MRI Of The Hand And Wrist Syllabus

2015-07-27

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7/16/2015

Imaging in the Diagnosis of Ulnar

Sided Wrist Pain

Kimberly K. Amrami, MD

Professor of Radiology

Chair, Division of Musculoskeletal Radiology

Mayo Clinic

Rochester, Minnesota

Sources of Ulnar Sided Wrist Pain

•TFCC –foveal attachment –UT

Ligament

•Distal Radioulnar Joint

•Extensor Carpi Ulnaris

•LT ligament

•Ulnocarpal Impaction

•Arthritis

Triangular Fibrocartilage Anatomy

7/16/2015

“Fovea” sign

S.C. Tay, K. Tomita, R.A. Berger

The “ulnar fovea” sign for defining

ulnar wrist pain: an analysis of

sensitivity and specificity

J Hand Surg Am 32(4) (2007), pp

438-44

SN 95.2%

SP 86.5%

19 year old collegiate baseball player

Being recruited by the Yankees Nephew of a colleague

X-ray slightly supinated

7/16/2015

Outside MRI - 1.5T

STIR FSE T2

Outside Diagnosis –Foveal Tear

Diagnosis:

Ulnotriquetral

ligament tear -

Partial foveal

tear

Tx: TFCC and

UT repair

Returned to

collegiate play

after surgery

7/16/2015

TFCC –Ulnotriquetral Ligament

•Important stabilizer of the ulnar wrist

•But tears may not lead to gross

instability

•Important source of pain

•Complete, partial and “split tears”

significant

Can you really see the UTL?

UTL –3 planes

7/16/2015

Courtesy Michael Ringler MD

Intact

Split Tear

UT Ligament Split Tear

Called Prospectively

UT Split Tear

Missed Prospectively

7/16/2015

75 100 100 100 94.9 100

100

SN 1.5T SN 3.0T SP 1.5T SP 3.0T Acc 1.5T Acc 3.0T

M.L. Anderson, J.A. Skinner, J.P. Felmlee,

R.A. Berger, K.K. Amrami

Diagnostic comparison of 1.5 Tesla and

3.0 Tesla preoperative MRI of the wrist in

patients with ulnar-sided wrist pain

J Hand Surg Am, 33 (7) (2008), pp. 1153–

1159

M.D.Ringler, B.M.Howe, K.K.Amrami, C.E.

Hagen, R.A. Berger

Utility of magnetic resonance imaging for

detection of longtudinal split tear of the

ulnotriquetral ligament

J Hand Surg Am, 38 (9)(2013), pp.1723-7

100% sensitivity

at 3T

30-58% sensitivity

1.5 and 3T

TFCC –Foveal Attachment

•Foveal attachment

•Critical attachment for stability

•High grade partial or complete

tears equally significant

•Healed partial tears with scarring

may be challenging

•Normal synovial reflection can be

confusing

55 yo male with ulnar wrist pain –fell while gardening

7/16/2015

Foveal Dissociation –UT Intact

7/16/2015

Neutral

Resisted Pronation

DRUJ Displacement on MRI

•Patients generally imaged in

pronation with some resistance

(“superman position”)

•Can displacement of DRUJ on axial

MRI represent foveal tears as on CT?

Ehman EC et al J Hand Surg am 36(11) 1780-4.

Measurement

Simplified measurement technique

Line spans sigmoid notch

Circle approximates articular curvature of ulna

Ulnar displacement = A/(A+B) x 100% - 50%

7/16/2015

DRUJ Displacement on MRI

•Greater than 15% displacement

associated with complete foveal tears

100% of time

•However –over 50% of cases with

foveal tears had less than 15%

displacement

•Useful as a “check” for second look

by radiologist?

•Usually visually obvious

DRUJ Displacement on MRI

Foveal Tear –Surgically

Confirmed

Radioulnar Ligaments Intact at Surgery

7/16/2015

Complex tears

•Fovea –body of TFCC –UT ligament

•Tears commonly extend up and down

this axis

•Fall on an outstretched hand is a

common mechanism

UT, TFCC and Foveal Tears

Foveal Tear is Complete

29 yo woman

Complete foveal Tear

ECU Subsheath Tear and Subluxation

Subluxation of the ECU

7/16/2015

Pre and Post TFCC Reconstruction

Repaired Foveal Disruption

Pre –displaced DRUJ Post –Normal Alignment

Extensor Carpi Ulnaris Tendon

•Some subluxation likely physiologic/positional

•In the absence of pain or instability not really relevant

•ECU subluxations may occur with subsheath

intact

•Dislocations usually mean subsheath is

disrupted

ECU Subsheath Tear

ECU dislocation with confirmed subsheath tear

Fovea and UT ligament intact

7/16/2015

Post-Op Pain

•MRI can assess post op changes and

integrity of ligamentous

reconstructions

•Not all pain is a recurrent tear

•Can be imaged through a cast if

necessary

•Imaging in the presence of metal also

possible

S/P TFCC Repair

Normal Dorsal and Volar Radioulnar Ligaments

Pain related to 4th extensor compartment tenosynovitis

Post-Op Imaging

U-head (3T) DRUJ Reconstruction (3T)

7/16/2015

DRUJ Reconstruction –3T

Post Op Pain

Intact Reconstruction –degenerative arthritis at the DRUJ

Conclusion

•Ulnar sided wrist pain is a

challenging clinical and imaging

problem

•Always use your best tools

•Work with your surgeons!

Thanks to:

Richard Berger, MD, PhD

Joel Felmlee, PhD

7/27/2015

Wrist MRI and Ulnar

Sided Wrist Pain

Christopher O. Bayne, MD

UC Davis Medical Center

July 27, 2015

Disclosures

None

Ulnar Sided Wrist Pain

Diagnostic

challenge

Complex anatomy

Small size of structures

Can cause vague,

intermittent sx

7/27/2015

Ulnar Sided Wrist Pain

Differential Diagnosis

Osseous

Ligamentous

Tendinous

Vascular

Neurologic

Magnetic Resonance Imaging

Can be useful

Diagnosis/Treatment

Soft tissue lesions

Ligament

Cartilage

Soft tissue tumor

Tendonitis

Effusions

Bone (Less osseous detail

than CT)

Edema/Occult fractures

Magnetic Resonance Imaging

DIAGNOSES:

TFCC/Ulnar impaction

Tendonopathy

ECU

Lunotriquetral Ligament

Tear

7/27/2015

Triangular Fibrocartilage Complex

Anderson et al, JHS 2008

1.5 T MRI--85% sens/ 75% spec

3.0 T MRI--94% sens/88% spec

Lee et al, MR Imaging 2013

MR Arthrogram

Sensitivity: 93-94%

Specificity: 97-100%

Anderson ML, et al. J Hand Surg Am. 2008

Shin AY, et al. JBJS 2004

Triangular Fibrocartilage Complex

CLASSIFICATION

Type 1 (Traumatic)

1A- Central

1B- Ulnar

1C- Distal

1. Transverse *

2. Longitudinal (UT Split)*

1D -Radial

Type 2 (Degenerative)

2A- TFCC wear/thinning

2B- Lunate/Ulna

2C- Perforation

2D- Ligament disruption

2E- Ulnocarpal/DRUJ arthritis

Triangular Fibrocartilage Complex

CLASSIFICATION

Type 1 (Traumatic)

1A- Central

1B- Ulnar

1C- Distal

1. Transverse *

2. Longitudinal (UT Split)*

1D -Radial

Type 2 (Atraumatic)

2A- TFCC wear/thinning

2B- Lunate/Ulna

2C- Perforation

2D- Ligament disruption

2E- Ulnocarpal/DRUJ arthritis

Tay SC MD, Berger RA, et al. Hand Clin. 2010

7/27/2015

Triangular Fibrocartilage Complex

CLASSIFICATION

Type 1 (Traumatic)

1A- Central

1B- Ulnar

1C- Distal

1. Transverse *

2. Longitudinal (UT Split)*

1D -Radial

Type 2 (Atraumatic)

2A- TFCC wear/thinning

2B- Lunate/Ulna

2C- Perforation

2D- Ligament disruption

2E- Ulnocarpal/DRUJ arthritis

Citation

Tay SC MD, Berger RA, et al. Hand Clin. 2010

Ulnar Fovea Sign

95 % sen si t iv it y, 86% sp ec if ic i ty

*Tay SC MD, Berger RA, et al. JHS (Am). 2007

Triangular Fibrocartilage Complex

*Ringler MD, Berger RA, et al. JHS (Am). 2013

CONSIDERATIONS

UT split: low

sensitivity/specificity

MR may be more helpful

to exclude concomitant

injury

Ulnar positive variance

Check lunate and ulnar

head –impaction signs

7/27/2015

Triangular Fibrocartilage Complex

TREATMENT

Non-operative

Acute Type 1

First line Type 2

Steroid injection x 1-3

Oral and topical NSAIDs

Splinting/Casting

(Muenster, if tolerated)

Triangular Fibrocartilage Complex

OPERATIVE

Arthroscopy vs Open

Central: Debridement

Ulnar: Repair

Distal: repair if mechanical instability/ persistent

pain (UT split)

Radial: ? Repair

Ulnar Impaction: ulnar shortening

Triangular Fibrocartilage Complex

REPAIR OPTIONS:

Arthroscopy assisted with extra capsular knot

All-inside anchor

Thermal Shrinkage (less favored)

+/- Ulnar shortening

7/27/2015

Ulnar Shortening

Wafer procedure Osteochondral osteotomy

7/27/2015

Tendinopathy

Extensor Carpi Ulnaris

Pathology:

Tenosynovitis

Rupture

Subluxation

Tendinopathy

Extensor Carpi Ulnaris

MRI:

Tenosynovitis - Thickened tendon. Fluid within sheath

Rupture - Discontinuity of tendon fibers

Subluxation –Nonspecific, consider dynamic study

Tendinopathy

Extensor Carpi Ulnaris

Treatment:

Non-operative

-NSAIDS

-Immobilization: (Muenster Cast/splint

6-8 weeks)

Tenosynovitis (Consider steroid

injection)

ECU Subluxation

Acute injuries

1st line chronic injuries

7/27/2015

Tendinopathy

Extensor Carpi Ulnaris

Operative Treatment

Tenosynovitis (Recalcitrant) –Tx to dorsum of hamate

Rupture - Repair

Subluxation –Reconstruction of ECU subsheath/groove

deepening

ECU Stabilization

7/27/2015

ECU Stabilization

7/27/2015

Lunotriquetral Ligament Tear

Images from Alexander Y Shin M.D.

Lunotriquetral Ligament Tear

Summary

Ulnar Wrist Pain

Can be challenging

History

Exam

Imaging

MRI

7/27/2015

Thank you

7/17/2015

Imaging of the Scapholunate

and Lunotriquetral Ligaments:

Normal anatomy, anatomic variants, and

injury assessment

Dr. Jean Jose

Associate Professor Radiology

Associate Section Chief, Musculoskeletal Division

University of Miami

Miller School of Medicine

TITLE: Imaging of Scapholunate and Lunotriquetral

Ligaments

NAME: Jean Jose

DISCLOSURE OF COMMERICAL INTEREST: My

disclosure is in the Final VuMedi Program.

I have no relevant disclosures.

Disclosure of Commercial Interest

Introduction

•Carpal instability is often a confusing and challenging topic, in part

related to many different patterns of instability and also to the

existence of countless intrinsic and extrinsic ligaments.

•Such instability relates to biomechanical alterations with multiple

causes that, if not identified and treated in a timely fashion, will lead

to gradual articular collapse.

•Understanding requires a basic knowledge of anatomy and

pathophysiology, which is critical for the proper prompt diagnosis

and treatment of carpal instability.

•Such knowledge can then be applied to the analysis of imaging

studies, including MRI, CT and US, allowing a more complete and

meaningful diagnosis in cases of wrist instability and a more

meaningful conversation between the radiologist and the referring

physician.

http://radsource.us/carpal-instability/

7/17/2015

Dissociative vs. Nondissociative

injuries

•Dissociative:

–Results from tear of the intrinsic ligaments.

–SL or LT dissociation leads to DISI (SLAC) or

VISI, respectively.

•Nondissociative:

–Results from a tear of the extrinsic ligaments.

http://radsource.us/carpal-instability/

Wrist Instability

•Pre-dynamic:

–Partial ligament tear.

–Plain radiographs are normal.

–Soft tissue injury seen with MRI, US, CT, or arthroscopy.

•Dynamic:

–Incompetent or complete ligament tear.

–Static (non-stress) plain radiographs are normal.

–Abnormal changes in carpal alignment are seen on stress

radiographs/dynamic US/cine MRI.

•Static (i.e. Scapholunate dissociation):

–Complete SLIL and volar or dorsal extrinsic disruption.

–Abnormal changes in carpal alignment seen on non-stress

radiographs.

http://radsource.us/carpal-instability/

Mayo Clinic Classification

•CID (carpal instability dissociative)- Intrinsic ligaments

–Disruption within a row; e.g., SL or LT disruptions/dissociation,

scaphoid fracture, and Kienbock’s disease (proximal carpal row);

or axial carpal dislocations (distal carpal row).

•CIND (carpal instability nondissociative)- Extrinsic ligaments

–Symptomatic carpal dysfunction between the radius and the

proximal row, or between the proximal and distal carpal rows,

without disruption within or between the bones of the proximal or

distal carpal row.

–CIND is subdivided into radiocarpal and midcarpal patterns.

•Radiocarpal- insufficiency or disruption of the obliquely orientated extrinsic

radiocarpal ligaments –RS, RSC, LRL ligaments- (i.e. RA, Madelung’s)

•Midcarpal- insufficiency or disruption of the triquetro-hamate-capitate (THC),

dorsolateral STT, dorsal radiocarpal and RSC ligaments.

http://radsource.us/carpal-instability/

7/17/2015

•CIC (carpal instability complex):

–Features of CID & CIND

–Lesser Arc (pure ligament injury) and Greater Arc (transosseous

injury)

–Five groups identified.

•Dorsal perilunate dislocation (lesser arc injury)

•Dorsal perilunate fracture-dislocation (greater arc injury)

•Palmar perilunate dislocation (lesser or greater arc injury)

•Axial dislocation Isolated carpal bone dislocation

•CIA (carpal instability adaptive):

–Extrinsic to wrist (result from extracarpal pathology); e.g.,

Malunion of distal radius fracture

Mayo Clinic Classification

http://radsource.us/carpal-instability/

Natural History of SL and LT Instability

•Static Instability (Scapholunate and Lunotriquetral dissociation)

–Interval diastasis > 3 mm

–Scapholunate dissociation- most common ligamentous cause of carpal

instability.

–Lunotriquetral dissociation- second most common ligamentous cause of

carpal instability.

•Increased frequency of lunotriquetral ligament tears in association with degenerative

tears of the triangular fibrocartilage (70% of cases).

•Dorsal Intercalated Segment Instability (DISI)-

–Most common form of carpal instability (dissociative type).

–Complete SLIL and failure of scaphoid stabilizers (volar extrinsic rupture,

with secondary changes in volar RSC, radiolunate, STT

(scaphotrapezoid), and dorsal intercarpal ligaments).

–Scaphoid tilts volarly and the lunate tilts dorsally, both the SL and CL

angles are increased (SL > 60°, CL > 30°).

http://radsource.us/carpal-instability/

•Volar Intercalated Segment Instability (VISI)

–Second most common type of carpal instability (dissociative type).

–Secondary to disruption of the lunotriquetral ligamentous complex.

–Results in volar rotation of the lunate and extension of the triquetrum.

–The SL angle is decreased (SL < 30°) and the CL angle is increased

(> 30°).

–The dorsal radiocarpal ligament is also injured in VISI.

•Scapholunate Advanced Collapse (SLAC), degenerative changes

typically in the following stages:

–Stage I: Styloid-scaphoid DJD

–Stage II: DJD of the proximal scaphoid facet

–Stage III: Capitolunate DJD

–Stage IV: Radiolunate/Pancarpal DJD

Natural History of SL and LT Instability

http://radsource.us/carpal-instability/

7/17/2015

Anatomy: Scapholunate Ligament

•C-shaped Ligament: 3

portions

–Dorsal

–Membranous (proximal)

–Volar

•Dorsal Component

–Transversely oriented collagen

(collagenous structure)

–Thickest and Strongest (300 N

failure force) Component

http://radsource.us/sll-tear-and-disi-deformity/

•Dorsal component

–Most critical of the SL stabilizers

–Primary restraint not only to

distraction, but also to torsional

and translational moments.

–SLL tear can lead to scapholunate

dissociation, which together with

dorsal intercarpal ligament (DICL)

tear results in DISI and SLAC.

J Hand Surg 2008;33A:998–1013.

Anatomy: Scapholunate Ligament

•Volar (palmar):

–Collagenous structure

–Considerably thinner

–Important contribution to

rotational stability

•Membranous (proximal):

–Fibrocartilaginous structure

–Little to no restraint to abnormal

motion

http://radsource.us/sll-tear-and-disi-deformity/

7/17/2015

Scapholunate Ligament (SLIL)

http://radsource.us/sll-tear-and-disi-deformity/

Interosseous Lunotriquetral Ligament

•V-Shaped ligament

•Together with the SLIL, links the bones of

the proximal carpal row, allowing

synchronous motion.

•Dorsal and volar bands (true ligamentous

components, consisting of collagen

fascicles) and structurally weaker proximal

(central) membranous parts

(fibrocartilaginous tissue similar to that of

the triangular fibrocartilage).

•The thickest and functionally most

important part of the LTL is the volar band,

with contributions from fibers of the

ulnocapitate ligament. Transmits extension

moment of the triquetrum

•LTL tear can lead to lunotriquetral

dissociation, which together with a tear of

the extrinsic dorsal radiocarpal ligament

(DRCL) results in VISI.

RadioGraphics 2011 31:1, 79-80

J Bone Joint Surg Am, 2000 Apr; 82 (4): 578 -578

http://radsource.us/sll-tear-and-disi-deformity/

•Imaging findings require correlation with the

clinical examination results, as ligamentous

perforations or tears of the SLL and LTL can

also be seen in asymptomatic patients.

•On radiographs, widening of the scapholunate

interval of more than 2 mm may indicate SLL

disruption.

•However, widening of the scapholunate interval

may not occur in all cases of SLL disruption, and

widening may occur as a normal variation with

lunotriquetral coalition.

RadioGraphics 2011 31:1, 79-80

Interosseous SLL and LTL

7/17/2015

MRI

•Accurate assessment of SLL and LTL injury with

MR imaging is often a diagnostic dilemma.

•Factors that contribute to this difficulty in

diagnostic assessment include:

1. Low image spatial resolution,

2. Low signal to noise ratio (SNR),

3. Low contrast resolution,

4. MRI artifacts (i.e. wrap, pulsation, motion etc),

5. Suboptimal imaging technique

6. Normal variant morphology of the ligaments.

RadioGraphics 2011; 31:63–78

Spatial resolution

RadioGraphics 2011; 31:63–78

Low and high spatial resolution. Note the marginal blurring of anatomic

structures and the loss of detail.

Signal to noise ratio (SNR)

RadioGraphics 2011; 31:63–78

Low and high SNR. Note the increased granularity and the loss of structural

information in low SNR image.

7/17/2015

Contrast to noise ratio (CNR)

RadioGraphics 2011; 31:63–78

Coronal gradient-echo (GRE) MR image of the wrist, obtained with low

contrast-to-noise ratio, shows preferential loss of small structure detail (eg,

the bone trabeculae).

MRI artifacts

RadioGraphics 2011; 31:63–78

J Magn Reson Imaging. 2011 Apr; 33(4): 908–915

•Nonuniform fat

saturation over the

ulnar styloid

•Pulsation artifact

adjacent to the radial

artery

•Wrap around artifact

AJNR 2004 25: 431-440

•Magic angle artifact

Interosseous scapholunate and

lunotriquetral ligament MR assessment

•MRI allows assessment of the three

SL and LT ligament components:

–Volar and dorsal components are best

assessed in the axial plane,

–Membranous segment is best assessed on

the coronal plane.

Skeletal Radiol (2014) 43:713–724

7/17/2015

Axial MRI:

Scapholunate Ligament

•In the axial plane:

–Ligament does not take on

strange shapes

–Easy to see volar and dorsal

portions as bands

–Suboptimal view of

membranous ligament

Skeletal Radiol (2014) 43:713–724

Axial MRI:

Scapholunate Ligament

Proton Density Fast Spin Echo (TE 28, TR 3000; slice thickness 3.00mm, 0.0 gap)

Skeletal Radiol (2014) 43:713–724

Normal dorsal and volar components of the SL

ligament “band-like” configuration

Skeletal Radiol (2014) 43:713–724

CTA

Skeletal Radiol (2013) 42:649–657

MRA

7/17/2015

Oblique axial MR imaging

•Improves assessment of the individual ligament components.

Skeletal Radiol (2006) 35: 765–773

SL LT

Oblique axial MR imaging

•Improves assessment of the individual SL and

LT ligament components.

Skeletal Radiol (2006) 35: 765–773

Conventional true axial axial oblique

SL LT

Normal Variant Anatomy

•Lack of familiarity with normal variant anatomic

MR imaging appearances of the LTL and SLL

may contribute to the suboptimal sensitivity and

specificity for lesion detection.

•Therefore, it is important to become familiar with

the morphology and signal intensity of the LTL

and SLL at high resolution MR imaging to

improve the accuracy of diagnosis of

ligamentous disease, and to differentiate actual

disease from normal or variant appearances.

RadioGraphics 2011; 31:63–78

7/17/2015

•The SLL varies in shape on coronal images from

trapezoidal in its volar aspect to triangular

centrally to band-like in its dorsal aspect, all with

heterogeneous internal signal intensity.

•On coronal images, the LTL varies in shape from

symmetrically triangular to a distorted triangle to

a linear conformation, with variable patterns of

curvilinear increased internal signal intensity.

RadioGraphics 2011; 31:63–78

Normal Variant Anatomy

(Coronal Images)

SL : MRI

•In the coronal plane:

–Volar portion: trapezoidal

and intermediate signal

intensity

–Membranous portion:

triangular in shape and lower

in signal

–Dorsal portion: band-like

shape

Coronal MRI

Skeletal Radiol (2014) 43:713–724

MRI Shape of SL Ligament

•Dorsal and volar components of the SLL are band-like.

•The proximal or membranous component of the SLL varies in shape

from its volar to its dorsal aspect on coronal images.

–Volar aspect of the membranous component has a trapezoidal

conformation, and attaches scaphoid and lunate cortex.

RadioGraphics 2011; 31:63–78

7/17/2015

MRI Shape of SL Ligament

•Dorsal and volar components of the SLL are band-like.

•The proximal or membranous component of the SLL varies in shape

from its volar to its dorsal aspect on coronal images.

–Volar aspect of the membranous component has a trapezoidal

conformation, and attaches scaphoid and lunate cortex.

–The central portion of the membranous component is triangular,

and attaches to the hyaline cartilage of the scaphoid and lunate

in most cases.

RadioGraphics 2011; 31:63–78

MRI Shape of SL Ligament

•Dorsal and volar components of the SLL are band-like.

•The proximal or membranous component of the SLL varies in shape

from its volar to its dorsal aspect on coronal images.

–Volar aspect of the membranous component has a trapezoidal

conformation, and attaches scaphoid and lunate cortex.

–The central portion of the membranous component is triangular,

and attaches to the hyaline cartilage of the scaphoid and lunate

in most cases.

–The dorsal aspect of the membranous component is band-like

on coronal images, and is variable in attachment, attaching to

the cartilage or cortex of the scaphoid and lunate in various

combinations.

RadioGraphics 2011; 31:63–78

Coronal MRI:

Scapholunate Ligament

•Volar portion:

trapezoidal and

intermediate signal

intensity

•Membranous portion:

triangular in shape and

lower in signal

•Dorsal portion: band-

like shape

7/17/2015

MR and CT Arthrogram

Skeletal Radiol (2014) 43:713–724

Intact membranous segment of the scapholunate ligament

MRI Signal Intensity SLL

•The volar portion of the SLL, with its band-like ligamentous

structure separated by loose vascular connective tissue,

demonstrates striated heterogeneous increased signal

intensity.

•Similarly, the fibrocartilaginous membranous portion has

been reported to predominantly demonstrate heterogeneous

signal intensity, which ranges from high-intermediate signal

intensity in its volar aspect to low signal intensity in its dorsal

aspect.

•The dorsal portion of the SLL has low internal signal

intensity, which is probably due to its constituent elements of

homogeneous transversely oriented collagen fascicles.

RadioGraphics 2011; 31:63–78 •

Shape and Signal Intensity LT

MRI

•A modified V- shaped configuration, with the dorsal and

volar components best seen on axial images, and with

the membranous portion best seen in on coronal images.

•The volar and dorsal components appear band-like on

axial images.

•The membranous portion (proximal zone) of the LTL has

a variety of normal variant shapes and signal

intensity on coronal images.

RadioGraphics 2011; 31:63–78 •

7/17/2015

Lunotriquetral ligament (LT)

“Band-Like Configuration”

Dorsal and volar components axial images

–Axial: easiest to see dorsal and volar portions

–Coronal: easiest to see proximal portion

Skeletal Radiol (2014) 43:713–724

Shape Variations Membranous

Portion (proximal zone) of the LTL

•Most commonly triangular or deltoid

region (geometry) of low signal

intensity (85.6% of cases).

•An alternative conformation of the

ligament is a linear or bar-like

geometry, which may mimic a tear

owing to absence of its distal vertex.

•An indistinct or amorphous shape of

the ligament may be seen in

asymptomatic older patients;

probably the result of degenerative

change.

RadioGraphics 2011; 31:63–78

Variations in LTL shape

Triangular Morphology

RadioGraphics 2011; 31:63–78

Regular (equilateral triangle) (41.1%) Broad-based isosceles triangle (20.0%)

7/17/2015

RadioGraphics 2011; 31:63–78

Narrow-based isosceles triangle (6.7%)Asymmetric (scalene) triangle (17.8%)

Variations in LTL shape

Triangular Morphology

RadioGraphics 2011; 31:63–78

Variations in LTL shape

Linear or bar-like morphology

Signal Intensity

•Variation in the internal signal

intensity of the membranous portion,

categorized as follows:

–The type 1 variant: uniform low

internal signal intensity (33.8% of

patients).

RadioGraphics 2011; 31:63–78

7/17/2015

Signal Intensity

•Variation in the internal signal

intensity of the membranous portion,

categorized as follows:

–The type 1 variant: uniform low

internal signal intensity (33.8% of

patients).

–The type 2 variant: thin line of

increased signal intensity inside

the triangular body (45.5%).

RadioGraphics 2011; 31:63–78

Signal Intensity

•Variation in the internal signal

intensity of the membranous portion,

categorized as follows:

–The type 1 variant: uniform low

internal signal intensity (33.8% of

patients).

–The type 2 variant: thin line of

increased signal intensity inside

the triangular body (45.5%).

–The type 3 variant: linear

increased signal intensity through

the triangle and traversing both

the proximal (base) and distal

margins of the membranous

component (20.8%).

RadioGraphics 2011; 31:63–78

Shape and signal intensity changes in

the LTL with different wrist positions

•The shape and signal intensity of the membranous

portion of the LTL change when the wrist is positioned in

ulnar or radial deviation, as the ligament is very flexible.

•With the wrist in ulnar deviation, the triangular shape is

distorted and decreased in size in comparison to the

appearance with the wrist in the neutral position.

•With the wrist in radial deviation, the triangular body

becomes wider and higher in internal signal intensity in

comparison to the appearance with the wrist in the

neutral position.

RadioGraphics 2011; 31:63–78

7/17/2015

Shape and Signal Intensity LTL Changes in Ulnar

and Radial Deviation

RadioGraphics 2011; 31:63–78 •

Ulnar deviation Neutral Radial deviation

MRI SL and LT Tear Findings

•Tears of the LTL and SLL are

diagnosed on the basis of MR

imaging findings of:

1. Irregular morphology,

2. Abnormal signal intensity,

3. Fluid (contrast) partially or completely

transecting the ligamentous

structures.

RadioGraphics 2011; 31:63–78

SLL disruption

•While complete disruption with static instability may

be identified on plain radiographs, less severe

injuries may pose a diagnostic dilemma.

•Different imaging modalities such as arthrography,

ultrasound, computed tomography (CT)

arthrography, and magnetic resonance imaging

(MRI) with or without MR arthrography have been

proposed for the detection of SLD.

•MRI is the imaging of choice of detection of SL

ligament tear.

•Arthroscopy remains the diagnostic gold standard.

Skeletal Radiol (2015) 44:1103–1110

7/17/2015

Interosseous Ligament Tears

•Tears of SLIL and LTL may occur

following acute trauma, such as a

fall on the outstretched hand,

from repetitive stress,

inflammatory disease, or

degeneration.

•Categorized as:

–Complete Tear: All portions are

disrupted.

–Full Thickness Tear: Focally

extends through the entire

thickness of the ligament.

–Partial Thickness Tear: Involves

a portion of the thickness of the

ligament.

Skeletal Radiol (2014) 43:713–724

Tear of the scapholunate ligament with

carpal stability maintained

RadioGraphics 1995: 15:575-587

Interval normal (< 3 mm) SL and CL angles are normal

(SL < 60°, CL < 30°) RSC, RLT , SRL ligaments are normal

Tear of the scapholunate ligament

with carpal instability (DISI)

RadioGraphics 1995: 15:575-587

Interval diastasis > 3 mm SL and CL angles are increased

(SL > 60°, CL > 30°).

7/17/2015

Caution

•Normal lunate appears more dorsally tilted on sagittal MR images

than on lateral radiographs, due to wrist positioning in coil. This is

particularly exacerbated when the wrist is in ulnar deviation or in

pronated position.

MRI of the Upper Extremity: Shoulder, Elbow, Wrist and

Hand. Christine B. Chung, Lynne S. Steinbach -

Wolters Kluwer Health 2009

Interval diastasis > 3 mm

Interval diastasis > 3 mm SL and CL angles

are increased (SL >

60°, CL > 30°)

RSC, RLT , SRL

ligaments are

abnormal

7/17/2015

MRI vs MRA for SL tear

•Non contrast MRI.

–Sensitivity (41-71 %)

–Specificity (60-100%)

–Accuracy (53-100%)

–Even with the 3.0-T field strength, differentiation between partial and complete

dorsal lesions remains difficult.

•MRA allows better evaluation of the SL ligament.

–Higher sensitivity (50–89 %),

–Higher specificity (52–100 %)

–Higher accuracy (60–98 %)

•Axial and coronal views are necessary for thorough evaluation of the

C-shaped fibers’ continuity.

•In general, the accuracy of diagnosing tears in the volar and dorsal

fibers is similar to those of the membranous fibers.

Skeletal Radiol (2014) 43:725–743

J Wrist Surg. 2013 Feb; 2(1): 69–72

Accuracy of LT tears MRI

•Accuracy of nonarthrographic MR imaging in diagnosing

tears of the LTL in clinical studies has also been widely

variable and suboptimal,

–Reported sensitivities of 40%–75%

–specificities of 64%–100% when arthroscopy was used as the

standard of reference.

•Direct MR arthrography appears to be more sensitive in

detection of LT lesions

–sensitivities of 86%–92%) but is not necessarily more specific

–(specificities of 46%–100%).

RadioGraphics 2011; 31:63–78

SL Ligament tear MRA

Skeletal Radiol (2014) 43:725–743

Full-thickness tear (arrows) of membranous and volar component of scapholunate

ligament, with by abnormal communication between the radiocarpal and mid-carpal

compartments.

Dorsal SL component is intact.

7/17/2015

UM Institutional Review

• We retrospective reviewed MRI’s of SL

tears and correlated with arthroscopy

findings.

•We identified several mistakes in MRI

interpretations.

Retrospective Mistake #1

Original Dictation: Full thickness tear of the dorsal portion

based on the coronal sequence

Tear??

volar dorsal

Retrospective Mistake #1

Original Dictation: full thickness tear of the dorsal portion

based on the coronal sequence

False Positive: No evidence of SLIL tear!!!

7/17/2015

Retrospective Mistakes # 2

Original Dictation: Full thickness tear of the volar and

proximal ligament

volar dorsal

Retrospective Mistake # 2

Original Dictation: full thickness tear of the volar and proximal

ligament

False Negative: Full thickness tear of the volar and proximal

ligament Complete tear of the SLIL

Operative Report…

“…the dorsal portion of the scapholunate ligament was

intact to its scaphoid attachment, but not to the lunate

side…”

7/17/2015

Lunotriquetral ligament tear with

carpal instability (VISI)

RadioGraphics 1995: 15:575-587

The SL angle is decreased (SL < 30°) and the CL angle is increased (> 30°).

The dorsal radiocarpal ligament is also injured in VISI.

MRA and CT Arthrogram (CTA)

In certain cases, CTA may increase sensitivity, specificity and accuracy compared with MRA.

Skeletal Radiol (2013) 42:649–657

Normal CTA- Intact LT, SLL, TFCC Abnormal CTA- Torn LT and TFCC

MRA of same patient showing torn LT and TFCC

MRA and CTA

Coronal

Skeletal Radiol (2013) 42:649–657

SL membranous component tear, with intact LT and TFCC.

Contrast extends into midcarpal space (asterisk) through SL tear.

7/17/2015

MRA and CTA

Coronal

Skeletal Radiol (2013) 42:649–657

SL dorsal and membranous component tear, with

intact volar component.

SLL tear MRA vs CTA

False Positive

Skeletal Radiol (2013) 42:1277–1285

Both CT and MR arthrography have a very high degree of accuracy for diagnosing

tears of the SLL and LTL, with both being more accurate than conventional MR

imaging.

Axial MRA - suspicious tear dorsal SLL Axial CTA- normal dorsal SLL

Skeletal Radiol (2013) 42:1277–1285

Occasionally, CTA will confirm ligament tears not appreciable with MRA

SLL tear MRA vs CTA

False Positive

7/17/2015

Skeletal Radiol (2013) 42:1277–1285

LTL tear MRI vs CTA

False negative

Occasionally, CTA will confirm ligament tears not appreciable with MRA

MRA vs CTA Post-Op

Skeletal Radiol (2013) 42:649–657

Scaphoid cartilage defect (arrow) is better delineated on the coronal CT-image

due to fewer metal artifacts. SL, LT and TFCC are intact.

Conclusion

•Intrinsic and extrinsic ligament defects may be small and

insignificant, or lesions that cause significant instability,

pain, and chronic disability.

•MRI, US and CT are all useful in the assessment of wrist

ligament tears, allowing sensitive detection and detailed

assessment, but the examination must be tailored based

on clinical considerations.

•Knowledge of the anatomy, dynamic function, and

instability patterns is central to evaluating these lesions.

•Accurate assessment of these injuries is important for

promptly determining the best conservative or surgical

approach to the injured patient.

http://radsource.us/sll-tear-and-disi-deformity/

7/17/2015

Questions and Answers

Section

•Cine MRI is an imaging technique that

allows acquisition of continuous MR

images with high spatial and temporal

resolution.

•May be useful in detecting dynamic

instability.

Skeletal Radiol (2015) 44:1103–1110

Cine MRI in diagnosis

of scapholunate dissociation

Skeletal Radiol (2015) 44:1103–1110

Cine MRI

Normal Volunteer

Normal SL interval

Neutral Radial Deviation Ulnar Deviation Clenched Fist

7/17/2015

Skeletal Radiol (2015) 44:1103–1110

Cine MRI Scapholunate dissociation

Increase SL interval with Ulnar Deviation and Clenched Fist

Neutral Radial Deviation Ulnar Deviation Clenched Fist

Sensitivity of US

•Visibility of the SLL and LTL at US varies depending on the equipment and

the operator’s experience

•Complete visibility of the dorsal band of the SLL in 48-97% and partial

visibility in 3-30% of wrists, and complete visibility of the volar band of the

SLL in 7-81% and partial visibility in 9-12% of those same wrists.

•Complete visibility of the dorsal band of the LTL in 61% and partial visibility

in 39% of normal wrists, and complete visibility of the volar band in 33% and

partial visibility in 7% of normal wrists.

•The reported sensitivity of US in depicting lesions of the dorsal band of the

SLL varies from 46% to 100%, while specificity varies from 92% to 100%.

•The results are less promising for LTL lesions, with sensitivity varying from

25% to 50% and specificity from 90% to 100%.

•Sonoarthrography in the presence of radiocarpal joint effusion improves the

visibility.

RadioGraphics 2011 31:1, 79-80

SL Ligament Ultrasound

•The SLL and LTL are considered

normal if they are seen as echogenic,

frequently fibrillar bands in their

expected anatomic locations.

•Partially torn ligaments show some

irregularity of the fibers.

•The ligaments are considered torn if

their fibers are not seen in the

expected anatomic locations between

the scaphoid and lunate or between

the lunate and triquetrum, or if

discontinuity of their fibers is seen.

•If a joint effusion is present or

sonoarthrography is performed, fluid

can be seen in the regions of torn

ligaments.

Skeletal Radiol (2014) 43:713–724

7/17/2015

RadioGraphics 2011 31:1, 79-80

SL Ligament Ultrasound

US of the dorsal band of the scapholunate ligament with

the wrist in pronation and slight flexion.

RadioGraphics 2011 31:1, 79-80

SL Ligament Ultrasound

Normal SL tear

7/17/2015

Scapholunate ligament tear

Skeletal Radiol (2004) 33:85–90

Arthrogram with contrast injected into the

midcarpal joint space confirms SL tear, with

contrast appearing in the radiocarpal joint space

(arrow)

SL tear

Volar band of the scapholunate

ligament

RadioGraphics 2011 31:1, 79-80

Normal

Skeletal Radiol (2005) 34: 513–521

Volar band of the scapholunate

ligament

7/17/2015

US of the volar band of the scapholunate ligament

with the wrist in supination and slight extension.

RadioGraphics 2011 31:1, 79-80

Volar band of the scapholunate

ligament

Normal SL tear

RadioGraphics 2011 31:1, 79-80

US Dorsal band of the

lunotriquetral ligament

7/17/2015

US of the dorsal band of the lunotriquetral ligament

with the wrist in pronation and slight flexion.

RadioGraphics 2011 31:1, 79-80

Lunotriquetral ligament tear

Skeletal Radiol (2004) 33:85–90

Midcarpal joint injection demonstrating

contrast in the radiocarpal joint at the

level of a lunatotriquetral tear (arrow)

NormalTear

RadioGraphics 2011 31:1, 79-80

US Volar band of the

lunotriquetral ligament

7/17/2015

US of the volar band of the lunotriquetral ligament

with the wrist in supination and slight extension.

RadioGraphics 2011 31:1, 79-80

Thank You

7/16/2015

Intercarpal Injuries

VuMedi Webinar

Robert RL Gray

July 27, 2015

Disclosures

•Reviewer, Injury

•Committee Member, ASSH Clinical Outcomes

Committee and Flatt Fellows Conference

Committee

•Speakers Bureau, Skeletal Dynamics

•Employee, NorthShore University HealthSystem

Mayo Classification of Carpal

Instability

•CID (Carpal Instability

Dissociative)

•CIND (Carpal

Instability

Nondissociative)

•CIC (Carpal Instability

Combined/Complex)

•CIA (Carpal Instability

Adaptive)

•CIND—Nearly 100%

overlap w Diagnosis of

Midcarpal Instability

•Implies extrinsic

Ligament

Derangement

•Think Ligamentous

Laxity

CID—Most Common

Proximal and Distal

Carpal Row Variants

Implies Ligament

Disruption or

Scaphoid Fracture

CIC—A Little from

Column A, A Little

from Column B

Perilunate injries,

Tire explosions

CIA—Adaptive

Changes secondary to

Distal Radius

Malalignment

Fracture Malunion

Madelung’s

Deformity

7/16/2015

Ganglionectomy

•Open

•Arthroscopic

•US-guided aspiration/injection

Recurrence rate 5-13%

7/16/2015

SL treatment

•Non-op

•Direct repair (book only)

•Capsulodesis

•Tenodesis (Brunelli or variant)

•SL reassociation (RASL, SLAM)

•Intercarpal fusion (STT, SC, SL)

Moran, S.L., Ford, K.S., Wulf, C.A., and Cooney,

W.P. Outcomes of dorsal capsulodesis and

tenodesis for the treatment of scapholunate

instability. J Hand Surg. 2006; 31A: 1438–1446

91% of contralateral grip strength

7/16/2015

Lunotriquetral Ligament

Tear

Images from Alexander Y Shin M.D.

Lunotriquetral Ligament

Tear

Lunotriquetral Ligament

Tear

MRI:

Sensitivity 30-50%

Specificity: 94-97%

MR Arthrography:

Sensitivity 50-60%

Specificity 94-97%

Moser T, Dosch JC, et al. Musk Imag 2007

7/16/2015

Lunotriquetral Ligament

Tear

Non-Operative

Cast immobilization

Initial management

(Acute/Chronic)

Pre-Dynamic

Dynamic

Operative

Static instability

Dynamic tears not

responsive to non-operative

treatment

Operative Treatment

Images from Alexander Y Shin M.D.

LT Instability Outcomes

Shin et al 2001

Reconstruction or repair:

•Better strength, motion, pain relief, satisfaction

Arthrodesis more likely to require further surgery at 5

years

(Probability of not requiring further surgery):

•Reconstruction 68.6%

•Repair 23.3%

•Arthrodesis 21.8%

Shin AY, Berger RA, Bishop AT et a. JBJS 2001.

7/16/2015

LT Instability Outcomes

Shin et al 2001

COMPLICATIONS:

Shin AY, Berger RA, Bishop AT et a. JBJS 2001.

T H A N K S . RGREEZY@GMAIL.COM

WWW.ROBGRAYMD.COM

7/27/2015

Magnetic Resonance Imaging

(MRI) of Ligamentous Injury

of the Thumb

Harry ‟Tate” G. Greditzer, IV MD, MSc

Department of Radiology and Imaging

Hospital for Special Surgery

New York, NY

HOSPITAL FOR SPECIAL SURGERY IMAGING & INTERVENTION

TITLE: Magnetic Resonance Imaging (MRI) of Ligamentous

Injury of the Thumb

NAME: Harry G. Greditzer IV, M.D.

DISCLOSURE OF COMMERICAL INTEREST: My

disclosure is in the Final VuMedi Program.

I have no relevant disclosures

Disclosure of Commercial Interest

HOSPITAL FOR SPECIAL SURGERY IMAGING & INTERVENTION

Introduction

•The ulnar collateral ligament (UCL) and radial

collateral ligament (RCL) are primary

stabilizers of the thumb metacarpophalangeal

(MP) joint

•Injury to these ligaments may result in joint

instability, leading to significant disability and

pain

•The diagnosis is best established clinically,

though MRI is the imaging modality of choice

for grading.

7/27/2015

HOSPITAL FOR SPECIAL SURGERY IMAGING & INTERVENTION

•Magnetic resonance imaging sensitivity and

specificity for UCL injury detection

approaches 100%

•With the latest generation of dedicated

extremity coils, it offers a level of detail that

can show the precise location of the torn

ligament within the accuracy of a millimeter

HOSPITAL FOR SPECIAL SURGERY IMAGING & INTERVENTION

MRI Protocol

•Patient supine with arm at their side

•Palm down with thumb in neutral position

•Place in dedicated wrist coil

HOSPITAL FOR SPECIAL SURGERY IMAGING & INTERVENTION

ANATOMY

7/27/2015

HOSPITAL FOR SPECIAL SURGERY IMAGING & INTERVENTION

Aponeurosis of Abductor

Pollicis Brevis tendon

Ulnar Collateral

Ligament

Aponeurosis of Adductor

Pollicis Tendon

Radial Collateral

Ligament

HOSPITAL FOR SPECIAL SURGERY IMAGING & INTERVENTION

Aponeurosis

of Abductor

Pollicis Brevis

tendon

Ulnar

Collateral

Ligament

Aponeurosis

of Adductor

Pollicis

Tendon

Radial Collateral

Ligament

HOSPITAL FOR SPECIAL SURGERY IMAGING & INTERVENTION

CASES

7/27/2015

HOSPITAL FOR SPECIAL SURGERY IMAGING & INTERVENTION

Case 1: Fall after skiing 11 days ago

HOSPITAL FOR SPECIAL SURGERY IMAGING & INTERVENTION

Case 1: Fall after skiing 11 days ago

Case 2: Skiing injury 1 month ago

7/27/2015

Case 3: NFL Running Back Injured

Thumb During Practice

Yo-Yo on

a String

HOSPITAL FOR SPECIAL SURGERY IMAGING & INTERVENTION

7/27/2015

Case 4: 48 y/o male suffers basketball injury

HOSPITAL FOR SPECIAL SURGERY IMAGING & INTERVENTION

Case 4: 48 y/o male suffers basketball injury

•Radial

collateral

ligament

repair

•Sagittal

band

repair

•Reduced

K-wire

HOSPITAL FOR SPECIAL SURGERY IMAGING & INTERVENTION

Summary

•MRI thumb positioning is paramount

•Small FOV and thin slices

•IR first to find the acute injury!

•Coronal plane is useful for ligamentous

injury

•Axial and sagittal planes for the plates and

sagittal bands

7/27/2015

HOSPITAL FOR SPECIAL SURGERY IMAGING & INTERVENTION

THANK YOU!

Surgical Treatment of

Thumb MCP Collateral

Ligament Injuries

Vumedi Webinar

July 27, 2015

Mark A. Vitale, MD, MPH

ONS Foundation for Clinical Research and Education

ONS, Greenwich, CT;

Attending Orthopaedic Surgeon

Greenwich Hospital

Yale-New Haven Health

Columbia Orthopaedics

I have no disclosures for potential conflicts of interest

specific to this presentation

Speaker’s bureau for Auxilium Pharmaceuticals (Xiaflex)

Disclosures

Columbia Orthopaedics

Ligamentous anatomy

Exam of thumb stability

When to order advanced imaging

How to treat surgically

–Acute versus chronic injuries

–Bony avulsions

–UCL versus RCL

–Postop protocol

Overview

Columbia Orthopaedics

Ligamentous Anatomy MCP Joint

Designed to be stable in extension AND flexion

Dynamic stability

Extrinsic stabilizers: EPL, EPB, FPL

Intrinsic stabilizers: APB, FPB and adductor pollicis

Static stability

Dorsal capsule and volar plate

UCL

Proper and accessory

Adductor aponeurosis volar and adjacent to UCL

RCL

Proper UCL originates more dorsally on MC head

Abductor aponeurosis dorsal to RCL

Columbia Orthopaedics

Physical Exam –UCL Rupture

Resting position of ulnar deviation

Tenderness to palpation at ligament

Palplable mass suggests but does not r/o Stenar lesion

Most importantly test joint stability . . .

Columbia Orthopaedics

Physical Exam –UCL Rupture

Evaluation of joint stability to radial/ulnar stress

Test MPJ in extension and 30°flexion

Instability = radial deviation > 35°or > 15°asymmetry

Flexion to test proper collateral ligament

Extension to test accessory ligament + volar plate

Instability > 35°implies tear of proper + accessory collaterals and

Stenar’s lesion present in 90% (Heyman et al 1993)

More reliable bc easy to be deceived by rotation of MC in flexion

Local local anesthetic to avoid guarding (Cooper et al 2005)

Columbia Orthopaedics

Advanced Imaging

My indications for MRI:

Difficult to get good exam because of guarding

Borderline degree of instability (e.g. 25°-30°)

Possible Stenar’s lesion (e.g. palpable mass)

Assess cartilage in chronic injuries to decide between

reconstruction vs fusion

NOT needed when clear instability with no form endpoint

Will change my surgical decision making when:

Stenar’s lesion

Relative indication if highly retracted tear w/o Stenar’s lesion

Articular injury/arthrosis

Columbia Orthopaedics

Acute UCL Rupture

Surgical indications:

Opening > 35°or 15°from

contralateral thumb

Stenar’s lesion

No discrete endpoint to radial stress

Relative indication: MRI reveals

significant retraction but borderline

instability and no Stenar’s lesion

Columbia Orthopaedics

Surgical Treatment –Acute UCL Rupture

(Trumble et al 1999)

Columbia Orthopaedics

Chronic UCL Rupture

May be attenuated and difficult to

mobilize to anatomic insertion

Textbook = approx 6 weeks

Reality = usually some robust local

tissue even months later

If poor local tissue present, may be

treated with

Dynamic stabilization (EIP/EPB

transfer, adductor advancement)

Static stabilization with tendon graft

(many configurations)

MCP fusion if arthritic –important to

assess cartilage (XR or MRI)

Columbia Orthopaedics

Surgical Treatment –Chronic UCL Rupture

Columbia Orthopaedics

Surgical Treatment –Chronic UCL Rupture

Columbia Orthopaedics

Surgical Treatment –Chronic UCL Rupture

Columbia Orthopaedics

Bony Avulsion

Often compromise stability if

involves entire ligament insertion

Nonunion rates of 25 –60%

Significant rotational deformity

My surgical indications:

Fractures a/w significant instability

Fractures with significant articular

displacement

Columbia Orthopaedics

Surgical Treatment –Bony Avulsion

Columbia Orthopaedics

RCL Rupture

RCL less common, “reverse gamekeeper’s”

10 –42% of thumb collateral ligament injuries

Pathoanatomical considerations

RCL avulses from MC head 55%, proximal phalanx 29%,

midsubstance 16%

Greater distal insertional area of RCL

No true Stenar’s lesion bc abductor aponeurosis dorsal to RCL

and much broader

Physical Exam

Stress testing

AP drawer test

More likely volar and rotatory subluxation

Columbia Orthopaedics

RCL Rupture

My surgical indications

Opening > 35°or 15°from contralateral thumb

No discrete endpoint to valgus stress

Significant radiographic volar subluxation or ulnar translation

No true Stenar’s lesion equivalent

Columbia Orthopaedics

Surgical Treatment –RCL Rupture

Columbia Orthopaedics

Surgical Treatment –RCL Rupture

Columbia Orthopaedics

Thumb spica splint/cast with IP free for 3 weeks

Removable orthoplast splint with therapy supervised by

therapist weeks 3 –6

Special attention to the patient with the stiff MP joint

Splint only for heavy activities weeks 6 - 12

Return to sport/heavy activity 3 –4 months

Postop Procotol

MRI Of The Hand And Wrist Syllabus

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