Magnetic resonance imaging of the dromedary camel carpus.

BACKGROUND: The dromedary camel (Camelus dromedarius) carpal joint presents multiple joints and constitutes several bones and soft tissues. Radiography and/or ultrasonography of the carpus are challenging due to structural superimposition. High-field magnetic resonance imaging (MRI) technique precludes superimposed tissues and offers high soft tissue contrast in multiple sequences and planes. Hence, understanding the normal MRI anatomy is crucial during clinical investigations. Magnetic resonance imaging is highly sensitive for investigation of soft tissues and articular cartilage; therefore, it is extensively used for outlining joint anatomy and evaluation of a wide range of musculoskeletal conditions. MRI images of a specific anatomical region acquired by using multiple sequences in various planes are necessary for a complete MRI examination. Given the dearth of information on the MRI features of the dromedary camel carpus, the current study demonstrates the MRI appearance of the clinically significant structures in the camel carpus in various sequences and planes using a high-field 1.5 Tesla superconducting magnet. For this purpose, twelve cadaveric forelimbs, obtained from 6 clinically sound lameness free adult dromedary camels, were examined. RESULTS: The cortex and medulla of the radius, carpal bones and metacarpus were evaluated. Articular cartilage of the carpal joints was depicted and showed intermediate intensity. Carpal tendons expressed lower signal intensity in all pulse sequences. The collateral and inter-carpal ligaments showed mixed signal intensity. CONCLUSIONS: The obtained data outlines the validation of MRI for investigation of the camel carpus and could set as a reference for interpretation in clinical patients.

Osteoid osteoma in the bones of the hand: a systematic literature review.

INTRODUCTION: Osteoid osteoma (OO) is a common benign bone tumor. OO is observed most frequently in the long bones, especially in the tibia and femur. When occurring in the bones of the hand, OO can be a diagnostic and therapeutic challenge. The aim of this study was to provide a systematic review of occurrence, symptoms, diagnosis and treatment options regarding OO in hand bones. MATERIALS AND METHODS: We performed a systematic review of the literature. All studies from the online databases PubMed and SpringerLink, which reported cases of osteoid osteomas in the bones of the hand, were included. By summarizing the literature, we evaluated the localization within the hand as well as diagnostic and therapeutic options. RESULTS: We included 133 studies reporting 401 cases. OO was mostly common in the phalanges. The diagnosis was mostly made by CT (computed tomography) scan. Most of the OO were treated surgically by open curettage or en bloc resection. CONCLUSIONS: Osteoid osteomas in the bones of the hand are rare and a delayed diagnosis is common. In cases of pain combined with particular symptoms such as nail hypertrophy and swelling OO should be considered. Of the most used imaging methods, CT scans have the highest sensitivity.

Comparison of radiography and CT for the evaluation of third carpal bone slab fractures in Thoroughbred racehorses.

Slab fractures of the third carpal bone (C3) are a common cause of lameness in Thoroughbred racehorses. Information on fracture morphology is commonly obtained from radiographs or CT. This retrospective, methods comparison aimed to explore the agreement between radiography and CT for imaging C3 slab fractures and discuss the contribution of the latter to clinical case management. Thoroughbred racehorses with a slab or incomplete slab fracture of C3 identified on radiographs that subsequently underwent CT examination were included. Fracture characteristics (location, plane, classification, displacement, comminution) and fracture length as a percentage of the proximodistal length of the bone, termed the proximodistal fracture percentage (PFP) were recorded independently from both modalities and then compared. Across all fractures (n = 82) radiographs and CT showed slight agreement on the presence of comminution (Cohen's Kappa (κ) 0.108, P 0.031) and moderate agreement on fracture displacement (K 0.683, P < 0.001). Computed tomography identified comminution in 49 (59.8%) and displacement in nine (11.0%) fractures that were not detected by radiographs. Half of the fractures were only seen on flexed dorsoproximal-dorsodistal oblique (DPr-DDiO) radiographs and therefore were of unknown length without additional CT imaging. Incomplete fractures that could be measured on radiographs (n = 12) had a median (IQR) PFP of 40% (30%-52%) on radiographs and 53% (38%-59%) on CT, a statistically significant difference (P = 0.026). Radiography and CT showed the poorest agreement when determining the presence of comminution. Additionally, radiography often underestimated the incidence of displacement, and fracture length, and resulted in more fractures being classified as incomplete when compared to CT.

[Arthroplasty of the hand and wrist]. / Endoprothetik an Hand und Handgelenk.

Arthrosis and autoimmune arthritis frequently lead to major impairment of hand function. Primary therapy consists of well- tried conservative treatments and joint preserving surgical options for special indications. In advanced stages silicon spacers remain the gold standard surgical option for replacement of proximal interphalangeal and metacarpophalgeal joints of the fingers. Alternatively, surface replacement prostheses can restore the biomechanical properties of these joints more porperly. In case of the carpometacarpal (CMC) joint of the thumb, arthroplasty is gaining popularity as modern implants show excellent mid-term outcome. Although current forth generation implants for wrist replacement are promising, total wrist arthroplasty is currently reserved for exceptional indications.

3T Magnetic resonance imaging and computed tomography of the bovine carpus.

BACKGROUND: Lameness in cattle is a major health problem and causes great economic losses. Carpal injury is a common cause of forelimb lameness in cattle. Radiography and/or ultrasonography of the carpus is a challenge due to complex anatomy of the joint. Additional imaging using computed tomography (CT) or magnetic resonance imaging (MRI) may be indispensable for reaching a decisive diagnosis. Precise evaluation of the clinical CT and MRI images necessitates an in-depth knowledge of the normal CT and MRI tissue variants. Therefore, our purpose was to provide a detailed description of the normal CT and MRI appearance of the osseous and soft tissue structures of twelve cadaveric bovine carpi using CT and 3 Tesla MRI. Carpi were frozen, transected in sagittal, dorsal and transverse planes then adjoined to their corresponding CT and MRI images. RESULTS: The clinically significant articular and peri-articular structures of the bovine carpus were identified and characterized on the CT and MRI images. CT images provided a remarkable delineation of the cortical, subchondral, and cancellous bone. The high-field 3 Tesla MRI offered high definition and distinction of the delicate soft tissues of the bovine carpus. CONCLUSIONS: 3 Tesla high-field MRI offers new opportunities in soft tissue tomography but cannot be compared with CT in terms of bone imaging. Clinicians have to determine whether CT, MRI or both imaging techniques are required in clinical situations.

The effect of CT and MRI with and without arthrography on the appearance of the feline carpal ligaments.

BACKGROUND: The current diagnosis of feline carpal injuries is based on radiographic examination including stress views and computed tomography; however, these techniques do not allow for direct evaluation of the carpal ligaments. The purpose of this cadaveric study was to assess the ability of CT arthrography (CTA) and MR arthrography (MRA) to provide this information using a single contrast mixture. A protocol for intra-articular injection of the feline carpus was also described. A contrast solution containing gadolinium and iohexol with a 50% gadolinium solution (Magnevist-gadolinium 0.5 mmol/mL diluted to a 0.05 mmol/mL solution) and 50% of iodine (Iohexol-iodine 300mgI/mL) was injected into the antebrachiocarpal and middle carpal joints of feline carpi using fluoroscopic guidance. RESULTS: CTA allowed for identification of intra-articular ligaments and the silhouette of select extra-articular ligaments when there was adequate joint distension, however it was not considered to be superior to MRI. MRA allowed for improved identification of the dorsal radiocarpal, accessorioulnocarpal, accessorioquartile, short ulnar and short radial collateral ligaments. CONCLUSION: In this ex-vivo study, combined CTA and MRA enhanced the appearance of the feline carpal ligaments and may provide a foundation for future studies in the diagnosis of carpal injuries.

A threshold volume of 10 ml is suggested for detecting articular cartilage defects in equine carpal joints using CT arthrography: Ex vivo pilot study.

Computed tomographic arthrography (CTA) has been described as a method for detecting articular cartilage defects in equine carpal joints; however, published studies on the effects of contrast volume for lesion detection are currently lacking. The purpose of this prospective, experimental, pilot study was to determine a threshold volume of iodinated contrast for CTA of the antebrachiocarpal (ABC) and middle carpal (MC) joints for detection of articular cartilage surface defects. Articular cartilage defects were iatrogenically created in the surfaces of the ABC and MC joints of 20 equine cadaver limbs using arthroscopy. Unaltered articular surfaces within some joints acted as controls. Joints were imaged precontrast using multidetector CT. The ABC and MC joints were injected with a 150 mg iodine/ml nonionic contrast medium, in 5 ml increments from 5 to 50 ml per joint with CT performed subsequent to each increment. Cartilage defects were measured grossly using a caliper. Detection (qualitative) and measurement (quantitative) of the defects were independently performed by two board-certified radiologists using medical imaging software. At each volume of contrast, the interrater reliability for gross examination and the two observers in the detection of a defect was calculated (Gwet's AC1). Logistic mixed-effects models of selected volumes, 0, 5, 10, 15, and 50 ml, demonstrated that at 10 ml contrast and above, no statistically significant difference between either observer and gross examination for defect detection was identified for either joint. Findings supported using a dose of 10 ml for 150 mg iodine/ml concentration contrast media when performing CTA of equine carpal joints.

Radiographic characterization of acute scaphoid fractures in children under 11 years of age.

BACKGROUND: Delayed diagnosis of scaphoid fractures can lead to long-term morbidity. While radiography is the preferred screening examination, there is a relative paucity of literature that examines fracture visibility in younger children, who have smaller ossification centers, an abundance of unossified cartilage and fractures that preferentially involve the distal scaphoid. OBJECTIVE: To characterize acute scaphoid fractures in younger children on radiographs with observer agreement and with respect to fracture location. MATERIALS AND METHODS: This institutional review board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPAA)-compliant cross-sectional study included children (≤10 years of age) with acute scaphoid fractures (≤7 days), who underwent radiographic examinations at a tertiary children's hospital between December 2008 and June 2019. Three readers (two pediatric radiologists and one orthopedic surgeon) reviewed each examination to determine fracture visibility on each radiographic view and fracture location. Kruskal-Wallis, Fisher exact and Cochran-Armitage tests were used to compare fracture visibility and location, and Kappa tests were used to calculate observer agreement. RESULTS: Twenty-eight children (15 boys, 13 girls; mean age: 9.5±0.6 years) with 10 (36%) distal corner, 11 (39%) distal body and 7 (25%) mid-body fractures, underwent 7 (25%) 4-view, 18 (64%) 3-view and 3 (11%) 2-view examinations. Twenty-six (93%) fractures were visible on at least one view with six (21%) fractures visible on all available views. No significant association was found between fracture visibility and fracture location (P=0.32). Observer agreement was substantial to almost perfect. CONCLUSION: Only 7% of these acute scaphoid fractures in younger children are inconspicuous on the initial radiographic examination.

Clinical outcomes and complications of pancarpal arthrodesis stabilised with 3.5†mm/2.7†mm locking compression plates with internal additional fixation in 12 dogs.

AIMS: To report the clinical outcomes and complications after the use of 3.5 mm/2.7 mm locking compression plates (LCP) with additional internal fixation for pancarpal arthrodesis (PCA) in dogs. METHODS: This was a retrospective study using medical records from a single orthopaedic referral hospital between December 2015 and April 2018. The inclusion criteria were the use of a dorsally applied LCP for PCA in dogs with a minimum follow-up period of 12 months. Additional crossed 2.7 or 3.5 mm cortical screws or Kirschner wires were placed in all limbs to further stabilise the joints. A light dressing without external coaptation was applied postoperatively to all limbs. Postoperative lameness assessment was recorded at the last clinical evaluation. RESULTS: Twelve dogs with 13 arthrodesed limbs were included, with carpal hyperextension injury being the most common indication for surgery (4/13; 31%). One dog was recorded with a minor complication, which was a metacarpal fracture distal to the bone plate. Major complications were observed in 4/13 (31%) limbs, with surgical site infection being recorded in all four limbs and screw loosening in one limb. No implant failure was reported. At the final clinical evaluation (43-437 days after surgery), none or mechanical lameness was recorded in 9/13 (69%) limbs, mild lameness in 3/13 (23%) limbs, and moderate lameness in one 1/13 (8%) limb. CONCLUSIONS AND CLINICAL RELEVANCE: Locking plate and screw fixation with additional internal fixation resulted in comparable complication and infection rates in canine PCA to previous published studies using hybrid dynamic compression plates. No implant failure was reported for any of the limbs despite the use of a light dressing without external coaptation.

The evolution of the manus of early theropod dinosaurs is characterized by high inter- and intraspecific variation.

The origin of the avian hand, with its reduced and fused carpals and digits, from the five-fingered hands and complex wrists of early dinosaurs represents one of the major transformations of manus morphology among tetrapods. Much attention has been directed to the later part of this transition, from four- to three-fingered taxa. However, earlier anatomical changes may have influenced these later modifications, possibly paving the way for a later frameshift in digit identities. We investigate the five- to four-fingered transition among early dinosaurs, along with changes in carpus morphology. New three-dimensional reconstructions from computed tomography data of the manus of the Triassic and Early Jurassic theropod dinosaurs Coelophysis bauri and Megapnosaurus rhodesiensis are described and compared intra- and interspecifically. Several novel findings emerge from these reconstructions and comparisons, including the first evidence of an ossified centrale and a free intermedium in some C. bauri specimens, as well as confirmation of the presence of a vestigial fifth metacarpal in this taxon. Additionally, a specimen of C. bauri and an unnamed coelophysoid from the Upper Triassic Hayden Quarry, New Mexico, are to our knowledge the only theropods (other than alvarezsaurs and birds) in which all of the distal carpals are completely fused together into a single unit. Several differences between the manus of C. bauri and M. rhodesiensis are also identified. We review the evolution of the archosauromorph manus more broadly in light of these new data, and caution against incorporating carpal characters in phylogenetic analyses of fine-scale relationships of Archosauromorpha, in light of the high degree of observed polymorphism in taxa for which large sample sizes are available, such as the theropod Coelophysis and the sauropodomorph Plateosaurus. We also find that the reduction of the carpus and ultimate loss of the fourth and fifth digits among early dinosaurs did not proceed in a neat, stepwise fashion, but was characterized by multiple losses and possible gains of carpals, metacarpals and phalanges. Taken together, the high degree of intra- and interspecific variability in the number and identities of carpals, and the state of reduction of the fourth and fifth digits suggest the presence of a 'zone of developmental variability' in early dinosaur manus evolution, from which novel avian-like morphologies eventually emerged and became channelized among later theropod clades.

[Distal radius fractures : Update on imaging]. / Distale Radiusfrakturen : Update zur Bildgebung.

Distal radius fractures are associated with high individual and socioeconomic relevance. Optimized radiography and computed tomography (CT) imaging are essential for individualized therapy planning. Plain CT imaging with 3D reconstruction and digital removal of the carpus and ulna is helpful for choosing the surgical approach in the presence of intra-articular radius fractures. If the fracture line leads towards the scapholunate compartment, ligamentous injury requiring treatment can be detected or ruled out before surgery with the help of direct CT arthrography (CTA). Acquisition of imaging data and morphometrical analysis must be standardized and reproducible. In the diagnostics of distal radius fractures it is necessary for radiologists and surgeons to use a unified fracture classification.

Comparison between magnetic resonance imaging, computed tomography, and arthrography to identify artificially induced cartilage defects of the equine carpal joints.

While articular cartilage changes are considered to be one of the initial events in the pathological cascade leading to osteoarthritis, these changes remain difficult to detect using conventional diagnostic imaging modalities such as plain radiography. The aim of this prospective, experimental, methods comparison study was to compare the sensitivity of magnetic resonance imaging (MRI), magnetic resonance arthrography, computed tomography (CT), and CT arthrography in the detection of artificially induced articular cartilage defects in the equine carpal joints. Defects were created in the antebrachiocarpal and middle carpal joint using curettage by a board-certified equine surgeon. Normal articular cartilage thickness varied from a maximum of 1.22 mm at the level of the distal aspect of the radius to a minimum of 0.17 mm in the proximal articular surface of the third carpal bone. Regarding cartilaginous defect measurements the remaining cartilaginous bed range from a maximum of 0.776 mm in the partial thickness defects, and 0 mm (defect reaches the subchondral bone) when total thickness defect were made. Computed tomography and magnetic resonance imaging were performed followed by CT arthrography and magnetic resonance arthrography after antebrachiocarpal and middle carpal intraarticular contrast administration. All images were reviewed by two board-certified veterinary radiologists, both of whom were blinded to the location, presence of, and thickness of the cartilage defects. A total number of 72 lesions in nine limbs were created. Mean sensitivity for localizing cartilage defects varied between imaging modalities with CT arthrography showing the best sensitivity (69.9%), followed by magnetic resonance arthrography (53.5%), MRI (33.3%), and CT (18.1%) respectively. The addition of contrast arthrography in both magnetic resonance and CT improved the rate of cartilage lesion detection although no statistical significance was found. Computed tomographic arthrography displayed the best sensitivity for detecting articular cartilage defects in the equine antebrachiocarpal and middle-carpal joints, compared to magnetic resonance arthrography, MRI, and CT.

Nonarticular osseous cyst-like lesions of the intermedioradial carpal bone may be incidental magnetic resonance imaging findings in dogs.

As magnetic resonance imaging (MRI) becomes more readily available and more frequently utilized in the assessment of canine carpal lameness, both normal variations and early pathologic conditions must be recognized to optimize patient care and provide accurate diagnosis. On cross sectional studies of the canine carpus, cyst-like lesions have been detected at the dorsolateral aspect of the intermedioradial carpal bone. The cross-sectional imaging and histologic properties of these lesions have not been described. The purpose of this observational study is to evaluate the MRI and histologic features of these cyst-like lesions in a cohort of clinically sound dogs. It was hypothesized that the lesions would show features similar to intraosseous ganglion cysts of the human wrist. Twenty-five cadaveric canine carpi were obtained and a total of 13 lesions were detected on MRI. Based on MRI, six carpi with lesions of varying size and one normal carpus were submitted for histological evaluation. Five of the abnormal carpi had nonarticular cyst-like lesions; one specimen with a positive magnetic resonance image for a cyst-like lesion had no cyst-like lesion on histology. Conspicuity of a medium-size lesion as evaluated on radiographs was poor. Given the presence of these nonarticular cyst-like lesions in a population of clinically sound patients, their clinical importance is uncertain. The development of these lesions may relate to altered mechanics or genetic predispositions, requiring additional study.

Flexural Limb Deformities of the Carpus and Fetlock in Foals.

Early recognition and treatment of congenital and acquired flexural deformities of the carpi and fetlocks of foals can lead to conformation correction and an athletic future. Treatment is often based on rigid external coaptation assisted by systemic medical treatment. Foals that readily respond to treatment and correct conformation faults can have normal adult athletic expectations.

Influence of Exercise and Intra-articular Site on Canals in Articular Calcified Cartilage of Equine Third Carpal Bones.

The third carpal bone (C3) responds to exercise by adaptive modeling of bone and articular calcified cartilage along the dorsal load path. Canals penetrating articular calcified cartilage, thought to contain vascular tissue, are reported in numerous species. Their significance remains unclear. Our objective was to determine if the number of canals was significantly different in strenuously exercised and control young horses and in a site of intermittent high loading compared to sites sustaining lower habitual loads. Volumetric bone mineral density in the radial facet of C3 of strenuously exercised and gently exercised (control) 19-month-old thoroughbred horses (n= 6/group) was determined by peripheral quantitative computed tomography. The hyaline cartilage was corroded to expose the surface of articular calcified cartilage. The number of canals penetrating the articular calcified cartilage surface in en face scanning electron microscopy images was compared in 4 regions. Volumetric bone mineral density of C3 was significantly greater (P= .004) in strenuously exercised horses. There were 2 morphologically distinct groups of canals and significantly fewer (P= .006) large canals in the dorsal than in the palmar aspect of C3 in control but not in exercised horses. Roughly circular depressions in the articular calcified cartilage surface around apparently forming canals were visible in some samples and have not been previously described in the literature. The canals may be evidence of chondroclastic activity reaching the interface of hyaline and calcified cartilage. Further work is needed to elucidate the relationships between presence of canals and the responses to exercise and to joint disease.

Understanding carpal instability: a radiographic perspective.

The wrist is disposed to a variety of instability patterns owing to its complex anatomical and biomechanical properties. Various classification schemes have been proposed to describe the different patterns of carpal instability, of which the Mayo classification is the most commonly used. Understanding the concepts and pertinent terminology of this classification scheme is important for the correct interpretation of images and optimal communication with referring physicians. Standard wrist radiographs are the first line of imaging in carpal instability. Additional information may be obtained with the use of stress radiographs and other imaging modalities.

MAGNETIC RESONANCE IMAGING SCORING OF AN EXPERIMENTAL MODEL OF POST-TRAUMATIC OSTEOARTHRITIS IN THE EQUINE CARPUS.

Magnetic resonance imaging (MRI) is the most sensitive imaging modality to detect the early changes of osteoarthritis. Currently, there is no quantifiable method to tract these pathological changes over time in the horse. The objective of this experimental study was to characterize the progression of MRI changes in an equine model of post-traumatic osteoarthritis using a semiquantitative scoring system for whole-organ evaluation of the middle carpal joint. On day 0, an osteochondral fragment was created in one middle carpal joint (OCI) and the contralateral joint (CON) was sham-operated in 10 horses. On day 14, study horses resumed exercise on a high-speed treadmill until the completion of the study (day 98). High-field MRI examinations were performed on days 0 (preosteochondral fragmentation), 14, and 98 and scored by three blinded observers using consensus agreement. Images were scored based on 15 independent articular features, and scores were compared between and within-groups. On days 14 and 98, OCI joints had significantly (P ≤ 0.05) higher whole-organ median scores (29.0 and 31.5, respectively), compared to CON joints (21.5 and 20.0, respectively). On day 14, OCI joints showed significant increases in high-signal bone lesion scores, and osteochondral fragment number and size. On day 98, high-signal bone lesion, low-signal bone lesion, osteophyte formation, cartilage signal abnormality, subchondral bone irregularity, joint effusion, and synovial thickening scores were significantly increased in OCI joints. Study results suggest that the MRI whole-organ scoring system reported here may be used to identify onset and progression of pathological changes following osteochondral injury.

Association between position of the fixed ulnar head and carpal translocation after the Sauvé-Kapandji procedure in patients with rheumatoid arthritis.

OBJECTIVE: The Sauvé-Kapandji procedure is a common surgical procedure for rheumatoid wrist, which involves fixing dissected ulnar head to the distal radius in order to provide "bony support" to the carpus. The purpose of this study was to investigate whether the position of the fixed ulnar head was associated with postsurgical carpus translocation. METHODS: We retrospectively reviewed radiographs of 40 patients who underwent the Sauvé-Kapandji procedure and were subsequently followed up for over two years. The association between the fixed ulnar head position and postsurgical carpus translocation was statistically analysed with a confidence interval of 95% (p < 0.05). RESULTS: Multiple regression analysis suggested that the radial inclination of the fixed ulnar head, the absence of increases in ulnar variance, and wide "bony support" were significantly associated with less postsurgical carpal translocation. CONCLUSION: Our study indicated that good concordance between the "bony support" and the carpus might be important in reducing postsurgical carpus translocation.

The effect of lunate morphology on the 3-dimensional kinematics of the carpus.

PURPOSE: To assess carpal kinematics in various ranges of motion in 3 dimensions with respect to lunate morphology. METHODS: Eight cadaveric wrists (4 type I lunates, 4 type II lunates) were mounted into a customized platform that allowed controlled motion with 6 degrees of freedom. The wrists were moved through flexion-extension (15°-15°) and radioulnar deviation (RUD; 20°-20°). The relative motion of the radius, carpus, and third metacarpal were recorded using optical motion capture methods. RESULTS: Clear patterns of carpal motion were identified. Significantly greater motion occurred at the radiocarpal joint during flexion-extension of type I wrist than a type II wrist. The relative contributions of the midcarpal and radiocarpal articulations to movement of the wrist differed between the radial, the central, and the ulnar columns. During wrist flexion and extension, these contributions were determined by the lunate morphology, whereas during RUD, they were determined by the direction of wrist motion. The midcarpal articulations were relatively restricted during flexion and extension of a type II wrist. However, during RUD, the midcarpal joint of the central column became the dominant articulation. CONCLUSIONS: This study describes the effect of lunate morphology on 3-dimensional carpal kinematics during wrist flexion and extension. Despite the limited size of the motion arcs tested, the results represent an advance on the current understanding of this topic. CLINICAL RELEVANCE: Differences in carpal kinematics may explain the effect of lunate morphology on pathological changes within the carpus. Differences in carpal kinematics due to lunate morphology may have implications for the management of certain wrist conditions.

Physical Examination of the Wrist: Useful Provocative Maneuvers.

Chronic wrist pain resulting from partial interosseous ligament injury remains a diagnostic dilemma for many hand and orthopedic surgeons. Overuse of costly diagnostic studies including magnetic resonance imaging, computed tomography scans, and bone scans can be further frustrating to the clinician because of their inconsistent specificity and reliability in these cases. Physical diagnosis is an effective (and underused) means of establishing a working diagnosis of partial ligament injury to the wrist. Carefully performed provocative maneuvers can be used by the clinician to reproduce the precise character of a patient's problem, reliably establish a working diagnosis, and initiate a plan of treatment. Using precise physical examination techniques, the examiner introduces energy into the wrist in a manner that puts load on specific support ligaments of the carpus, leading to an accurate diagnosis. This article provides a broad spectrum of physical diagnostic tools to help the surgeon develop a working diagnosis of partial wrist ligament injuries in the face of chronic wrist pain and normal x-rays.