Computed tomography for the detection of distal radioulnar joint instability: normal variation and reliability of four CT scoring systems in 46 patients (original) (raw)
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Journal of Hand Surgery (European Volume), 2017
This study evaluated the value of computed tomography scans for the diagnosis of distal radioulnar joint instability. A total of 46 patients, conservatively treated for a unilateral distal radius fracture, were evaluated. Clinical instability was tested using the stress test and clunk test. A computed tomography scan of both wrists was performed in pronation and supination. Two independent observers reviewed the computed tomography scans using: the radioulnar line, subluxation ratio, epicentre and radioulnar ratio methods. Radiological distal radioulnar joint instability was assessed by comparing the measurements of the injured wrist with those of the contralateral uninjured wrists. A total of 22 patients had clinical instability of whom 12 suffered from pain in the injured wrist. Distal radioulnar joint instability was diagnosed on computed tomography in 29 patients. Reliability analysis between clinical and radiological evaluations showed at best moderate, but generally poor agreement. The diagnostic ability of computed tomography for identifying distal radioulnar joint instability seems limited.
Clinical and non-clinical aspects of distal radioulnar joint instability
The open orthopaedics journal, 2012
Untreated distal radioulnar joint (DRUJ) injuries can give rise to long lasting complaints. Although common, diagnosis and treatment of DRUJ injuries remains a challenge. The articulating anatomy of the distal radius and ulna, among others, enables an extensive range of forearm pronosupination movements. Stabilization of this joint is provided by both intrinsic and extrinsic stabilizers and the joint capsule. These structures transmit the load and prevent the DRUJ from luxation during movement. Several clinical tests have been suggested to determine static or dynamic DRUJ stability, but their predictive value is unclear. Radiologic evaluation of DRUJ instability begins with conventional radiographs in anterioposterior and true lateral view. If not conclusive, CT-scan seems to be the best additional modality to evaluate the osseous structures. MRI has proven to be more sensitive and specific for TFCC tears, potentially causing DRUJ instability. DRUJ instability may remain asymptomati...
Dynamic CT technique for assessment of wrist joint instabilities
Medical Physics, 2011
To develop a 4D [three-dimensional (3D) þ time] CT technique to capture high spatial and temporal resolution images of wrist joint motion so that dynamic joint instabilities can be detected before the development of static joint instability and onset of osteoarthritis (OA). Methods: A cadaveric wrist was mounted onto a custom motion simulator and scanned with a dual source CT scanner during radial-ulnar deviation. A dynamic 4D CT technique was utilized to reconstruct images at 20 equidistant time points from one motion cycle. 3D images of carpal bones were generated using volume rendering techniques (VRT) at each of the 20 time points and then 4D movies were generated to depict the dynamic joint motion. The same cadaveric wrist was also scanned after cutting all portions of the scapholunate interosseus ligament to simulate scapholunate joint instability. Image quality were assessed on an ordinal scale (1-4, 4 being excellent) by three experienced orthopedic surgeons (specialized in hand surgery) by scoring 2D axial images. Dynamic instability was evaluated by the same surgeons by comparing the two 4D movies of joint motion. Finally, dose reduction was investigated using the cadaveric wrist by scanning at different dose levels to determine the lowest radiation dose that did not substantially alter diagnostic image quality. Results: The mean image quality scores for dynamic and static CT images were 3.7 and 4.0, respectively. The carpal bones, distal radius and ulna, and joint spaces were clearly delineated in the 3D VRT images, without motion blurring or banding artifacts, at all time points during the motion cycle. Appropriate viewing angles could be interactively selected to view any articulating structure using different 3D processing techniques. The motion of each carpal bone and the relative motion among the carpal bones were easily observed in the 4D movies. Joint instability was correctly and easily detected in the scan performed after the ligament was cut by observing the relative motion between the scaphoid and lunate bones. Diagnostic capability was not sacrificed with a volume CT dose index (CTDI vol) as low as 18 mGy for the whole scan, with estimated skin dose of approximately 33 mGy, which is much lower than the threshold for transient skin erythema (2000 mGy). Conclusions: The proposed dynamic 4D CT imaging technique generated high spatial and high temporal resolution images without requiring periodic joint motion. Preliminary results from this cadaveric study demonstrate the feasibility of detecting joint instability using this technique. V
Comparison of Plain X-Rays and Computed Tomography for Assessing Distal Radioulnar Joint Inclination
Purpose To compare the inclination of the distal radioulnar joint (DRUJ) on computed to-mography (CT) and plain radiography (XR) in order to assess the effect of narrowing the range of inclination used in the original Tolat classification system to identify potentially problematic reverse oblique DRUJs. Methods Two independent investigators compared the angle of inclination and Tolat type on matched wrist XRs in the coronal plane and CTs of the same patients with normal DRUJs. The degree of agreement between XR and CT was determined. Inter-and intra-observer reliabilities were calculated. The prevalence of the 3 inclination types of the DRUJs using Tolat's definition was recorded. Their original quantitative definition of the parallel Tolat type 1 DRUJ included all DRUJs with a measured inclination of AE10. We noted and compared the resultant changes in prevalence of the different DRUJ types after narrowing the inclination range to AE5 and AE3. Results Highly significant correlation between CT and XR measurements were found for both observers. Despite this, the limits of agreement between CT and XR in determining the sigmoid notch inclination was e9 to 11 (AE2 standard deviations from the mean difference). When measured from the CTs and using Tolat's original algorithm, the prevalence of Tolat type 1 DRUJ was 47% (N ¼ 34), type 2 was 51% (N ¼ 37), and type 3 was 1% (N ¼ 1). These percentages changed to 7% (N ¼ 5) for type 1, 78% (N ¼ 56) for type 2, and 15% (N ¼ 11) for type 3 when applying narrower ranges of inclination. Conclusions Narrowing the range of sigmoid notch inclination that defines type 1 (parallel) DRUJs when using CT provided a more accurate representation of the morphological types. It revealed an increased number of potentially problematic type 3 DRUJs. However, the statistical limits of agreement between CT and XR suggested that high-resolution 3-dimensional imaging is required to apply the new algorithm. (J Hand Surg Am. 2014;-(-):-e-. Type of study/level of evidence Diagnostic II.
Journal of Wrist Surgery
Background Four-dimensional computed tomography (4D CT) is a rapidly developing diagnostic tool in the assessment of dynamic upper limb disorders. Functional wrist anatomy is incompletely understood, and traditional imaging methods are often insufficient in the diagnosis of dynamic disorders. Technique This study has developed a protocol for 4D CT of the wrist, with the aim of reviewing the clinical utility of this technology in surgical assessment. A Toshiba Aquilion One Vision scanner was used in the protocol, in which two- and three-dimensional “static” images, as well as 4D “dynamic” images were produced and assessed in the clinical context of each patient. These consisted of a series of multiple 7-second movement clips exploring the nature and range of joint motion. Patients and Methods Nineteen patients with symptoms of dynamic instability were included in the study. Patients were assessed clinically by two orthopaedic surgeons, and qualitative data were obtained from radiolog...
The Journal of Hand Surgery, 1986
The kinematics of the normal distal radioulnar joint (DRUJ) and the stabilizing function of various structures about the DRUJ were investigated in a study involving six fresh frozen cadavers. Sequential division of the supporting structures was correlated with abnormalities detected by computerized tomography (CT). The infratendinous portion of the extensor carpi ulnaris is a major restraint against dorsal and palmar subluxation. Division of the radioulnar ligaments and triangular fibrocartilage alone produced only minor changes. Lateral displacement was controlled by the interosseous membrane and the pronator quadratus. CT is a useful method of gaining objective and quantifiable information regarding incongruity of the DRUJ. Three scans-one each in pronation, neutral, and supination-would be optimal. The pronation scan is likely to detect palmar subluxation, while the neutral scan is sensitive for dorsal subluxation and DRUJ diastasis. The supination view should confirm reduction of any subluxation. An important observation of this study was the spontaneous reduction of palmar, dorsal, and lateral displacement in supination. This suggests that immobilization in supination may be indicated in cases of acute DRUJ injury. (J HAND SURG 11A:711-17,
Skeletal Radiology, 2018
Distal radioulnar joint (DRUJ) dysfunction is a common cause of ulnar sided wrist pain. Physical examination yields only subtle clues towards the underlying etiology. Thus, imaging is commonly obtained towards an improved characterization of DRUJ pathology, especially multimodality imaging, which is frequently resorted to arrive at an accurate diagnosis. With increasing use of advanced MRI and CT techniques, DRUJ imaging has become an important part of a musculoskeletal radiologist's practice. This article discusses the normal anatomy and biomechanics of the DRUJ, illustrates common clinical abnormalities, and provides a comprehensive overview of the imaging evaluation with an insight into the role of advanced cross-sectional modalities in this domain.