MRI and Arthroscopic Correlation of The Wrist

REVIEW ARTICLE
MRI and Arthroscopic Correlation of the Wrist

Nicholas C. Nacey, MD,* Jeffrey D. Boatright, MD,†
and Aaron M. Freilich, MD†
interference in steady state, axial T1, axial T2-weighted with

Abstract: Since its introduction in 1979, the practice of and indi- fat saturation, and sagittal proton density with fat saturation.
cations for wrist arthroscopy in the diagnosis and treatment of Imaging with a dedicated wrist coil greatly improves image
pathologic conditions in the wrist continues to grow. Magnetic signal to noise ratio, and the patient’s hand should be placed
resonance imaging (MRI) is another commonly used tool to non-
over the patient’s head in the so-called “Superman” position so
invasively examine the anatomy and pathology of the wrist joint.
Here, we review the normal wrist anatomy as seen arthroscopically that the wrist is in the isocenter of the magnet. Quality images
and through MRI. We then examine the various common patho- can be obtained with either 1.5 or 3 T systems although
logic entities and define both the arthroscopic findings and corre- the improved resolution of 3 T magnets may mildly improve
lated MRI findings in each of these states. sensitivity and specificity.5
Key Words: MRI, magnetic resonance imaging, wrist arthroscopy,
TFCC, scapholunate ligament, ganglion cyst WRIST ARTHROSCOPY—OVERVIEW
AND TECHNIQUE
(Sports Med Arthrosc Rev 2017;25:e18–e30)
Arthroscopy of the wrist allows direct visualization of
both normal and pathologic structures within the joint as well
as dynamic examination and therapeutic treatment.6 This
A s a diagnostic tool, wrist arthroscopy was introduced in

1979.1 It has continued to grow into the powerful ther-
apeutic tool it has become today. With the further description
includes evaluation of intrinsic ligaments, chondral surfaces,
triangular fibrocartilage complex (TFCC), ganglion cysts, and
fractures. The ability to dynamically probe the anatomic
of volar and distal radial-ulnar joint (DRUJ) portals, its structures in the wrist during arthroscopy is a major advantage
indications and utility continues to expand.2 Long considered
the gold standard in diagnosing intra-articular pathology of
the joint, it nevertheless remains an invasive procedure.3,4
From an evaluation and imaging perspective, radiography,
ultrasound, and computed tomography are useful tools for
initial patient evaluation. However, magnetic resonance
imaging (MRI) has emerged as the best noninvasive evaluation
technique for the soft tissues, vascular supply, and cartilage of
the wrist. Knowledge of the strengths and weaknesses of these
treatment and diagnostic tools improves both the surgeons’
and radiologists’ ability to best make recommendations and
treat the patient.
MRI PROTOCOL
MRI of the wrist requires a combination of T1-weighted
images for anatomic depiction as well as fluid sensitive
sequences to detect pathology. Fluid sensitive images can be
from either short tau inversion recovery, T2-weighted fat
saturation, or proton density fat saturation sequences. Often a
combination of these different sequences is used in different
planes to take advantage of the differences in spatial resolution
and homogeneity of fat saturation between the sequence types.
A high-resolution 3D sequence is also helpful for evaluating
the intrinsic ligaments, triangular fibrocartilage, and wrist
cartilage as the small size of these structures can make visu-
alization difficult in conventional sequences. At the authors’
institution, a typical protocol consists of coronal T1, coronal
short tau inversion recovery, coronal 3D constructive
From the Departments of *Radiology; and †Orthopaedic Surgery,

University of Virginia, Charlottesville, VA.
Disclosure: The authors declare no conflict of interest.
Reprints: Aaron M. Freilich, MD, Department of Orthopaedic Surgery,
University of Virginia, 400 Ray C. Hunt Dr. Suite 330, Charlot-
tesville, VA 22908-0159.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. FIGURE 1. Arthroscopic set up and markings for standard portals.
e18 | www.sportsmedarthro.com Sports Med Arthrosc Rev Volume 25, Number 4, December 2017
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Sports Med Arthrosc Rev Volume 25, Number 4, December 2017 MRI and Arthroscopic Correlation of the Wrist
direct visualization of the TFCC and the lunotriquetral

TABLE 1. Arthroscopic Portals (LT) ligament. Depending on the area of the joint that
1-2 Radial portal rarely used due to radial artery and ssrn needs access either an accessory 1 to 2 (radial) or 6U
risk (ulnar) portal are occasionally used. Once survey of the
3-4 Working, viewing portal usually established first. radiocarpal joint has been completed, the midcarpal joint
Visualization of majority of radiocarpal joint can be assessed. The scope is usually introduced through
4-5 Working portal allowing access to both radial and ulnar
the midcarpal radial portal and the instruments through
radiocarpal joint
6R Access to and visualization of TFCC or LTIL
the midcarpal ulnar portal. Portions of the STT joint can
6U Access to TFCC and styloid. Rarely used due to dorsal be visualized, a dynamic assessment of the SL and LT
sensory ulnar nerve injury risk ligaments can be performed and the hamate articulation
Volar Improved visualization of dorsal capsule and with a type II lunate can be accessed. Several other portals
radial debridement of volar ganglion cysts. Limited open have been described and advocated for various proce-
approach to establish dures. Volar radial and ulnar portals can be accessed
Volar Visualization of ulnar wrist. Can be used to access the through limited open approaches.2 These give good visu-
ulnar DRUJ. Must be made with a direct open approach alization of the dorsal capsule and extrinsic ligaments as
DRUJ indicates distal radial-ulnar joint; LTIL, lunotriquetral inteross- well as dorsal ganglion cysts. Proximal and distal dorsal
eous ligament; TFCC, triangular fibrocartilage complex. DRUJ portals and volar DRUJ portals have also been
described (Table 1).
NORMAL ANATOMY
over static MRI imaging, and is likely the source of many The joint is usually assessed in a systematic manner.
discrepancies when correlating MRI and arthroscopy findings. Initially the radial styloid, scaphoid fossa, and scaphoid
The basic technique of wrist arthroscopy has been well cartilage is assessed (Fig. 2). Next, the radioscaphocapitate,
described. Typically a 2.9 mm small joint arthroscope is long and short radiolunate ligaments and ligament
used for visualization, although variably a 2.3 or 1.9 mm of testut are seen volarly (Fig. 3). The radiocarpal
scope can be used as needed. A tourniquet is typically used side of the SL interosseous ligament can be seen (Fig. 4).
and the arm is placed into a traction tower to help provide Moving ulnarly, the TFCC and volar and dorsal ulno-
joint distraction during the procedure and aid in visual- carpal ligaments are seen as is the prestyloid recess
ization. Ten to 15 lbs of traction is applied with the higher (Fig. 5). The radiocarpal portion of the LT can also be
end of the range being necessary for adequate visualization seen (Fig. 6). In the midcarpal joint the capitate and
of the midcarpal joint. The skin is typically marked to hamate articular surfaces can be seen and the distal
identify anatomic landmarks and help localize the portal portion of the SL and LT intervals can be seen and pro-
locations (Fig. 1). bed. The capito-hamate articulation helps identify the LT
Arthroscopy is typically begun with introduction of right below it (Fig. 7).
the arthroscope through the dorsal 3 to 4 portal. This
allows immediate visualization of the radius scaphoid and
lunate fossa, the intrinsic scapholunate (SL) ligament, the PATHOLOGIC STATES
radial styloid, and the volar extrinsic ligaments. Next
either a 4 to 5 or a 6R portal is localized with a needle Intrinsic Ligaments (SL and LT)
under direct visualization and then established. A shaver Clinical Presentation
or probe can be introduced through this portal to continue Concern for injury to the scapholunate interosseous
the diagnostic arthroscopy. The scope may need to be ligament (SLIL) or lunotriquetral interosseous ligament
repositioned through one of these portals to allow better (LTIL) is a common source of referral for both
FIGURE 2. Normal magnetic resonance imaging (A) and arthroscopic (B) radiocarpal anatomy. The cartilage surfaces of the proximal
scaphoid (arrow) and radial styloid (arrowhead) are well visualized on this coronal constructive interference in steady state (3D con-
structive interference in steady state) image (A). Normal radial styloid (arrowhead) and proximal scaphoid (arrow) articular surfaces
viewed through the dorsal 3 to 4 portal (B).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. www.sportsmedarthro.com | e19
Nacey et al Sports Med Arthrosc Rev Volume 25, Number 4, December 2017
FIGURE 3. Normal magnetic resonance imaging (A, B) and arthroscopic (C) appearance of the volar extrinsic ligaments. Coronal short
tau inversion recovery (A) and sagittal PD fat saturated (B) images demonstrate the normal appearances of the radioscaphocapitate
(arrow) and long radiolunate (arrowhead) extrinsic ligaments along the volar aspect of the wrist. Note the normal striated appearance of
the ligaments when viewed in the coronal plane. Radioscaphocapitate (arrow) and long radiolunate (arrowhead) extrinsic ligaments
viewed through the dorsal 3 to 4 portal (C). PD indicates proton density.
FIGURE 4. Normal magnetic resonance imaging (A–D) and arthroscopic (E) appearance of the proximal scapholunate interval.
Sequential coronal constructive interference in steady state images progressing from dorsal to volar through the scapholunate ligament
demonstrate the thick dorsal band (arrow in A), triangular membranous portion extending across only the proximal aspect of the
scapholunate interval (dashed arrow in B), and the slightly heterogenous volar band (arrowhead in C). The ligament is located in the
interval between the scaphoid (S) and lunate (L) bones, distal to the radius (R). An axial T2 fat saturated image (D) provides a helpful
secondary check of the scapholunate dorsal (long solid arrow) and volar (arrowhead) bands. Note that the dorsal band has a more
homogenous and hypointense appearance relative to the volar band given its more organized collagen fascicles. The extrinsic radio-
scapholunate ligament (short arrow) passes along the volar aspect of the scapholunate ligament and should not be mistaken for an intact
volar band. The proximal scaphoid (S) and lunate (L) with interposed membranous portion of the scapholunate ligament (asterisk)
viewed through the dorsal 3 to 4 portal (E).
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FIGURE 5. Normal magnetic resonance imaging (A) and arthroscopic (B) appearance of the triangular fibrocartilage complex (TFCC).
This coronal constructive interference in steady state image demonstrates the intricate anatomy of the TFCC (A). The TFC body makes up
the bulk of the structure and is a homogenously hypointense triangular structure, similar to a knee meniscus (long solid arrow). Note that
the radial aspect of the TFCC body attached to intermediate signal intensity radial cartilage (arrowhead) as opposed to the bony cortex.
The peripheral fibers of the TFCC have a more heterogenous appearance with the distal lamina (long dashed arrow) attaching to the
ulnar styloid and the proximal lamina (short dashed arrow) attaching to the fovea; intermediate signal intensity in between the 2 lamina
represents vascularized connective tissue referred to as the ligamentum subcruentum. The membranous portion of the lunotriquetral
ligament (short solid arrow) is visible as a triangular structure just distal to the TFCC body. Arthroscopic appearance of the intact TFCC
including the volar radioulnar ligament (arrowhead), dorsal radioulnar ligament (thin arrow), articular disc (thin arrow), and prestyloid
recess (asterisk) viewed through the dorsal 3 to 4 portal (B).
FIGURE 6. Normal magnetic resonance imaging (A–C,) and arthroscopic (D) appearance of the proximal lunotriquetral interval.
Sequential coronal constructive interference in steady state images progressing from dorsal to volar through the lunotriquetral ligament
demonstrate the dorsal band (solid arrow in A), triangular membranous portion (dashed arrow in B), and the strong volar band
(arrowhead in C). The radius (R) and ulna (U) are labeled for orientation. The membranous band is the easiest to visualize and does not
progress across the entire distal extent of the interval between the lunate (L) and triquetrum (T). The volar and dorsal bands are often
more difficult to visualize. The proximal lunate (L) and triquetrum (T) with interposed membranous portion of the lunotriquetral ligament
(asterisk) and underlying triangular fibrocartilage complex articular disc viewed through the dorsal 3 to 4 portal (D).
varying appearances. The volar and dorsal bands both have

a sheet-like appearance and traverse the entire proximal to
distal portion of the SL interval on coronal images; the
dorsal band being the strongest portion has homogenous
low signal due to its organized collagen structure whereas
the volar band can be more intermediate and striated in
signal due to its looser connective tissue.10 The proximal
membranous portion has a variable shape with its central
portion typically being triangular but it does not traverse the
entire proximal to distal aspect of the SL interval on coronal
images.
Fluid-like signal or distortion of normal ligamentous
morphology is consistent with a tear. SL ligament injuries
can be classified on MRI as to whether they are com-
municating (full thickness) or noncommunicating (partial
thickness) between the radiocarpal and intercarpal
compartments, as well as whether the tear includes
the volar, membranous, or dorsal bands. The size of the
FIGURE 7. Normal arthroscopic view of the ulnar-sided mid- ligamentous gap may also be relevant as it pertains to
carpal joints. Typical “baby’s bottom” shape of the proximal
the Geissler arthroscopic grading system.11 Perforations
capitate (C) hamate (H) articulation is used as an arthroscopic
landmark for orientation in the midcarpal space. Below the distal in the membranous segment are common and usually
lunate (L) triquetrum (T) articulation is identified as viewed asymptomatic. Axial images can be a helpful adjunct
through the radial midcarpal portal. to coronal images when evaluating the SL ligament.12
The lunate attachment of the SL ligament is stronger
arthroscopy and MRI evaluation. Although typically thus ligament tears typically occur on the scaphoid
associated with a fall onto an extended ulnarly deviated attachment.
wrist as described by Mayfield and colleagues, they can be Similar to the SL ligament, the volar and dorsal
present due to age and degenerative conditions.7,8 LT bands of the LT ligament are collagenous and band-like,
ligament tears can also be a result of ulnocarpal impac- although in the case of the LT ligament the volar band is
tion as well. Patients will typically present with dorsal structurally more important. The membranous portion is
radiocarpal wrist pain and or stiffness and radiographs highly variable in signal and shape, although it is typically
that may or may not demonstrate SL or LT widening on triangular. Evaluating the LT ligament by MRI is much
clenched fist views or an altered SL angle on lateral views. more difficult than the SL ligament given the former’s
Untreated pathology can lead to progressive arthritis and smaller size and often incomplete visualization. As
deformity.9 Both the SL and LT ligaments are primarily expected, MRI sensitivity for detecting LT abnormalities
composed of 3 portions; volar, dorsal, and membranous is significantly lower than for the SL ligament.13 The
central portion. The strongest portion of the SL is the membranous portion of the LT ligament is the easiest to
dorsal, whereas the strongest portion of the LT is the routinely visualize. Linear intermediate increased signal
volar portion. in the LT ligament is a common normal variant, and it is
not until this signal becomes fluid-like in signal intensity
MRI Findings that a tear can be diagnosed.10 Although often triangular,
Owing to its C-shaped morphology in the sagittal the morphologic shape of the LT membranous portion is
plane, the different segments of the SL ligaments have also variable. The volar and dorsal bands are typically
FIGURE 8. Magnetic resonance imaging (A, B) and arthroscopic (C) appearance of scapholunate ligament tear. This coronal
T2-weighted image with fat saturation (A) demonstrating fluid signal within the membranous portion of the scapholunate ligament
consistent with full thickness tearing. Extension into the volar band (arrowhead) is best seen on an axial T2-weighted fat saturated image
(B). Severe tear and substantial fraying of the membranous portion of the scapholunate ligament (asterisk) draped into the radiocarpal
joint (C). Note the chondral lesions on both the scaphoid (S) and lunate (L).
and radiocarpal spaces. This is termed a “drive-through

TABLE 2. Geissler Classification of SL Instability sign.”
Grade
I Attenuation of ligament in radiocarpal joint but no TFCC
incongruence on midcarpal arthroscopy
II Midcarpal incongruence with gap between bones less Clinical Presentation
than or equal to probe width Ulnar wrist pain is another common complaint
III Radiocarpal and midcarpal incongruence and step off. resulting in referral for potential arthroscopy or MRI eval-
Probe can be inserted and rotated fully uation. Pathologic states of the TFCC, LT, pisotriquetral
IV Gross instability with drive through sign joint, and extensor carpi ulnaris tendon can all result in pain
SL indicates scapholunate. in this area. One of the most common causes of ulnar wrist
pain is injury or degenerative tearing of the TFCC. Tears
are commonly grouped using the Palmer classification and
can broadly be divided into 2 categories; traumatic and
difficult to visualize either with coronal or straight axial degenerative.19,20 On presentation, patients may have ulnar
images, although oblique axial images have been used by wrist pain with palpation the TFCC at the fovea and with
some.14 Widening of the LT interval is not commonly seen pain at extremes of supination or pronation or even insta-
even with complete tear; however, subtle disruption of the bility of the DRUJ (Table 3).
carpal arcs may be present.15
MRI Findings
MRI of the triangular fibrocartilage has yielded vari-
Arthroscopic Findings and Correlation able results, with sensitivity ranging from 44% to 93% and
Initial evaluation of the SL and LT ligaments takes specificity ranging from 54% to 100%.21 The increased
place within the radiocarpal articulation. Attenuation or prevalence of MRI units with 3 T magnetic strength how-
frank tearing of the membranous portion can frequently be ever may produce better results than was seen historically.13
seen and debrided as needed (Fig. 8). Ideal evaluation of the MRI arthrography produces mild distention of the joint
SL and LT and classification takes place from the midcarpal and may make subtle tears more apparent, however at the
portals. A probe can be introduced and a dynamic exam decreased specificity as there may be passage of contrast
performed. The Geissler classification is used to grade SL into the distal radioulnar joint through small micro-
tears and instability16,17 (Table 2). perforations that are not apparent at arthroscopy.13 The
Originally described for the SLIL, this classification normal TFC disk should be homogenously hypointense on
system can be applied to LTIL tears as well.18 In a grade I all sequences.
injury, the probe will not be able to be inserted fully into TFC tears will typically manifest themselves on MRI
the SL space and the only indication of injury may be as disruption of the TFC with increased fluid signal within
bulging or attenuation on the radiocarpal side. Grade II the defect, with abnormal signal extending to the proximal
lesions will start to show some incongruence in the and/or distal surfaces. The tear should be localized to the
midcarpal articulation and the probe can be inserted radial attachment, the ulnar attachment, the midportion of
into the interval but will not be able to be turned the TFC body, or less commonly distal avulsions of the
(Figs. 9, 10). Grade III injuries demonstrate progressive ulnolunate and ulnotriquetral ligaments. Degenerative type
step off and the 1 mm probe can be fully rotated within tears are common and may be associated with chondral
the interval (Fig. 11). In the most severe state, Geissler abnormalities in the proximal carpal row or LT ligament
grade IV, the dorsal SL is completely torn and the probe abnormalities. Perforation type tears with fluid signal
and/or scope can be freely driven between the midcarpal extending across a small pinhole in the midportion of the
FIGURE 9. Magnetic resonance imaging (A, B) and arthroscopic (C) appearance of Geissler grade II scapholunate carpal instability.
Coronal (A) and axial (B) T2-weighted images demonstrate abnormal fluid-like signal and altered morphology in the membranous
portion (best seen on the coronal) and the dorsal band (best seen on the axial). There is no significant associated scapholunate interval
widening on these static images. During arthroscopy (C), the probe can be inserted between the scaphoid (S) and lunate (L). Camera and
probe are in the radial and ulnar midcarpal portals, respectively.
FIGURE 10. Magnetic resonance imaging (A) and arthroscopic (B) appearance of Geissler grade II lunotriquetral carpal instability. This
coronal T2-weighted image with fat saturation demonstrated abnormal morphology in the membranous portion of the lunotriquetral
ligament with fluid signal within the ligament, consistent with tearing (A). L indicates Lunate; T, Triquetrum.
TFC body are often seen by MRI, and are often asympto- lower specificity of 63%.22 With a peripheral TFC tear,
matic. Intermediate signal cartilage is seen at the radial there may be a shift of the TFC disk in a more radial
attachment of the TFC body and should not be mistaken for direction.
a tear; the volar and dorsal radioulnar ligaments attach
directly to the radial cortex.10 Arthroscopic Findings and Correlation
The peripheral triangular fibrocartilage has 2 distinct Arthroscopic evaluation takes place within the radi-
lamina attaching to the ulnar styloid and the fovea with ocarpal joint using either a 4 to 5 or 6R working portal.
vascularized intermediate signal connective tissue in The radial articular attachment and central disc are easily
between the 2 lamina sometimes referred to as the liga- seen and probed (Fig. 12). These are typically 1A or 1D or
mentum subcruentum.10 Both the lamina can also have a type 2 tears. These tears can be debrided of any loose
striated appearance. This complex appearance makes edges or flaps leaving the more important dorsal and
tears in the peripheral lamina of the fibrocartilage par- volar stabilizing structures intact. A trampoline test can
ticularly difficult to identify by MRI. Ligamentous dis- be performed to assess overall stability of the TFCC
ruption is a fairly specific sign of peripheral TFC tear (Fig. 13). Loss of normal tautness can be a result of a
although has a reported sensitivity of only 17%; using the peripheral tear (type 1B) or foveal detachment. In a foveal
presence of fluid signal as a marker for tear increases the injury, the TFCC may appear to still be attached to the
sensitivity somewhat to 42% although at the expense of a volar and dorsal capsule in the radiocarpal joint, but will
FIGURE 11. Magnetic resonance imaging (A) and arthroscopic (B) appearance of Geissler grade III scapholunate carpal instability viewed
through the midcarpal space. There is high-grade tearing of the scapholunate ligament on this coronal T2-weighted image, with mild
widening of the scapholunate interval measuring almost 3 mm. Associated marrow edema is noted in the scaphoid bone at the expected
attachment site of the scapholunate ligament (A). On arthroscopy (B), note the probe can be inserted and fully turned when placed
between the scaphoid (S) and lunate (L). If the 2.9 mm arthroscope could be driven into this space to reach to the radiocarpal joint, this
would classify as Geissler grade IV carpal instability.
TABLE 3. Palmer Classification TFCC Tears

Traumatic—type 1
1A Central disk perforation
1B Peripheral TFCC tear (capsular or foveal)
1C Tear of the ulnocarpal ligaments from carpus
1D Tear off the distal radius insertion of the TFCC
Degenerative—type 2
2A Wear without frank tear of TFCC
2B Wear with lunate chondromalacia
2C TFCC central perforation with lunate or ulnar
chondromalacia
2D TFCC central perforation with lunate chondromalacia and
LT ligament perforation
2E Above plus ulnocarpal arthritis
LT indicates lunotriquetral; TFCC, triangular fibrocartilage complex.
FIGURE 13. Normal arthroscopic trampoline test of the triangular

have a loose, bulging quality. A tear can be inferred from fibrocartilage complex (TFCC). The articular disc (asterisk) of the
this or can be visualized through a DRUJ portal as TFCC is depressed with the arthroscopic probe. The volar radio-
ulnar ligament (arrow) can be seen.
described by Slutsky.2 The fovea can be fixed using
an arthroscopic-assisted technique to repair the TFCC
through a bone tunnel (Fig. 14). A peripheral type 1B
tear can usually be visualized and probed for capsular due to nonunion. Cystic changes can be seen in the radial
detachment (Fig. 15). Multiple techniques have been head or in the lunate or triquetrum in a location opposite
reported for including all inside, inside out, and outside in either the ulna or styloid.
repairs (image).23–27 Synovitis may be seen in the recess Ulnar impaction has characteristic findings on MRI.
and can be debrided as well (Fig. 16). Ulnar positive variance may be seen but is better assessed
on a standard PA radiograph; ulnar positioning on
Ulnocarpal and Stylocarpal Impaction coronal MRI can be variable due to differences in posi-
Palmar type 2 tears of the TFCC are degenerative and tioning of the wrist.28 Degenerative tearing with the TFC
are commonly associated with impaction of the ulnar and LT ligament is often seen on coronal images. Chon-
structures to the lunate, LTIL, and triquetrum. This is dral loss may be present along the proximal aspects of the
usually due to length discrepancy of the ulna in relation to lunate and triquetrum, with the ulnar proximal pole of the
the radius. lunate being the most involved. This chondral loss is
Patients will typically present with ulnar-sided wrist frequently associated with T2 hyperintense marrow
pain that may or may not be associated with a traumatic edema, a focal subchondral cyst, and/or T1 hypointense
event x-rays may demonstrate extension of the ulnar head sclerotic changes. Less commonly impaction can occur
beyond the level of the radius articular surface. A styloid between the triquetrum and either a prominent ulnar
nonunion piece can be seen in cases of stylocarpal impaction styloid or a displaced ulnar styloid avulsion fracture; the
FIGURE 12. Magnetic resonance imaging (A) and arthroscopic (B) appearance of a type 1D triangular fibrocartilage complex (TFCC)
tear. This coronal T1-weighted image obtained after radiocarpal injection of dilute gadolinium demonstrates disruption and irregularity of
the triangular fibrocartilage body consistent with tearing near its radial attachment (arrow). There is extension of gadolinium contrast
through the TFC tear into the distal radioulnar joint (A). Arthroscopic probe elevating and exposing the TFCC (asterisk) disruption at the
radial (R) attachment viewed from the dorsal 3 to 4 portal. Arrows indicate the anatomic location of the radial attachment (B).
FIGURE 14. Magnetic resonance imaging (A) and arthroscopic (B–D) appearance of a foveal detachment injury to the triangular
fibrocartilage complex (TFCC). This coronal T2-weighted image demonstrates subtle irregularity in the peripheral attachments of the
triangular fibrocartilage, suspicious for foveal tearing (A). On arthroscopy, note the detachment of the convergence of the volar and
dorsal radioulnar ligaments (asterisk) from the foveal insertion on the ulna (U) (B). Status postarthroscopic-assisted foveal TFCC suture
repair by an ulnar transosseous tunnel (C). Intraoperative radiograph showing the trajectory of the transosseous bone tunnel (D).
FIGURE 15. Magnetic resonance imaging (A) and arthroscopic (B, C) appearance of a type 1B dorsal peripheral triangular fibrocartilage
complex tear. This coronal short tau inversion recovery image demonstrates intact appearing triangular fibrocartilage proximal and distal
lamina with interposed intermediate signal from the ligamentum subcruentum. The distal lamina appears minimally thickened (arrow).
However, note extensive edema distal to the ulnar styloid in the expected location of the meniscal homologue and ulnar collateral
ligament (arrowhead) (A). Note the tear detaching the articular disc (asterisk) from the dorsal radioulnar ligament (arrow) (B). Status
postarthroscopic outside in suture repair (C).
FIGURE 16. Magnetic resonance imaging (MRI) (A) and arthroscopic (B, C) appearance of pisotriquetral recess synovitis. There is a small
joint effusion in the inferior recess of the pisotriquetral joint on this coronal T2-weighted image with fat saturation. With appropriate
windowing, there is visible complexity of the joint effusion contents with some components relatively hypointense compared with the
bright joint fluid (arrow), consistent with synovitis (A). Intravenous administration of gadolinium contrast can help make areas of synovitis
more conspicuous on MRI imaging. Note the arthroscopic appearance of synovitis consisting of engorged hyperemic vascularity within
the synovium of the pisotriquetral recess (asterisk) prearthroscopic (B) and postarthroscopic (C) debridement. The arthroscopic shaver
can be seen at work in these pictures.
marrow changes and cartilage loss in this situation are to the enhancement.32 Many ganglia have a multilocular
more centered on the triquetrum as the point of contact is appearance or septations, a small neck can often be seen
in a more ulnar location compared with the more com- extending to the wrist joint most commonly either
mon ulnolunate impaction. through the dorsal band of the SL ligament or along the
Arthroscopically, the degenerative tear in the TFCC is volar aspect of the distal radius along the volar joint
usually seen in the central avascular portion. Prominence of capsule.
the ulnar head can make arthroscopy and evaluation of this Historically, open excision of the cyst was performed;
area difficult, and scoping after shortening can make eval- however, arthroscopic dorsal ganglion excision has become
uation and treatment of the TFCC pathology easier. In a mainstay of treatment.33 This technique allows treatment
cases where the ulnar positive variance will be treated with of the cyst in addition to exploration of the remainder of
wafer excision of the ulnar head, the burr is introduced the joint for both diagnosis of associated pathology as well
through the tear in the TFCC and the ulnar head burred as treatment as needed. Dorsal wrist syndrome or dorsal
until it no longer contacts the lunate or LTIL.27 Further wrist capsular impingement has also been described as
evaluation with the scope will demonstrate chondral injury a cause of wrist pain in the absence of a cyst or other
to the lunate ulnar corner, the LT or the triquetrum pathology.34 This clinical entity has been described as
(Fig. 17). resulting from trauma and partial avulsion of the dorsal
In stylocarpal impaction, the chondral injury will be wrist ligaments from the carpus leading to redundant
located toward the styloid tip and the triquetral contact. The capsular tissue that can impinge during motion. Arthro-
tip of the styloid that is prominent or the nonunion ossicle scopic treatment has also been described for identification
can be localized with a small needle or fluoroscopic control and treatment of this syndrome as well. Matson and col-
and then excised either open or with a burr leagues reported good results with debridement in a small
arthroscopically.29 If the styloid is treated or excised, care series of 19 patients.
should be taken not to detach the peripheral attachment of A variety of arthroscopic techniques have been
the TFCC. described.31,33,35,36 The ganglion typically is located over-
lying the location of the 3 to 4 portal. As a result, either a
Dorsal Ganglia, Dorsal Capsular Impingement 4 to 5 or a 6R portal is established first to visualize the
Dorsal wrist pain or pain with loading and wrist dorsal capsule in the region of the cyst. A small bulge or
extension are common complaints seen in the hand sur- “pearl” can sometimes be seen at the region of the in-
geon’s practice. In the absence of obvious ligamentous folding adjacent to the SLIL. However, redundant cap-
injury or other cause, frequently the diagnosis of dorsal sule may be all that is seen. Some authors advocate
ganglion cyst or dorsal wrist capsular impingement is injection of dilute methylene blue into the cyst to help
made.30,31 identify its location; however, care should be taken not to
Ganglion cysts typically demonstrate T1 hypointen- inject the substance intra-articularly.37 Some authors
sity and T2 hyperintensity on MRI with a thin hypo- advocate visualizing the dorsal capsule from a volar
intense peripheral wall. If contrast is administered, radial portal so the capsule will be visualized directly
ganglia may demonstrate slight enhancement of the wall instead of obliquely.3 Before conclusion of the procedure,
but should not have central enhancement. However, in the midcarpal joint should be entered and the SL and LT
some cases of extremely small ganglia with low volume ligaments tested for stability. Resection of the cyst takes
of fluid, there may be a somewhat solid appearance place after establishing the 3 to 4 portal as a working site.
FIGURE 17. Typical magnetic resonance imaging (A, B) and arthroscopic (C–E) appearance of ulnocarpal impaction syndrome.
This coronal proton density-weighted image with fat saturation demonstrates extensive degeneration and tearing of the trian-
gular fibrocartilage body (arrow). There is high-grade chondral loss along the proximal ulnar aspect of the lunate bone
(arrowhead) with underlying irregularity of the subchondral bone and associated mild marrow edema (A). This coronal
T2-weighted fat saturated image demonstrates the typical findings of advanced ulnolunate abutment including ulnar positive
variance, chondral loss in the distal ulna and proximal lunate, degenerative marrow changes in the distal ulna, extensive tearing of
the triangular fibrocartilage (arrow), and nonvisualization of the normal triangular appearing membranous portion of the
lunotriquetral ligament between the lunate and triquetral cartilage surfaces secondary to tearing (arrowhead) (B). Note the grade
IV chondromalacia of the lunate (L) with significant degeneration and fraying of the triangular fibrocartilage complex (TFCC)
(asterisk) due to long standing ulnocarpal impaction syndrome. An exposed, arthritic ulnar head (U) can be seen as well (C). In
this arthroscopic image chondral thinning of the lunate (L) and fraying of the TFCC (asterisk) can once again be seen (D). The
same arthroscopic image status postarthroscopic TFCC (asterisk) debridement back to stable margins and arthroscopic burring of
the underlying distal ulna (U) (wafer procedure), done to reestablish an anatomic ulnar negative variance and offload the arthritic
lunate (L) (E).
The shaver can be introduced and the cyst excised at its of chondral injuries on the capitate or hamate can be
stalk along with a segment of surrounding capsule. identified. These can be a source of midcarpal region
Resection should be stopped when the extensor tendons pain.39,40 Those whose lunate morphology has only 1 facet
are visualized through the capsular resection (Fig. 18). are termed type I lunates, whereas those with a second facet
In cases where a cyst has not been identified but dorsal are termed type II. Although chondral injuries can be seen in
wrist syndrome is suspected, the redundant and inflamed either situation, they are typically associated with trauma
dorsal capsule and synovium in the region of the scaphoid and other ligamentous injury in patients with type I lunates.
and SLIL can be excised to provide symptomatic relief. However in type II lunates, a chondral lesion or injury can
Care should be taken to avoid resection of the dorsal be seen in the hamate articulation with the lunate even in the
structural portion of the SL ligament. absence of any associated ligamentous injury. In these
patients, this chondral injury can be a source of continued
Midcarpal Chondral Injuries ulnar midcarpal pain. Partial thickness cartilage wear can be
There is variation in the morphology of the lunate at its debrided with a shaver, however full thickness or larger
midcarpal articulation. In 40% only 1 facet is present lesions may need to be addressed with burr resection or
articulating with the capitate, but in the remainder of peo- microfracture.
ple, a second variable sized facet is present also articulating The lunate may either have a single facet articulating
with the hamate.38 In both arthroscopic reports examining with the capitate (type I morphology) or a secondary
the midcarpal joint as well as cadaver dissections, a variety facet which also articulates with the hamate (type II
FIGURE 18. Magnetic resonance imaging (MRI) (A) and arthroscopic (B–D) appearance of a dorsal ganglion cyst. A small T2 hyper-
intense fluid filled ganglion (arrow) is seen on this axial T2-weighted MRI image, immediately adjacent to the dorsal band of the
scapholunate ligament (A). Note the redundant dorsal capsular tissue (asterisk) seen immediately volar to the ganglion cyst (B).
Arthroscopic action shot of the shaver resecting this dorsal capsular tissue (C), until the overlying extensor tendons (arrow) can be
visualized from within the joint (D).
morphology). A type II lunate is present by MRI in performed if indicated. A burr can be introduced through the
approximately half of individuals.41 Chondral loss with portal for resection as indicated as well (Fig. 19).
associated subchondral bone marrow changes may be
present in the proximal pole of the hamate; previously
this was reported to be an often occult finding on MRI42; CONCLUSIONS
however, it is likely apparent in more cases on newer Arthroscopy at this time remains the gold standard for
generation MRI units. diagnosis and treatment of a variety of wrist pathologies. It
During arthroscopy, these lesions can be inspected from allows static inspection of the radiocarpal, midcarpal, and
the standard midcarpal radial and midcarpal ulnar portals. DRUJ joints for diagnosis but also allows dynamic exami-
Chondral wear on the capitate can be staged for future nation of the capsular and ligamentous structures. Further,
determination of salvage with either 4 corner fusion or all arthroscopic or arthroscopic-assisted treatments have
proximal row carpectomy as indicated. Hamate chondral been developed and can be performed at the same operative
lesions can also be identified and treated through these por- setting. However, it remains an invasive surgical procedure.
tals with shave chondroplasty or a k-wire can be introduced MRI techniques and understanding continues to improve
through the dorsal capsule and microfracture of the lesion they will remain an important diagnostic technique.
FIGURE 19. Magnetic resonance imaging (A) and arthroscopic (B, C) appearance of a type II lunate. There is type II lunate morphology
on this coronal STIR image, with associated full thickness chondral loss in the proximal pole of the hamate (arrow) and underlying marrow
edema (A). Severe chondral wear within the proximal pole of the hamate (H) and chronic degenerative Geissler grade III carpal instability
between the lunate (L) and triquetrum (T) can be seen in these arthroscopic images (B, C).
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MRI and Arthroscopic Correlation of The Wrist

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REVIEW ARTICLE

MRI and Arthroscopic Correlation of the Wrist

interference in steady state, axial T1, axial T2-weighted with

A s a diagnostic tool, wrist arthroscopy was introduced in

From the Departments of *Radiology; and †Orthopaedic Surgery,

direct visualization of the TFCC and the lunotriquetral

varying appearances. The volar and dorsal bands both have

and radiocarpal spaces. This is termed a “drive-through

TABLE 3. Palmer Classification TFCC Tears

FIGURE 13. Normal arthroscopic trampoline test of the triangular

REFERENCES 23. Atzei A, Luchetti R, Braidotti F. Arthroscopic foveal repair of

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