DOI:10.2214/AJR.04.1640
AJR 2006; 186:800-804
© American Roentgen Ray Society
Direct Arthrography of the Pisotriquetral Joint
Eric Pessis1,
Jean-Luc Drapé2,
Fabienne Bach2,
Antoine Feydy2,
Henri Guerini2 and
Alain Chevrot2
1 Department of Radiology, Centre Cardiologique du Nord, 32-36 rue des moulins
gémeaux, Saint Denis 93200, France.
2 Department of Radiology B, CHU Cochin, Assistance Publique-Hôpitaux de
Paris, Université Paris V, Paris, France.
Received October 21, 2004;
accepted after revision January 31, 2005.
Address correspondence to E. Pessis
(epessis{at}free.fr).
Abstract
OBJECTIVE. The purpose of this study was to describe and evaluate a
simple and safe procedure for direct arthrography of and steroid injection
into the pisotriquetral joint.
CONCLUSION. Direct pisotriquetral arthrography using a medial
approach is an effective and easy-to-perform technique for injection of
steroids.
Keywords: arthrography • pisotriquetral joint • steroid injection • ulnar wrist pain
Introduction
The pisotriquetral joint is subject to all the diseases that affect any
synovial joint, including the common conditions osteoarthritis and rheumatoid
arthritis
[1-4].
Degenerative changes of the pisotriquetral joint are a cause of ulnar-sided
wrist pain [5]. A
pisotriquetral joint disorder may be difficult to distinguish from other
ulnocarpal problems, and intraarticular injection of a steroid and local
anesthetic into the pisotriquetral joint is a useful tool to determine whether
there is a relationship between chronic ulnar wrist pain and the
pisotriquetral joint [3].
Intraarticular injection into the pisotriquetral joint can be performed with a
radiocarpal injection for patients with an arthrographic communication between
the radiocarpal joint and the pisotriquetral joint. Because there is no
arthrographic communication between the radiocarpal joint and the
pisotriquetral joint (Figs. 1A
and 1B) in 12-25% of subjects
[4,
6-8],
arthrography of specifically the pisotriquetral joint can be necessary. To our
knowledge, a specific approach to entering the pisotriquetral joint has never
been described in the literature. Our purpose is to describe our experience
using a new, safe procedure for direct arthrography of and steroid injection
into the pisotriquetral joint.
Materials and Methods
Over a 2-year period, 52 patients with chronic ulnar wrist pain believed to
be related to the pisotriquetral joint underwent pisotriquetral arthrography
using steroid and local anesthetic injection. The patients were referred from
orthopedic surgeons or rheumatologists and included 27 men and 25 women (age
range, 26-63 years; mean, 41 years). In all patients, the pisotriquetral joint
arthrography was indicated to establish the cause of ulnar-sided wrist pain
and for therapeutic purposes. Radiographic evidence of osteoarthritis of the
pisotriquetral joint was found in four patients. The procedures were performed
by three radiologists who had experience (11, 9, and 2 years) in
musculoskeletal radiology, including imaging-guided injections. They performed
12, 28, and 12 pisotriquetral injections. One of the three radiologists had
performed a pisotriquetral injection (once) on a study subject before this
study. All procedures were performed without sedating or premedicating the
patients. Oral informed consent was obtained from all patients after the
nature of the procedure had been fully explained.
The patients sat in front of the fluoroscopy table. Using fluoroscopic
guidance, we accessed the pisotriquetral joint with the hand in the extreme
prone position and the wrist in mild palmar flexion
(Fig. 2). The central beam was
vertically oriented to show the pisotriquetral joint space (Figs.
3A,
3B, and
3C). Using a medial approach
parallel to the X-ray beam with intermittent fluoroscopy, we introduced a
23-gauge, 1.9-cm-long butterfly needle vertically and toward the
pisotriquetral joint space until the needle came into contact with the
pisiform bone margin. Using a slight posterior angulation, we then advanced
the needle toward the pisotriquetral joint space. When direct access proved
too difficult because of severe joint-space narrowing or osteophytes, the
needle was repositioned as necessary toward the superior articular surface of
the triquetral bone (Figs. 4A
and 4B). The adequacy of needle
placement was confirmed by progressive filling of the proximal and distal
synovial recesses of the pisotriquetral joint (Figs.
3A,
3B,
3C,
4A, and
4B) with 0.5-1.0 mL of contrast
medium (iohexol [Omnipaque 300], Amersham Health; 300 mg of iodine per
millimeter). Then, 0.5-1.0 mL of a long-acting preservative-free local
anesthetic (bupivacaine hydrochloride, 0.5%, Abbott Laboratories) was
injected, followed by injection of 0.5-1.0 mL of a long-acting steroid
(cortivazol [Altim], Diamant). The exact volume injected depended on the
amount required to distend the joint without encountering substantial
pressure. Fluoroscopy was performed intermittently throughout the injection to
help identify and localize possible pathologic conditions. The number of
attempts required to position the needle intraarticularly was recorded. In the
fluoroscopy room immediately after the pisotriquetral joint injection had been
completed, patients were asked to verbally grade their level of pain during
the procedure on a scale of 0 (no pain) to 10 (worst pain imaginable).
Repositioning of the needle because of excessive pain was recorded. Four
months afterward, the wrist was examined clinically because of the potential
risk that a painful neuroma might have developed after neural impalement.
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Fig. 2 —33-year-old woman. Position of hand for direct arthrography of
pisotriquetral joint. Hand is overpronated, with mild palmar flexion. Dorsal
surface of thumb is placed on table. Central beam (arrow) is
perpendicular to table and centered on pisotriquetral joint.
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Fig. 3A —47-year-old man. Direct access of pisotriquetral joint under
fluoroscopic guidance, with hand in extreme prone position. P = pisiform bone,
T = triquetral bone. With dorsal flexion of wrist, pisotriquetral joint space
is narrowed (arrow).
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Fig. 3B —47-year-old man. Direct access of pisotriquetral joint under
fluoroscopic guidance, with hand in extreme prone position. P = pisiform bone,
T = triquetral bone. With mild palmar flexion of wrist, pisotriquetral joint
space is enlarged (asterisk).
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Fig. 3C —47-year-old man. Direct access of pisotriquetral joint under
fluoroscopic guidance, with hand in extreme prone position. P = pisiform bone,
T = triquetral bone. 23-gauge butterfly needle is positioned directly in joint
space. Correct positioning of needle is confirmed arthrographically by
progressive filling of pisotriquetral joint.
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Fig. 4A —58-year-old woman. Direct access of pisotriquetral joint under
fluoroscopic guidance. P = pisiform bone, T = triquetral bone. Oblique view of
wrist shows advanced osteoarthritis of pisotriquetral joint with narrowing of
joint space. Needle position is modified as necessary toward distal surface of
joint (asterisk) to avoid narrowed pisotriquetral joint space.
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Fig. 4B —58-year-old woman. Direct access of pisotriquetral joint under
fluoroscopic guidance. P = pisiform bone, T = triquetral bone. Correct
positioning of needle is confirmed arthrographically by progressive filling of
pisotriquetral joint.
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Results
Direct pisotriquetral arthrography was successful in all 52 patients.
Arthrographic communication between the pisotriquetral and radiocarpal joints
was found in 38 patients (73%). Intraarticular injection of contrast medium
was successful in all patients. In the first attempts of each radiologist, in
three, two, and two patients, the needle had to be repositioned slightly to
reach the pisiform bone margin. After coming into contact with the pisiform
bone, the needle was advanced into the pisotriquetral joint space, and
repositioning of the needle for soft-tissue extravasation of contrast medium
was not necessary in any patient. Pisotriquetral arthrograms were obtained
with a mean fluoroscopic time of 20.7 sec (range, 12-42 sec). The mean level
of pain reported by the patients during the procedures was 2.8 on a scale of
0-10. Repositioning of the needle for excessive pain was not reported for any
patient. No clinical evidence of painful neuroma was found at the site of
injection at 4 months' follow-up.
Discussion
Disorders of the pisotriquetral joint are a common cause of chronic
ulnar-sided wrist pain. However, such disorders may be difficult to
distinguish from other ulnocarpal problems such as triangular fibrocartilage
complex tears, lunotriquetral instability, distal radioulnar joint disease,
extensor carpi ulnaris subluxation, calcific flexor carpi ulnaris tendinitis,
and pisotriquetral arthritis
[5]. The pisotriquetral joint
may be filled through a radiocarpal approach. Direct injection of a local
anesthetic and steroid into the pisotriquetral joint can test for relief of
symptoms related to the pisotriquetral joint. Furthermore, pisiformectomy is a
reliable operation [2,
3,
9], especially in young
patients with a definite history of trauma and a positive response to
intraarticular injection of local anesthetic in the pisotriquetral joint
[3]. A reliable, easy technique
for direct pisotriquetral joint injection is needed because there was no
arthrographic communication between the radiocarpal joint and the
pisotriquetral joint (Figs. 1A
and 1B) in up to 25% of
patients in previous studies
[4,
6-8]
and in 27% of the patients in this study. We used a medial approach toward the
pisotriquetral joint because a lateral approach may impale the ulnar nerve and
ulnar artery in Guyon's canal. With a medial approach, the dorsal sensory
branch of the ulnar nerve that overlies the medial aspect of the wrist can be
injured [10,
11]. However, we did not need
to reposition the needle because of excessive pain, and we found no clinical
evidence of painful neuroma at the site of injection at 4 months'
follow-up.
The procedure was completed in all patients. Slight repositioning of the
needle was required to reach the pisiform bone margin in seven patients (13%),
who were those on which the radiologists made their earliest attempts. This
repositioning reflects the learning curve for this procedure, because
repositioning of the needle was not necessary for the patients with severe
joint-space narrowing or osteophytes.
With extension of the wrist, the pisotriquetral joint space may be narrowed
(Figs. 3A,
3B, and
3C), especially in the presence
of osteoarthritis (Figs. 4A and
4B). With mild palmar flexion
of the wrist, the pisotriquetral joint space opens and introduction of the
needle is much easier. In this study, in cases of severe joint-space narrowing
or osteophytes (n = 4), direct access to the pisotriquetral joint
space proved to be difficult, and the needle was repositioned as necessary
toward the superior articular surface of the triquetral bone (Figs.
4A and
4B). However, in these four
cases, the procedure was successful on the first attempt. Direct access to the
superior recess can be chosen instead of targeting the pisotriquetral joint
space. However, this recess can be small, and in our experience, direct access
of the joint space is much easier, even in cases of severe joint-space
narrowing. This technique might be difficult in cases of adhesive capsulitis.
However, this condition is uncommon in the wrist
[12] and even more so in the
pisotriquetral joint.
In conclusion, direct arthrography of the pisotriquetral joint is safe,
simple, and effective. For intraarticular steroid injection of the
pisotriquetral joint, direct access of the pisotriquetral joint can be made
first to avoid unnecessary injection of the radiocarpal joint.
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Abstract
Introduction
