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1
Department of Radiology, Yale University School of Medicine, 333 Cedar St., P.
O. Box 208042, New Haven, CT 06520-8042.
2
Department of Radiology, Thomas Jefferson University Hospital, 111 S. 11th
St., Philadelphia, PA 19107.
3
Department of Orthopedic Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA 19107.
Received July 6, 2001;
accepted after revision August 22, 2001.
Address correspondence to A. H. Haims.
Abstract
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MATERIALS AND METHODS. Eighty-six MR imaging examinations of the wrist (41 indirect MR arthrograms and 45 unenhanced MR images) were evaluated: 20 wrists with surgically confirmed peripheral triangular fibrocartilage complex tears and 66 wrists with surgically documented normal ulnar attachment. These cases were evaluated by three experienced musculoskeletal radiologists, who were unaware of the surgical findings, to assess the presence of peripheral triangular fibrocartilage complex tears or fluid signal at the ulnar attachment of the triangular fibrocartilage complex.
RESULTS. The sensitivity for evaluation of the peripheral triangular fibrocartilage complex tear was 17%, with a specificity of 79% and an accuracy of 64%. High signal intensity at the ulnar insertion of the triangular fibrocartilage complex as a marker for tear showed a sensitivity of 42%, a specificity of 63%, and an accuracy of 55%. Weighted kappa values revealed only fair agreement among the three observers.
CONCLUSION. MR imaging does not adequately reveal the peripheral attachment of the triangular fibrocartilage complex.
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The parameters for unenhanced MR imaging were as follows: coronal fast spin-echo fat-suppressed T2-weighted images (TR/TE, 6,000/70; matrix size, 256 x 256; excitations, 4; echo-train length, 4; field of view, 10 cm; slice thickness, 3 mm; interslice gap, 1 mm); coronal three-dimensional gradient-echo images (58/ 12; flip angle, 10°; matrix size, 256 x 128; excitations, 2; field of view, 8 cm; slice thickness, 1.2 mm; interslice gap, 0); coronal T1-weighted spin-echo images (500/14; matrix size, 256 x 192; excitations, 3; field of view, 10 cm; slice thickness, 3 mm; interslice gap, 1 mm); and axial fast spin-echo fat-suppressed T2-weighted images (8,000/85; matrix size, 256 x 256; excitations, 4; echo-train length, 8; field of view, 10 cm; slice thickness, 3 mm; interslice gap, 1 mm).
The parameters for the indirect MR arthrography were as follows: coronal fast spin-echo fat-suppressed T2-weighted images (6,000/70; matrix size, 256 x 256; excitations, 4; echo-train length, 4; field of view, 10 cm; slice thickness, 3 mm; interslice gap, 1 mm); coronal three-dimensional spoiled gradient-echo images (46/15; flip angle, 45°; matrix size, 256 x 128; excitations, 2; field of view, 8 cm; slice thickness, 1.2 mm; interslice gap, 0); coronal T1-weighted spin-echo images (500/ 14; matrix size, 256 x 192; excitations, 3; field of view, 10; slice thickness, 3 mm; interslice gap, 1 mm); and coronal and axial fat-suppressed two-dimensional spoiled gradient-echo images (220/9.3; flip angle, 90°; matrix size, 256 x 128; excitations, 2; field of view, 10 cm; slice thickness, 3 mm; interslice gap, 1 mm).
All cases were included, regardless of image quality, unless the operative data or the images could not be obtained. The MR images were independently evaluated by three musculoskeletal radiologists who were unaware of the surgical findings. The observers used a three-point scale for the ulnar attachment of the triangular fibrocartilage complex: normal (Figs. 1 and 2), high signal intensity at the ulnar insertion (Fig. 3), or tear at the ulnar insertion.
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Wrist arthroscopy was performed on all patients within 10 months after the MR imaging examinations, with an average interval of 2.5 months (range, 1 week—10 months). At arthroscopic surgery, the peripheral attachment of the triangular fibrocartilage complex was identified by the surgeon as normal or torn. All peripheral triangular fibrocartilage complex tears were arthroscopically repaired at the time of surgery.
Statistical comparisons were performed using the Student's t test with a p value of less than 0.05 considered statistically significant. Weighted kappa values were obtained to determine the agreement among the three observers.
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When the peripheral attachment of the triangular fibrocartilage complex was considered torn, the average sensitivity was 17%, specificity was 79%, and accuracy was 64% for the three observers (Table 1). The sensitivity ranged from 5% to 30% for the three observers. The specificity ranged from 68% to 91%.
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There was no significant difference between the operating characteristics of the unenhanced MR imaging and the indirect MR arthrography (p = 0.60). The indirect MR arthrography (combined for the three observers) had a sensitivity of 12%, a specificity of 81%, and an accuracy of 74%. The unenhanced MR imaging (combined for the three observers) had a sensitivity of 18%, a specificity of 77%, and an accuracy of 68%.
When high signal intensity was found at the peripheral attachment of the triangular fibrocartilage complex, viewed as a possible marker for peripheral tear, the combined sensitivity was 42%, specificity was 63%, and accuracy was 55% (Table 2). The sensitivity ranged from 35% to 50% for the three observers. The specificity ranged from 56% to 70%. There was no significant difference between the unenhanced MR imaging and the indirect MR arthrography (p = 0.09). The indirect MR arthrography (combined for the three observers) had a sensitivity of 45%, a specificity of 69%, and an accuracy of 56%. The unenhanced MR imaging (combined for the three observers) had a sensitivity of 37%, a specificity of 59%, and an accuracy of 55%.
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Weighted kappa values were also performed to evaluate the agreement between the three observers. Weighted kappa values were 0.220 for observers 1 and 2, 0.308 for observers 1 and 3, and 0.262 for observers 2 and 3, showing only fair agreement.
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Our results, which reveal the limited utility of MR imaging in evaluation of the peripheral attachment of the triangular fibrocartilage complex, are not incompatible with the brief mention made in the current literature. In an extensive study of 56 tears of the triangular fibrocartilage complex, Oneson et al. [11] found only four cases of ulnar avulsion. The sensitivity of the two observers in this study was 25% and 50%. The poor sensitivity was attributed to the presence of striated fascicles, which are difficult to evaluate by MR imaging. Totterman et al. [10] found two abnormal ulnar attachments and two tears at the ulnar insertion. In this study, it was concluded that lesions of the ulnar attachments of the triangular fibrocartilage complex were often overstaged. In the largest published series, Potter et al. [12] evaluated 57 tears of the triangular fibrocartilage complex. The tears in this study were put into four categories: central, radial, ulnar, and complex. No specific mention was made of ulnar avulsions or peripheral tears. Pederzini et al. [8] had one case of ulnar detachment in the 11 patients in their study. Using MR imaging, the authors correctly described the case of ulnar detachment as being torn. However, they stated that "it was not possible with MR imaging to define the exact site of the lesion (radial, central, or ulnar)." An investigation by Corso et al. [14] included 45 patients with peripheral triangular fibrocartilage complex tears, and only a minority of these patients had consistent findings on MR imaging. Five patients in this study had negative findings on both MR imaging and arthrographic examinations.
Zanetti et al. [15] have shown on arthrography that partial avulsions of the triangular fibrocartilage complex off of the ulna were frequently symptomatic. In this study, however, there was no surgical confirmation of the arthrographic findings. Additionally, 27% of the asymptomatic wrists in this study had similar noncommunicating defects. Two other studies showed that ulnar detachment of the triangular fibrocartilage complex is seldom seen on arthrography [16, 17].
There were two major clinical correlates in the 20 wrists with peripheral triangular fibrocartilage complex tears. At surgery, 10 of the 20 wrists with peripheral tears were at the dorsal attachment of the ulna. We solely evaluated the peripheral attachment in these patients in the coronal plane. If we had evaluated these patients in the sagittal or axial planes, we may have had greater accuracy. Second, all of these peripheral tears were associated with a synovitis at arthroscopy. It is possible that the finding of a focal synovitis at the ulnar attachment could be used as a marker for peripheral tear. This focal synovitis could potentially be differentiated from fluid with the use of unenhanced and enhanced imaging.
Our study has several limitations. First, there were patients who had MR imaging and wrist arthroscopy, but either their images or the operative results could not be obtained. Although we believe this cohort is not different from our study patients, we cannot confirm this belief, and thus, the cohort could be a source of bias in our study population. Our study population included only patients who had arthroscopic wrist surgery, suggesting that our population would prospectively be expected to have a higher incidence of triangular fibrocartilage complex abnormalities. Additionally, our study population included both unenhanced MR imaging and indirect MR arthrography, yielding a somewhat heterogeneous population. However, there was no statistically significant difference in accuracy between the two modalities.
In conclusion, our findings support the limited imaging literature in that MR imaging performs poorly in the evaluation of the ulnar attachment of the triangular fibrocartilage complex. Further investigation might include axial and sagittal imaging and greater attention to the findings of synovitis. Additionally, unenhanced and enhanced MR imaging may be helpful in differentiating joint fluid from synovitis. Although the current findings are disappointing, the clinical need for accurate preoperative planning remains, and continuing advances in MR imaging techniques offer the potential to achieving this objective.
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