Musculoskeletal Imaging Companion
2nd Edition

Chapter 9
Hand and Wrist
Thomas H. Berquist
Protocols
  • Routine radiographs
    • Hand: posteroanterior (PA), lateral, oblique views
    • Wrist: PA, lateral, scaphoid views
    • Wrist motion (instability) series: PA views with radial deviation, ulnar deviation, and clenched fist; lateral views with dorsal and palmar flexion
  • Computed tomography (CT)
    • Two- to 3-mm axial and direct coronal or sagittal images for conventional studies. Axial images at 1- and 0.5-mm intervals for coronal and sagittal reformatting or three-dimensional reconstruction.
  • Magnetic resonance imaging (MRI)
    • Field of view: 8 to 12 cm
    • Coil: wrist coil or flat 5-inch coil (motion studies)
    • Patient position: arm at side when possible; otherwise, arm above head (Table 9-1)
P.564

TABLE 9-1 MAGNETIC RESONANCE IMAGING PARAMETERS
Plane Pulse Sequence Thickness/Skip FOV Matrix Acquisitions
Wrist
Axial T1 SE 417/12 3 mm/0.5 mm 8 cm 512 × 224 1
Axial PD FSE 2400/19 3 mm/0.5 mm 8 cm 256 × 224 1
Coronal T1 SE 417/12 3 mm/0.5 mm 8 cm 512 × 224 1
Axial T2 FSE 3500/90 3 mm/0.5 mm 8 cm 256 × 192 1
Coronal DESS 24/7, FA 25 degrees 3 mm/0.5 mm 8 cm 256 × 192 1
Hand/Finger
Coronal T1 SE 417/12 1–3 mm/0.5 mm 6 cm 512 × 224 1
Axial T1 SE 417/12 3 mm/0.5 mm 6 cm 512 × 224 1
Sagittal T2* FSE 3500/90 1–3 mm/0.5 mm 6 cm 256 × 192 1
Sagittal T1* SE 417/12 1–3 mm/0.5 mm 6 cm 512 × 224 1
Wrist Arthrogram
Coronal T1 SE 600/18, FS 3 mm/0.5 mm 8 cm 256 × 256 2
Sagittal T1 SE 600/18, FS 3 mm/0.5 mm 8 cm 256 × 256 2
Axial T1 SE 600/18, FS 3 mm/0.5 mm 8 cm 256 × 256 2
Coronal GRE 45/9, 30 degrees 3 mm/0.5 mm 8 cm 256 × 192 1
FOV, field of view; SE, spin-echo; FSE, fast spin-echo; PD, proton density; DESS, double-echo steady state; FS, fat suppression; GRE, gradient-recalled echo.
* Flexion and extension.
Suggested Reading
Berquist TH. MRI of the musculoskeletal system. Philadelphia: Lippincott Williams & Wilkins; 2006:719–801.
Schweitzer ME, Natale P, Winalski CS, et al. Indirect wrist MR arthrography: The effects of passive motion versus active exercise. Skel Radiol 2000;29:10–14.
Truong NP, Mann FP, Gilula LA, et al. Wrist instability series: Increased yield with clinical-radiological screening criteria. Radiology 1994;192:481–484.
P.565

Fractures/Dislocations: Distal Radius/Ulnar Fractures—Colles Fracture
P.566

FIGURE 9-1 Lateral radiograph of the wrist demonstrating incomplete fractures of the ulna (arrowhead) and a torus (buckle) fracture of the radius (curved arrow).
P.567

FIGURE 9-2 Lateral and PA radiographs of the wrist showing a typical Colles fracture with dorsal impaction of the radius and an ulnar styloid fracture. The fracture extends into the DRUJ (Type B).
P.568

FIGURE 9-3 Coronal (A) and sagittal (B) CT images clearly demonstrate the fracture fragments and the extent of articular separation (open arrow in B).
P.569

FIGURE 9-4 PA radiograph of an old Colles fracture with shortening of the radius and decreased radial inclination (lines). There is degenerative arthritis and an associated fifth metacarpal fracture (arrow).
Suggested Reading
Cooney WP, Dobyns JH, Linscheid RL. Complications of Colles’ fractures. J Bone Joint Surg 1980;62A:613–619.
Orthopedic Trauma Association Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma 1996;10:26–30.
P.570

Fractures/Dislocations: Distal Radius/Ulnar Fractures—Smith Fracture
FIGURE 9-5 AP (A) and lateral (B) radiographs of a Smith fracture with palmar displacement of the distal radius.
Suggested Reading
Thomas FB. Reduction of Smith’s fracture. J Bone Joint Surg 1957;37B:463–470.
P.571

Fractures/Dislocations: Distal Radius/Ulnar Fractures—Barton Fracture
FIGURE 9-6 Zones of radial styloid (Barton fracture). Zone I: styloid tip, may be stable with no ligament injury. Zone II: possible ligament injury, may have articular deformity. Zone III: likely to have ligament injury and joint deformity.
P.572

FIGURE 9-7 Dorsal Barton fracture. AP (A) and lateral (B) radiographs of an intra-articular fracture of the lateral aspect of the radius.
P.573

Suggested Reading
DeOliveira JC. Barton’s fracture. J Bone Joint Surg 1973;55A:586–594.
Putnam MD. Radial styloid fractures. In: Blair WF, ed. Techniques in hand surgery. Baltimore: Williams and Wilkins; 1996:322–329.
P.574

Fractures/Dislocations: Distal Radius/Ulnar Fractures—Chauffeur’s Fracture
FIGURE 9-8 PA radiograph of a Chauffeur’s fracture during reduction with an external fixation.
P.575

Suggested Reading
Wood MB, Berquist TH. The hand and wrist. In: Berquist TH, ed. Imaging of orthopedic trauma, 2nd ed. New York: Raven Press; 1992:749–870.
P.576

Fractures/Dislocations: Galeazzi Fractures
FIGURE 9-9 PA (A) and lateral (B) radiographs showing a distal radial fracture with dislocation of the DRUJ.
P.577

FIGURE 9-10 PA radiograph after plate and screw fixation of the radial fracture and K-wire fixation of the joint.
Suggested Reading
Wood MB, Berquist TH. The hand and wrist. In: Berquist TH, ed. Imaging of orthopedic trauma, 2nd ed. New York: Raven Press; 1992:749–870.
P.578

Fractures/Dislocations: Distal Radioulnar Joint Subluxation/Dislocations
FIGURE 9-11 Axial fat-suppressed T2-weighted magnetic resonance (MR) image showing dorsal subluxation of the ulna (arrow) and absence of the extensor carpi ulnaris tendon (open arrow) as the result of a complete tear.
Suggested Reading
Hamlin C. Traumatic disruption of the distal radioulnar joint. Am J Sports Med 1977;5:93–96.
Nakamura R, Horie E, Imaeda T, et al. Criteria for diagnosing distal radioulnar joint subluxation by computed tomography. Skel Radiol 1996;25:649–653.
P.579

Fractures/Dislocations: Scaphoid Fractures
P.580

FIGURE 9-12 (A) Locations of scaphoid fractures: 1, tubercle; 2, distal articular surface; 3, distal third; 4, waist; 5, proximal pole. (B) Oblique fracture. Shearing forces (arrows) lead to instability and displacement. (C) Transverse waist fracture is more stable.
P.581

FIGURE 9-13 (A) Subtle scaphoid fracture with absent navicular fat stripe (arrow). (B) Displaced scaphoid waist fracture.
P.582

FIGURE 9-14 Humpback deformity. (A) Sagittal proton density-weighted MR image demonstrates fluid (open arrow) in the fracture line and deformity (white lines) caused by dorsal separation of the fracture’s fragments. (B) Sagittal reformatted CT image demonstrates a similar humpback deformity (lines) with sclerosis of the proximal fragment caused by AVN.
P.583

FIGURE 9-15 Coronal T2-weighted MR image showing fluid (arrow) between the fragments caused by nonunion.
P.584

FIGURE 9-16 PA view of a displaced scaphoid fracture with Herbert screw fixation. The proximal pole is sclerotic because of AVN.
Suggested Reading
Cooney WP III. Isolated carpal fractures. In: Cooney WP III, Linscheid RL, Dobyns JH, eds. The wrist: Diagnosis and operative treatment. St. Louis: Mosby; 1998:474–487.
Fisk GR. An overview of injuries of the wrist. Clin Orthop 1980;149:137–144.
P.585

Fractures/Dislocations: Other Carpal Fractures
FIGURE 9-17 PA and lateral views showing a triquetral fracture (arrow) seen only on the lateral radiograph.
FIGURE 9-18 Coronal T1-weighted (A) and T2-weighted (B) images of a capitate fracture (arrow) with surrounding edema. Radiographs were normal.
FIGURE 9-19 Sagittal T2-weighted fast spin-echo image with fat suppression demonstrating an undisplaced lunate fracture (arrow).
P.586

Suggested Reading
Berquist TH. Imaging of orthopedic trauma, 2nd ed. New York: Raven Press; 1992:749–870.
P.587

Fractures/Dislocations: Carpal and Carpometacarpal Dislocations
P.588

FIGURE 9-20 Transscaphoid perilunate dislocation seen on PA (A) and lateral (B) radiographs. The lunate and proximal scaphoid are in nearly normal position on the PA view (A). The second carpal row is irregularly aligned (lines). The displacement of the capitate (C) compared with the lunate (L) is obvious on the lateral view.
P.589

FIGURE 9-21 PA (A) and lateral (B) radiographs of a carpometacarpal fracture/dislocation.
Suggested Reading
Gregor DP, O’Brien ET. Classification and management of carpal dislocations. Clin Orthop 1980;149:55–72.
P.590

Fractures/Dislocations: Metacarpal Fractures
P.591

FIGURE 9-22 Radiograph of the thumb demonstrating an intra-articular fracture (1), Bennett fracture with lines demonstrating metaphyseal (2), diaphyseal (3), and distal neck fractures (4).
P.592

FIGURE 9-23 The second to fifth metacarpals. There is laxity in the transverse metacarpal ligament between the fourth and fifth metacarpals that leads to shortening and rotation with oblique or spiral factures. There is more motion allowed at the fourth and fifth metacarpal bases.
FIGURE 9-24 PA view of a fifth metacarpal neck fracture (boxer’s fracture) (arrow).
P.593

FIGURE 9-25 PA radiograph showing intra-articular fractures of the second and third metacarpals and an undisplaced fracture of the fifth metacarpal base (arrow).
Suggested Reading
Berquist TH. Imaging of orthopedic trauma, 2nd ed. New York: Raven Press; 1992:749–870.
P.594

Fractures/Dislocations: Phalangeal Fractures/Dislocations
FIGURE 9-26 Lateral radiograph of an angulated proximal phalangeal fracture.
FIGURE 9-27 Lateral view of a dorsal phalangeal dislocation (arrow).
P.595

FIGURE 9-28 PA (A), oblique (B), and lateral (C) radiographs of a subtle volar plate middle phalanx (arrow) hyperextension injury.
FIGURE 9-29 Lateral view of a hyperflexion Mallet fracture of the distal phalanx.
P.596

Suggested Reading
Ruby LK. Common hand injuries in athletes. Orthop Clin North Am 1980;11:819–839.
P.597

Carpal Instability
FIGURE 9-30 Lateral radiographs of the wrist demonstrating the normal scapholunate angle (lines, ∼45 degrees) (A), DISI with increased scapholunate angle and the lunate angled dorsally (B), and volar intercalated segment instability with a decreased scapholunate angle and the lunate angled volarly (C).
P.598

FIGURE 9-31 Scapholunate advanced collapse wrist. PA (A) and lateral (B) radiographs of the wrist demonstrate marked widening of the scapholunate space (open arrow) with proximal displacement of the capitate (arrow) and DISI deformity on the lateral radiograph (lines in B).
Suggested Reading
Cohen MS. Degenerative arthritis of the wrist: Proximal row carpectomy versus scaphoid excision and four corner arthrodesis. J Hand Surg 2001;26A:94–104.
Linscheid RL, Dobyns JH, Beabout JW, et al. Traumatic instability of the wrist: Diagnosis, classification, and pathomechanics. J Bone Joint Surg 1972;54A:1612–1632.
P.599

Soft Tissue Trauma/Miscellaneous Conditions: Ligament Injuries
P.600

FIGURE 9-32 Arthrogram of the first MCP joint showing extravasation (arrow) resulting from gamekeeper’s thumb with an ulnar collateral ligament tear.
P.601

FIGURE 9-33 Conventional wrist arthrogram in a patient with ulnar pain showing injection of the DRUJ. Contrast passes through a triangular fibrocartilage tear (1) into the radiocarpal joint and then through a lunotriquetral ligament tear (2) into the intercarpal joint.
FIGURE 9-34 Scapholunate tear. (A) Clenched-fist view showing widening of the scapholunate joint (arrow). (B) Coronal T2-weighted image showing the ligament tear (arrow).
P.602

FIGURE 9-35 Triangular fibrocartilage tear. MR arthrogram showing contrast in the radiocarpal joint with a tear (arrow) in the triangular fibrocartilage.
Suggested Reading
Girgis W, Epstein RE. Magnetic resonance imaging of the hand and wrist. Semin Roentgenol 200;35:286–296.
Schweitzer ME, Brahine SK, Holder J, et al. Chronic wrist pain: Spin-echo and short TI inversion recovery MR imaging and conventional and MR arthrography. Radiology 1992;182:205–211.
P.603

Soft Tissue Trauma/Miscellaneous Conditions: Tendon Injuries
FIGURE 9-36 The normal tendon is low intensity on MRI and has minimal high signal intensity fluid in the tendon sheath. This T2-weighted image shows fluid-distended tendon sheaths caused by flexor tenosynovitis.
P.604

FIGURE 9-37 Flexor tendon and pulley injuries. (A) The pulley system that maintains position of the flexor tendons. (B) Sagittal fat-suppressed fast spin-echo T2-weighted image demonstrates a tear with slight separation of the flexor tendon (arrows). The relationship to the phalanges is maintained indicating the pulley system is intact. Images in flexion would confirm the intact pulley system.
P.605

Suggested Reading
Clavero JA, Alomar X, Moukill JM, et al. MR imaging of ligament and tendon injuries of the fingers. Radiographics 2002;22:237–257.
Paradella JA, Balkisoon ARA, Hayes CW, et al. Bowstring injury of the flexor tendon pulley system: MR imaging. AJR Am J Roentgenol 1996;167:347–349.
P.606

Soft Tissue/Miscellaneous Conditions: de Quervain Tenosynovitis and Intersection Syndrome
FIGURE 9-38 De Quervain and intersection syndrome (squeaker’s wrist).
P.607

FIGURE 9-39 De Quervain tenosynovitis. Coronal fast spin-echo fat-suppressed T2-weighted image demonstrates marrow edema in the radial styloid and thickening (arrow) of the adjacent tendons.
FIGURE 9-40 Intersection syndrome. Axial fat-suppressed T2-weighted image demonstrating a fluid-filled bursa (arrow).
Suggested Reading
Costa CR, Morrison WB, Carrino JA. MRI features of intersection syndrome of the forearm. AJR Am J Roentgenol 2003;181:1245–1249.
Glajchen N, Schweitzer ME. MRI features in de Quervain’s tenosynovitis of the wrist. Skel Radiol 1996;25:63–65.
P.608

Neoplasms: Bone Tumors
FIGURE 9-41 Enchondromas. PA radiograph of the hand demonstrating multiple lytic expanding lesions in the second metacarpal and second and third phalanges.
P.609

TABLE 9-2 BONE TUMOR AND TUMORLIKE CONDITIONS IN THE HAND AND WRIST
Benign No. in Hand and Wrist/Total/%
Enchondroma 130/290/45%
Giant cell tumor 84/568/15%
Aneurysmal bone cyst 34/289/12%
Osteoid osteoma 29/331/9%
Chondromyxoid fibroma 3/45/7%
Osteochondroma 30/872/3%
Osteoblastoma 3/87/3%
Chondroblastoma 1/119/0.8%
Benign vascular tumors 0/108/0%
Fibrous defects 0/125/0%
Malignant No. in Hand and Wrist/Total/%
Hemangioendothelioma 6/80/7.5%
Malignant fibrous histiocytoma 2/83/2%
Chondrosarcoma 18/895/2%
Fibrosarcoma 5/255/2%
Osteosarcoma 17/1649/1%
Ewing sarcoma 6/512/1%
Lymphoma 6/694/0.8%
Metastasis 2/3000/0.06%
Myeloma 0/814/0%
Suggested Reading
Pozanski AK. The hand in radiologic diagnosis. Philadelphia: WB Saunders; 1984.
Unni KK. Dahlin’s bone tumors: General aspects and data on 11,087 cases, 5th ed. Philadelphia: Lippincott-Raven; 1996.
P.610

Neoplasms: Soft Tissue Masses
FIGURE 9-42 Coronal T1- (A) and fat-suppressed fast spin-echo T2-weighted (B) images of the wrist demonstrating a lobulated ganglion cyst (arrow).
P.611

FIGURE 9-43 Lipoma. Axial (A) and sagittal (B) T1-weighted images of a lobulated fatty lesion (arrows) characteristic of a lipoma.
Suggested Reading
Butler ED, Hamell JP, Seipel RS, et al. Tumors of the hand. A 10-year survey and report of 437 cases. Am J Surg 1960;100:293–302.
P.612

Arthropathies
TABLE 9-3 ARTHROPATHIES OF THE HAND AND WRIST
Image Features Rheumatoid Psoriasis Osteoarthritis CPPD Gout
Soft tissues Symmetric wrist, MCP, PIP Fusiform, sausage digit DIP and PIP joints Mild swelling Nodular
Subluxation MCP late Distal if present DIP and PIP joints No uncommon
Bone density Decreased Normal to ↑ Normal to ↑ Normal Normal
Erosions Poorly defined Large, pencil in cup Central in erosive OA No Well defined, overhanging edge
Joint space Uniformly narrowed Widened Narrowed Narrowed Narrowed
Calcifications No No No Yes Tophi
New bone formation No Yes Osteophytes Osteophytes ±
Distribution PIP, MCP, wrist Distal DIP, PIP, MCP, wrist, variable MCP, wrist Random
CPPD, calcium pyrophosphate dihydrate deposition; DIP, distal interphalangeal; PIP, proximal interphalangeal; MCP, metacarpophalangeal; OA, osteoarthritis.
P.613

FIGURE 9-44 PA view of the hand and wrist with changes of osteoarthritis in the distal phalangeal joints and wrist. There are changes of erosive osteoarthritis in the second through fourth distal phalangeal joints.
P.614

FIGURE 9-45 Rheumatoid arthritis. (A) Early changes in the wrist with soft tissue swelling and erosions (arrowheads). (B) Advanced rheumatoid arthritis with carpal collapse and erosion of the distal radius and ulna.
FIGURE 9-46 Rheumatoid arthritis. (A) Coronal T1-weighted image demonstrating erosions (arrows) not apparent on radiographs. (B) Contrast-enhanced image shows enhancing synovium and carpal erosions in the capitate and trapezium.
P.615

FIGURE 9-47 Psoriatic arthritis. PA radiograph demonstrates fusiform swelling of the third and fourth fingers with increased bone density and aggressive erosive changes in the proximal interphalangeal and to a lesser degree the distal interphalangeal joints. The MCP and wrist are spared.
Suggested Reading
Brower AC. Arthritis in black and white. Philadelphia: WB Saunders; 1997:33–67.
P.616

Avascular Necrosis
FIGURE 9-48 Normal (neutral), ulnar positive, and ulnar negative variance. Ulnar negative variance is associated with AVN of the lunate. Ulnar positive variance is associated with ulnar lunate abutment syndrome.
P.617

FIGURE 9-49 Baseball player with hand pain after trauma. (A) Initial radiograph is normal. (B) Eight weeks later, there is fragmentation of the fourth metacarpal head as the result of AVN.
P.618

FIGURE 9-50 AVN of the lunate. (A) Initial T1-weighted MR image showing no signal (arrow) in the lunate because of AVN. (B) Follow-up T1-weighted image after 3 months of cast immobilization showing return of signal to near normal after revascularization.
P.619

Suggested Reading
Barnes NA, Howes AJ, Jeffers H, et al. Avascular necrosis of the third metacarpal head. Eur Radiol 2000;3:115–117.
Reinus WR, Conway WF, Totty WG, et al. Carpal avascular necrosis. MR imaging. Radiology 1986;160:689–693.
P.620

Nerve Compression Syndromes: Carpal Tunnel Syndrome
FIGURE 9-51 The relationships of the median and ulnar nerves in the wrist.
P.621

FIGURE 9-52 Axial T2-weighted MR image showing deformity and increased signal intensity in the median nerve (arrow) causing carpal tunnel syndrome.
Suggested Reading
Ikeda K, Haughton VM, Hu KC, et al. Correlative MR anatomic study of the median nerve. AJR Am J Roentgenol 1996;167:1233–1236.
Mauer J, Bleochkowski A, Tempka A, et al. High-resolution MR imaging of the carpal tunnel and wrist. Acta Radiol 2000;41:78–83.
P.622

Nerve Compression Syndromes: Ulnar Nerve Compression
FIGURE 9-53 Axial T2-weighted image demonstrates increased signal intensity and enlargement of the ulnar nerve (arrow) resulting from trauma. Findings correlated with electromyography.
P.623

FIGURE 9-54 Fibrolipoma of the ulnar nerve. Axial T1-weighted images (A,B) demonstrate an enlarged low signal intensity nerve with associated fatty tissue (arrow).
Suggested Reading
Berquist TH. MRI of the musculoskeletal system, 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2006:789–797.
P.624

Ulnar Lunate Abutment Syndrome
FIGURE 9-55 Ulnar lunate abutment syndrome. (A) PA radiograph demonstrates ulnar positive variance (line), prominent ulnar styloid, and sclerotic changes in the lunate and triquetrum caused by cartilage loss (open arrows).
P.625

FIGURE 9-56 MR images in patients with ulnar lunate abutment syndrome. (A) T1-weighted image shows low signal intensity in the lunate and adjacent triquetrum. (B) Gradient echo coronal shows displacement of the radial aspect of the triangular fibrocartilage (open arrow) and a peripheral tear (black arrow).
Suggested Reading
Cerezal L, del Pinal F, Abascal F, et al. Imaging findings in the ulnar-sided wrist impaction syndromes. Radiographics 2002;22:105–121.
Palmer AK, Werner FW. Triangular fibrocartilage complex of the wrist—anatomy and function. J Hand Surg 1981;16:153–162.