Pathology of Extrinsic Ligaments: A Pictorial Essay

Abstract

The role of the extrinsic ligaments, together with the intrinsic ligaments, appears to be much more important than previously thought in the setting of carpal stability. The anatomy and pathology of the extrinsic wrist ligaments is complex. Magnetic resonance imaging (MRI) with thin slices is essential for visualization. This article describes the pathological appearance of the extrinsic palmar and dorsal radiocarpal and ulnocarpal ligaments on MRI, correlated with arthroscopy (performed by two skilled hand surgeons), clinical findings, and follow-up. High-resolution MRI, especially using isotropic three-dimensional sequences with orthogonal multiplanar reconstructions on 3T MR systems, allows detailed depiction of many of the extrinsic ligaments affected in carpal injuries. Recognition of ligament abnormalities is improved by intra-articular or intravenous injection of contrast before the examination. Both techniques may help to determine the precise localization, size, and extent of dorsal and palmar radiocarpal and ulnocarpal ligament lesions. Further experience with these techniques is needed to define the place of MRI in the management of traumatic wrist injuries.

Keywords

MRI - extrinsic ligaments - wrist - carpal instability - 3T

• References

• 1 Linscheid RL, Dobyns JH, Beabout JW, Bryan RS. Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. J Bone Joint Surg Am 1972; 54 (8) 1612-1632
• 2 Trail IA, Stanley JK, Hayton MJ. Twenty questions on carpal instability. J Hand Surg Eur Vol 2007; 32 (3) 240-255
• 3 Schmitt R, Froehner S, Coblenz G, Christopoulos G. Carpal instability. Eur Radiol 2006; 16 (10) 2161-2178
• 4 Gilula LA, Weeks PM. Post-traumatic ligamentous instabilities of the wrist. Radiology 1978; 129 (3) 641-651
• 5 Theumann NH, Etechami G, Duvoisin B , et al. Association between extrinsic and intrinsic carpal ligament injuries at MR arthrography and carpal instability at radiography: initial observations. Radiology 2006; 238 (3) 950-957
• 6 Camus E. Carpal biomechanics: Application to ligamentous injuries. In: Camus E, Van Overstraeten L, eds. Ligamentous Surgery of the Wrist. Berlin, Germany: Springer Verlag; 2012
• 7 Schmitt R, Lanz U. Diagnostic Imaging of the Hand. New York, NY: Thieme International; 2007: 98-122
• 8 Roulot E. Arthroscopie du poignet. Intérêt diagnostique et thérapeutique dans Imagerie du poignet et de la main. In: Godefroy D, LeViet D, Rodineau J, Drapé JL, Tavernier T, Railhac JJ, eds. Paris, France: Sauramps Médical; 2001
• 9 Dautel G. Normal wrist arthroscopy. In: Camus E, Van Overstraeten L, eds. Ligamentous Surgery of the Wrist. Berlin, Germany: Springer Verlag; 2012
• 10 Totterman SM, Miller R, Wasserman B, Blebea JS, Rubens DJ. Intrinsic and extrinsic carpal ligaments: evaluation by three-dimensional Fourier transform MR imaging. AJR Am J Roentgenol 1993; 160 (1) 117-123
• 11 Smith DK. Dorsal carpal ligaments of the wrist: normal appearance on multiplanar reconstructions of three-dimensional Fourier transform MR imaging. AJR Am J Roentgenol 1993; 161 (1) 119-125
• 12 Smith DK. Volar carpal ligaments of the wrist: normal appearance on multiplanar reconstructions of three-dimensional Fourier transform MR imaging. AJR Am J Roentgenol 1993; 161 (2) 353-357
• 13 Shahabpour M, De Maeseneer M, Pouders C , et al. MR imaging of normal extrinsic wrist ligaments using thin slices with clinical and surgical correlation. Eur J Radiol 2011; 77 (2) 196-201
• 14 Shahabpour M, Ceuterick P, Allemon B, Mimoun K, DeMaeseneer M, de Mey J. MR imaging of volar radiocarpal and ulnocarpal ligamentous lesions using thin slices with clinical and surgical correlation. Poster presented at: Radiological Society of North America Annual Meeting; 2008; Chicago, IL
• 15 Shahabpour M, Ceuterick P, Allemon B , et al. MRI of normal anatomy and injuries of extrinsic ligaments. In: Camus E, Van Overstraeten L, eds. Ligamentous Surgery of the Wrist. Berlin, Germany: Springer Verlag; 2012
• 16 Van Overstraeten L. Arthroscopic anatomy and lesions of the extrinsic ligaments. In: Camus E, Van Overstraeten L, eds. Ligamentous Surgery of the Wrist. Berlin, Germany: Springer Verlag; 2012
• 17 Dréant N. Dynamic arthroscopic testing. In: Camus E, Van Overstraeten L, eds. Ligamentous Surgery of the Wrist. Berlin, Germany: Springer Verlag; 2012
• 18 Scheck RJ, Romagnolo A, Hierner R, Pfluger T, Wilhelm K, Hahn K. The carpal ligaments in MR arthrography of the wrist: correlation with standard MRI and wrist arthroscopy. J Magn Reson Imaging 1999; 9 (3) 468-474
• 19 Maizlin ZV, Brown JA, Clement JJ , et al. MR arthrography of the wrist: controversies and concepts. Hand (NY) 2009; 4 (1) 66-73
• 20 Viegas SF, Patterson RM, Hokanson JA, Davis J. Wrist anatomy: incidence, distribution, and correlation of anatomic variations, tears, and arthrosis. J Hand Surg Am 1993; 18 (3) 463-475
• 21 Viegas SF, Patterson RM, Ward K. Extrinsic wrist ligaments in the pathomechanics of ulnar translation instability. J Hand Surg Am 1995; 20 (2) 312-318
• 22 Feipel V, Rooze M. The capsular ligaments of the wrist: morphology, morphometry and clinical applications. Surg Radiol Anat 1999; 21 (3) 175-180
• 23 Berger RA, Landsmeer JMF. The palmar radiocarpal ligaments: a study of adult and fetal human wrist joints. J Hand Surg Am 1990; 15 (6) 847-854
• 24 Rominger MB, Bernreuter WK, Kenney PJ, Lee DH. MR imaging of anatomy and tears of wrist ligaments. Radiographics 1993; 13 (6) 1233-1246 ; discussion 1247–1248
• 25 Brown RR, Fliszar E, Cotten A, Trudell D, Resnick D. Extrinsic and intrinsic ligaments of the wrist: normal and pathologic anatomy at MR arthrography with three-compartment enhancement. Radiographics 1998; 18 (3) 667-674
• 26 Taleisnik J. The ligaments of the wrist. J Hand Surg Am 1976; 1 (2) 110-118
• 27 Reicher MA. Normal wrist anatomy, biomechanics, basic imaging protocol, and normal multiplanar MRI of the wrist. In: Reicher MA, ed. MRI of the Wrist and Hand. New York, NY: Raven; 1990: 17-48
• 28 Short WH, Werner FW, Green JK, Masaoka S. Biomechanical evaluation of ligamentous stabilizers of the scaphoid and lunate. J Hand Surg Am 2002; 27 (6) 991-1002
• 29 Berger RA. The anatomy of the ligaments of the wrist and distal radioulnar joints. Clin Orthop Relat Res 2001; (383) 32-40
• 30 Timins ME, Jahnke JP, Krah SF, Erickson SJ, Carrera GF. MR imaging of the major carpal stabilizing ligaments: normal anatomy and clinical examples. Radiographics 1995; 15 (3) 575-587
• 31 Theumann NH, Pfirrmann CW, Antonio GE , et al. Extrinsic carpal ligaments: normal MR arthrographic appearance in cadavers. Radiology 2003; 226 (1) 171-179
• 32 Short WH, Werner FW, Green JK, Masaoka S. Biomechanical evaluation of the ligamentous stabilizers of the scaphoid and lunate: Part II. J Hand Surg Am 2005; 30 (1) 24-34
• 33 Boutry N, Lapegue F, Masi L, Claret A, Demondion X, Cotten A. Ultrasonographic evaluation of normal extrinsic and intrinsic carpal ligaments: preliminary experience. Skeletal Radiol 2005; 34 (9) 513-521
• 34 Taljanovic MS, Goldberg MR, Sheppard JE, Rogers LF. US of the intrinsic and extrinsic wrist ligaments and triangular fibrocartilage complex—normal anatomy and imaging technique. Radiographics 2011; 31 (1) e44
• 35 Connell D, Page P, Wright W, Hoy G. Magnetic resonance imaging of the wrist ligaments. Australas Radiol 2001; 45 (4) 411-422
• 36 Berger RA, Kauer JM, Landsmeer JM. Radioscapholunate ligament: a gross anatomic and histologic study of fetal and adult wrists. J Hand Surg Am 1991; 16 (2) 350-355
• 37 Ishii S, Palmer AK, Werner FW, Short WH, Fortino MD. An anatomic study of the ligamentous structure of the triangular fibrocartilage complex. J Hand Surg Am 1998; 23 (6) 977-985
• 38 Nakamura T, Takayama S, Horiuchi Y, Yabe Y. Origins and insertions of the triangular fibrocartilage complex: a histological study. J Hand Surg [Br] 2001; 26 (5) 446-454
• 39 Tanaka T, Ogino S, Yoshioka H. Ligamentous injuries of the wrist. Semin Musculoskelet Radiol 2008; 12 (4) 359-377
• 40 Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989; 14 (4) 594-606
• 41 Palmer AK. Triangular fibrocartilage disorders: injury patterns and treatment. Arthroscopy 1990; 6 (2) 125-132
• 42 Oneson SR, Scales LM, Erickson SJ, Timins ME. MR imaging of the painful wrist. Radiographics 1996; 16 (5) 997-1008
• 43 Theumann N, Kamel EM, Bollmann C, Sturzenegger M, Becce F. Bucket-handle tear of the triangular fibrocartilage complex: case report of a complex peripheral injury with separation of the distal radioulnar ligaments from the articular disc. Skeletal Radiol 2011; 40 (12) 1617-1621
• 44 Tay SC, Berger RA, Parker WL. Longitudinal split tears of the ulnotriquetral ligament. Hand Clin 2010; 26 (4) 495-501
• 45 Herron ML, Craigen MAC. Arthroscopy of the wrist for trauma. Trauma 2001; 3: 9-16
• 46 Short WH, Werner FW, Green JK, Sutton LG, Brutus JP. Biomechanical evaluation of the ligamentous stabilizers of the scaphoid and lunate: part III. J Hand Surg Am 2007; 32 (3) 297-309
• 47 Slutsky DJ. The incidence of dorsal radiocarpal ligament tears in patients having diagnostic wrist arthroscopy for wrist pain. J Hand Surg Am 2008; 33 (3) 332-334
• 48 Resnick D, Kang HS, Pretterklieber ML. Wrist and hand. In: Internal Derangements of Joints. 2nd ed. Philadelphia, PA: Saunders; 2007. 1. 1218-1418
• 49 Mitsuyasu H, Patterson RM, Shah MA, Buford WL, Iwamoto Y, Viegas SF. The role of the dorsal intercarpal ligament in dynamic and static scapholunate instability. J Hand Surg Am 2004; 29 (2) 279-288