Arthrography of the Wrist Joint

Transcription

1 Cops right 954 b The Journal of Bone and Joint Surgery. lncorporated Arthrography of the Wrist Joint AN EXPERIMENTAL STUDY* BY ZELIMIR Di. MIKIC. M.D., D.SCJ, NOVI SAD, YUGOSLAVIA Iron: tile Cli,:i (9 Orthopaedics and Trauinatologv. i-aeidt of Medicine. Nail Sad ABSTRACT: Arthrography using 60 per cent Urografin was done on twenty fresh cadaver wrist joints. The wrists were then dissected and the arthrographic picture was correlated with the anatomical findings. The study showed that the contrast solution exactly delineated the radiocarpal joint cavity. It passed through all cartilage. Promising results have been reported. but the procedure is not accepted as a routine diagnostic test. The aim of the present study was to investigate cxperimentally the accuracy of arthrography and to extend a previous study so as to establish the normal patterns in arthrograms of the wrist joint. Additionally. I undertook a Ft;. I Drawings of a normal arthrogram (left) and of a conditionally pathological arthrogram (right). I. recessus prescaphoideus; 2. recessus preradialis: 3. recessus prestyloideus: 4. recessus pretriquetralis: 5. pisiform joint cavity: 6. cavity of the distal radio-ulnar joint. with a picture of the perforation of the articular disc: and 7. mediocarpal joint cavity with perforation of the interosseous ligament between the scaphoid and lunate. apertures into the adjacent joints. The arthrographic picture accurately corresponded to the anatomical observations. The pattern ofa normal arthrogram was thus established. The preliminary results of a parallel clinical study in forty-nine patients are briefly described. I concluded that contrast arthrography can be helpful in the diagnosis of several conditions that show no findings on plain radiographs. Several investigators have studied arthrograms of the wrist in an effort to find a reliable method of visualizing radiolucent structures, especially the triangular fibro- * Read in part at the Congress of the Soci#{233}t#{233} Internationale de Chirurgie Orthopedique et Traunlatologique, Rio de Janeiro. Brazil. August 30 through September y Medicinski Fakultet. Hajduk Veljkova I Novi Sad. Yugoslavia. clinical study to investigate the practical value of the diagnostic procedure. Material and Methods Twenty wrist joints were obtained from fifteen cadavera of individuals ranging in age from twenty to ninety-two years. Four were female and eleven, male. Death had resulted from causes that were not associated with primary joint disease. There was no abnormality or sign of injury in the joints that were studied. A 60 per cent solution of Urografin (sodium diatrizoate and meglumine diatrizoate) was used as the contrast medium, and two to three milliliters was injected from the dorsal side between the distal border of the radius and the bones of the proximal carpal row. Routine anteroposterior. lateral, and oblique radiographs of the wrist joint were then VOL. 66-A, NO. 3. MARCH

2 372. DJ. MIKIC Fio. 2 A. Arthrogram of a large recess next to the ultlar styloid process (recessus prestloideus). The empty space between the ulnar head and the contrast line designates the articular disc. shose earpal side appears to he regular and smooth. B. The same specitilen at dissection. r = radius and d = discus articularis. Next to the articular disc is the entrance into the large prestyloid recess. made. In three specimens one milliliter of contrast medium was subsequently injected into the distal radio-ulnar joint, and additional radiographs were tiiade. After the arthrograms had been studied. the wrist was opened from the dorsal side and the distal radio-ulnar and radiocarpal joints were examined grossly. The findings on the arthrograms were compared with the anatomical details of the joints at dissection. To apply the results to patients. fifty wrists with various lesions were studied (Table I) in forty-nine patients. Twentyone patients were female and twenty-eight were male. Their ages ranged from seventeen to sixty-two years. Results The arthrographic study in cadavera showed that in each specimen. with one exception. the contrast solution filled the four normal recesses of the joint cavity and the communication to the carpopisiform joint. Accordingly, it was possible to establish the pattern of a normal arthrogram (Fig. 1 ). The exception (non-filling of a recess) involved the preradial recess in half of the specimens. The radiocarpal joint cavity appeared on the normal arthrograms (Figs. 1 and 8) as a regular. continuous line between the forearm bones and the carpus. ending laterally at the radial styloid process and medially at a point just inferior to the ulnar styloid process. The four standard synovial recesses were found to be smoothly delineated as typical extensions originating from the basal line (Fig. I ). The recessus prestyloideus is a synovial diverticulum, varying in size and shape. that is situated just below the ulnar styloid process. It was evident in all specimens. and its arthrographic appearance corre- THE JOURNAL OF BONE AND JOINT SURGERY

3 ARTHROGRAPHY OF THE WRIST JOINT 373 FIG. 3 The antebrachial side of the right carpus. I. recessus prescaphoideus: 2. recessus pretriquetralis: and 3. natural aperture into the pisiform joint. sponded absolutely with the anatomical findings (Figs. I and 2). Similarly, the so-called recessus prescaphoideus was always present both arthrographically and anatomically (Figs. I. 4. and 8). The contrast tnediuni in that recess. which filled this large synovial space around the scaphoid. was found to be situated mostly on the dorsoradial side of the joint (Fig. 7). A synovial pocket on the volar side of the scaphoid (part of the prescaphoid recess) also was a constant finding (Figs. 3 and 5). The recessus preradialis. a small recess located next to the radial attachment of the Testut-Kuenz ligament (Figs and 5). was not so constant and was seen on only twelve of the arthrograms although it was present in all of the dissected specimens. All ofthese recesses have been reported previously. In addition, in all wrists, both on the arthrograms and at dissection there was a synovial pouch on the volar side of the triquetral bone (Figs. I A. 6-B, and 7) which I named the recessus pretriquetralis. In a few specimens there also was a small, pyramid-like recess next to the radial styloid process (Fig. 7). In eleven joints (55 per cent) the contrast medium penetrated through the macroscopically visible aperture (Fig. 3) into the pisiform joint cavity. giving a typical picture on the arthrograms of a ring with a small pea-like extension on its distal end (Figs. I and 7). The radiolucency on the arthrograms between the contrast line and the ulnar head represents the intra-articular disc. In specimens in which the disc was not perforated the contrast medium outlined its carpal surface very accurately as a regular convex line (Figs. 1 and 2). In three specimens in which the distal radio-ulnarjoint was also injected it was possible to delineate the disc from both the ulnar and the carpal side (Fig. 8). In twelve joints in which the disc was perforated the contrast solution passed through the hole so as to outline the cavity of the distal radio-ulnar joint as a rounded, L-shaped shadow with a smooth margin (Fig. 1). The passage ofthe solution precisely indicated the existence. location. size, and sometimes the form of the perforation (Fig. 9). The contrast medium in the distal radio-ulnar joint Ft;. 4 Arthrogram of the recessus prescaphoideus ( I ) and the recessus preradialis (2). VOL. 66-A, NO. 3. MARCH 1984

4 i DJ. MIKIC -- :..: :.: r...i,... S i FIX. 5 The interior of the right radiocarpal joint. viessed from the dorsal side. r = radius. s = scaphoid. I = lunate. T = Teslut-Kuenz ligament (the recessus preradialis is visible next to the radial attachment of this ligament). and p = recessus prescaphoideus. also outlined the ulnar surface of the disc. In ten specimens it could be demonstrated that the interosseous ligaments had disintegrated: four of the ligaments were between the scaphoid and lunate and six, between the lunate and triquetrum. The contrast medium penetrated into the mediocarpal joint. IndicatIng these communications very clearly (FIgs. 6-A and 6-B). No communication between the wrist joint and the nearby tendon sheaths was seen. In the fifty patients who had an arthrogram made for various conditions (Table I) a lesion was found in twentyseven wrists. while in twenty-three the arthrograms were normal (Fig. 10). The most common pathological finding was passage of the contrast tiiedium through the triangular fibrocartilage and through the intercarpal ligaments. This occurred mostly in young patients (thirty years old or less). Leakage of the contrast medium out of the joint cavity was a less common finding. and a corrugated pattern of the FIG. 6-A Arthrograms of the right wrist joint of a cadaver. Note the penetration of the contrast medium through the interosseous ligament between the lunate and triquetrum into the mediocarpal joint. The recessus prestvloideus ( I ) and recessus pretriquetralis (2) are smooth. THE JOURNAL OF BONE AND JOINT SURGERY

5 ARTHROGRAPHY OF THE WRIST JOINT 375 FIG. 6-B The same specimen at dissection. The degenerative disintegration of the interosseous ligament between the lunate and triquetrum which allows the penetration of the contrast mediutn is clearly visible. Note also the recessus prestyloideus and recessus pretriquetralis. The articular disc is intact. synovial cavity was seen in rheumatoid patients. Discussion The results of this study showed convincingly that the wrist joint can he accurately examined by contrast arthrography and that the soft-tissue elements of the wrist like the articular disc, interosseous ligaments. and synovial tissue, not visible on standard radiographs. can be visualized by this technique. The study also showed that the arthrographic picture nearly always correlated well with the anatomical details of the joint. It is obvious from the literature that there is controversy concerning the various elements that make up the picture of the so-called normal arthrogram. The margins of the contrast material that outlines the joint cavity and all its extensions should normally be sharply delineated and smooth, indicating normal cartilage and synovial tissue. Irregular margins and a corrugated appearance of the synovial lining, especially in the so-called recessus sacciformis of the distal radio-ulnar joint. are pathological findings, as has been pointed out by Ranawat et alj 4. The recessus prestyloideus (or ulnar styloid bursa7, or recessus ulnaris21). was described and named by Testut in 1904 and by Poirier and Charpy in and its existence by Soleilhac and by Rieunau et al. It is a small synovial pocket on the volar aspect of the distal end of the radius, and is very often covered with synovial villi. It was demonstrated on the arthrograms in only about half of the wrists in this study, but could always be demonstrated at dissection. In the arthrograms in the present study, the largest quantity of radiopaque solution always was found in the area of the scaphoid bone. and that pattern was constantly present in other series as well34k23. The recess is called the recessus prescaphoideus im.2i or recessus dorsalis23. It was described by Vallois in 1926 as a synovial pouch on the volar aspect of the scaphoid and is a constant characteristic of the wrist joint. However, separate from this recess there always is a synovial enlargement on the dorsoradial side of the scaphoid. and filling of both these recesses with the contrast medium gives the typical picture on arthrograms. For that reason the names given to this arthrographic pattern seem to be incorrect. ln my opinion it would be much more convenient to use the terms recessus periscaphoideus volaris and dorsalis. In all of the wrists of this series and in all joints from the previous large anatomical study a synovial pouch was found, located on the volar aspect of the triquetral bone, which was nicely outlined arthrographically especially on the oblique views (Figs. 3, 6-A, 6-B, and 7). As I was not able to find any description of this recess in the literature I named it the recessus pretriquetralis. Winter mentioned this recess, but he considered it to be a bursa of the pisiform joint. To me that seems incorrect because the recess also was present in specimens in which there was no commu- was later confirmed by many authors45 #{176} 4. L5. 7. is.23#{149} Lewis et al.9 found it in all fifty joints that they dissected. It was found in all of the specimens described in the current study and in I 80 joints in a separate anatomical study. From these observations it can be concluded that this recess is a constant feature of the wrist joint. According to Lewis et al.9, it is a phylogenetic remnant and may be variable in form and size. It is always present on the volar side of the ulnar styhoid process and is always evident on arthrography. The recessus preradialis. described by Vallois in 1926, has mostly been ignored in the literature. It was mentioned FIG. 7 Normal arthrogram of the radiocarpal joint. I. recessus prescaphoideus: 2. pyramid-like recess next to the radial styloid process; 3, recessus prestyloideus; 4, recessus pretriquetralis; and 5. pisiform joint. VOL. 66-A, NO. 3. MARCH 1984

6 376. DJ. MIKIC Ft. 8 An experimental double arthrogratit of the x rist mint. A. Initial arthrogram of the radiocarpal oint. 8. Arthrogram after contrast medium was injected into the distal radio-ulnar (lint. The articular disc is delineated (mill both sides. nlcatlon between the radiocarpal and pisotriquctral joints. The occasional comtiiunicatton between the radiocarpal and pisifortil joints has been noticed for a long time. but there is a lack of agreement concerning its incidence. Rieunau et al. thought that it is always present Haage4. Haage and Cornelius6. and Winter fund it in 75 per cent of wrists: and Lewis et al. found It in 34 per cent of wrists. In the present material it was found in 55 per cent and in a previous study of 180 joints of individuals of all ages. in 56 per cent. l his aperture wastound in all age groups. ltthereftre seems to he congenital and tn;t represent one of the phylogenetically inherited variants5 One of the most controversial questions about arthrography of the wrist is whether penetration of the contrast medium through the articular disc into the distal radio-ulnar joint is abnormal. Most authors have thought so. and considered it indicative of datiiage to the articular disc. This is true if one assumes that normally the articular disc always is unbroken and the radiocarpal and distal radioulnar joints are distinct. With regard to perforation of the articular disc of the wrist joint opinions as to whether or not that is pathological, and its incidence. vary considerably On the basis of the study of 180 wrist joints :)t individuals ranging in age from fetuses to ninetyfour years. I concluded that a disc perfration is degenerative in nature: there were 110 perfrations in the first two decades of life: in the third the incidence was 7.6 per cent: in the fourth per cent: in the fifth per cent: in the sixth per cent: and in older patients. 53. I per cent. I concluded that this degenerative change is fundamentally part of the normal aging process. If so. the penetration of the radiopaque solution through the articular disc cannot be Fi; Experimental irthrograni sho ing the penetration of the contrast solution into the distal radio-ulnar joint through ts o perforations of the articular disc: a large one periradiail and a smaller one at the [)erist bid part of the disc. B, Dissection of the satile specitlieti proved the accuracy of the arthrographic findings. There are two holes in the disc: a large one periradially and a smaller one next to the ulnar styloid process. THE JOURNAL 01 BONE AND JOINT SURGERY

7 ARTHROGRAPHY OF THE WRIST JOINT 377 TABLE I Ci.INICA1. AR THROGRAPHY IN FIFTY W RIST JOINTS Type of Pathological Condition No. of Arthrograms No. of Positive Arthrograms No. of Negative Arthrograms Suspected isolated lesion of the triangular librocartilage Colles fracture Suspected Galeazzi fracture-dislocation Suspected dislocation of the distal radio-ulnar joint in fractures of the forearm Suspected Essex-Lopresti fracture Distal radio-ulnar arthropathy after resection of the radial head Rheumatoid arthritis Total considered pathological. In some instances it may be conditionally pathological (Fig. 1 ). which means that in a young person (until the age of thirty) the perforation should be regarded as pathological, but in an older person its possible pathological significance must be correlated with other arthrographic, radiographic, and clinical findings. I apply the same interpretation to the passage of contrast medium into the mediocarpal joint. That demonstrates the viduals in the first two decades of life, and from the third decade on their frequency increased progressively. In a group of 109 wrists observed in individuals past the third decade of life, the interosseous ligament between the scaphoid and lunate was perforated in forty-seven (43 per cent) and between the lunate and triquetrum, in sixty joints (55 per cent). On the basis of these data, it appears that the passage of the contrast medium from the radiocarpal joint FIG. 10 This patient had a suspected Galeazzi fracture-dislocation. Negative arthrography proved that the triangular fibrocartilage was intact and that there was no dislocation of the distal radio-ulnar joint. The patient was treated for an isolated fracture of the radius. existence of an aperture in the interosseous ligaments between the scaphoid and lunate or between the lunate and triquetrum (Fig. I). The nature and incidence of these changes have been also variously described in the literature According to the results of my previous anatomical study. the perforations in the interosseous hgaments are acquired degenerative and age-related changes. There were no such perforations in specimens from mdiinto the mediocarpaljoint is also a conditionally pathological finding. My results in clinical use of wrist arthrography confirm that this diagnostic method may be useful for detecting obscure pathological processes, especially lesions of the triangular fibrocartilage and synovial involvement in rheumatoid arthritis. A negative arthrogram also may be quite helpful for ruling out some lesions (Fig. 10). VOL. 66-A, NO. 3. MARCH 1984

8 DJ. MIKIC References I. COLEMAN. H. M.: Injuries of the Articular I)isc at the Wrist. J. Bone and Joint Surg.. 42-B(3): FISCHER, E.: Weichstrahldiagnostik des vergr#{246}sserten Recessus sacciformis des distalen Radio-ulnargelenks. Radiologe. 15: , GUILLERMO, J.: Le fibro-cartilage de larticulation radio-cubitale inf#{233}rieure chez I adulte (en marge des traumatismes radio-carpiens). Rev. orthop.. 25: HAAGE. HORST: Die Arthrographie des Handgelenks. I. Mitteilung. Das normale Gelenk und seine Variationen. Radiologe. 6: HAAGE. H.. and CORNELIUS. H. : Die Arthrographie des Handgelenks. II. Mitteilung. Der pathologische Discus articularis. Radiologe. 6: I HARRISON. M. 0.: FREIBERGER. R. H.: and RANAWAT. C. S.: Arthrography of the Rheumatoid Wrist Joint. Am. J. Roentgenol.. 112: , KESSLER. I., and SILBERMAN, Z.: An Experimental Study ofthe Radiocarpal Joint by Arthrography. Surg., Gynec. and Obstet.. 112: LEWIS, 0. J.: Evolutionary Change in the Primate Wrist and Inferior Radio-ulnar Joints. Anat. Rec.. 151: , LEWIS, 0. J. ; HAMSHERE. R. J. : and BUCKNII.1.. T. M.: The Anatomy of the Wrist Joint. J. Anat., 106: , MARAVAL-BONNET. M.: Etude anatomo-radiologique du ligament triangulaire du poignet. These. Toulouse, I I. MIKIC. Z. Dj.: Age Changes in the Triangular Fibrocartilage of the Wrist Joint. J. Anal.. 126: POIRIER, P., and CHARPY. A.: Trait#{233}danatomie humaine. Ed. 3. Paris, Masson RANAWAT. C. S.: HARRISON. M. 0.: and JORDAN, L. R.: Arthrography ofthe Wrist Joint. Clin. Orthop.. 83: 6-12, RANAWAT. C. S.: FREIBERGER. R. H.: JORDAN. L. R.: and STRAUB. L. R.: Arthrography in the Rheumatoid Wrist Joint. A Preliminary Report. J. Bone and Joint Surg.. 51-A: Oct RESNICK. D.: Arthrography in the Evaluation of Arthritic Disorders of the Wrist. Radiology, 113: lb. RIEUNAU. G.; GAY. R. ; MARTINEZ. C.: MANSAT, C. : and MANSAT. M.: Lesions de l articulation radio-cubitale inf#{233}rieure dans les traumatismes de I avant-bras et du poignet. Int#{233}r#{233}t de larthrographie. Rev. chir. orthop.. 57 (Supplement I): , RosLi, A.: Die Arthrographie. em Beitrag zur Handgelenkdiagnostik. Schweizerische med. Wochenschr.. 93: SOLEILHAC. R.: L Arthrographie opaque du poignet. These. Toulouse STUART. C.: Lartografia gassosa e opaca per lo studio dellarticolazione radio-ulnare distale. Radial. med.. 53: , TESTUT, J. L.: Trait#{233}danatomie humaine. Ed. 5. Paris, Doin, VALLOIS. H. V.: Arthrologie. in Traite d anatomie humaine, by P. Poirier and A. Charpy. Ed. 3. Paris, Masson, WEIGL. K., and SPIRA. E.: The Triangular Fibrocartilage of the Wrist Joint. Reconstr. Surg. and Traumatol., 11: , WINTER, P. M.: Untersuchungen am Discus articularis ulnae mit Hilfe der Arthrographie des Handgelenkes. Handchirurgie. 8: THE JOURNAL OF BONE AND JOINT SURGERY