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1 Department of Radiology, St. Paul's Hospital, 1081 Burrard St., Vancouver, BC
V6Z 1Y6, Canada.
2 Department of Surgery, St. Paul's Hospital, BC V6Z 1Y6, Canada.
Received April 10, 2003;
accepted after revision August 27, 2003.
Address correspondence to A. D. Wong
(Twong{at}providencehealth.bc.ca).
Abstract
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SUBJECTS AND METHODS. Thirteen patients with clinically suspected triangular fibrocartilage tears prospectively underwent sonography, followed by MRI, of their wrists. Triangular fibrocartilage tears were classified as predominantly ulnar or predominantly radial. Only the surgeon was aware of the results of both studies, and eight patients subsequently underwent arthroscopy. The findings of the different techniques were compared.
RESULTS. For the presence or absence of a tear, seven (87.5%) of eight sonographic examinations correlated with arthroscopy, and 11 (84.6%) of 13 sonographic examinations correlated with MRI. Sonography missed one small radial tear that was detected at arthroscopy and MRI, but sonography showed an ulnar tear in triangular fibrocartilage that appeared normal on MRI.
CONCLUSION. High-resolution sonography shows good correlation with MRI and arthroscopy for the evaluation of triangular fibrocartilage tears. Sonography has the potential to be a rapid and cost-effective means of diagnosing tears of the triangular fibrocartilage, particularly those involving the ulnar aspect of the cartilage.
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Sonography of the wrist is frequently performed to evaluate pain and swelling, predominantly concentrating on extraarticular abnormalities, such as tenosynovitis or ganglia [7–9]. Chiou et al. [10] compared high-resolution sonographic findings of the triangular fibrocartilage with arthrography. Besides that study, little attention has been paid to sonography of the triangular fibrocartilage, despite improvements in technology.
The aim of our study was to compare the findings of high-resolution sonography of the triangular fibrocartilage with the findings of MRI and the gold standard, arthroscopy.
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Sonography was performed with a 12-5–MHz linear array probe using real-time compound spatial imaging (ATL, Bothell, WA). The same radiologist obtained all scans. Unlike scans obtained for previous reports [10], scans for this study were obtained with the patient's hand prone in mild radial deviation using the extensor carpi ulnaris tendon as an acoustic window (Fig. 1). Scanning was performed in the transverse and longitudinal planes. For the longitudinal scans, the probe was angled toward the radial aspect and then was swept to the ulnar aspect of the triangular fibrocartilage (Fig. 2). A tear (i.e., positive findings on a scan) was diagnosed when a hypoechoic line was present in the normally homogeneous hyperechoic cartilage (Figs. 3 and 4A, 4B). The site of the tear was designated as primarily ulnar or primarily radial, although overlap occurred with large transverse tears. In contrast to Chiou et al. [10], we did not measure the dimensions of the triangular fibrocartilage. When a questionable abnormality was present, comparison was made with the asymptomatic side. In general, examination time was less than 5 min.
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All 13 patients subsequently underwent MRI. This examination was performed using a 0.5-T magnet (General Electric Medical Systems, Milwaukee, WI) with dual 3-inch (8-cm) surface coils. Coronal T1-weighted, axial proton density–weighted, and T2-weighted sequences were performed. The primary diagnostic sequence, however, was a 3D coronal gradient-recalled acquisition in the steady state with contiguous 1.5-mm slices (TR/TE, 25/45; flip angle, 15°; field of view, 16 cm; matrix, 256 x 256; and number of excitations, 2). The scans were interpreted by a radiologist who was unaware of the results of sonography. The site of the tear was specified in a similar fashion to the sonogram.
Eight patients then underwent arthroscopy. These procedures were performed by a hand surgeon in a standard fashion. The surgeon was aware of the results of both sonography and MRI preoperatively.
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Thirteen patients underwent sonography and MRI. MRI showed six ulnar tears, three radial tears, and four normal triangular fibrocartilages. Sonography showed all the ulnar tears, and arthroscopy, two of the three radial tears. Sonography also revealed a possible ulnar tear in one patient who had normal findings at MRI. This patient did not undergo arthroscopy.
Our results can be summarized as follows: for the presence or absence of a tear, seven (87.5%) of eight sonographic examinations correlated with arthroscopy, and 11 (84.6%) of 13 sonographic examinations correlated with MRI. Sonography missed one small radial tear (detected at arthroscopy and MRI) and also showed an ulnar tear in a triangular fibrocartilage that appeared to be normal on MRI. However, no surgical confirmation was available for the latter case.
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The significance of triangular fibrocartilage perforations also generates debate. Perforations have been shown in asymptomatic wrists [2, 3], and whether these perforations are congenital or due to normal aging and degeneration is unclear [15, 16]. It is generally accepted that triangular fibrocartilage tears, particularly in young patients, are a source of symptoms and that these patients may benefit from surgery.
It was against this background that we decided to perform our study. Sonography provides a rapid, readily available, noninvasive, and inexpensive technique for examining superficial structures with excellent resolution. However, despite the growing use of wrist sonography, little attention has been paid to the triangular fibrocartilage. Chiou et al. [10], using 7- and 10-MHz probes, described the normal and pathologic appearances of the triangular fibrocartilage on sonography compared with arthrography. Tears presented as hypoechoic areas within the cartilage or, more commonly, as thinning of the triangular fibrocartilage. Chiou et al. scanned over the volar aspect of the wrist. We found scanning through the extensor carpi ulnaris tendon to be more helpful and, with the benefit of high-resolution probes and real-time spatial compound imaging, we thought that we could visualize tears directly as hypoechoic lines. We therefore did not measure the thickness of the triangular fibrocartilage, although conceivably this measurement could further improve diagnostic accuracy. We found the longitudinal scans to be the most helpful. The tears could also be visualized with transverse scanning, but these scans did not provide additional information about the triangular fibrocartilage. The difference between these views may be analogous to comparing coronal and axial MRIs of the cartilage. One patient had a partial tear of the extensor carpi ulnaris; this partial tear was readily visualized because the tendon was used as the acoustic window (Fig. 5A, 5B).
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Rather than attempt to classify triangular fibrocartilage tears according to the Palmer classification [17], we designated tears as primarily radial or ulnar because this distinction has clinical relevance. In our institution, ulnar tears are repaired and sutured, whereas radial tears are débrided. This information allows improved preoperative patient consent and planning.
A small tear at the radial insertion of the triangular fibrocartilage was missed at sonography, and it is this area—deep within the joint—where sonography performs less well. Radial deviation helped maximize visualization, and although sonographic arthrography may also improve radial views, the investigation then becomes more time-consuming and invasive. The ulnar aspect of the triangular fibrocartilage, however, is well visualized on sonography; all ulnar tears in this study were diagnosed at sonography. Interestingly, defects in this area are least well seen at MRI and arthrography [2, 6, 18], which suggests that sonography may complement these investigations depending on the location of the lesion.
There are a number of limitations of this study and indeed of the technique. The study group was selected and did not include asymptomatic patients with normal triangular fibrocartilage. However, this study was primarily clinical, and one of the strengths of sonography is the additional clinical information gained from real-time examination, thereby allowing one to concentrate on the relevant area. In addition, the high prevalence of findings in asymptomatic wrists on MRI and arthrography and the impossibility of performing arthroscopy on asymptomatic patients render assessment of true normal anatomy difficult.
The small number of patients precludes statistical inference, but we believe that our results, if taken as those of a prospective pilot study, are promising and that the technique deserves further evaluation in a larger group. Fears have been expressed that when one concentrates on the triangular fibrocartilage, other abnormalities—including synovitis, chondromalacia, and ligamentous injury—may be missed. This concern is always present with musculoskeletal sonography, but clinical evaluation at the time of scanning allows focused examination. Ideally, the patient should also have radiographs and stress views in cases of suspected instability. Arthrography and MRI may also miss additional abnormalities [1, 14].
In conclusion, to our knowledge, this study is the first to compare sonography of the triangular fibrocartilage with arthroscopy and MRI. We emphasized direct visualization of triangular fibrocartilage tears rather than cartilage measurement. Although tears of the radial insertion of the triangular fibrocartilage may be difficult to see, the ulnar aspect is well visualized and is an area in which other imaging techniques perform poorly. We believe sonography shows good correlation with MRI and arthroscopy for the evaluation of the triangular fibrocartilage and that high-resolution sonography will prove to be a rapid, noninvasive means of diagnosing tears of the triangular fibrocartilage.
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