Skeletal Radiol (2004) 33:85–90

DOI 10.1007/s00256-003-0698-x A RT I C L E

K. Finlay Ultrasound of intrinsic wrist ligament

R. Lee
L. Friedman and triangular fibrocartilage injuries

Received: 22 April 2003
Revised: 3 September 2003
Accepted: 4 September 2003
Published online: 22 October 2003
© ISS 2003
K. Finlay · R. Lee · L. Friedman
Department of Radiology,
Henderson General Hospital,
Hamilton Health Sciences,
McMaster University,
Hamilton, Ontario, Canada
R. Lee (✉)
3038 Lakeshore Road, Burlington,
Hamilton, Ontario, Canada L7N 1A1
Tel.: +1-905-6320014
Abstract Objective: The objective
of this study was to evaluate ultra-
sound as a diagnostic tool for inves-
tigating scapholunate and lunatotri-
quetral ligamentous and triangular
fibrocartilage (TFC) tears. Ultra-
sound findings were compared to
conventional arthrogram findings, as
the reference gold standard. Design
and patients: In total 26 patients,
17 males and 9 females ranging in
age from 17 to 35 (mean age, 34),
were evaluated on referral for inves-
tigation of wrist pain. All patients
were examined by high resolution
ultrasound, using a 9–13 MHz trans-
ducer. All wrist ultrasound examina-
tions were also compared to conven-
tional tricompartmental arthrogra-
phy, as the diagnostic gold standard
reference. Results: All ten scapholu-
nate tears confirmed on arthrography
were detected on ultrasound. Two of
8 lunatotriquetral and 7 of 11 TFC
tears were correctly diagnosed on
ultrasound. Sensitivity of ultrasound
diagnosis ranged from 25% for
lunatotriquetral tears to 100% for
scapholunate tears. No false positive
results were recorded for any of the
three examined structures. Conclu-
sion: The study results suggest that
sonography is accurate for scapho-
lunate tears, but is not accurate for
evaluation of lunate-triquetral tears.
It has intermediate accuracy for tri-
angular fibrocartilage tears.
Keywords Scapholunate ligament ·
Lunatotriquetral ligament ·
Triangular fibrocartilage ·
Ultrasound · Wrist

Introduction with magnetic resonance imaging (MRI) representing a

The intrinsic ligaments of the wrist connect the carpal
bones to one another and act to stabilize the wrist by
maintaining normal alignment and limiting excessive in-
tercarpal motion. The two intrinsic ligaments of greatest
clinical importance are the scapholunate and lunatotri-
quetral ligaments. Injury or disruption of these liga-
ments can result in pain, instability, carpal dissociation
and/or rotatory subluxation. It has been reported that up
to 30% of wrist injuries can exhibit some degree of car-
pal instability [1]. An additional cause of wrist pain
stems from injury to the triangular fibrocartilage com-
plex (TFCC).
Traditional imaging tools for investigation of wrist
pain include plain radiographs and wrist arthrography,
recent additional method of investigation. Ultrasound
continues to develop as a viable imaging tool in the
assessment of musculoskeletal disorders. The advent
of high-resolution probe technology with transducer fre-
quencies above 10 MHz has expanded the variety of
superficial anatomic structures amenable to ultrasound
evaluation. The purpose of this study is to evaluate high
resolution ultrasound of the wrist for assessment of
intrinsic ligament and triangular fibrocartilage injury,
comparing ultrasound findings with those from conven-
tional tricompartment wrist arthrography as the reference
gold standard.
86
Fig. 1 Transverse orientation of the ultrasound probe on the dor-
sal surface of the wrist for evaluation of the scapholunate and
lunatotriquetral ligaments
Subjects and methods
Patients
A total of 26 patients (17 males and 9 females, ranging in age
from 17 to 35, mean age 34) were referred with nonspecific wrist
pain. The patients were initially assessed by a sports medicine
physician specialist or an orthopedic surgeon, and selected for
both ultrasound and wrist arthrography by the referring clinician.
The patient population represented a select group with a high clin-
ical suspicion of ligament or TFC pathology. All wrists were ex-
amined with high resolution GE 700 MR (General Electric Medi-
cal Systems, Milwaukee, Wis.) or ATL 5000 (Advanced Technolo-
gy Laboratories, Bothell, Wash.) ultrasound units. All examina-
tions utilized linear-array multi-frequency 9 to 13 MHz transduc-
ers. Bilateral wrist ultrasound assessments were performed, to al-
low for side-to- side comparison. Examinations were concurrently
performed by a MSK fellowship trained radiologist with 5 years
of experience in wrist ultrasound.
The symptomatic wrist was also assessed with tricompartment
wrist arthrography, using digital subtraction technique. Three to
5 cc of Omnipaque 240/300 was injected into the midcarpal joint,
subsequently, 1.5 cc into the distal radioulnar joint, then 3 to 5 cc
into the radiocarpal joint. Bilateral wrist arthrograms were not per-
formed, primarily due to the invasiveness of the procedure, with
the exception of one patient who had positive ultrasound findings
on the asymptomatic side. This bilateral ultrasound examination
was as requested by the referring clinician. All the arthrograms
and sonograms were performed by a single musculoskeletal radi-
Fig. 2 Normal transverse ultrasound image of the scapholunate
ligament. The arrow indicates the ligament, bridging between the
lunate (L) and scaphoid (S) bones. The normal ligament has a tri-
angular configuration, with compact fibrillar echotexture
ologist. Patients first underwent wrist ultrasound examination, fol-
lowed by arthrography. The arthrogram was performed as a sepa-
rate examination appointment, with all examinations performed
within 3 weeks of ultrasonography. Results of the previous ultra-
sound were not available at the time of the arthrogram. The two
test results were retrospectively reviewed and correlated.
Ultrasound technique
For assessment of both the scapholunate and lunatotriquetral liga-
ments, the patient was positioned facing the examiner, forearm
prone, with the wrist positioned over a volar pad (Fig. 1). The lig-
aments were assessed in the neutral position, as well as dynami-
cally, placing the wrist in extreme flexion and in both ulnar and
radial deviation. Lister’s tubercle (dorsal tubercle of the radius)
was first identified on transverse imaging. The transducer was
then slowly moved distally to the first carpal row, identifying the
scaphoid bone. The V-shaped articulation between the scaphoid
and lunate bones was seen distal and ulnar to Lister’s tubercle.
The normal scapholunate ligament was visualized as an echo-
genic triangular structure, with a compact fibrillar echotexture, po-
sitioned between the scaphoid and lunate bones (Fig. 2). The nor-
mal ligament is a U-shaped structure with a thick dorsal and ven-
tral portion and a thinner central portion. It has been reported that
the dorsal aspect is the most ultrasonographically accessible por-
tion of the scapholunate ligament and is visualized at least partial-
ly in up to 78% of normal wrists [2]. The transducer was then
moved laterally to identify the lunatotriquetral ligament in a simi-
lar fashion (Fig. 3).
Scapholunate and/or lunatotriquetral tears were interpreted as
being present on ultrasound when there was loss of the normal
echogenic appearance, disruption or absence of the normal liga-
ment, or in the presence of concurrent fluid or an associated gan-
glion.
To visualize the TFC, the forearm was positioned prone with
the wrist in flexion, draped over a volar pad. The wrist was again
assessed with dynamic manipulation of the hand in the neutral,
maximal radial and ulnar deviation. With the probe in longitudinal
(Fig. 4) and transverse orientations, the cartilage over the distal
ulna, the ulnar styloid process, distal radius, ulna, and triquetrum
were individually identified.

Fig. 3 Normal transverse ultrasound of the lunatotriquetral liga-
ment. The arrow indicates the normal ligament positioned be-
tween the lunate (L) and the triquetrum (T). The ligament demon-
strates a compact fibrillar appearance
Fig. 4 Longitudinal, paracoronal orientation of the ultrasound
probe, for evaluation of the TFC
The normal TFC meniscal homologue/articular disc appeared
as a homogeneous inverted triangular echogenic structure, with its
wide base on the dorsal aspect of wrist (between the distal ulna
and triquetrum) and its apex at the volar aspect (attaching to the
tip/capsular margin of radius). The thinnest/apical portion has
been reported as normally averaging 2 mm, and the thicker base
measuring about 4.5 mm [3]. With the probe oriented as illustrated
in Fig. 4, the TFC was located distal to the ulnar styloid and deep
to the extensor carpi ulnaris tendon (Fig. 5). Being composed of
fibrocartilage histologically, the hyperechoic TFC was distinguish-
able from hypoechoic synovial cartilage.
87
Fig. 5 Normal ultrasound image of the triangular fibrocartilage
(TFC). Longitudinal, paracoronal image at the ulnar aspect of the
wrist, with arrows indicating the triangular configuration of the
normal TFC, distal to the ulna (U). The TFC is identified deep to
the extensor carpi ulnaris tendon (ECU)
TFC tears were detected as loss of the normal homogeneous
echotexture and triangular structural appearance, absence of a por-
tion of the structure, especially the TFC tip, lucent/hypoechoic de-
fects, or linear clefts/cysts [4]. Tears have been reported as tending
to occur either close to the wide base between the ulnar head and
the lunate bone or near the sigmoid notch of the radius where
there is normal anatomic thinning of the TFC [5, 6].
Results
Of the 26 patients studied, arthrography confirmed 10
scapholunate tears (Fig. 6A, B), 8 lunatotriquetral tears
(Fig. 7A, B) and 11 TFC tears (Fig. 8A, B). There were
two combined scapholunate/lunatotriquetral tears, two
patients with tears involving all three structures, and two
combined lunatotriquetral/TFC tears. No false positive
results were recorded for any of the ultrasound examined
structures.
All arthrographically diagnosed scapholunate tears
were identified on ultrasound (Fig. 6A, B). All 16 of
those with arthrogram negative results were also nega-
tive on ultrasound. There were zero false positive or
false negative results. The prevalence of scapholunate
tears in our patient population was 38.5%. With our re-
sults, sensitivity, specificity, positive and negative pre-
dictive values (PPV/NPV) and diagnostic accuracy were
all 100%.
The prevalence of lunatotriquetral tears in the study
group was 30.08%. Two of the eight confirmed lunato-
triquetral ligament tears were detected on ultrasound
(Fig. 7A, B). All of the 18 arthrogram negative results
88
Fig. 6 A Scapholunate ligament tear. Transverse image at the
level of the scaphoid (S) and lunate (L). A scapholunate tear is
illustrated, with loss of the normal configuration and replacement
by fluid. The arrow indicates the abnormal hypoechoic appearance
at the site of tear. B Arthrogram with contrast injected into the
midcarpal joint space. Study confirms a tear at the level of the
scapholunate interval, with contrast appearing in the radiocarpal
joint space (arrow)
were also negative on ultrasound. There were six false
negative ultrasounds, and zero false positive results. Al-
though specificity was 100%, ultrasound was only 25%
sensitive in detecting lunatotriquetral tears. Likewise,
although PPV was 100%, NPV was only 75% and diag-
nostic accuracy 76.9%.
The prevalence of TFC tears in our population was
42.3%. Ultrasound correctly diagnosed 7 of 11 of these
tears, with 4 false negative results (Fig. 8A, B). No false
Fig. 7 A Lunatotriquetral ligament tear. Transverse image at the
level of the lunate (L) and triquetral (T) bones. Tear of the lunato-
triquetral ligament is demonstrated with disruption of the normal
hyperechoic linear structure (arrow). B Midcarpal joint injection
demonstrating contrast in the radiocarpal joint at the level of a
lunatotriquetral tear (arrow)
positive results were recorded. All 15 arthrographically
negative wrists were also negative on ultrasound. Speci-
ficity and PPV were again 100%. Sensitivity however
was 63.6% and NPV 78.9%. Diagnostic accuracy of
ultrasound was 84.6%.

Fig. 8 A TFC tear. Longitudinal ultrasound at the level of the
TFC demonstrates loss of the normal hyperechoic triangular fibro-
cartilage (arrow). A fluid-filled tract consistent with a tear is indi-
cated by the calipers. T Triquetral bone, U distal ulna. B Radio-
carpal joint injection confirms a TFC tear with abnormal extension
of contrast into the distal radioulnar joint (arrow)
Discussion
Wrist pain is a common complaint, often with a nonspecif-
ic clinical presentation. The differential diagnosis can be
broad, encompassing many conditions such as tendonitis,
tenosynovitis, arthritis, and ganglions, to mention a few.
Plain film assessment of the wrist can be quite unsatisfy-
ing. Widening of the scapholunate interval by more than
2 mm can be suggestive of dissociation; however, this may
be seen as a normal variant with lunatotriquetral coalition.
Conversely, widening may not be a predictable or reliable
finding in the setting of ligamentous disruption [7].
89
Until recently, arthrography has been the primary imag-
ing tool for assessment of the integrity of the intrinsic liga-
ments of the wrist and the TFC. Intraarticular communica-
tion of contrast between the radiocarpal and intercarpal
joints can occur with ligamentous perforations or tears, but
can also be seen in otherwise asymptomatic wrists.
Arthrography has been reported as being best at as-
sessing the proximal/middle portion of the scapholunate
ligament, but not necessarily the volar or dorsal compo-
nents [8]. Further, as an invasive procedure, pain that is
sometimes persistent, infection, radiation exposure and
contrast reactions are all well recognized complications.
Although MRI is recognized as a valuable tool for the
assessment of undiagnosed wrist pain, ultrasound offers
both cost and time savings, and is perhaps currently
more readily accessible in many communities. MRI sen-
sitivity in detecting scapholunate tears nonetheless has
been reported to range from 52, to 90% with the addition
of MR arthrography [9] and MRI detection of TFC tears
ranges from 88 to 95% depending on the correlation with
arthrography and surgical findings [10, 11, 12, 13].
In our experience, the quality of the diagnostic exami-
nation begins with a thorough clinical history to guide the
ultrasound investigation. Although wrist pain can be gener-
alized and nonspecific, injury or pain lateralizing to the ra-
dial side can be more indicative of a scapholunate injury.
Conversely, ulnar-sided injuries or symptoms can be more
consistent with lunatotriquetral or TFC injuries. Ultrasound
comparison with the unaffected side is extremely valuable
for appreciation of subtle differences and, in addition, the
ability to dynamically evaluate the wrist is often valuable.
In our study, the sensitivity of ultrasound testing
varied widely, ranging from a low of 25% for detecting
lunatotriquetral tears because of a high proportion of
false negative results, to a high of 100% for detecting
scapholunate tears. Ultrasound was 100% specific in all
three diagnostic areas as a result of the 0% false positive
rate for each. Ultrasound of all three structures also dem-
onstrated a 100% positive predictive value, such that if
ultrasound was positive, there was a 100% chance of
having a tear on arthrography.
No false negative results were seen with ultrasound of
the scapholunate ligament. However, ultrasound missed 4
of 11 TFC tears and 6 of 8 lunatotriquetral tears seen with
arthrography. Clearly our results were most promising for
ultrasound assessment of scapholunate ligament injuries,
with a 100% diagnostic accuracy rate. Detection of a nor-
mal dorsal component of the scapholunate ligament essen-
tially negates the presence of dissociation. Even with our
results, potential challenges include reports that in up to
23% of cases, there can be difficulty visualizing the dorsal
component of the scapholunate ligament [2]. Nonvisual-
ization does not necessarily equate, however, with an inju-
ry. Griffith et al. [2] also reported that only in 15% of
cases was the less critical volar component visualized,
which also was difficult to distinguish from the palmar
90

radiocarpal ligament. We did not examine the scapholu-
nate joint margin width as an indicator of injury. It has
been reported that there are no reproducible ultrasound
landmarks with which to measure the scapholunate inter-
val, and further, with dynamic repositioning, the scapholu-
nate interval is not predictably variable [2]. Nonetheless,
the scapholunate joint space is better visualized by ultra-
sound than by plain radiography.
There is a paucity of ultrasound literature regarding
the lunatotriquetral ligament and the TFC. Our study
suggests that ultrasound is currently not a good screen-
ing modality for detection of lunatotriquetral ligament
tears, with a sensitivity of only 25%. Of interest, the two
cases that were detected were confirmed to be present on
arthrography. Allowing for the relatively high proportion
of true negative results, the diagnostic accuracy nonethe-
less approached 77%. Seven of the 11 TFC tears were
detected on ultrasound, resulting in a sensitivity ap-
proaching 64% and a diagnostic accuracy of 85%. Again
ultrasound was 100% specific. These results suggest that
with training, experience and reliable technique, ultra-
sound may prove a reasonable screening modality for
detection of TFC injuries.
Limitations of our study include the relatively small
number of participants examined. The study group was a
selected group of symptomatic patients, referred with
high clinical suspicion of ligament or TFC injuries. Our
study only examined individuals with wrist pain, all of
whom had positive clinical findings, introducing a po-
tential selection bias. Our patient population was young
(age 17–35), and the results perhaps cannot be general-
ized to an older age group. Furthermore, ultrasound is a
dynamic modality that is very operator dependent. With
the newer high resolution technology and the ability to
evaluate previously unexamined structures, there is an
operator learning curve that is difficult to quantify. Ex-
pertise and proficiency in MSK ultrasound interpretation
could be considered beyond the usual scope of a general
radiologist, and our results may be applicable only in
centers with MSK-trained ultrasonographers and radiolo-
gists. In addition, our results were compared to conven-
tional arthrogram, whereas surgical correlation would
likely offer the most definitive diagnostic reference for
the presence or absence of true tears.
In summary, triangular fibrocartilage, scapholunate and
lunatotriquetral ligament injuries are frequent causes of
wrist pain and instability. Ultrasound offers the advantage
of a dynamic and non-invasive test that is less costly than
MRI. With further development of high resolution probe
technology, as well as appropriate training and technique,
superficial structures amenable to ultrasound evaluation
are ever increasing. This study suggests that high resolu-
tion ultrasound, with proper technique and operator exper-
tise, can be a valuable tool, most reliably in the detection
of scapholunate tears. It is only intermediate in accuracy
for TFC tears and not accurate for lunatotriquetral liga-
ments. The positive predictive value for this selected pa-
tient population was good, indicating that ultrasound
could be a useful noninvasive screening technique. How-
ever, it is important to recognize the limitations of ultra-
sound for two of the three structures imaged. The potential
role of ultrasound in the evaluation of these important an-
atomical structures warrants further investigation.
Acknowledgements We wish to thank Bruce Weaver of the
Department of Epidemiology at McMaster University. Patient
data was collected from Guelph General Hospital, 115 Delhi St.,
Guelph, Ontario, Canada N1E 4J4 and Henderson General Hospi-
tal, 711 Concession St., Hamilton, Ontario, Canada L8 V 1C3

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