticosteroids localizes the pain to the wrist joint itself and serves as treatment. Rarely, arthrography will be used to make the diagnosis of a nonunion (contrast is identified in the gap between the ununited fracture fragments).

Although thorough evaluation of the wrist requires three-compartment arthrography, this is only indicated if the referring physician requests determination of all wrist pathology. Much of the data obtained by this approach are wasted because treatment is only justifiable at sites where patient symptomatology correlates with the arthrographic findings.[12,13,14,15] Alternatively, arthroscopy, given its high sensitivity to wrist pathology, is an alternative method providing thorough assessment of the intrinsic and extrinsic wrist ligaments.[16]

A more effective way of approaching wrist arthrography, however, is to perform a tailored wrist arthrogram -- that is, assessment for a particular ligamentous or capsular injury based on the physical examination of the patient. With this approach, RCJ and/or MCJ arthrography only will be performed if the referring physician suspects scapholunate ligament injury. Similarly, RCJ and/or DRUJ arthrography only will be performed if injury to the triangular fibrocartilage is suspected (Figs. 14,15). This approach requires a good history from the referring physician.

Figure 14. Arthrogram of the left wrist, radiocarpal compartment injection. Ionic contrast medium is seen within the radiocarpal and distal radioulnar compartments. A wisp of contrast identified within the radial aspect of the triangular fibrocartilage represents the site of communication between the radiocarpal and distal radioulnar compartments.
Figure 15. Arthrography of the left wrist. Fluoroscopic spots taken during (a) radiocarpal and (b) distal radioulnar compartment injections, respectively. Contrast distribution is normal within the radiocarpal compartment. A curvilinear band of contrast extends caudally from the distal radioulnar compartment and represents a defect of the triangular fibrocartilage. Because this defect does not extend to the radiocarpal compartment it is called a noncommunicating defect.

Contraindications to wrist arthrography are few. Infection at or near the puncture site would be an absolute contraindication. Air arthrography may be used in those patients with contrast allergies.

No long-term complications of arthrography have been documented. However, patients may experience synovitis within 72 hours of arthrography. This is due to the contrast in the joint and is a temporary discomfort, relieved with anti-inflammatory drugs.

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