- Email: [email protected]
Magnetic Resonance Arthrography of the Wrist: Case Presentation and Discussion
Magnetic Resonance Arthrography of the Wrist: Case Presentation and Discussion Kimberly K. Amrami, MD From the Department of Radiology, Mayo Clinic, Rochester, Minnesota.
42-year-old woman had a complaint of chronic wrist pain that resulted in limitations of her activities of daily living. On physical examination, she had diffuse tenderness with focal pain at the ulnar aspect of the wrist on deep palpation. There was no instability at the distal radioulnar joint. Radiographs were normal (Fig. 1). Conventional magnetic resonance imaging (MRI) showed a tear in the central disk of the triangular fibrocartilage complex (TFCC), but a tear in the scapholunate ligament could not be confirmed (Fig. 2). MRI performed after injection of dilute gadolinium into the radiocarpal joint confirmed the tear in the TFCC and also demonstrated a tear in the scapholunate ligament with a narrow tail of contrast seen going from the tear to the midcarpal compartment (Fig. 3). The findings were confirmed with arthroscopy. Direct magnetic resonance arthrography (MRA) combines the strengths of conventional arthrography
A
Figure 1. Normal posteroanterior radiograph of the wrist. Note position in radial deviation.
with the advantages of standard magnetic resonance imaging.1,2 Although conventional arthrography remains the reference standard for tears of the intrinsic carpal ligaments and triangular fibrocartilage complex, it is inadequate for visualizing intrasubstance tears, cartilage, and soft tissues.1 Conventional arthrography is often a dynamic test, with real-time visualization of the flow of contrast and bony relationships with motion. MRI, on the other hand, is generally a static test usually performed with the patient’s wrist in fixed pronation or supination. The ability to combine these two imaging modalities has the potential to be very powerful in assessing structures that are generally not well seen in the normal, nondistended joint even on cross-sectional imaging. Conventional arthrography has long been considered the imaging gold standard, and yet a study by Weiss et al3 found only 56% sensitivity and 60%
Figure 2. Coronal T2-weighted fast spin echo image with fat suppression of the wrist shows a tear in the TFCC and indeterminate increased signal in the scapholunate interosseous ligament (arrow). On this image, the bright signal is nonspecific fluid.
The Journal of Hand Surgery
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The Journal of Hand Surgery / Vol. 31A No. 4 April 2006
accuracy for scapholunate, lunotriquetral, and TFCC tears at triple-injection cinearthrography when compared with arthroscopic findings. Specificity was somewhat better, at 80%, but Weiss noted that there were several patients in the study who had massive disruptions of the scapholunate ligament with negative arthrographic findings. Weiss concluded that a positive finding at arthrography was very accurate for the presence of a lesion but that negative findings were not conclusive. The patients in Weiss’s study were young—the average age was 36, and all had wrist pain referable to ligamentous disruptions. A study of 462 three-compartment arthrograms with 226 intercompartmental defects showed no positive association with symptoms regardless of whether the defects were uni- or bidirectional, concluding that there is little clinical importance to findings at arthrography and questioning the diagnostic value and reliability of the test.4,5 The authors of these two papers suggested that the frequency of perforations unrelated to clinical symptoms may be an age-related phenomenon that severely limits the value of wrist arthrography. In another study of asymptomatic young adults 27% of cases showed abnormal communications after single-compartment injection, suggesting that the interpretation of arthrography even in young patients may be confounded by significant normal variation.6 In addition to these limitations,
Figure 3. Coronal T1-weighted image with fat suppression and intra-articular gadolinium shows contrast extending to the midcarpal compartment from a tear in the scapholunate ligament (arrow). On this image, the bright signal is intraarticular gadolinium.
which are considerable, conventional arthrography lacks information about soft tissues, cartilage, and incompletely torn ligaments; at its best it only shows full-thickness tears. Based on the work by Weiss et al,3 even technically well-performed wrist arthrography may fail to demonstrate directional or partial tears. Unenhanced MRI of the wrist has also been used to evaluate the carpal ligaments, both intrinsic and extrinsic. Accuracy for lesions in the TFCC has been shown to be very high with a sensitivity of 100%, specificity of 90%, and an accuracy of 97% in the hands of experienced orthopedic radiologists using specialized techniques.7 A study comparing enhanced to unenhanced MRI of the wrist for ligament tears confirmed at multiportal arthroscopy showed good visualization of all ligaments on 10% of the unenhanced images and 90% with intra-articular gadolinium present, for an overall sensitivity of 81% without contrast and 97% with contrast.8 A more recent study showed visualization of defects in the scapholunate ligament with high diagnostic confidence in only 42% of cases with a sensitivity and specificity of only 52% and 34%, respectively, using arthroscopy as a gold standard.9 As with arthrography, the effects of age confound results, as intrasubstance degeneration or redundancy within a ligament may be hard to distinguish from a tear and may lead to the low specificity observed in all of these
Figure 4. Coronal T1-weighted image of the wrist with fat suppression shows bright gadolinium in the scapholunate interval indicating a tear after radiocarpal injection of contrast.
Amrami / Magnetic Resonance Arthrography of the Wrist
studies. The only truly sensitive sign of a carpal ligament tear on an unenhanced MRI is fluid within a visualized gap in the ligament, and this depends on having enough intra-articular fluid to distend the joint and no redundancy or overlap in the ligament. Fluid may be present in each of the wrist’s three compartments without meaning that a tear is present–secondary signs such as these are not generally helpful. MRA combines the advantages of conventional arthrography with the ability to directly visualize structures on magnetic resonance imaging (MRI).1,2 The sum is actually greater than the parts because of the joint distension afforded by the contrast injection, which allows for better visualization of ligament tears as well as cartilage irregularity and defects that otherwise might be difficult to see. When the intraarticular injection of contrast is done with the addition of iodinated contrast under fluoroscopic control, the effect is even greater, using real-time visualization of contrast flow through tears and between compartments. The sensitivity, specificity, and accuracy of carpal ligament tears using MRA has been reported to be as high as 90% and as low as 65%, still appreciably better than either unenhanced MRI or conventional arthrography alone.8 –10 The best results are consistently seen with scapholunate interosseous ligament tears, where the combination of intra-articular contrast and joint distension leads to a sensitivity and specificity of 90% and 87%, respectively compared with arthroscopy as a gold standard.8 A study by Zanetti et al used two- or three-compartment arthrography and reported sensitivity for TFCC tears of 85% with specificity of 94% even using relatively thick sections (2 to 3 mm) and a very large field of view (17 to 20 cm).10 The worst results in all studies were for the lunotriquetral ligament on both enhanced and unenhanced studies with only 62% to 69% sensitivity.8,10 The extrinsic ligaments remain problematic, but very high-resolution imaging using three-dimensional techniques is promising (though not ready for application in clinical practice). As with conventional arthrography, there is some controversy regarding single- versus multiple-compartment injections. Proponents of triplecompartment injections claim the highest degree of sensitivity and specificity,10 but interpretation of multicompartment injections on the static MRI images obtained after arthrography is complex, as no “subtraction” techniques are available; it can be difficult to sort out which ligaments are completely or partially torn and what the direction of contrast
671
flow has been. Single-compartment arthrography is more definitive: if the injection was performed via the radiocarpal joint, and if there is contrast in the distal radioulnar joint, the presence of a tear is not equivocal. Some authors have advocated performing a single injection in the most clinically relevant compartment and then adding additional injections if a tear is not seen on the conventional arthrogram preceding MRI examination. Each technique has its proponents and advantages. I prefer a singlecompartment injection planned with the referring surgeon, consistent with the conclusions of Mann et al11 that the first injection of three-compartment arthrography shows unidirectional communications to best effect. The technique of MRA relies on the availability of fluoroscopy and MRI in close proximity. Some practitioners have suggested performing the joint injection under MRI guidance using either open- or closed-bore systems, but this a is time-consuming and awkward method compared with conventional arthrography. The patient is brought to the fluoroscopy suite and is prepared in the usual fashion. Although the use of gadolinium for intra-articular injections is not specifically approved by the Food and Drug Administration in its list of indications, it has been used for many years as a safe, off-label application. The mixture of gadolinium, saline, and iodinated contrast has been shown to be safe with no appreciable dissociation of the gadolinium from its chelate.12 There is no affect of iodinated contrast on the T1 shortening of gadolinium, which gives it its characteristic bright signal on T1-weighted imaging. Some operators prefer to inject iodinated contrast alone after placing the needle in the joint space; with this technique, if the initial needle positioning is not correct, it can be repositioned without leaving telltale signs of gadolinium outside of the joint. The dilute gadolinium is injected after intra-articular needle position is confirmed. Other operators prefer to combine saline, iodinated contrast, and gadolinium in a single injection.1 Dilute gadolinium is injected at a concentration of 1:200 to 1:250, usually by mixing 0.1 mL of gadopentate dimeglumine in 20 mL of either straight saline or a mixture of saline and iodinated contrast to achieve a concentration of the gadolinium of 2 mmol/L.1,2 At this concentration, gadolinium is bright on T1-weighed images (Fig. 4). Care must be taken to maintain this low concentration because if there is too much gadolinium in the mixture, the result can be a complete loss of
672
The Journal of Hand Surgery / Vol. 31A No. 4 April 2006
signal. After the arthrogram is completed, the patient is brought to the MRI suite as soon as possible in order to image while the joint is still distended. As with all MRI scans, technique is very important to optimize resolution. It is possible to perform MRA using low-field systems or dedicated extremity magnets, but in general it is preferable to perform these exams on at least a 1.0T system. On fluid-sensitive sequences, the dilute intra-articular gadolinium will signal similar to joint fluid, and it cannot be distinguished from normal joint fluid. The key sequence for visualizing the gadolinium is a T1-weighed sequence with fat suppression, which can be achieved using either a spin echo, a fast spin echo, or a gradient echo technique. Some authors have advocated high-resolution three-dimensional gradient echo techniques and have even shown arthroscopic flythrough projections that can be done using custom software,13 but the basics of wrist MRI remain important. The use of a dedicated wrist coil, the smallest possible field of view, the highest spatial resolution, and optimum signal-to-noise ratio are critical for successful MRA. The cost of the examination is usually similar to a contrast-enhanced MRI; the cost of the fluoroscopically guided injection may or may not be included in the charge. The indications for MRA of the wrist are evolving. At the current time, the technique is best used in young patients with indeterminate physical examinations and normal radiography in whom intrinsic ligament or TFCC tears are suspected in order to assist decision making regarding the performance of arthroscopy. It is particularly helpful when scapholunate ligament tears are suspected clinically but static and motion series radiographs are normal. It is also a helpful technique to use for patients who have other types of joint pathology and may have multiple problems contributing to pain, and where MRA will show both the ligament tears and other findings such as chondromalacia, ulnar impaction, and early degenerative joint disease. With appropriate technique, MRA can provide more information than either conventional arthrography or unenhanced MRI either alone or in combination. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Corresponding author: Kimberly K. Amrami, MD, Department of Radiology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905; e-mail: [email protected]. Copyright © 2006 by the American Society for Surgery of the Hand 0363-5023/06/31A04-0024$32.00/0 doi:10.1016/j.jhsa.2006.03.015
References 1. Steinbach LS, Palmer WWE, Schweitzer ME. Special focus session. MR arthrography. Radiographics 2002;22:1223– 1246. 2. Elentuck D, Palmer WE. Direct magnetic resonance arthrography. Eur Radiol 2004;14:1956 –1967. 3. Weiss AC, Akelman E, Lambiase R. Comparison of the findings of triple-injection cinearthrography of the wrist with those of arthroscopy. J Bone Joint Surg 1996;78-A(3):348 – 356. 4. Metz VM, Mann FA, Gilula LA. Lack of correlation between site of wrist pain and location of non-communicating defects shown by three-compartment wrist arthrography. AJR 1993;160(6):1239 –1243. 5. Metz VM, Mann FA, Gilula LA. Three-compartment wrist arthrography: correlation of pain site with location of uni and bidirectional communications. AJR 1993;160(4):819 – 822. 6. Kirschenbaum D, Sieler S, Solonick D, Loeb DM. Cody RP. Arthrography of the wrist. Assessment of the integrity of the ligaments in young asymptomatic adults. J Bone Joint Surg 1995;77-A(8):1207–1209. 7. Potter HG, Asnisernberg L, Weiland AJ, Hotchkiss RN, Peterson MGE, McCormack RR. The utility of high resolution magnetic resonance imaging in the evaluation of the triangular fibrocartilage complex of the wrist. J Bone Joint Surg 1997;79-A:1675–1684. 8. Scheck RJ, Romagnolo A, Hierner R, Pfluger T, Wilhelm K, Hahn K. The carpal ligaments in MR arthrography of the wrist: correlation with standard MRI and wrist arthroscopy. J Magn Resonance 1999;9:468 – 474. 9. Scheck RJ, Kubitzek C, Hiener R, Szeimies U, Pfluger T, Wilhelm K, Hahn K. The scapholunate interosseous ligament in MR arthrography of the wrist: correlation with non-enhanced MRI and wrist arthroscopy. Skeletal Radiol 1997;26:263–271. 10. Zanetti M, Bram J, Hodler J. Triangular fibrocartilage and intercarpal ligaments of the wrist: does MR arthrography improve standard MRI? J Magn Resonance 1997;7(3):590 – 594. 11. Mann FA, Wildon AJ, Gilula LA. Triple-injection wrist arthrography: unidirectional communications are due to technical factors. J Hand Surg (Am) 1998;23(1):82– 88. 12. Brown RR, Clarke DW, Daffner RH. Is mixture of gadolinium and iodinated contrast material safe during MR arthropgraphy? AJR 2000;175:1087–1090. 13. Sahin G, Dogan BE, Demirtas M. Virtual MR arthroscopy of the wrist joint: a new intraarticular perspective. Skeletal Radiol 2004;33:9 –14.
42-year-old woman had a complaint of chronic wrist pain that resulted in limitations of her activities of daily living. On physical examination, she had diffuse tenderness with focal pain at the ulnar aspect of the wrist on deep palpation. There was no instability at the distal radioulnar joint. Radiographs were normal (Fig. 1). Conventional magnetic resonance imaging (MRI) showed a tear in the central disk of the triangular fibrocartilage complex (TFCC), but a tear in the scapholunate ligament could not be confirmed (Fig. 2). MRI performed after injection of dilute gadolinium into the radiocarpal joint confirmed the tear in the TFCC and also demonstrated a tear in the scapholunate ligament with a narrow tail of contrast seen going from the tear to the midcarpal compartment (Fig. 3). The findings were confirmed with arthroscopy. Direct magnetic resonance arthrography (MRA) combines the strengths of conventional arthrography
A
Figure 1. Normal posteroanterior radiograph of the wrist. Note position in radial deviation.
with the advantages of standard magnetic resonance imaging.1,2 Although conventional arthrography remains the reference standard for tears of the intrinsic carpal ligaments and triangular fibrocartilage complex, it is inadequate for visualizing intrasubstance tears, cartilage, and soft tissues.1 Conventional arthrography is often a dynamic test, with real-time visualization of the flow of contrast and bony relationships with motion. MRI, on the other hand, is generally a static test usually performed with the patient’s wrist in fixed pronation or supination. The ability to combine these two imaging modalities has the potential to be very powerful in assessing structures that are generally not well seen in the normal, nondistended joint even on cross-sectional imaging. Conventional arthrography has long been considered the imaging gold standard, and yet a study by Weiss et al3 found only 56% sensitivity and 60%
Figure 2. Coronal T2-weighted fast spin echo image with fat suppression of the wrist shows a tear in the TFCC and indeterminate increased signal in the scapholunate interosseous ligament (arrow). On this image, the bright signal is nonspecific fluid.
The Journal of Hand Surgery
669
670
The Journal of Hand Surgery / Vol. 31A No. 4 April 2006
accuracy for scapholunate, lunotriquetral, and TFCC tears at triple-injection cinearthrography when compared with arthroscopic findings. Specificity was somewhat better, at 80%, but Weiss noted that there were several patients in the study who had massive disruptions of the scapholunate ligament with negative arthrographic findings. Weiss concluded that a positive finding at arthrography was very accurate for the presence of a lesion but that negative findings were not conclusive. The patients in Weiss’s study were young—the average age was 36, and all had wrist pain referable to ligamentous disruptions. A study of 462 three-compartment arthrograms with 226 intercompartmental defects showed no positive association with symptoms regardless of whether the defects were uni- or bidirectional, concluding that there is little clinical importance to findings at arthrography and questioning the diagnostic value and reliability of the test.4,5 The authors of these two papers suggested that the frequency of perforations unrelated to clinical symptoms may be an age-related phenomenon that severely limits the value of wrist arthrography. In another study of asymptomatic young adults 27% of cases showed abnormal communications after single-compartment injection, suggesting that the interpretation of arthrography even in young patients may be confounded by significant normal variation.6 In addition to these limitations,
Figure 3. Coronal T1-weighted image with fat suppression and intra-articular gadolinium shows contrast extending to the midcarpal compartment from a tear in the scapholunate ligament (arrow). On this image, the bright signal is intraarticular gadolinium.
which are considerable, conventional arthrography lacks information about soft tissues, cartilage, and incompletely torn ligaments; at its best it only shows full-thickness tears. Based on the work by Weiss et al,3 even technically well-performed wrist arthrography may fail to demonstrate directional or partial tears. Unenhanced MRI of the wrist has also been used to evaluate the carpal ligaments, both intrinsic and extrinsic. Accuracy for lesions in the TFCC has been shown to be very high with a sensitivity of 100%, specificity of 90%, and an accuracy of 97% in the hands of experienced orthopedic radiologists using specialized techniques.7 A study comparing enhanced to unenhanced MRI of the wrist for ligament tears confirmed at multiportal arthroscopy showed good visualization of all ligaments on 10% of the unenhanced images and 90% with intra-articular gadolinium present, for an overall sensitivity of 81% without contrast and 97% with contrast.8 A more recent study showed visualization of defects in the scapholunate ligament with high diagnostic confidence in only 42% of cases with a sensitivity and specificity of only 52% and 34%, respectively, using arthroscopy as a gold standard.9 As with arthrography, the effects of age confound results, as intrasubstance degeneration or redundancy within a ligament may be hard to distinguish from a tear and may lead to the low specificity observed in all of these
Figure 4. Coronal T1-weighted image of the wrist with fat suppression shows bright gadolinium in the scapholunate interval indicating a tear after radiocarpal injection of contrast.
Amrami / Magnetic Resonance Arthrography of the Wrist
studies. The only truly sensitive sign of a carpal ligament tear on an unenhanced MRI is fluid within a visualized gap in the ligament, and this depends on having enough intra-articular fluid to distend the joint and no redundancy or overlap in the ligament. Fluid may be present in each of the wrist’s three compartments without meaning that a tear is present–secondary signs such as these are not generally helpful. MRA combines the advantages of conventional arthrography with the ability to directly visualize structures on magnetic resonance imaging (MRI).1,2 The sum is actually greater than the parts because of the joint distension afforded by the contrast injection, which allows for better visualization of ligament tears as well as cartilage irregularity and defects that otherwise might be difficult to see. When the intraarticular injection of contrast is done with the addition of iodinated contrast under fluoroscopic control, the effect is even greater, using real-time visualization of contrast flow through tears and between compartments. The sensitivity, specificity, and accuracy of carpal ligament tears using MRA has been reported to be as high as 90% and as low as 65%, still appreciably better than either unenhanced MRI or conventional arthrography alone.8 –10 The best results are consistently seen with scapholunate interosseous ligament tears, where the combination of intra-articular contrast and joint distension leads to a sensitivity and specificity of 90% and 87%, respectively compared with arthroscopy as a gold standard.8 A study by Zanetti et al used two- or three-compartment arthrography and reported sensitivity for TFCC tears of 85% with specificity of 94% even using relatively thick sections (2 to 3 mm) and a very large field of view (17 to 20 cm).10 The worst results in all studies were for the lunotriquetral ligament on both enhanced and unenhanced studies with only 62% to 69% sensitivity.8,10 The extrinsic ligaments remain problematic, but very high-resolution imaging using three-dimensional techniques is promising (though not ready for application in clinical practice). As with conventional arthrography, there is some controversy regarding single- versus multiple-compartment injections. Proponents of triplecompartment injections claim the highest degree of sensitivity and specificity,10 but interpretation of multicompartment injections on the static MRI images obtained after arthrography is complex, as no “subtraction” techniques are available; it can be difficult to sort out which ligaments are completely or partially torn and what the direction of contrast
671
flow has been. Single-compartment arthrography is more definitive: if the injection was performed via the radiocarpal joint, and if there is contrast in the distal radioulnar joint, the presence of a tear is not equivocal. Some authors have advocated performing a single injection in the most clinically relevant compartment and then adding additional injections if a tear is not seen on the conventional arthrogram preceding MRI examination. Each technique has its proponents and advantages. I prefer a singlecompartment injection planned with the referring surgeon, consistent with the conclusions of Mann et al11 that the first injection of three-compartment arthrography shows unidirectional communications to best effect. The technique of MRA relies on the availability of fluoroscopy and MRI in close proximity. Some practitioners have suggested performing the joint injection under MRI guidance using either open- or closed-bore systems, but this a is time-consuming and awkward method compared with conventional arthrography. The patient is brought to the fluoroscopy suite and is prepared in the usual fashion. Although the use of gadolinium for intra-articular injections is not specifically approved by the Food and Drug Administration in its list of indications, it has been used for many years as a safe, off-label application. The mixture of gadolinium, saline, and iodinated contrast has been shown to be safe with no appreciable dissociation of the gadolinium from its chelate.12 There is no affect of iodinated contrast on the T1 shortening of gadolinium, which gives it its characteristic bright signal on T1-weighted imaging. Some operators prefer to inject iodinated contrast alone after placing the needle in the joint space; with this technique, if the initial needle positioning is not correct, it can be repositioned without leaving telltale signs of gadolinium outside of the joint. The dilute gadolinium is injected after intra-articular needle position is confirmed. Other operators prefer to combine saline, iodinated contrast, and gadolinium in a single injection.1 Dilute gadolinium is injected at a concentration of 1:200 to 1:250, usually by mixing 0.1 mL of gadopentate dimeglumine in 20 mL of either straight saline or a mixture of saline and iodinated contrast to achieve a concentration of the gadolinium of 2 mmol/L.1,2 At this concentration, gadolinium is bright on T1-weighed images (Fig. 4). Care must be taken to maintain this low concentration because if there is too much gadolinium in the mixture, the result can be a complete loss of
672
The Journal of Hand Surgery / Vol. 31A No. 4 April 2006
signal. After the arthrogram is completed, the patient is brought to the MRI suite as soon as possible in order to image while the joint is still distended. As with all MRI scans, technique is very important to optimize resolution. It is possible to perform MRA using low-field systems or dedicated extremity magnets, but in general it is preferable to perform these exams on at least a 1.0T system. On fluid-sensitive sequences, the dilute intra-articular gadolinium will signal similar to joint fluid, and it cannot be distinguished from normal joint fluid. The key sequence for visualizing the gadolinium is a T1-weighed sequence with fat suppression, which can be achieved using either a spin echo, a fast spin echo, or a gradient echo technique. Some authors have advocated high-resolution three-dimensional gradient echo techniques and have even shown arthroscopic flythrough projections that can be done using custom software,13 but the basics of wrist MRI remain important. The use of a dedicated wrist coil, the smallest possible field of view, the highest spatial resolution, and optimum signal-to-noise ratio are critical for successful MRA. The cost of the examination is usually similar to a contrast-enhanced MRI; the cost of the fluoroscopically guided injection may or may not be included in the charge. The indications for MRA of the wrist are evolving. At the current time, the technique is best used in young patients with indeterminate physical examinations and normal radiography in whom intrinsic ligament or TFCC tears are suspected in order to assist decision making regarding the performance of arthroscopy. It is particularly helpful when scapholunate ligament tears are suspected clinically but static and motion series radiographs are normal. It is also a helpful technique to use for patients who have other types of joint pathology and may have multiple problems contributing to pain, and where MRA will show both the ligament tears and other findings such as chondromalacia, ulnar impaction, and early degenerative joint disease. With appropriate technique, MRA can provide more information than either conventional arthrography or unenhanced MRI either alone or in combination. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Corresponding author: Kimberly K. Amrami, MD, Department of Radiology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905; e-mail: [email protected]. Copyright © 2006 by the American Society for Surgery of the Hand 0363-5023/06/31A04-0024$32.00/0 doi:10.1016/j.jhsa.2006.03.015
References 1. Steinbach LS, Palmer WWE, Schweitzer ME. Special focus session. MR arthrography. Radiographics 2002;22:1223– 1246. 2. Elentuck D, Palmer WE. Direct magnetic resonance arthrography. Eur Radiol 2004;14:1956 –1967. 3. Weiss AC, Akelman E, Lambiase R. Comparison of the findings of triple-injection cinearthrography of the wrist with those of arthroscopy. J Bone Joint Surg 1996;78-A(3):348 – 356. 4. Metz VM, Mann FA, Gilula LA. Lack of correlation between site of wrist pain and location of non-communicating defects shown by three-compartment wrist arthrography. AJR 1993;160(6):1239 –1243. 5. Metz VM, Mann FA, Gilula LA. Three-compartment wrist arthrography: correlation of pain site with location of uni and bidirectional communications. AJR 1993;160(4):819 – 822. 6. Kirschenbaum D, Sieler S, Solonick D, Loeb DM. Cody RP. Arthrography of the wrist. Assessment of the integrity of the ligaments in young asymptomatic adults. J Bone Joint Surg 1995;77-A(8):1207–1209. 7. Potter HG, Asnisernberg L, Weiland AJ, Hotchkiss RN, Peterson MGE, McCormack RR. The utility of high resolution magnetic resonance imaging in the evaluation of the triangular fibrocartilage complex of the wrist. J Bone Joint Surg 1997;79-A:1675–1684. 8. Scheck RJ, Romagnolo A, Hierner R, Pfluger T, Wilhelm K, Hahn K. The carpal ligaments in MR arthrography of the wrist: correlation with standard MRI and wrist arthroscopy. J Magn Resonance 1999;9:468 – 474. 9. Scheck RJ, Kubitzek C, Hiener R, Szeimies U, Pfluger T, Wilhelm K, Hahn K. The scapholunate interosseous ligament in MR arthrography of the wrist: correlation with non-enhanced MRI and wrist arthroscopy. Skeletal Radiol 1997;26:263–271. 10. Zanetti M, Bram J, Hodler J. Triangular fibrocartilage and intercarpal ligaments of the wrist: does MR arthrography improve standard MRI? J Magn Resonance 1997;7(3):590 – 594. 11. Mann FA, Wildon AJ, Gilula LA. Triple-injection wrist arthrography: unidirectional communications are due to technical factors. J Hand Surg (Am) 1998;23(1):82– 88. 12. Brown RR, Clarke DW, Daffner RH. Is mixture of gadolinium and iodinated contrast material safe during MR arthropgraphy? AJR 2000;175:1087–1090. 13. Sahin G, Dogan BE, Demirtas M. Virtual MR arthroscopy of the wrist joint: a new intraarticular perspective. Skeletal Radiol 2004;33:9 –14.