MR arthrography of the wrist: controversies and concepts.

Magnetic resonance arthrography (MRA) has become the preferred modality for imaging patients with internal derangement of the wrist. However, several aspects of MRA use need to be clarified before a standardized approach to the imaging of internal derangement of the wrist can be developed. The objective of the study is to evaluate the efficiency of different magnetic resonance (MR) sequences in the detection of lesions of the triangular fibrocartilage complex (TFCC) and scapholunate and lunotriquetral ligaments on direct MRA. Thirty-one consecutive direct magnetic resonance arthrographic examinations of the wrist using a wrist surface coil were performed for the assessment of the TFCC and intrinsic ligaments on a 1.5-T MR imaging system (Signa; 16 channel, Excite, GE Healthcare, Milwaukee, WI, USA). All patients had wrist pain, and in six cases, there was associated clinical carpal instability. The presence, location, and extent of TFCC, scapholunate ligament (SLL), and lunotriquetral ligament (LTL) lesions on T1 fat-saturated, multiplanar gradient recalled (MPGR) and short tau inversion recovery (STIR) images were identified, compared, and analyzed. Forty-one lesions of the TFCC, SLL, and LTL were visualized on contrast-sensitive (T1 fat-saturated) images in 23/31 (74.2%) patients. Twenty-one lesions of the TFCC and intrinsic ligaments were visualized on noncontrast-sensitive (MPGR and STIR) images (15 tears of the TFCC and six tears of the SLL and LTL). All of these lesions were seen on T1 fat-saturated images; 48.8% (20/41) lesions seen on T1 fat-saturated images (eight tears of TFCC and 12 tears of SLL and LTT) were not seen on MPGR and/or STIR images. Superior contrast resolution, joint distention, and the flow of contrast facilitate the diagnosis of lesions of the TFCC and intrinsic ligaments on contrast-sensitive sequences making MRA the preferred modality for imaging internal derangements of the wrist. Little agreement exists regarding the value and location of perforations of the intrinsic ligaments given that both traumatic and degenerative perforations may be symptomatic. Noncommunicating defects of the ulnar attachments of the triangular fibrocartilage (TFC), tears of the dorsal segment of the SLL, and defects at the lunate attachment of the SLL have a higher likelihood of being symptomatic and caused by trauma rather than by degenerative perforation. Although no consensus exists, it would appear that most arthrographies should be started with a radiocarpal injection. Injection into the distal radioulnar joint should be added if no communicational defects are visualized following radiocarpal injection in patients with ulnar-sided wrist pain.

Motor recovery, functional status, and health-related quality of life in patients with complete spinal cord injuries.

STUDY DESIGN: A retrospective cohort with cross- sectional follow-up. OBJECTIVES: The primary objective was to determine motor recovery in patients with complete traumatic spinal cord injury (SCI). Secondary objectives included: 1) determining which factors predict local recovery, 2) assessing functional status using the Functional Independence Measure (FIM), and 3) assessing generic health-related quality of life using the Short Form-36 (SF-36). SUMMARY OF BACKGROUND DATA: Motor recovery following complete SCI has been documented in the literature; however, it has been difficult to interpret: 1) spinal shock is often not addressed; 2) the definition of complete SCI has changed over the last 10 years; and 3) few studies differentiate between local neurologic recovery in the zone of partial preservation and neurologic recovery caudal to the lesion. METHODS: All patients admitted to Vancouver Hospital with a complete SCI between 1994 and 2001 were identified and included in the study if they remained complete following the resolution of spinal shock. Minimum 2-year follow-up consisted of an ASIA motor score, an FIM, and the SF-36. RESULTS: Of 133 patients identified, 94 were eligible and 70 completed follow-up. For the tetraplegic patients, the average ASIA motor score was 11.9 +/- 10.7 on admission and 20.1 +/- 10.8 at follow-up, a change reflecting local recovery only. For the paraplegic patients, the average ASIA motor score was 49.3 +/- 2.4 on admission and 50.6 +/- 1.7 at follow-up. CONCLUSIONS: Motor recovery does not occur below the zone of injury for patients with complete SCI. Varying degrees of local recovery can be expected in tetraplegic individuals.

Surgical approach to the triangular fibrocartilage complex.

There are few descriptions of the surgical exposure of the ulnar aspect of the wrist. The anatomy of the dorsoulnar aspect of the wrist was explored in 7 cadaver wrists with special attention to developing a surgical approach to the dorsum of the radio-ulno-carpal joint. Using the experience from previous authors and the knowledge gained from our cadaveric dissections, a surgical approach was designed that provides wide exposure of the dorsoulnar aspect of the wrist. The anatomic layers are dissected in a distinct pattern that allows preservation of the extensor carpi ulnaris and its sheath as well as a strong closure of each layer and restoration of the anatomy. Minimal postoperative immobilization is required, and rehabilitation can be started as early as 2 weeks postoperatively. This approach provides access to the distal radioulnar joint, triangular fibrocartilage complex, distal ulna, and lunotriquetral joint, thus allowing multiple possible procedures through a single, universal approach.