Imaging of the Upper Extremity
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Imaging of the Upper Extremity

Imaging of the Upper Extremity
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Key Points

  • PA wrist radiograph: Shoulder abducted to 90º, elbow at 90º, and wrist in neutral rotation.
  • Lateral wrist radiograph: Volar pisiform surface midway between volar capitate and distal scaphoid.
  • 30º pronation wrist view: to assess metacarpals for fracture or dislocation.
  • 30º supination view: pisotriquetral joint visualization.
  • Thumb stress view or Robert’s view for assessing the thumb carpometacarpal joint.
  • PA clenched fist view to assess scapholunate ligament integrity.
  • CT scans are excellent for visualizing occult carpal fractures or non-unions.
  • MRI are excellent for ligament, TFCC and tendon injuries (hand and wrist) and rotator cuff or labroligamentous tears (shoulder).
  • Ultrasounds are excellent for visualizing foreign bodies and soft tissue masses.

In November 1895 Wilhelm C. Roentgen discovered the x-ray. When the lead disk he was holding passed through the invisible beam, he was astonished to see the shadow of a circle upon a screen along with the outline of his thumb and forefinger and the bones within them. The field of medical imaging was born. The clinical application of this discovery ensued immediately thereafter with the first clinical application on January 19, 1896 when Eddie McCarthy fell while skating on the Connecticut River and fractured his wrist. 1 After a 20-minute radiographic exposure a fracture of the distal forearm was noted on a crude radiograph (Fig. 1). 2

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The prolific evolution of diagnostic imaging over the last century has revolutionized how we practice medicine. Radiographs are still the mainstay for assessing abnormalities of the upper extremity and are currently acquired with millisecond x-ray exposures and largely performed utilizing digital radiography. Cross-sectional imaging has further advanced our abilities to detect and characterize abnormalities and includes the use of x-rays for computed tomography (CT), radiofrequency waves for magnetic resonance (MR) imaging, ultrasound waves for ultrasound (US), gamma rays for single-photon emission computed tomography (SPECT) and positron emitters for positron emission tomography (PET). Each technique varies in its inherent spatial, contrast, and temporal resolution capabilities. Modifying parameters of each modality has led to advances such as MR/CT arthrography, CT/MR angiography, MR neurography, and sonoelastography. Furthermore, image guided interventions offer the promise of minimally invasive treatment options for patients.

This chapter will review the imaging arsenal available to the surgeon in evaluation of the upper extremity. By reviewing the advantages and disadvantages of each technique the surgeon will be better able to choose the most appropriate imaging study for evaluation of the clinical issue at hand.

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Techniques

 
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Radiography

Radiography is the preferred modality for initial imaging evaluation of the upper extremity due to its widespread availability, low cost, and relative ease of acquiring. It is the ideal initial evaluation of suspected osseous pathology such as fractures, inflammatory arthritis, osteoarthritis, malalignment, or congenital abnormalities. Proper positioning is mandatory to obtain reproducible and comparable views. Ideally the x-ray beam should be orthogonal to the joint in question or pathology in question and performed in a minimum of two planes. In the wrist this is especially important given the complex 3-dimensional anatomy and curvilinear nature of the articular surfaces. The evaluation is further hampered by the inherent limitation of visualizing 3-dimensional anatomy on a 2-dimensional medium. Modern radiography exhibits high spatial resolution but poor contrast resolution. Radiography is limited in its depiction of the soft tissues although this has slightly improved with digital radiography. The initial evaluation radiographs can indirectly identify soft tissue pathology such as swelling, masses, and/or calcifications, which can prompt further investigation.

Standard views of the hand and wrist include a 0° posterior-anterior (PA) and lateral orthogonal radiographs. These should be obtained with the shoulder abducted 90°, the elbow flexed 90°, and the wrist in neutral position lying on the plate with the patient in a seated position with the x-ray beam centered on the third metacarpal head for PA hand radiography and on the capitate for the wrist. In addition, the fingers should be fanned on the lateral hand radiograph for optimal visualization of the digits. An adequate lateral view of the wrist can be confirmed by seeing the volar surface of the pisiform midway between the volar aspect of the capitate and the distal pole of the schaphoid. 3 Often these views are supplemented with oblique radiographs given the complex anatomy as discussed above. A 30° oblique in pronation allows greatest visualization of the dorsal and ulnar wrist/metacarpals, while a 30° oblique in supination allows optimal visualization of the volar and ulnar wrist and in particular the pisotriquetral joint (Fig. 2). Other special views include the scaphoid view in which the hand is placed flat on the table in forced ulnar deviation and the carpal tunnel view where the wrist is dorsiflexed 30–35° and the x-ray beam is directed along the longitudinal axis of the third metacarpal (Fig. 3). In addition, stress views can be obtained such as the modified thumb CMC stress view of Wolf et al 4 (Fig. 4), the Robert’s view for the thumb carpometacarpal joint and the clenched fist PA view to assess scapholunate ligament disruption.

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Figure 4

The normal scapholunate angle on a lateral radiograph is 30–60° and is formed by the axis of the two bones (Fig. 5). 5 The radiolunate angle is considered normal between 15° of lunate flexion and 20° of lunate extension and is usually about 10° of flexion. The lunocapitate angle is usually equivalent to the radiolunate axis and is abnormal when it exceeds 15°. Three carpal arcs have been described on the PA radiograph and include arc I following the convex curvatures of the proximal row, arc II following the distal concave border of the proximal row, and arc III following the proximal convex curvature of the capital and hamate. 6 Disruption of the arc is indicative of loss of joint integrity (Fig. 6). Carpal height can be calculated by measuring the distance between the base of the third metacarpal and the subchondral region of the distal radius. 7 The ratio of this distance to the length of the third metacarpal is equal to 0.54 +/- 0.03 (Fig. 7). When the entire 3rd metacarpal is not captured on the radiograph, the modified carpal height ratio -- carpal height divided by capitate length -- may be utilized. Normal value is 1.57 +/- 0.05. A Ulnar variance depends on the position of the wrist and should be measured with the wrist in neutral position. Pronation increases the apparent length of the ulna and supination decreases it, and minor changes are noted with changes in shoulder position. The oldest method 8 of measuring ulnar variance consists of drawing a horizontal line perpendicular to the axis of the radius starting from the distal ulnar border of the radius. Ulnar variance is the distance between this line and the ulnar distal rim. Several other methods are described and all seem reliable. 9 , 10 , 11 A power grip PA radiograph may be used to show maximal ulnar positive variance if dynamic ulnar impaction is suspected as relative lengthening of the ulna occurs with pronation and forced finger flexion. 3

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Figure 7

Orthogonal AP and lateral radiographs usually suffice in assessing the long bones of the forearm and upper arm. Occasionally oblique views are necessary to further evaluate subtle abnormities or better assess status of fracture healing.

Orthogonal AP and lateral elbow radiographs can be supplemented with radial head or oblique radiographs for further assessment of occult fracture or early arthropathy. The lateral radiograph obtained in 90 degrees of flexion allows identification of the important fat pads of this joint.

Given the obliquity of the glenohumeral joint, a straight AP radiograph is not orthogonal to the shoulder. Therefore, a true orthogonal radiograph requires an AP radiograph obtained in a 40° posterior oblique position. 12 Two additional orthogonal radiographs can be taken to complete an orthogonal set (Fig. 8) by obtaining an axillary lateral radiograph and a scapular Y radiograph which is acquired with the patient in a 60° anterior oblique position. 13 , 14

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Operating Room Radiation Exposure

Radiation exposure of the hand surgeon during intraoperative imaging has been provided useful information and guidelines to minimize risk. In an early study, mini c-arm fluoroscopy exposed the surgeon’s hands to an average of 20mrem/case, B a dose similar to a chest radiograph. A more recent study documented an even lower exposure of 6.3 mrem/case. C Both of these studies documented an exposure less than the annual recommended limit of less than 50,000 mrem/year. Exposure is minimized by decreasing fluoroscopy time, increasing distance/keeping the surgeons’ hands out of the image, and shielding. Additionally, exposure may be limited if the surgeon stands behind the image intensifier (Fig. A). D


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Computed Tomography

Modern CT utilizing multidetector computed tomography (MDCT) technology demonstrates high spatial resolution and superior osseous detail with the ability to acquire an isotropic volumetric dataset through a region of interest that can be reconstructed into any plane (typically in the standard three orthogonal planes—axial, sagittal, and coronal) relative to the anatomy of interest. Curvilinear reformats can be performed to further define anatomy or pathology. Although the contrast resolution is improved as compared to radiographs, it is still inferior to that of MR and as such it is not ideal for further investigation of soft tissue abnormalities. Reconstruction algorithms can be applied to the dataset to highlight osseous or soft tissue detail. CT is ideally suited for assessment of occult fractures, documenting and characterizing complex fractures, evaluating healing (Fig. 9), evaluating malrotation, evaluating joint subluxations, further characterizing osteoarthritis, and identifying the presence of loose bodies. It also is ideally suited for characterization of osseous lesions when calcified matrix is present or for characterization of calcifications in soft tissues. Volume rendered 3-dimensional reconstructions 15 , 16 can be generated with commercially available software which can be an adjunct in assessment of complex fracture patterns or complex anatomy, preoperative planning including virtual “disarticulation” (Fig. 10), or for global display of advanced arthritis/osseous deformities. The greatest limitation of CT is the risk of ionizing radiation. However, the effective doses for CT of the upper extremity are very low ranging from 0.03 millisievert for the hand up to 2.06 millisievert for the shoulder; note that yearly background radiation from natural sources is 3 millisievert. 17

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Ideally with CT imaging of the hand and wrist, the patient is positioned with the arm above the head lying prone in a superman position. For CT imaging of the elbow the patient is supine with the arm extended above the head and the elbow straight. For the shoulder the patient’s arm is positioned at the side with palm facing up. The contralateral arm ideally is raised.

MDCT arthrography is a powerful tool for detection of traumatic and degenerative lesions of a joint. It is performed following the intra-articular administration of iodinated contrast usually combined with anesthetic into the joint of interest. 18 For the wrist, double and triple compartment injections have been utilized, but monoarticular arthro-CT alone is a reliable alternative to MRI in detection of ligamentous injury. 19 MDCT is more accurate than MRI or MR arthrography in discerning partial tears of the scapholunate and lunotriquetral ligaments; however, it is limited for assessment of surrounding soft tissues and marrow abnormalities (Fig. 11). 20 It is comparable to MR arthrography in detection of cartilaginous lesions in the elbow and a valid alternative for imaging the shoulder in patients with contraindications to MR, after failed MR, or who are postoperative (Fig. 12). 21 , 22

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CT angiography is capable of providing high-resolution vascular imaging in cases of trauma or vascular insufficiency (Fig. 13). It has several advantages over traditional angiography including more anatomic and spatial detail, elimination of arterial puncture risks, decreased radiation exposure, and lower cost. 23 , 24

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Magnetic Resonance Imaging

MR imaging plays an important role in assessment of internal derangement of joints and soft tissue disorders. It provides superb contrast resolution for evaluating soft tissue pathology and identifying subtle marrow processes but is still inferior to CT in evaluating cortical bone and in its inherent spatial resolution, although MR is continually advancing. Improvements in magnet quality, magnet strength, surface coil design, and sequence design have made high resolution MR imaging with high signal-to-noise ratio (SNR) images routine. This is especially important in the hand and wrist where structures are no greater than 1–2 mm thick (Fig. 14). 25 To maximize imaging parameters it is important to utilize dedicated surface coils and targeted field of views (FOV). Numerous surface coils are available to choose from and include quadrature and multichannel phased array coils as well as microscopy coils. In general the smaller the coil, the higher the resolution possible, but a trade off exists as FOV tend to be smaller. In general >20 cm FOV are used in screening imaging of the forearm and upper arm, 14–18 cm FOV for the shoulder, 12–16 cm FOV for the elbow, 10–14 cm for the wrist, and as low as 6 cm for targeted finger applications using microscopy coils. Patients should be imaged with the area of interest in the isocenter of the magnet whenever possible to achieve the best imaging quality: this means arms overhead for imaging of the elbow, wrist, and hand. Patient comfort needs to be balanced in order to minimize motion and therefore in some patients imaging of the elbow, wrist, or hand by the side may be performed to maximize image quality. Typically the shoulder is imaged with the arm by the side and with thumb or palm up to ensure proper rotation of the humerus. Specialized or stress positioning can be used for improved visualization of specific structures, such as an abduction and external rotation (ABER) position for evaluation of the anteroinferior labroligamentous complex (Fig. 15), a flexion abduction supination (FABS) position for evaluation of the distal long head biceps tendon (Fig. 16), and supination/pronation axial imaging of the wrist for evaluation of the extensor carpi ulnaris subsheath (Fig. 17). 26 , 27

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Current state of the art 3.0 tesla (T) systems provide a twofold increase in SNR, which can be used to increase spatial resolution or decrease imaging times. 28 In the future, higher strength MR systems up to 7.0 T and 8.0 T may become state of the art for peripheral musculoskeletal applications allowing for even higher spatial resolution, although at the current time these are purely investigational with technical limitations yet to be overcome. 29 , 30 Limitations of higher strength systems include increased specific absorption rates (SAR)—the measurement of the energy deposited by a radiofrequency field in a given mass of tissue—that may result in body heating, increased flow artifacts, and increased magnetic susceptibility issues. This latter problem limits use of 3.0-T MR imaging in patients with metallic hardware at the site of interest.

Direct MR arthrography has clearly proven superior to MR imaging alone in evaluating joint pathology of the upper extremity whether it be shoulder labroligamentous or rotator cuff tears (Fig. 18), elbow collateral ligament injury (Fig. 19), wrist intrinsic ligament injury (Fig. 20), or in evaluation of hyaline cartilage injury. 20 , 31 , 32 , 33 Despite this evidence, controversies exist. For the shoulder several authors have questioned the modest added benefit of arthrography over conventional MR at both 1.5 T and 3.0 T given its added cost and invasiveness. 34 , 35 , 36 Magee in 2009 stated that the fluid distension of MR athrography simulates the condition present during arthroscopy and allows labral tears to be better identified. In the wrist, no consensus exists regarding whether single radiocarpal versus triple compartment injection MR arthrography should be performed, or whether the slight improvement in accuracy of MR arthrography over conventional MR is justified. 37 , 38 , 39

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Indirect MR arthrography, which is based on the premise that contrast material will diffuse into the joint space over time after intravenous administration, has been shown as an alternate to direct MR arthrography. Although it suffers from less consistent enhancement of the joint space and the inability to distend the joint capsule, it has been shown to be equivalent to MR arthrography in assessing shoulder labroligamentous injuries and rotator cuff tears. 40 , 41 , 42 Its value as compared to direct MR arthrography in assessing hyaline articular cartilage is uncertain. In the wrist, indirect MR arthrography demonstrates improved ability to detect TFCC tears but is no better than conventional MR for the evaluation of the scapholunate or lunotriquetral ligaments. 43 Overall its usefulness as compared to direct MR arthrography is controversial. 44

Recent advances in MR angiography have allowed for 4-dimensional MR angiography (the addition of temporal resolution to anatomic imaging). 45 Both non-contrast and contrast techniques are available and allow one to evaluate the hemodynamics of complex upper extremity vascular disease in a similar fashion as digital subtraction angiography without compromising spatial resolution (Fig. 21).

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Technological advances in 3.0-T MR imaging have allowed the generation of high resolution and high contrast images of peripheral nerves making it ideal for preoperative evaluation of suspected peripheral neuropathies. 46 , 47 MR neurography provides better anatomic localization of the site of entrapment than electromyogram (EMG) studies as well as information regarding the underlying causative lesion. 48 Three types of MR techniques are used in peripheral nerve imaging and include diffusion-based techniques, T2-based techniques, and hybrid techniques. At the higher field strength 3 T magnets, the acquisition of 3-dimentional datasets with isotropic voxel resolution (0.4–1 mm in plane resolution) is possible utilizing T2 based sequences such as 3D SPAIR (spectral adiabatic inversion recovery; Siemens, Erlangen, Germany), SPACE (sampling perfection with application optimized contrasts by using different flip angle evolutions; Siemens, Erlangen, Germany) and 3D STIR (short-tau inversion recovery) SPACE. 46 These datasets can then be reconstructed into any plane, including curvilinear planes for optimal assessment of the nerve in question. The hybrid approach utilizes the 3-dimensional DW-PSIF (diffusion weighted reversed fast imaging with steady-state free precession) sequence and has elements of diffusion weighting and T2 weighting as well as improved visualization of peripheral nerves due to selective suppression of vascular flow. 49 Normal nerves demonstrate a fascicular appearance and are isointense to minimally hyperintense to muscle on T2 weighted sequences and maintain a preserved plane of fat surrounding the nerve on T1 weighted images. Abnormal nerves may show focal or diffuse enlargement, T2 hyperintensity approaching adjacent vessels, fascicular abnormality, course deviations, discontinuity, loss of surrounding T1 fat plane or abnormal enhancement (Fig. 22). 50 MR also allows for the identification of secondary changes such as intrinsic muscle edema in acute/subacute nerve injury and lipoatrophy in more chronic injury. 51

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Ultrasound (US)

Musculoskeletal ultrasound of the upper extremity is increasingly used in clinical practice. New ultra-high frequency probes with smaller footprints have led to improved image quality, particularly when assessing small parts such as the hand and wrist. 52 Ultrasound offers several advantages including lack of ionizing radiation, noninvasiveness, portability, and low cost; it also allows for comparative and dynamic studies to be easily performed.

Ultrasound is an effective imaging modality to evaluate rotator and non-rotator cuff disorders with the ability to both complement MR and provide a viable alternative to MR. 53 Ultrasound reliably identifies pathology of tendons (Fig. 23), ligaments, vessels, and nerves and is well suited for imaging the relatively superficial structures of the upper extremity. 54 , 55 , 56 The key advantages of ultrasound include the ability to dynamically image suspected snapping or subluxing tendons such as the “snapping triceps syndrome” and allow dynamic stress of ligaments during imaging which improves accuracy of diagnosing tendon or ligament injury. 57 , 58 Disadvantages of ultrasound are its high operator dependence and reproducibility in nonexperienced hands, as well as limited visualization of deeper structures when using high frequency probes necessary for better resolution in musculoskeletal applications.

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Ultrasound has emerged as the study of choice for detection and localization of radiolucent soft-tissue foreign bodies and aid in assessment of their associated complications. 59

Sonoelastography is a newer technique to assess the inherent structure of tissue and is based on the principle of tissue deformity with the application of pressure. Softer tissues will deform more than hard tissues, and therefore sonoelastrography is a noninvasive means of garnering information regarding the stiffness/elasticity of the tissue. 60 It has been shown that healthy tendons are harder or stiffer while unhealthy tendons are softer. 61 , 62 These findings are typically displayed on an elastogram (a color-coded image superimposed on the gray-scale image). Sonoelastography holds great promise in quantifying alterations in tissue elasticity that occur with tendon degeneration or other pathological processes. 63

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Miscellaneous Techniques

Bone scintigraphy has historically played an important role in the work-up of orthopedic disorders. It has high sensitivity given it can detect altered bone metabolism before morphologic changes are detected with radiography but low specificity because if its poor depiction of morphologic features. 64 , 65 , 66 , 67 , 68 Bone scintigraphy has been used in clinical practice for evaluation of osseous metastic disease, specific primary bone tumors (e.g., osteoid osteoma), evaluation of occult osseous trauma or injury, infection, arthritis, bone infraction, and metabolic bone diseases. Bone scintigraphy has a high negative predictive value is assessing osseous disorders. On the other hand, a positive result, although it may help localization, often requires further imaging with MR or CT to further characterize the abnormality.

Combining SPECT (single-photon emission computed tomography) with CT in so-called hybrid imaging has been demonstrated to considerably increase diagnostic accuracy over scintigraphy or stand-alone SPECT in the care of patients with orthopedic disorders of the peripheral extremities, especially tumor-like lesions, suspected osteomyelitis, and traumatic bone changes. 69

Digital tomosynthesis (DTS) is a technique in which multiple low-dose exposures are acquired from a linear x-ray tube sweep toward a stationary digital detector in a selected body part. 70 In essence DTS is a process that reconstructs 3-dimensional images from 2-dimensional scans. This method has been extensively used in mammography but has recently been described in musculoskeletal applications. In particular, it is demonstrated to be a viable alternative in detecting radiograph occult scaphoid fractures. 71 , 72 Its exact role in the imaging algorithm of suspected occult osseous injury is yet to be determined.

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Image-guided Intervention

Image-guided intervention can be performed using any imaging modality but is most often performed under ultrasound or fluoroscopic guidance in the upper extremity. It is a burgeoning frontier that can be used both for diagnostic and therapeutic reasons. 73 Ultrasound-guided arthrocentesis has been shown to produce a higher success rate than blind arthrocentesis, particularly in smaller joints of the hand. 74 Image-guided percutaneous biopsy, image-guided aspiration and drainage procedures (ganglion cyst, abcesses, calcific tendinitis), and image-guided ablation of soft tissue and osseous lesions (i.e., osteoid osteoma) have been well described with excellent outcomes. 75 , 76 , 77 , 78 , 79 , 80 Other image-guided procedures including percutaneous tenotomy and directed therapeutic injections of tendons, ligaments and joints have been described with overall mixed results (Fig. 24). 81 , 82 , 83 Lastly, percutaneous image-guided sclerotherapy has demonstrated efficacy with low complications in the treatment of peripheral low flow vascular malformations. 84

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Specific Pathology

 
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Osseous Injury and Healing

Radiography is still the preferred initial exam of choice in evaluation of suspected osseous injury. 85 , 86 , 87 This is best illustrated in the scenario of suspected carpal bone fractures. The prevalence of occult scaphoid fractures following abnormal initial radiography ranges between 9% and 33%. 88 , 89 Multiple imaging protocols exist including the use of repeat radiography in 1–2 weeks. Early bone scintigraphy, digital tomosynthesis, and even targeted ultrasound have demonstrated clinical impact by allowing the early detection of fracture without unnecessary immobilization. 90 , 91 , 93

Although CT has been demonstrated to be superior to MR in identifying occult cortical injury, the evidence-based literature suggest that MR imaging is most suitable due to the ability to evaluate the bone marrow directly, diagnose trabecular injury, and identify other associated soft tissue injuries (Fig. 25). 94 , 95 , 96 This algorithm can be applied throughout the upper extremity. Similarly for a suspected stress injury of the upper extremity MR is best suited as it can depict early bone marrow changes, has high specificity, and can provide information regarding additional associated injuries. 97

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MDCT is the gold standard for evaluation of fracture healing when radiographs are indeterminate and clinical suspicion warrants further investigation. 98 It allows for high-quality multiplanar reformatting and visualization of the fracture in a true orthogonal plane.

Assessment of the viability status of the proximal pole of the scaphoid is an important clinical scenario with avascular necrosis reported to occur in 13–50% of scaphoid fractures and predominantly in fractures involving the proximal fifth of the scaphoid. 99 Both routine MR and dynamic gadolinium enhanced MR have been described to evaluate proximal pole scaphoid viability. Although the literature is inconsistent, recent literature suggests that routine unenhanced imaging utilizing the criterion of diffusely decreased T1 signal, equal to or less than that of skeletal muscle in the proximal pole of the scaphoid, demonstrates a high specificity and high positive predictive value (PPV) with moderately high accuracy; the diagnostic performance of dynamic contrast enhanced MR was not superior to that of the standard unenhanced MR. 100 , 101

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Soft Tissue Injury and Instability

Both MR imaging and ultrasonography are well suited for evaluation of upper extremity soft tissue injury in myriad clinical scenarios including suspected muscle, tendinous, ligamentous, or nerve injury. In evaluation of rotator cuff tears, MR arthrography is the most sensitive and specific technique for diagnosing both full- and partial-thickness rotator cuff tears, with ultrasound and MRI demonstrating comparable performance. 102 In evaluation of the shoulder labrum, MR arthrography at 3.0 T is superior to conventional MR with MDCT arthrography remaining a valid alternative for shoulder imaging in patients with contraindication to MRI, after failed MRI, or who are postoperative. 22 , 30

In the elbow the accuracy of ultrasound for diagnosing lateral epicondylitis is variable in the literature. 103 Ultrasound has been shown to have a high false-positive rate in evaluating lateral epicondylitis. 104 However, combining Doppler imaging with gray-scale techniques may allow one to conclusively rule out lateral epicondylitis. 105 Generalizing this concept, ultrasound is best in targeted applications to confirm or exclude a diagnosis, and in patients with contraindication to MR. In evaluation of elbow pain in the throwing athlete, MR arthrography is the gold standard of imaging 106 although controversy exists regarding whether its added benefit outweighs its risk, cost, and invasiveness.

In evaluating the wrist, the literature is muddled in large part because of the multitude of techniques employed during the rapid advancement of technology. This makes the comparison of studies difficult. 3.0-T MRI is the current state of the art 107 and MR arthrography further improves the MR evaluation of intra-articular pathology (Fig. 26). However, consensus has not been reached regarding whether its slightly improved sensitivity justifies its use. This is further illustrated in midcarpal instability, where although ligamentous defects can be demonstrated with MR, the accuracy of these techniques and the role they play in the management of patients has yet to be determined. 108 MDCT arthrography is a valid alternative technique in patients who have contraindications to MR or who are postoperative. Targeted ultrasound in experienced hands can be of value in evaluation of intrinsic and extrinsic ligament injury as well as in peripheral nerve entrapments and tendon injury (Fig. 27). 109 , 110 , 111 , 112

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Arthritis

Traditionally radiographs have been used to diagnose and follow arthritis. While still widely used, MR has proven to be the method of choice in imaging arthritis and, in particular, inflammatory arthropathy as it allows for early diagnosis where treatment will be most efficacious. 113 It can identify and quantify synovitis, bone marrow edema, early erosions, and other associated abnormalities such as tenosynovitis (Fig. 28). 114 Targeted ultrasound with Doppler techniques has shown clinical benefit with improved results over radiography alone. 115

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Summary

While imaging has revolutionized our ability to diagnose and characterize pathology, it is important to keep in mind that some conditions may not immediately require imaging to reach the diagnosis. Each case is unique and there are often many literature-supported options in the imaging evaluation of pathology. When determining the best modality for solving a clinical problem, the local availability and experience of the radiologist (as well as comfort of the surgeon in the modality) need to be considered. A negative imaging study does not always infer the clinical diagnosis is wrong; on the other hand, a positive imaging study does not always correlate with the clinical diagnosis. This is summed up best by C.L. Colton who stated, “To attempt to define surgery as pure science is a delusion; it is a scientific art... [and] a tool in the hands of the artist.” 116

 

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