Joseph E. Sheppard

Sonography and Sonoarthrography of the Scapholunate and Lunotriquetral Ligaments and Triangular Fibrocartilage Disk Initial Experience and Correlation With Arthrography and Magnetic Resonance Arthrography

The purpose of this study was to determine the utility of sonography and sonoarthrography in evaluation of dorsal bands of the scapholunate ligament (SLL), lunotriquetral ligament (LTL), and triangular fibrocartilage (TFC) disk in correlation with arthrography and magnetic resonance arthrography (MRA).

Quantitative Analysis of the Medial Ulnar Collateral Ligament Ulnar Footprint and Its Relationship to the Ulnar Sublime Tubercle

Background: The medial ulnar collateral ligament is the major soft tissue restraint to valgus displacement of the elbow. Currently, little has been published regarding the medial ulnar collateral ligament’s ulnar footprint. Hypothesis: The medial ulnar collateral ligament has a long attachment onto the ulna and the anatomy of the footprint is consistent. Study Design: Descriptive laboratory study. Methods: The authors studied the morphologic characteristics of the ulnar footprint of the medial ulnar collateral ligament in 10 fresh-frozen cadaveric specimens, 100 osseous specimens, and with 3-dimensional computed tomography in an additional 10 osseous specimens. They measured the length of the anterior band’s ulnar attachment and the entire ligament length. They also measured the length of the osseous ridge, which extends distally from the sublime tubercle in both osseous specimens and on computed tomography. Results: The mean length of the medial ulnar collateral ligament was 53.9 mm and the mean length of the ulnar soft tissue footprint was 29.2 mm. The authors identified an osseous ridge that extended distally from the sublime tubercle to just medial to the ulnar insertion of the brachialis muscle tendon. This osseous ridge was present in all osseous and fresh-frozen cadaveric specimens. The mean length of this osseous ridge was 24.5 mm. Conclusion: The medial ulnar collateral ligament has a long attachment along the proximal ulna. The ligament attaches to a previously undescribed ridge of bone located on the medial aspect of the proximal ulna, the medial ulnar collateral ligament ridge. This ridge is present in all skeletal specimens. Clinical Relevance: Injuries to the medial ulnar collateral ligament are common. Published success rates after reconstruction of the medial ulnar collateral ligament are highly variable. The present study illustrates how current reconstruction techniques fail to fully restore the true anatomy of the native ligament. Further studies are needed to investigate this issue.

US of the Intrinsic and Extrinsic Wrist Ligaments and Triangular Fibrocartilage Complex—Normal Anatomy and Imaging Technique

Injuries of the intrinsic and extrinsic wrist ligaments can lead to chronic wrist pain and carpal instability, while injuries of the triangular fibrocartilage complex are a frequent cause of ulnar-sided wrist pain. Currently, magnetic resonance (MR) arthrography is the preferred imaging modality for the evaluation of these structures, but good results can also achieved with MR imaging without preceding arthrography and computed tomographic (CT) arthrography. Promising results have been published on ultrasonography (US) and sonoarthrography of the intrinsic wrist ligaments and the triangular fibrocartilage complex and on US of the majority of extrinsic wrist ligaments. Visualization of these structures can be achieved by using high-frequency linear transducers. US has the advantages of MR imaging and MR arthrography: lower cost, no known contraindication for imaging, and real-time technique with possible dynamic evaluation. This technique does not require imaging guided intraarticular injection of contrast medium prior to MR arthrography or CT arthrography and does not use ionizing radiation; however, US is operator dependent, which can be compensated for by using standardized imaging techniques. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.e44/-/DC1.

Imaging and Treatment of Scaphoid Fractures and Their Complications

The scaphoid is the most commonly fractured carpal bone, with frequent complications that are predisposed by its anatomical location, anatomical configuration (shape and length), and vascular supply. The most common mechanism of injury is a fall onto an outstretched hand. Imaging plays a significant role in the initial evaluation and treatment of scaphoid fractures and their complications. Radiography should be the first imaging modality in the initial evaluation and follow-up of scaphoid fractures. Computed tomography with its superb spatial resolution enables better visualization and characterization of the fracture line, and the amount of displacement and angulation of the fracture fragments. Using the metal reduction artifact with computed tomography allows good follow-up of scaphoid fractures despite surgical hardware. Magnetic resonance imaging without contrast is the imaging modality of choice for depiction of radiographically occult scaphoid fracture, bone contusion, and associated soft tissue injury; contrast-enhanced imaging aids assessment of scaphoid fracture nonunion, osteonecrosis, fracture healing after bone grafting, and revitalization of the necrotic bone after bone grafting. Proper identification and classification of scaphoid fracture and its complications is necessary for appropriate treatment. This article describes the normal anatomy, mechanism of injury, and classification of stable and unstable fractures, together with the imaging and treatment algorithm of scaphoid fractures and their complications with an emphasis on magnetic resonance imaging.

Spectrum of Carpal Dislocations and Fracture-Dislocations: Imaging and Management

OBJECTIVE The objectives of this article are to discuss the imaging of carpal dislocations and fracture-dislocations and to review the ligamentous anatomy of the wrist, mechanisms of injury, and routine management of these injuries. CONCLUSION Perilunate dislocations, perilunate fracture-dislocations (PLFDs), and lunate dislocations are high-energy wrist injuries that can and should be recognized on radio-graphs. These injuries are a result of important sequential osseous and ligamentous injuries or failures. Prompt and accurate radiographic diagnosis aids in the management of patients with perilunate dislocations, PLFDs, and lunate dislocations while assisting orthopedic surgeons with subsequent surgical planning. CT may better show the extent of the injury and help in treatment planning particularly in cases of delayed treatment or chronic perilunate dislocation. A CT examination with coronal, sagittal, and 3D reformatted images is ordered at our institution in cases in which the extent of the carpal injuries is poorly shown on radiographic examination.

Normal anatomy of the extrinsic capsular wrist ligaments by 3-T MRI and high-resolution ultrasonography.

The anatomy of the extrinsic capsular wrist ligaments is complex. These ligaments are probably as important as the intrinsic interosseous ligaments for the maintenance of carpal stability. The extrinsic capsular wrist ligaments are frequently divided into dorsal, palmar, and collateral depending on their anatomical location. They have known origin and attachment sites with recognized anatomical variants. However, there is controversy in the literature related to their anatomy and nomenclature. In the past two decades, imaging has gained an important role in the evaluation of the extrinsic capsular wrist ligaments. Both 1.5-T magnetic resonance imaging (MRI) and magnetic resonance arthrography can provide good evaluation of the extrinsic capsular wrist ligaments; 3-T MRI with improved resolution provides better visualization of the same anatomical structures. Ultrasonography using high-resolution linear transducers allows good visualization of the extrinsic capsular wrist ligaments with results that are comparable with MRI. This article describes the normal anatomy of the dorsal, palmar, and collateral extrinsic capsular wrist ligaments on 3-T MRI and high-resolution ultrasonography.

Coccidioides immitis osteomyelitis of the radius presenting as Ewing's sarcoma.

Coccidioides immitis osteomyelitis is a relatively rare manifestation of a disease that most commonly presents with pulmonary infection. Disseminated disease occurs in approximately 1% of infected individuals, with bony involvement in 10% to 50% of those patients with extrapulmonary infection. Diagnosis and treatment of patients with primarily osteoarticular complaints is frequently delayed, which may result in progression of disease and suboptimal results. This article discusses the successful treatment of a patient whose initial presentation was suggestive of Ewings sarcoma of the proximal radius, but was found on biopsy to have coccidioidomycosis osteomyelitis. The patient was treated with surgical debridement and systemic as well as intralesional antifungal therapy.

Transstyloid, translunate fracture-dislocation of the wrist: case report.

Earlier reports have described characteristic fracture-dislocation patterns of the carpus and distal radius. Most result from a fall onto an outstretched arm, with an applied force directed in a radial-to-ulnar direction across the wrist. We present the clinical, radiographic, and arthroscopic findings noted with an unusual pattern of injury resulting from a force applied at the ulnar side of the wrist.

Imaging and management of thumb carpometacarpal joint osteoarthritis

Primary osteoarthritis (OA) involving the thumb carpometacarpal (CMC) joint is a common and frequently debilitating disease. Clinical examination and radiographs are usually sufficient for diagnosis; however, familiarity with the cross-sectional anatomy is useful for diagnosis of this condition. The most widely used classification system for the radiographic staging of thumb carpometacarpal joint OA was first presented by Eaton and Littler, ranging from mild (stages I and II) to severe (stage IV) disease. If conservative treatment fails, surgical treatment is considered. A variety of surgical techniques have been developed and implemented for the management of this pervasive and disabling condition. The purpose of this article is to review the anatomy of the basal joints of the thumb, pathophysiology, preoperative imaging, and various surgical techniques that are utilized in the treatment of OA of the basal joints of the thumb with emphasis on normal postoperative radiographic findings and possible postoperative complications.

Accuracy of High-Resolution Ultrasonography in the Detection of Extensor Tendon Lacerations

BackgroundLacerations to the extensor mechanism are usually diagnosed clinically. Ultrasound (US) has been a growing diagnostic tool for tendon injuries since the 1990s. To date, there has been no publication establishing the accuracy and reliability of US in the evaluation of extensor mechanism lacerations in the hand. The purpose of this study is to determine the accuracy of US to detect extensor tendon injuries in the hand. MethodsSixteen fingers and 4 thumbs in 4 fresh-frozen and thawed cadaveric hands were used. Sixty-eight 0.5-cm transverse skin lacerations were created. Twenty-seven extensor tendons were sharply transected. The remaining skin lacerations were used as sham dissection controls. One US technologist and one fellowship-trained musculoskeletal radiologist performed real-time dynamic US studies in and out of water bath. A second fellowship trained musculoskeletal radiologist subsequently reviewed the static US images. Dynamic and static US interpretation accuracy was assessed using dissection as “truth.” ResultsAll 27 extensor tendon lacerations and controls were identified correctly with dynamic imaging as either injury models that had a transected extensor tendon or sham controls with intact extensor tendons (sensitivity = 100%, specificity = 100%, positive predictive value = 1.0; all significantly greater than chance). Static imaging had a sensitivity of 85%, specificity of 89%, and accuracy of 88% (all significantly greater than chance). The results of the dynamic real time versus static US imaging were clearly different but did not reach statistical significance. ConclusionsDiagnostic US is a very accurate noninvasive study that can identify extensor mechanism injuries. Clinically suspected cases of acute extensor tendon injury scanned by high-frequency US can aid and/or confirm the diagnosis, with dynamic imaging providing added value compared to static. Ultrasonography, to aid in the diagnosis of extensor mechanism lacerations, can be successfully used in a reliable and accurate manner.