European Journal of Radiology 56 (2005) 286295

Variants, pitfalls and asymptomatic ndings in wrist and hand imaging

Christian W.A. Prrmann , Marco Zanetti
University Hospital Balgrist, Radiology, University of Zurich Switzerland, Forchstrasse 340, CH-8008 Zurich, Switzerland Received 3 March 2005; received in revised form 10 March 2005; accepted 15 March 2005

Abstract Anatomic variants of the bones, ligaments, tendons and muscles are frequent ndings in imaging of the wrist and hand. Many ndings especially changes in the triangular brocartilage (TFC) and the interosseous ligaments are asymptomatic, their incidence is increasing with age, and they are frequently found bilaterally. Abnormalities such as increased signal within tendons are common in asymptomatic subjects. They may be explained by normal physiology, anatomical variability, MR artifacts or true abnormalities without clinical importance. Although it is not always possible to differentiate variants and artifacts from clinically relevant ndings it is important to know their potential etiology and clinical importance and not to over report them as abnormality requiring additional imaging or treatment. 2005 Published by Elsevier Ireland Ltd.
Keywords: Artifacts; Joints/anatomy and histology/injuries/pathology; Magnetic resonance imaging; Wrist joint/anatomy and histology

1. Introduction Knowledge of normal anatomic variants, asymptomatic ndings and other diagnostic pitfalls is crucial for accurate analysis of wrist and hand imaging. Variants and pitfalls are commonly found as coincidental ndings and may easily be misdiagnosed as relevant abnormality. The consequences may be over treatment. This article starts with a short discussion of technical issues as far as relevant for wrist and hand imaging, followed by a discussion of common anatomical variants of bones, ligaments, tendons and muscles.

the radius is of major importance in the treatment of such fractures. The articular surface of the radius normally has a palmar tilt of 12 in women and 9 in men. Improper positioning with supination or pronation of the wrist can result in incorrect measurements of the palmar tilt (Fig. 1). The apparent palmar tilt of the distal radius increases with forearm supination and decreases with pronation [1]. Scapho-pisocapitate (SPC) alignment is a reliable criterion to establish a reproducible neutral lateral view of the wrist [2] (Fig. 2). 2.2. Assessment of ulnar variance Ulnar variance is the length between the distal end of the ulna and the radius as measured on antero-posterior radiographs. Neutral rotation radiographs of the wrist are recommended to standardize the measurement of ulnar variance because it is known that changes in forearm rotation result in changes of this measurement. Ulnar variance refers to the roentgenographic distance between contiguous articular surfaces of the distal radiocarpal and ulnocarpal joints. The ulnar variance changes with wrist and forearm position. Supination decreases the measurement of ulnar variance. Pronation increases the measurement of ulnar variance up to 2 ml [3,4]. A

2. Imaging technique 2.1. Assessment of the palmar tilt of the radius after distal radius fractures Fractures of the distal radius are among the most common bone injuries. The assessment of the distal surface of

Corresponding author. Tel.: +41 1 386 3305; fax: +41 1 386 3319. E-mail address: christian@prrmann.ch (C.W.A. Prrmann).

0720-048X/$ see front matter 2005 Published by Elsevier Ireland Ltd. doi:10.1016/j.ejrad.2005.03.010

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Fig. 1. Assessment of the palmar tilt: Improper positioning with supination (1) or pronation (2) of the same wrist results in incorrect measurements of the palmar tilt.

eral radiographs of the wrist. Lunate dorsiexion is a wellrecognized sign of an intercarpal ligamentous injury pattern known as dorsal intercalated segment instability. Theoretically, such diagnosis can also be made on sagittal MR images. In a series of 10 normal wrists a DISI conguration would have been diagnosed on sagittal MR images in 4 of 10 subjects with neutrally positioned wrists and in eight of 10 subjects with ulnarly deviated wrists. It is usually difcult to obtain a perfectly neutral position of the wrist during MR imaging. On sagittal images the lunate apparently is more dorsally tilted than on standard lateral radiographs. When the patient is examined with the hand above the head, ulnar tilting is very common. Therefore, analysis of a DISI or VISI conguration should only be performed on standard lateral radiographs to avoid this pitfall [6] (Fig. 3).

standardized PA view of the wrist is taken with the palm at on the table, elbow abducted to shoulder height and exed to 90 , with the forearm and wrist in neutral rotation. A standardized PA view is recognized when the extensor carpi groove is proled at the ulnar aspect of the ulna [5]. 2.3. Assessment of dorsal intercalated segment instability (DISI) on sagittal MR images of the wrist Lunar tilt is an important diagnostic sign of a static carpal instability. It is usually diagnosed on standardized lat-

3. Osseous variants 3.1. Lunotriquetral coalition Isolated carpal coalitions have a general prevalence of 0.1%, occur more commonly in the black population, have a strong female predilection, and are frequently bilateral

Fig. 2. Neutral lateral view of the wrist: scapho-piso-capitate (SPC) alignment is a reliable criterion to establish a reproducible neutral lateral view of the wrist. The palmar outline of the pisiforme (P) should be between the palmar outline of the scaphoid (S) and the capitate (C).

Fig. 3. Sagittal T1w SE image of a wrist demonstrating a signicant dorsal tilt of the lunate. On sagittal images the lunate is often dorsally tilted and a pseudo DISI conguration is mimicked.

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[7]. The most common isolated carpal coalition is the lunotriquetral, followed by the capito-hamate. Metz and coworkers [8] analyzed the radiologic appearances of 70 lunotriquetral coalitions in 52 patients. In 32 of 70 wrists, a wide scapholunate joint space was detected. Instability tests and arthrography were normal with respect to the scapholunate ligament in all cases. The authors concluded that widening of the scapholunate joint space is a normal variant that is common in patients with lunotriquetral coalition [8]. 3.2. Carpal boss The carpal boss refers to a bony protuberance which is located at the dorsum of the wrist at the base of the second or third metacarpal bone (Fig. 4). This bony prominence is usually caused by the presence of an os styloideum, an accessory ossication center. The os styloideum may be or may not be fused with the base of the metacarpal bone. Patients may present with complaints of pain and limitation of motion of

Fig. 5. Coronal proton density fat saturated MR image after arthrography demonstrates a type 2 lunate with a hamato-lunate facet (arrowhead). The proximal pole of the hamate shows advanced cartilage damage (arrow).

the affected hand. The symptoms may be the result from an overlying ganglion or bursitis, or from osteoarthritic changes at this site [9]. 3.3. Type 2 lunate The type 2 lunate is a very common variant of the wrist joint (Fig. 5). Two distinct types of lunates can be identied: the type I without a medial facet and the type II with a medial facet articulating with the hamate. In a series 165 cadaveric wrists Viegas et al. [10] found a frequency of 65% of type 2 lunates. Signicant cartilage erosion with exposed subchondral bone at the proximal pole of the hamate was evident at dissection in 44.4% of the type II lunates, while none of the type I lunates had such associated hamate pathologic conditions. The association of a hamatolunate facet with advanced cartilage damage in the proximal pole of the hamate (Fig. 5) has also been demonstrated with MR arthrography [11]. This type II lunate, with the high incidence of associated hamate pathology, may be an unidentied cause of wrist pain on the ulnar side.

4. Triangular brocartilage (TFC) and ligaments 4.1. MR imaging of the attachments of the TFC The MR imaging the TFC is a hypointense discs in all sequences. However, the radial and ulnar attachments of the triangular brocartilage often show a intermediate to high signal intensity which may be a potential imaging pitfall. The ulnar attachment of the TFC is composed of two distinct laminae: the distal lamina is orientated horizontally and extends between the articular disc and the styloid process of the ulna. The proximal lamina is orientated vertically and curves from the undersurface of the articular disc to the ulnar

Fig. 4. Transverse CT image and sagittal reformat through the base of the third metacarpal bone demonstrating a carpal boss or os styloideum (curved arrow). The os styloideim is not fused (arrowhead) with the base of the third metacarpal bone.

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Fig. 6. Coronal PD fat sat TSE MR image demonstrating high signal at the ulnar attachments of the TFC. The ulnar attachment of the TFC is composed of two distinct laminae: the distal lamina is orientated horizontally and extends between the articular disc and the styloid process of the ulna (black arrowhead). The proximal lamina is orientated vertically and curves from the undersurface of the articular disc to the ulnar fovea (white arrowhead). The two laminae are separated by the ligamentum subcruentum which represents bro vascular tissue (arrow).

Fig. 7. At the radial attachment of the TFC hyaline cartilage (arrow) curves around the ulnar edge of the radius giving a linear area of high signal with should not be misinterpreted as a tear on this coronal PD fat sat TSE MR image.

fovea. The two laminae are separated by the ligamentum subcruentum which represents bro vascular tissue. Therefore, this attachment has usually an intermediate signal intensity on T1 and T2 weighted images and sometimes internal striations are present [12] (Fig. 6). At the radial attachment of the TFC hyaline cartilage curves around the ulnar edge of the radius giving a linear area of high signal on T2 or uid sensitive sequences with should not be misinterpreted as a tear (Fig. 7). 4.2. Communicating and non-communicating defects of the TFC With increasing age defects and central communication within the TFC increase in frequency (Fig. 8). Many of these defects have no clinical signicance. Zanetti et al. [13] have shown that radial-sided communicating TFC defects are commonly seen bilaterally and in asymptomatic wrists. In this series of 56 patients communications within the TFC were noted 64% of symptomatic and in 46% asymptomatic wrists. Sixty nine percent of the defects were bilat-

eral and almost all of these defects were located radially. Non-communicating defects (Fig. 9) were identied in 50% of symptomatic wrists and in 27% of asymptomatic wrists. Non-communicating and communicating defects of the TFC near the ulnar attachment were more reliable associated with symptomatic wrists than the radial communicating defects [13].

Fig. 8. Arthrogram of the wrist demonstrating a central communication of the TFC (arrow). A nding which is often asymptomatic and bilateral.

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Fig. 9. Arthrogram (left) and corresponding MR arthrography (right) of the distal radio ulnar joint demonstrating a radial non communicating defect (arrowhead) of the TFC.

4.3. Interosseous ligaments Findings of various cadaveric and arthrographic studies have demonstrated that defects occur within the substance of the scapholunate and lunotriquetral ligaments, as senescent changes in asymptomatic wrists. The scapholunate ligament and the lunotriquetral ligament are U shaped and connect the bones of the proximal carpal row along their dorsal, palmar, and proximal margins. The ligaments have three distinct components. The palmar and dorsal portions are composed of transversely oriented very strong collagen bers. The largest component of the ligament is the central (also known as the proximal) segment or pars membranacea. Histologically, it is distinctly different from the dorsal and ventral portions and is actually brocartilage rather than a true ligament. It is well known that perforations in the scapholunate ligaments can be present in asymptomatic patients and are found in cadavers with no known history of wrist injury (Fig. 10). These perforations rarely are present before 20 years of age but occur more frequently with advancing age and reach approximately a 50% prevalence by the eighth decade of life [14]. In a study of Linkous et al. [15] analyzing bilateral wrist arthrograms of 30 consecutive patients with a history of wrist trauma and unilateral wrist pain bilateral tears in the central portion of the interosseous ligament were frequent. However, defects in the dorsal portion of the scapholunate ligament were more common in symptomatic wrists than in asymptomatic wrists (Fig. 11).

Fig. 10. Coronal T1w SE MR image shows a defect of the proximal part of the lunotriqutral ligament. Defects within the substance of the scapholunate and lunotriquetral ligaments are often seen as senescent changes in asymptomatic wrists.

normal nding. The extensor carpi ulnaris muscle is composed of two muscle bellies (one originating from the lateral epicondyle and the other from the ulnare diaphysis dorsally) the tendon is then formed from spiral bers originating from these two muscle bellies. At histology the center of this tendon shows brovascular tissue explaining the high signal intensity in the center of the tendon substance. 5.2. The rst extensor compartment and the abductor pollicis longus The rst extensor compartment of the wrist is composed of the tendons of the abductor pollicis longus and the extensor pollicis brevis and their fascial sheath. The tendon of the

5. Tendons and tendons sheath 5.1. Extensor carpi ulnaris tendon Centrally increased signal within the tendon of the extensor carpi ulnaris muscle at the level of the distal radioulnar joint is a frequent nding (Fig. 12) and may represent an
Fig. 11. Transverse T1w SE MR image of the wrist shows a defects in the dorsal portion of the scapholunate ligament (arrow). These defects more commonly seen in symptomatic wrists than in asymptomatic wrists and may more likely represent posttraumatic changes (S: scaphoid bone, L: lunate bone).

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Fig. 12. Centrally increased signal (arrow) within the tendon of the extensor carpi ulnaris muscle on this PD fat sat TSE MR image at the level of the distal radioulnar joint is a often a normal nding.

abductor pollicis longus is frequently composed of multiple bundles [16]. The resulting signal changes should therefore not be misinterpreted as longitudinal tears or tendinopathy (Fig. 13). In a study of 300 cadaveric wrists the variation in the pattern of the tendons and septa in the rst extensor compartment was analyzed. Complete or partial septation of the compartment was found in 40%. In about a third of the cadaveric specimens, the rst extensor compartment was divided by a septum and two tendons or more were present within the major subcompartment [17]. Septations within the rst extensor compartment may be an important nding for the treatment of Quervains disease, however, these septions my be very hard to diagnose on MR images. 5.3. The third extensor compartment and the extensor pollicis longus The extensor pollicis longus tendon lies within the third extensor compartment. The tendon has an oblique course distal to Listers tubercle. Very frequently there is high signal high signal within this tendon distal to Listers tubercle [16] due to the magic angle phenomenon (Fig. 14). This effect is commonly found in ligaments and other ordered structures when they are oriented approximately 55 to the main magnetic eld (B0). This orientation leads to shortening of the apparent T1 time, resulting in an increase in signal intensity

Fig. 13. Transverse PD fat saturated TSE MR image demonstrating the rst extensor compartment of the wrist which is composed of the tendons of the abductor pollicis longus (white arrow) and the extensor pollicis brevis (black arrow). Note the multiplebundles (white arrow) of the abductor pollicis longus tendon which is a normal nding and should not be misinterpreted as a lesion.

of the tendon, which may simulate the appearance of a tear or tendinosis [18]. This phenomenon is most pronounced when a short echo time is used. 5.4. Flexor pollicis longus The exor pollicis longus has very similar to the extensor pollicis longus tendon an oblique course distal to the carpal tunnel. The magic angle phenomenon in this tendon is often very pronounced. The exor pollicis longus is usually readily identiable within the carpal tunnel just ulnar to the exor carpi radialis, however, distal to the carpal tunnel, the tendon is sometimes almost invisible and has virtually the same signal intensity as the thenar muscles, especially on T1w SE images (Fig. 15).

6. Musclar variants Many musclar variants have been described about the wrist joint. The most common anomalies affect the abductor digiti minimi, the palmaris longus, the exor digitorum supercialis, and exor carpi ulnaris [19]. Most commonly these

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Fig. 14. (a, b) The extensor pollicis longus tendon (arrows) on transverse PD fat sat TSE images (a) lies within the third extensor compartment. The tendon has an oblique course distal to Listers tubercle (arrowheads) (b). Note high signal high signal within this tendon distal to Listers tubercle (image part 2 and 3).

variants are incidental asymptomatic ndings, however, an anomalous muscle may be the cause of a compressive neuropathy at the wrist. 6.1. Accessory abductor digiti minimi The accessory abductor digiti minimi is the most common muscular variant about the wrist joint. It is occurring in up to 24% of all wrists [20]. The accessory abductor digiti minimi muscle is usually identied radial and anterior to the pisiform bone on transverse MR images and has therefore an intimate relationship with Guyons canal (Fig. 16). The accessory abductor digiti minimi originates either from the

palmar exterinsic carpal ligaments, the tendon of the palmaris longus muscle or the fascia of the forearm. The insertion site is together with the abductor digiti minimi muscle on the medial aspect of the base of proximal phalanx of the small nger. Usually this muscle is asymptomatic. However, occasionally this muscle can cause compressive ulnar or median neuropathy, particularly when the muscle is hypertrophied [21]. 6.2. Variants of the lumbrical muscles Normally the lumbrical muscle arise from the exor digitorum tendon at the level just distal to the carpal

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Fig. 15. (a, b) Transverse T1w SE MR images (a) and corresponding coronal proton density fat saturated TSE MR image showing the location of the transverse images (b). The Flexor pollicis longus tendon (arrow) is located next to the exor carpy radialis tendon (arrowhead) within the carpal tunnel and has an oblique course distal to the carpal tunnel. The magic angle phenomenon in this tendon is often very pronounced and the tendon is often hardly visible within the tenar muscules (image part 2).

tunnel. However, in about 22% of individuals the lumbrical muscle arise within the carpal tunnel [22]. This anatomic variant my cause carpal tunnel syndrome, especially in cases with hypertrophy of the muscle belly [23] (Fig. 17). 7. Anatomic variants of the arteries and nerves within the carpal tunnel In a study analyzing of 526 elective carpal tunnel releases a total of 31 anatomic variants (6%) were seen, including anomalies of the median nerve, a median artery persistence, and variants of the ulnar nerve [24]. A persistent median artery was noted in 3.4% of all hands. Anomalies of the median nerve or its palmar cutaneous or motor branches were observed in 1%. 7.1. Persistent median artery A persistent median arteries has a low incidence (24%) (Fig. 18) [25]. Median nerve compression in the carpal tunnel by a thrombosed persistent median artery has been described in several cases. Usually a persistent me-

dian artery is asymptomatic, however, an anomalously enlarged median artery may lead to carpal tunnel syndrome [26]. 7.2. Anatomic variants of the median nerve The alignment of the median nerve in the carpal tunnel, its shape, and its relationship to the exor tendons is very variable and dependent on wrist positioning. Because of this dynamic variability, the position of the median nerve within the carpal tunnel should therefore not be used as a relevant diagnostic criterion. However, this characteristic may explain why certain wrist motions, exion in particular, predispose a person to carpal tunnel syndrome [27]. A bid median nerve is an anatomic variation that may be associated with carpal tunnel syndrome. High division of the median nerve proximal to the carpal tunnel or bid median nerve has been described in the surgery literature as a median nerve anomaly with an incidence of 3% [28]. It is important for the surgeon to be aware of the existence of this condition preoperatively in order to plan the carpal tunnel release [29].

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Fig. 16. Transverse T1w SE MR image of a wrist at the level of the pisiforme bone (asterisk) showing an accessory abductor digiti minimi (arrow) radial and anterior to the pisiforme bone with an intimate relationship with Guyons canal (arrowhead).

Fig. 18. A persistent median artery (straight arrow) next to the median nerve (curved arrow) is shown on this transverse proton density fat saturated TSE MR image.

8. Conclusion Anatomic variants are frequent ndings in imaging of the wrist and hand. Abnormalities such as increased signal within normally hypointense structures, form/attachment abnormalities, are common in asymptomatic subjects. They may be explained by normal physiology, anatomical variability, MR artifacts or true abnormalities without clinical importance. Many ndings especially changes in the TFC and the interosseous ligaments are asymptomatic, the incidence is increasing with age, and are frequently found bilaterally. Although it is not always possible to differentiate variants and artifacts from clinically relevant ndings it is important to know their potential etiology and clinical importance and not to over report them as abnormality requiring additional imaging or treatment. Thorough knowledge of normal anatomy is crucial.

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Fig. 17. In 22% of individuals the lumbrical muscles (arrowheads) arise within the carpal tunnel. Median nerve (arrow), transverse T1w SE MR image.

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