Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Reviews
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : TE01 - TE07 Full Version

MRI and MR Arthrography Imaging of the Pathologies of the Wrist: A Pictorial Essay


Published: December 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/59277.17323
Anjuna Reghunath, Dharmendra Kumar Singh, Anuj Aggarwal, Nikhil Babbar, Rahul Choudhary, Samar Surya

1. Senior Resident, Department of Radiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India. 2. Associate Professor, Department of Radiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India. 3. Senior Resident, Department of Radiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India. 4. Postgraduate Resident, Department of Radiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India. 5. Senior Resident, Department of Radiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India. 6. Senior Resident, Department of Radiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.

Correspondence Address :
Dharmendra Kumar Singh,
Associate Professor, Department of Radiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi-110029, India.
E-mail: dksinghrad@gmail.com

Abstract

Magnetic Resonance Imaging (MRI) has a special advantage over radiographs and Computed Tomography (CT) in evaluating an anatomically complex structure like wrist, owing to its excellent soft-tissue resolution and multiplanar imaging functionality. MR arthrography further improves the diagnostic value of MRI by virtue of its meticulous depiction of even small tears involving the Triangular Fibrocartilage Complex (TFCC), intrinsic and extrinsic ligaments of the wrist. This article focuses on the MRI and MR arthrography illustration of various traumatic as well as non traumatic pathologies affecting the wrist region and is mainly intended to educate the residents by comprehensively reviewing the imaging features of the major afflictions of this complex joint in a systematic fashion using checklists.

Keywords

Computed tomography, Multiplanar imaging, Triangular fibrocartilage complex

The MRI is pivotal in the assessment of internal derangement of joints and is the investigation of choice in the evaluation of soft tissue pathologies of the wrist (1). The most common indication for wrist MRI is acute, subacute, or chronic wrist pain (2). The major stabilising structure at the radiocarpal joint is TFCC (Table/Fig 1). MR arthrography is more effective in evaluating TFCC, intrinsic and extrinsic ligaments of the wrist, relative to conventional MRI (3). Information provided from MRI decides further management and the surgical approach (2). While intra-articular soft-tissue pathologies are mostly managed with arthroscopic surgery, osseous pathologies may necessitate treatment with open surgery (2).

The MRI of the wrist requires optimising imaging parameters, and the usage of a pain marker is highly recommended. A higher magnetic field strength (ideally 3T) allows for better contrast and spatial resolution to assess internal joint derangement (4). MR arthrography may be performed in two ways: direct, in which contrast cocktail is percutaneously injected into the target joints (radiocarpal, midcarpal, distal radioulnar joints), and indirect, in which standard gadolinium dose is injected intravenously and recruited to a specific joint via exercise-induced hyperemia (4). Dallaudière B et al., observed that axial traction in wrist arthrography using finger traps and a pulley system was advantageous to study intrinsic and extrinsic ligaments and cartilage but added no benefit in evaluating tendons or nerve disorders (3).

ANATOMY OF THE WRIST

A brief review of the anatomy of the wrist joint along with the illustration of TFCC and main ligaments on MRI (Table/Fig 1),(Table/Fig 2) and the significant pathologies afflicting the joint is enumerated in (Table/Fig 3) (2),(4),(5).

PATHOLOGIES OF THE WRIST

This pictorial review aims to cover some of the common pathologies involving the wrist.

TFCC injuries: Perforation of TFCC is a chronic process seen in the elderly population, where discontinuity is present, but the edges are regular, and there is an absence of marrow oedema and adjacent fluid. A tear is an acute traumatic condition where there is a discontinuity in TFCC with reactive synovitis, edge irregularity, and adjacent marrow changes (Table/Fig 4). However, there are no specific imaging characteristics to differentiate between traumatic and degenerative tears. Hyperintense signal within the TFCC disk proper without extension to the articular surface is considered mucoid degeneration (1). Palmer’s classification distinguishes TFCC tears into traumatic and degenerative (2) (Table/Fig 5),(Table/Fig 6).

Carpal instability: Mayo’s classification categorises carpal instability into four types. Type I results from intrinsic ligament injury (carpal instability dissociative), whereas Type II is due to extrinsic or radiocarpal ligament injury (carpal instability non dissociative). Type III is a combination of the first two (carpal instability complex), while Type IV is due to pathology outside the carpals or wrist (carpal instability adaptive) (5) (Table/Fig 7).

Distal Radioulnar Joint (DRUJ) instability: Dorsal dislocation of DRUJ is commoner than volar.The epicentre method is the most explicit and preferred method for evaluating DRUJ instability as it considers the normal translational movement of DRUJ (6) (Table/Fig 8).

Ligament tear: Dorsal Intercalated Segment Instability (DISI) deformity occurs due to a tear of the dorsal component of the scapholunate ligament, causing flexion of the scaphoid and extension of the lunate and triquetrum (7). However, injury to portions of the volar extrinsic ligaments or dorsal intercarpal ligaments may also lead to DISI. Volar Intercalated Segment Instability (VISI) occurs from tears of the volar component of the lunotriquetral ligament or tears of the dorsal radiocarpal ligaments (8). In both DISI and VISI, the capitolunate angle is >30°. In DISI, the scapholunate angle is >80°, whereas, in VISI, it is <30°.

Carpal dislocation: Perilunate dislocation is the most common carpal dislocation and may be associated with purely ligamentous injuries or carpal fractures. Both perilunate and lunate dislocations are a part of a spectrum of carpal instability, from least severe to most severe being scapholunate dissociation, perilunate dislocation, mid-carpal dislocation, and lunate dislocation. In perilunate dislocation, the relationship of lunate with radius is maintained, while the ligamentous attachments of lunate with scaphoid, capitate and triquetrum are affected (Table/Fig 9). Lunate dislocation occurs with dorsal radiolunate ligament injury. The lunate dislocates volarly, and the remaining carpal bones maintain their normal relationships with each other and with the radius (9).

Carpal fracture and osteonecrosis: The most common carpal bone to be fractured is the scaphoid. A single intraosseous artery enters the scaphoid at the waist and supplies the proximal pole in a retrograde manner. Proximal pole fractures can lead to osteonecrosis, which shows hypointense T1/T2 signal, fragmentation, and collapse (Table/Fig 10). There is a traditional 4-stage classification scheme of Scapholunate Advanced Collapse (SLAC) and Scaphoid Non union Advanced Collapse (SNAC) wrists (Table/Fig 11). Kienböck disease is the osteonecrosis of the lunate bone and has an association with negative ulnar variance (Table/Fig 12). According to Lichtman’s classification, the disease progresses in four stages (Table/Fig 13) (8).

Synovial pathologies: Inflammatory arthritis, infective synovitis, and pigmented villonodular synovitis (Table/Fig 14) are the most frequent synovial pathologies involving the wrist. Inflammatory arthritis commonly presents with synovial thickening and marrow oedema, and the most common site of involvement is the attachment site of the intrinsic ligaments. Typical imaging features in Rheumatoid Arthritis (RA) (Table/Fig 15) include active tenosynovitis (fluid in tendon sheath with enhancement), tendinopathy (thickening with heterogeneous high signal intensity on fluid sensitive sequences), ulnar styloid erosion and rice bodies in palmar bursa. Extensor tendon involvement is seen in 50-64%, with the Extensor Carpi Ulnaris (ECU) being the most frequently affected tendon in early disease (4). MRI can also detect the most crucial predictor of an aggressive disease course, inflammation within the bones (osteitis) (10).

The characteristic features of tuberculous infection of the wrist (Table/Fig 16) include synovial thickening and T2W hyperintensity around the joints and tendons, tenosynovitis, rice bodies which appear as small low-signal and non enhanced foci in the synovial fluid, bone erosion, osteomyelitis, and occasionally encasement of the median nerve. The imaging features are often indistinguishable from RA. However, unilaterality of wrist involvement points towards infective aetiology compared to the bilateral presentation in inflammatory arthritis like RA (11).

Soft tissue and bony pathologies: The common soft tissue tumours at the wrist are ganglion cysts, lipoma, haemangiomas, peripheral nerve sheath tumours (Table/Fig 17), neuromas (Table/Fig 18), Giant Cell Tumour (GCT) of tendon sheath (Table/Fig 19), synovial chondromatosis, undifferentiated pleomorphic sarcoma, and liposarcoma (12). Ganglion cysts are the most prevalent benign soft tissues of the wrist. Ganglia may be found in both the volar and dorsal periarticular region, associated with injured ligaments, or reveal intraosseous connection. They are typically T1 hypointense and hyperintense on fluid-sensitive sequences, and may be complex, with debris, loculations or septations (13). Complex Regional Pain Syndrome (CRPS) (Table/Fig 20), Brodie’s abscess (Table/Fig 21) and hypertrophic osteoarthropathy are often seen around wrist. CRPS has been classified into types 1 and 2 based on the absence or presence of an underlying nerve lesion, respectively. Among bony tumours, GCT (Table/Fig 22), aneurysmal bone cyst, parosteal osteosarcoma, epitheloid haemangioma of bone are typically seen in the wrist region (12).

Intersection syndromes: Distal intersection syndrome occurs at the crossing point of the third extensor compartment with the second (8) (Table/Fig 23). The involved tendons may be thickened, with or without altered intratendinous signal intensity, particularly at their intersection (8). The surrounding subcutaneous tissues, muscles, and bones may show oedema. Proximal intersection syndrome, which is more common than the distal syndrome, occurs nearly 4–8 cm proximal to the Lister tubercle, where the first extensor compartment crosses the second compartment. The MRI findings are comparable to those of distal intersection syndrome and comprise thickening, tendinosis and adjacent T2 signal hyperintensity due to tenosynovitis, with surrounding soft tissue oedema. Contrast-enhanced sequences may depict peritendinous enhancement (8).

Entrapment syndromes: MRI features in patients with Carpal Tunnel Syndrome (CTS) are T2 hyperintensity in the median nerve, nerve enlargement at the level of pisiform as compared to the level of DRUJ, and flattening at the level of the hamate (Table/Fig 23). Ng A et al., found that a nerve Circumferential Surface Area (CSA) of 15 mm2 proximal or distal to the tunnel could be used as a diagnostic criterion for CTS and 19 mm2 proximal to the tunnel as a marker of severe disease (14). CTS is commonly seen in patients with compressive tumours in the carpal tunnel, diabetes, hypothyroidism, and amyloidosis. Enhancement of the median nerve due to oedema may occur as well as thenar muscle atrophy in chronic cases (14).

Entrapment and enlargement of the ulnar nerve as it passes through Guyon’s canal (formed by the pisiform and the hamate) is called Guyon’s canal/ulnar tunnel syndrome. It is typically caused by handlebars and hence is also known as “handlebar palsy”. Fracture of the hook of hamate, compression from adjacent masses, ganglion cysts, anomalous muscles and tendons, fibrous palmar arch, ulnar artery aneurysm, repetitive trauma, osteoarthritis of the pisotriquetral joint, os hamuli proprium, and dislocation of the pisiform bone are the usual causes of this condition (15).

Discussion

The wrist is a highly complex anatomical region with various stabilising structures holding the carpal bones, metacarpals, distal radius, and ulna. Although high soft tissue spatial resolution MRI of the wrist at a 3T scanner obviates the necessity of MR arthrography in most situations, it is worthwhile to perform this invasive study in indeterminate cases to attain accurate interpretation. Disruption of either scapholunate or lunotriquetral ligaments will result in the communication of the radiocarpal compartment proximally with the midcarpal compartment distally (4). Hence, midcarpal contrast injection is done first in suspected injury to these ligaments. Contrast material seen in the DRUJ indicates disruption to the triangular fibrocartilage complex or distal radioulnar ligaments (4). Hence, contrast imbibtion in the DRUJ following a radiocarpal injection strongly suggests a TFCC tear or perforation in the appropriate clinical setting. Appreciating the location of pathology as intra-articular versus extra-articular and further narrowing down the origin of pain to soft tissue or osseous aetiology on MRI facilitates the surgical management approach. MRI and MR arthrography also helps in determining the extent and severity of the pathology and incorporation of the relevant surgical classification systems in the report aids in appropriate communication with the referring clinician.

However, judicious use of MRI is recommended for evaluation of wrist pain as observed in a retrospective review on patients aged 20–60 years, where MRI affected treatment recommendation of ligamentous injury in only 28% of patients (16). Another study on the clinical significance of wrist and hand MRI in 316 patients found that diagnosis remained unsolved in 24% of cases, although MRI played a role in reassuring the patient, obviating further follow-up in 70% of case (17). A study evaluating 307 wrists MRIs in a tertiary care paediatric hospital revealed that unexplained wrist pain was a common presentation in children and MRI helped in the delineation of a mass/cyst and detection of infection/ arthropathy (18). Advances in wrist imaging include quantitative assessment with T2 and T1 rho mapping, compresses sensing, and isotropic 3D imaging using driven equilibrium sequences, and parallel imaging, which promise better outcomes with patient management (19).

This pictorial review highlights the common wrist pathologies presenting to a tertiary hospital occupied with 3T MRI scanner and facility for fluoroscopic guided MR arthrography. In the author’s experience, the most common indication for MRI of the wrist is ulnar-sided wrist pain, which mostly results from TFCC tear. MR arthrography is reserved for cases with equivocal/suspicious findings in cases of trauma and it was observed that it provides optimal recognition of the location of TFCC or ligament tears. In authors experience, abnormalities afflicting the wrist on MRI may be predominantly classified as osseous, soft-tissue, and joint pathologies. Trauma was observed as the most common aetiology affecting this anatomical region, with soft-tissue injuries involving TFCC tendons, and ligaments recording the highest incidence. Other common soft tissue pathologies at this site were ganglion cysts, carpal tunnel syndrome, tenosynovitis, and tendinopathy. Fractures and avascular necrosis of scaphoid/lunate were more common osseous pathologies with respect to impingement/impaction syndromes or bony tumors. As far as joint pathologies were concerned, post-traumatic carpal and DRUJ dislocation were found to be more frequent than inflammatory/infective synovial conditions.

Conclusion

The MRI is a valuable modality to diagnostically assess the wrist with high-resolution and multiplanar imaging without employing ionising radiation. MR arthrography is particularly advantageous in the evaluation of TFCC and ligaments of the wrist. Knowledge of the intrinsic anatomy of the wrist and the MR appearances of common pathologies enables prompt detection and management of wrist pathologies.

References

1.
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DOI and Others

DOI: 10.7860/JCDR/2022/59277.17323

Date of Submission: Jul 24, 2022
Date of Peer Review: Aug 28, 2022
Date of Acceptance: Oct 19, 2022
Date of Publishing: Dec 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 25, 2022
• Manual Googling: Oct 01, 2022
• iThenticate Software: Oct 18, 2022 (11%)

ETYMOLOGY: Author Origin

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