January 2016, VOLUME 206
NUMBER 1

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January 2016, Volume 206, Number 1

Musculoskeletal Imaging

Original Research

Wrist Traction During MR Arthrography Improves Detection of Triangular Fibrocartilage Complex and Intrinsic Ligament Tears and Visibility of Articular Cartilage

+ Affiliation:
1All authors: Department of Imaging and Interventional Radiology, Prince of Wales Hospital, Chinese University of Hong Kong, Rm 2A061, 2/F, New Extension Block, 30-32 Ngan Shing St, Shatin, New Territories, Hong Kong, SAR.

Citation: American Journal of Roentgenology. 2016;206: 155-161. 10.2214/AJR.15.14948

ABSTRACT
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OBJECTIVE. The purpose of this study was to assess the effects of traction during MR arthrography of the wrist on joint space widening, cartilage visibility, and detection of tears of the triangular fibrocartilage complex (TFCC) and intrinsic ligaments.

SUBJECTS AND METHODS. A prospective study included 40 wrists in 39 patients (25 men, 14 women; mean age, 35 years). MR arthrography was performed with a 3-T MRI system with and without axial traction. Two radiologists independently measured wrist and carpal joint space widths and semiquantitatively graded articular cartilage visibility. Using conventional arthrography as the reference standard and working in consensus, they assessed for the presence of tears of the TFCC, lunotriquetral ligament (LTL), and scapholunate ligament (SLL). Visibility of a tear before traction was compared with visibility after traction.

RESULTS. With traction, all joint spaces in the wrist and carpus were significantly widened (change, 0.15–1.01 mm; all p < 0.006). Subjective cartilage visibility of all joint spaces improved after traction (all p ≤ 0.048) except for that of the radioscaphoid space, which was well visualized even before traction. Conventional arthrography depicted 24 TFCC tears, seven LTL tears, and three SLL tears. The accuracy of tear detection improved after traction for the TFCC (98% after traction vs 83% before traction), the LTL (100% vs 88%), and the SLL (100% vs 95%). Tear visibility improved after traction for 54% of TFCC tears, 71% of LTL tears, and 66% of SLL tears.

CONCLUSION. Wrist MR arthrography with axial traction significantly improved the visibility of articular cartilage and the detection and visibility of tears of the TFCC and intrinsic ligaments. The results favor more widespread use of traction during MR arthrography of the wrist.

Keywords: articular cartilage, intrinsic ligament, MR arthrography, triangular fibrocartilage complex, wrist traction

MRI is the main imaging modality used to diagnose abnormalities of the wrist joint, such as tears of the triangular fibrocartilaginous complex (TFCC) and the intrinsic ligaments and defects of articular cartilage. MRI has high accuracy for showing tears of the TFCC, moderate accuracy for intrinsic ligament tears, but only fair accuracy for showing articular cartilage defects [16]. The difficulty in detecting intrinsic ligament tears and cartilage defects is related to the thinness of articular cartilage, the curved articular and ligament contours, and the close apposition of the carpal bones [710]. Wrist arthroscopy and open surgery are used to repair TFCC and intrinsic ligament tears and cartilage defects [11, 12]. Accurate wrist imaging facilitates appropriate triage of patients for wrist arthroscopy and surgery [11, 12]. Refinements to conventional MRI of the wrist, such as the use of dedicated wrist coils, microscopy coils, dedicated high-resolution sequences, and MR arthrography, have improved visualization of the TFCC, intrinsic ligaments, and articular cartilage of the wrist [16, 13]. Although the overall diagnostic capability of MRI of the wrist is high, a small number of TFCC and intrinsic ligament tears and a larger number of cartilage defects are still overlooked, even in state-of-the-art MRI examinations [16].

In 2011, Guntern et al. [14] showed how traction of the wrist during MR arthrography widens the radiocarpal and lunocapitate spaces, facilitating visualization of articular cartilage. In 2013, Cerny et al. [15] further showed that MR arthrography with traction improved depiction of scapholunate ligament (SLL) and lunotriquetral ligament (LTL) tears. We undertook this MR arthrographic study to further investigate the effect of traction on joint space widening and cartilage visibility and on detection of tears of the TFCC and intrinsic ligaments.

Subjects and Methods
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This prospective study was approved by the local ethics review board. All patients provided signed informed consent.

Study Population

Forty wrists in 39 patients (25 men, 14 women; mean age, 35 years; range, 19–63 years) consecutively examined between November 2013 and August 2014 were referred for MR arthrography of the wrist. One patient underwent examinations of each wrist 2 weeks apart. All patients had wrist pain after contusion or sprain injury, and one of four orthopedic surgeons (8–20 years of experience) suspected the presence of TFCC or intrinsic ligament injury. All patients underwent conventional wrist arthrography followed immediately by MR arthrography with and without traction within 2 months of clinical assessment.

Wrist Arthrography

Three-compartment intraarticular injection of a gadolinium-based contrast agent (gadoterate meglumine, Dotarem, Guerbet) was performed by one of two musculoskeletal radiologists using fluoroscopic guidance and a dorsal approach. A 25-gauge needle was first advanced into the radiocarpal joint between the radius and scaphoid bones. The position of the needle tip was verified with a test injection of a small amount of iodinated contrast agent (iohexol, Omnipaque 300, GE Health-care). The MRI contrast mixture was 2 mL of gadoterate meglumine diluted in 200 mL of saline solution. After a satisfactory test injection, 3–5 mL was injected into the radiocarpal joint under fluoroscopic control. If communication with the midcarpal joint was present, an additional 3–5 mL was injected. With communication to both the midcarpal and the distal radioulnar joints, a further 2–3 mL was injected, making a total of 8–10 mL. If no communication was present, 3–5 mL of solute was subsequently injected into the midcarpal (inter-space between lunate, capitate, triquetrum bones) joints and 2–3 mL into the distal radioulnar joints.

MR Arthrography of the Wrist

MR arthrography was performed with a 3-T whole-body MRI system (Achieva TX series, Philips Healthcare) with a commercially available dedicated eight-channel wrist coil array (SENSE Wrist Coil 8, Philips Healthcare). The patient lay prone with the affected upper limb placed in a fully extended position over the head. The pronated wrist was positioned parallel to the long axis of the gantry. The wrist traction device was set up before MRI was performed (Fig. 1). Finger traps (TractionTower Extremity Traction Device, ConMed Linvatec) were applied to the index and ring fingers and connected to a preselected weight by a nonelastic cord routed over the edge of the MRI gantry table [14, 15]. All of the metal parts of the finger traps were removed so that the traps were MRI compatible. The weight used was 7 kg for men and 5 kg for women. MR images were acquired initially without traction and then with traction. The MRI sequences before and after traction are listed in Table 1. Overall mean time for MR arthrography with and without traction was 50 minutes, excluding the time for conventional arthrography. The sequences performed before traction took 30 minutes to complete. The sequences performed after traction took 15 minutes to complete. The time to set up the traction device was less than 5 minutes.

TABLE 1: MRI Sequences Before and After Wrist Traction
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Fig. 1A —Wrist traction device.

A, Photograph shows finger traps applied to index and ring fingers (white arrow). Black arrow indicates cord connecting traps to weight.

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Fig. 1B —Wrist traction device.

B, Photograph shows finger traps connected to weight (arrowhead) by nonelastic cord (arrow) routed through pulley system developed in-house.

Analysis of Conventional and MR Arthrographic Images

Three musculoskeletal radiologists with 18, 8, and 6 years of experience evaluated all of the fluoroscopic and MR images. All images were interpreted at a dedicated PACS workstation (Carestream Solutions version 11.0, Carestream Health). All images were zoomed, and the gray-scale contrast was adjusted to optimize visualization of the structures being assessed.

Joint space width—Two radiologists measured the minimum joint space width of the radioscaphoid, radiolunate, ulnolunate, ulnotriquetral, scaphocapitate, lunocapitate, lunohamate, triquetrohamate, lunate-TFCC, TFCC-LTL, and radius-SLL joints independently on intermediate-weighted coronal images before and after traction. Measurements of joint space width before and after traction were performed in the same sitting. One of the two radiologists repeated the same joint space width measurements 2 weeks later. The minimum space width was defined as the shortest distance between the opposing surfaces, that is, either opposing articular cartilage surface; between articular cartilage and the TFCC articular disk, SLL, or LTL; or between the TFCC articular disk and the LTL. If an intrinsic ligament or TFCC articular disk was torn or a cartilage defect was present, we estimated the expected location of the ligament or articular disk or cartilage using the residual ligament or articular disk or cartilage as a landmark [14, 15]. If the articular cartilage surface was poorly seen, we measured the shortest extent of contrast material contained within the joint space.

Visibility of articular cartilage—Two radiologists semiquantitatively graded the visibility of articular cartilage as good, intermediate, or poor by consensus. Good visibility was a clear articular contour with an unambiguously sharp outline; poor referred to lack of visibility of the articular cartilage contour; and intermediate referred to the contour's being visible but not sharply demarcated. Articular cartilage visibility at the radioscaphoid, radiolunate, scaphocapitate, lunocapitate, and triquetrohamate articulations was independently assessed.

Detection and visibility of triangular fibrocartilaginous complex and intrinsic ligament tears—Two radiologists determined the absence or presence of a full-thickness tear in the TFCC, LTL, and SLL using conventional arthrography as the reference standard. Conventional arthrography has high sensitivity and specificity for showing full-thickness TFCC and intrinsic ligament tears [5, 16, 17]. The criterion for a full-thickness TFCC or ligament tear on conventional arthrograms was contrast communication between the radiocarpal joint and the midcarpal joint or the distal radioulnar joint. The MRI criterion used for diagnosis of a full-thickness TFCC or ligament tear was visualization of a defect in the articular disk of the TFCC or intrinsic ligament with fluid continuity from one joint space to another. The final diagnosis of tear on MR images was reached by consensus. The MR images obtained before and after traction were read separately. The visibility of tears on MR images before and after traction was compared and graded as better, similar, or worse.

Statistical Analysis

All analyses were performed with SPSS software, version 20 (IBM-SPSS). All data were tested for normal distribution. The two-tailed paired t test was used to compare mean joint space widths before and after traction. Intraobserver and interobserver agreement of joint space width were calculated by intraclass correlation with the following criteria applied to the agreements: r > 0.8, excellent; 0.6–0.8, good; 0.4–0.6, moderate; 0.2–0.4, fair; < 0.2, poor. Differences in articular cartilage visibility before and after traction were calculated with the chi-square test. For all tests, p < 0.05 was regarded as statistically significant. Sensitivity, specificity, and accuracy of the different imaging modalities in the detection of SLL, LTL, and TFCC tears were calculated.

Results
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Conventional Arthrography

In eight of the 40 (20%) wrists examined, three-compartment arthrography showed no contrast leakage from the radiocarpal articulation into the distal radioulnar or midcarpal joints consistent with an intact TFCC, LTL, and SLL. In the other 32 wrists (80%), there was abnormal contrast leakage between the wrist compartments compatible with tears of the TFCC (24 of 40 wrists), LTL (seven of 40 wrists), and SLL (three of 40 wrists).

MR Arthrography

Joint space width—Joint width was calculated as the mean of both observers' measurements. With traction, the narrowest joint space width significantly increased (Table 2). Joint space widening was greatest at the radiolunate articulation. Both interobserver correlation (r = 0.61–0.74) and intraobserver correlation (r = 0.65–0.79) for measurement of narrowest joint space width were good.

TABLE 2: Comparison of Mean Narrowest Joint Space Width on MR Arthrograms Before and After Traction

Visibility of articular cartilage—Articular cartilage visibility improved with traction at all joint spaces except that at the radioscaphoid articulation (Table 3). Radioscaphoid cartilage visibility was good even before traction, so even though visibility improved with traction, the difference was not statistically significant. Articular cartilage visibility was most increased at the intercarpal joint spaces, followed by the radiolunate joint space. Figure 2 shows improvement in cartilage visibility after traction.

TABLE 3: Comparison of Visibility of Articular Cartilage at Different Joint Spaces Before and After Traction
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Fig. 2 —35-year-old man with wrist pain. Coronal intermediate-weighted MR arthrograms without (left) and with (right) traction show that after traction, cartilage visibility at radioscaphoid, radiolunate, scaphocapitate, lunocapitate, and lunohamate intervals improved from intermediate to good. Cartilage visibility at triquetralhamate interval did not and was graded as poor. Small full-thickness central articular disk tear of triangular fibrocartilage complex (arrow) is better shown in before traction image than in after traction image because image after traction is only slice away from tear.

Detection of triangular fibrocartilage complex and intrinsic ligament tears—Twenty-four TFCC tears, seven LTL tears, and three SLL tears were detected with conventional arthrography. Of these, 20 TFCC tears, four LTL tears, and two SLL tears were detected with MR arthrography without traction, and 23 TFCC tears, seven LTL tears, and three SLL tears were detected with MR arthrography with traction. The sensitivity, specificity, and accuracy of detecting TFCC, LTL, and SLL tears before and after traction are shown in Table 4, as are the numbers of true-positive, true-negative, false-positive, and false-negative findings. Before traction, four TFCC tears, three LTL tears, and one SLL tear were missed at MR arthrography. After traction, all but one TFCC tear were visible at MR arthrography. Three TFCC tears, two LTL tears, and one SLL tear were false-positive findings at MR arthrography before traction, and all were correctly diagnosed at MR arthrography after traction. Thus, the accuracy of MR arthrography for detecting a tear improved after traction from 83% to 98% for TFCC tear, from 88% to 100% for LTL tear, and from 95% to 100% for SLL tear. Figures 3 and 4 show examples of false-negative and false-positive TFCC tear findings before traction. Figures 5 and 6 show examples of false-negative SLL and LTL tear findings before traction.

TABLE 4: Diagnostic Performance of MR Arthrography in Detection of Ligament Tears Before and After Traction
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Fig. 3 —29-year-old woman with wrist pain. Coronal intermediate-weighted MR arthrograms without (left) and with (right) traction show that before traction, there is focal increase in signal intensity of articular disk near radial attachment (black arrow), suggesting mucoid degeneration. After traction, full-thickness tear (white arrow) of articular disk is clearly evident. Conventional arthrographic findings confirmed presence of full-thickness tear of articular disk near radial attachment.

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Fig. 4 —29-year-old man with wrist pain. Coronal intermediate-weighted MR arthrograms without (left) and with (right) traction show that before traction, there is suspected tear of articular disk at radial attachment (black arrow). After traction, articular disk is intact though severely thinned (white arrow). Conventional arthrography showed no tear of articular disk and no contrast material communicating between radiocarpal and distal radioulnar joint spaces.

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Fig. 5 —31-year-old woman with wrist pain. Coronal intermediate-weighted MR arthrograms without (left) and with (right) traction show that before traction, appearances are consistent with partial-thickness tear (black arrow) of membranous fibers of scapholunate ligament (SLL). After traction, full-thickness tear of SLL (white arrow) is clearly evident. Conventional arthrography showed tear of SLL with contrast leakage from radiocarpal to midcarpal joint space.

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Fig. 6 —30-year-old man with wrist pain. Coronal intermediate-weighted MR arthrograms without (left) and with (right) traction show that before traction, there is no tear (black arrow) in membranous fibers of lunotriquetral ligament (LTL). After traction, LTL tear is clearly evident close to triquetrum (white arrow). Conventional arthrographic findings confirmed tear in LTL with contrast material leaking from radiocarpal to midcarpal joint space. Small avulsion tear of articular disk at radial attachment (arrowheads) also is present.

Visibility of triangular fibrocartilage complex and intrinsic ligament tears—Tear visibility was graded as better for 13 of 24 (54%) TFCC tears, five of seven (71%) LTL tears, and two of three (67%) SLL tears. Only one of the 24 (4%) TFCC tears was graded as having worse visibility after traction. The visibility of the other TFCC, LTL, and SLL tears was graded as similar before and after traction.

Wrist arthroscopy—Six of the 40 patients underwent wrist arthroscopy after MR arthrography (mean, 65 days; range, 15–120 days). These arthroscopic examinations revealed a total of five TFCC tears, two SLL tears, and one LTL tear. All except one, a TFCC tear, of these tears was seen with MR arthrography without traction, and all tears were correctly identified with traction MR arthrography.

Discussion
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Nonarthrographic CT of carpal bone position before and after axial wrist traction has shown how wrist traction results in widening of the radiocarpal and lunocapitate joint spaces, dorsal displacement of almost all of the carpal bones, slight extension of the scaphoid, and radial translation of the lunate and triquetrum [18]. Other than scaphoid extension, little rotation of the carpal bones occurs with axial wrist traction [18].

Our study validates and builds on the findings of two MR arthrographic studies from one institution investigating the benefit of wrist traction [14, 15]. Guntern et al. [14] found a statistically significant increase in radioscaphoid, radiolunate, and lunocapitate spaces after traction, and Cerny et al. [15] found a statistically significant increase in the scapholunate space after traction. In the current study, we confirmed that wrist traction widened the joint spaces of the radiocarpal, ulnocarpal, and intercarpal articulations [15]. Joint space widening was most pronounced at the radiolunate joint, followed by the radioscaphoid and intercarpal joint space, and was least noticeable at the ulnocarpal joint space. Judging from the large variation in the degree of joint space widening that occurs with wrist traction across the study cohort, one can appreciate that there is considerable individual variation in response to axial traction [18]. This variation was apparent in both sexes, though it is recognized that the wrists of women tend to distract with traction more than the wrists of men do [18]. This difference may be related to increased intrinsic ligament laxity or reduced muscle contraction [19].

Determining articular cartilage status is an important aspect of MRI examinations of the wrist [9, 10]. We found that cartilage visibility at nearly all joints improved considerably after wrist traction. This improvement in cartilage visibility paralleled the increase in joint space widening, being most pronounced in the intercarpal joints, less pronounced at the radiolunate joint space, and least pronounced at the radioscaphoid joint space. The perceived lack of improvement in radioscaphoid articular cartilage visibility reflected good visibility of this articular cartilage even before traction, so that even though some improvement in visibility was found after traction, the difference did not reach statistical significance for this particular joint.

TFCC and intrinsic ligament tears are another common pathologic finding during MRI examinations of the wrist. Cerny et al. [15] in a study of 20 patients identified one additional SLL and two additional LTL tears but no additional TFCC tears after wrist traction. The TFCC and intrinsic ligaments were not assessed in the study by Guntern et al. [14]. Our study of 40 patients showed that wrist traction allowed detection of one additional SLL tear, two additional LTL tears, and three additional TFCC tears.

The accuracy of nontraction MR arthrography for detecting TFCC and intrinsic ligament tears was 83% for TFCC tears and 88–95% for intrinsic ligament tears. These results are similar to those reported for other studies of nontraction MR arthrography [16]. Eight of the 34 (24%) tears (24 TFCC tears, 10 intrinsic ligament tears) visualized with conventional arthrography were not seen with nontraction MR arthrography. Use of traction for MR arthrography markedly improved the detection of TFCC and intrinsic ligament tears. The sensitivity of detection of tears of intrinsic ligaments was particularly increased, from 57% to 100% for the LTL and from 66% to 100% for the SLL. Only one of the 34 (3%) tears (a single TFCC tear) was not detected with traction MR arthrography. Use of traction MR arthrography was associated with statistically significant improvement in detection of both TFCC and intrinsic ligament tears with accuracy of 98% for TFCC tears and 100% for intrinsic ligament tears. Not only did tear detection significantly improve, but also more than one-half of TFCC tears and more than two-thirds of intrinsic ligament tears were better seen after traction. Although not specifically tested in this study, this improved visibility should translate into improved diagnostic confidence for reporting TFCC and intrinsic ligament tears in clinical practice.

The significantly increased detection of both TFCC and intrinsic ligament tears with traction and increased visibility of these tears most likely results from increased distraction of the ulnolunate, lunate-TFCC, scapholunate, and lunotriquetral joints, leading to widening of these tears and increased conspicuity as a result. In this study, MR arthrography was performed both with and without traction. In all cases, nontraction MR arthrography was performed first to ensure that image quality would not be compromised by reabsorption of contrast material. In only one isolated situation was visibility of a TFCC tear better without traction than with it. In all other instances, traction MR arthrography preformed either better than or similar to nontraction MR arthrography for cartilage visibility and for detection and visibility of TFCC and intrinsic ligament tears. These findings suggest that radiologists should consider using traction MR arthrography as a stand-alone investigation when performing MR arthrography of the wrist. The same sequence protocol as for nontraction MRI can be applied. The main concerns are likely to be the lack of availability of the traction device, time efficiency, and the possibility of patient discomfort or harm.

The traction device was easy to set up and took less than 5 minutes to apply. No dedicated equipment other than the readily available customized (i.e., MRI compatible) finger traps is necessary. The traction weight is simply suspended from the edge of the MRI gantry table. No undue discomfort, movement, or other artifact was induced by traction. The traction force used in the current study was well tolerated by all patients, who were referred for investigation of wrist pain associated with clinically suspected TFCC or intrinsic ligament injury. No patient reported discomfort during MRI acquisition and no MRI examination had to be interrupted or prematurely terminated because of discomfort.

We used a traction force of 7 kg for men and 5 kg for women, which is comparable to the 4- to 7-kg traction force used during wrist arthroscopy [20] and much less than the 10-kg traction force used by Leventhal et al. [18] in a CT study but greater than the 3-to 4-kg traction force used in previous MR arthrography studies [14, 15]. Manual axial traction has been used previously to separate the wrist joint before application of traction weight to maintain the separation [14, 15, 19]. We did not use the previously described manual axial traction but chose to use slightly heavier weights of 5–7 kg because this is the weight our orthopedic surgeons routinely use during wrist arthroscopy. Traction is widely applied during wrist arthroscopy, and to our knowledge, no complications of wrist traction have been reported [14, 15, 18]. Only a few traction MRI and CT studies have been performed [14, 15, 18], and no complications have been reported to date.

There were limitations to this study. First, we did not specifically evaluate the level of discomfort patients felt during traction. Before imaging, all patients did receive instructions to report any discomfort during the MRI examination. No patient, however, reported discomfort, and no MRI examination was halted prematurely owing to discomfort. Second, although all 40 patients were referred by experienced hand surgeons, only six patients subsequently underwent arthroscopy. This low rate of arthroscopic referral was also a finding of the other two studies on this subject [14, 15]. In the current study, we used conventional arthrography as an alternative reference standard. Arthrography is accurate for revealing full-thickness TFCC and intrinsic ligament tears but is not accurate at revealing cartilage defects and partial-thickness ligament tears [9, 10]. Hence, we report on cartilage visibility and not cartilage defects or partial-thickness ligament tears. Third, although 40 wrists were included in the study, the prevalence of LTL and SLL tears was small. Nevertheless, the results of this study were encouraging because all intrinsic ligament tears not seen with standard nontraction MR arthrography were seen after application of traction, and most of the tears seen with nontraction MR arthrography were better seen with traction. Finally, we evaluated the benefit of traction during MR arthrography and did not address whether a similar benefit would be found with standard nonarthrographic MRI of the wrist.

Conclusion
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The results of this study confirm that the use of traction in MR arthrography of the wrist widens all wrist and intercarpal joint spaces with unequivocal improvement in articular cartilage visibility and in the detection and visibility of tears of the TFCC and intrinsic ligaments. These findings validate the results of previous studies. After application of traction, the accuracy of MR arthrography for detection of TFCC tears improved to 98% and of intrinsic ligament tears to 100%. No clinical limitation to the use of traction was identified. We encourage the more widespread use of axial traction during MR arthrography of the wrist.

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