Ligament Injuries

Abstract

The precise evaluation of major intrinsic ligaments remains a challenge. Obvious and large lesions can be demonstrated indirectly on standard views or directly by US.

An SLL tear may appear as a widened SL space filled with fluid and an absent SL ligament, juxta-articular BMO, and at a later stage, subchondral cysts. Dynamic diastasis in the SSL joint space due to an elongation of the SLL can show very subtle signal changes of the SLL. Tears in the SLL may or may not change after an indefinite period of time. On the contrary, large SLL tears may be replaced by wide, ill-defined, heterogeneous scar tissue. Arthrosynovial cysts are very often associated with SLL tears.

A lesion of this even smaller intrinsic ligament can be suspected on standard PA views. Indirect signs, such as sclerotic margins at the LT joint, indicate a response to abnormal mobility. Additional MRI examination should include the entire horseshoe-shaped ligament from dorsal to palmar. Fine images in at least two orthogonal directions can show the extent of the LTL lesion. The ligament is usually torn in the L. The palmar part of the LTL is most significant.

TFCC is a unit of multiple and very different parts. The location of the tear and its extent are assessed on at least two perpendicular images, usually coronal and axial. A frequent pitfall is the brighter signal of the small area of cartilage adjacent to the sigmoid notch.

Isolated rupture of the scaphotrapezial ligament is a very rare finding. An arthrosynovial cyst may also develop here.

The exact evaluation of extrinsic multidirectional ligaments remains an even greater challenge, partly because of their anatomical location in the capsule. The striated aspect is erased and replaced by a higher and more homogeneous signal, possibly with small cyst components. Stretching and/or partial tearing give rise to oedema between the low-signal stripes and/or with partial tearing of the low-signal stripes, respectively. The ligamentous lesion may be accompanied by a bony detachment. More often, periosteal stripping at the carpal attachments leads to focal BMO.

1 Intrinsic Ligaments SL, LT, TFCC and Others

1.1 SL Ligament

The exact evaluation of this important intrinsic ligament remains challenging (Andersson et al. 2015; Bencardino and Rosenberg 2006; Boutry et al. 2005; Davis and Blankenbaker 2010; De Santis et al. 2021; Gilula 1979; Gilula and Weeks 1978; Girgis and Epstein 2000; Gitto et al. 2017; Lee et al. 2013a, 2017; Lee and Elfar 2015; Loredo et al. 2005; Mayfield 1984; Meyer 1991; Michelotti et al. 2018; Pulos and Bozentka 2015; Ringler 2013; Ringler and Murthy 2015). Obvious and large lesions may be shown indirectly by SL diastasis on standard views (Said et al. 2018) (Fig. 1a, b) or directly by US (Fig. 1c, d).

Fig. 1

Standard PA views in neutral position (a) and ulnar deviation (b); US Ax in neutral position (c) and ulnar deviation (d). The standard PA view is considered normal (a). Diastasis at the SL joint in ulnar deviation (b). US may be diagnostic in obvious lesions of the SLL with absence of the ligament (c) and SL diastasis in ulnar deviation (d)

An extensive lesion of the SLL (Athlani et al. 2020; Buijze et al. 2011; Lok et al. 2014; Shahabpour et al. 2015) (Fig. 2a–c) does not always lead to changes in standard views (Couzens et al. 2014; Linscheid et al. 1983) (Fig. 2d, e). The additional MRI exam should always include T1 and T2-WI in order to not only evaluates the form and continuity of the SLL, but also the signal of the ligament on both sequences (Fig. 2a–c, f). The images need to cover the whole horseshoe-shaped ligament from dorsal to palmar (Hafezi-Nejad et al. 2016; Scheck et al. 1997) (Fig. 3). Fine images in at least two orthogonal directions show the extent of the SLL lesion (Fig. 4).

Fig. 2

Cor T2-WI FS (a, c); Standard PA (d) and lateral (e) views; Cor T1-WI (f). Extensive injury of the complete SLL (a, c), although the standard views are normal (d, e). Evaluation of the presence, form, and signal of the SLL on both T2 (a, c) and T1-WI (f) is mandatory

Fig. 3

Cor T2-WI FS (D-C-P). Thin images from dorsal (D1–2) over central (C1–2) to palmar (P1–2) are mandatory. The SLL shows a discontinuity of a part of the typical dorsal striation (D1–2), a central deformation (C1–2) and a diffuse focal signal increase

Fig. 4

Cor (a, c) and Ax (d–f) 3D GRE. Fine images in at least two orthogonal directions show the extent of the dorsocentral SLL lesion (a–f) with a small remnant of the most important dorsal part (a)

Controversially, extensive lesions at standard views do not always implicate a rupture of the SLL (Fig. 5).

Fig. 5

Standard lateral view (a); Cor T2-WI FS (b) and Standard PA view (c). The SL angle is about 65° (possibly also influenced by the position of the R epiphysis) (a) after a semi-recent Pouteau fracture (a, c). There is a clear step off at the first and second line of Gilula (b, c) with diffuse hydrops at the main three wrist compartments. The SL is, however, continuous but deformed (b)

The SLL tear will preferably appear and be looked for at the S side (Mania et al. 2022; Messina et al. 2013) (Fig. 6), as the attachment to the cortex of the L through Scharpey fibres is very firm. An indirect sign may be the presence of a dynamic diastasis at the SL space (Chan et al. 2019; Cheriex et al. 2017; Demehri et al. 2016) (Fig. 7a, b), which corresponds on MRI with a broadly widened SL space filled with fluid and an absent SL ligament (Fig. 7c, d). A standard PA view with clenched fist (Dornberger et al. 2015; Garcia-Elias et al. 2006; Linscheid 1984; Metz et al. 1993; Poznanski 1984; Ozçelik et al. 2005; Patel et al. 2015; Pliefke et al. 2008) may also show an indirect sign, known as the “vacuum phenomenon” (Fig. 8a). The SLL tear is directly shown (Fig. 8b). Juxta-articular BMO (Gornitzky and Carrigan 2016) may appear after a SLL tear (Fig. 9). In a later stage, subchondral cysts (Ramdhian-Wihlm et al. 2012) may appear at the insertion of the torn SLL, mostly on the L side, surrounded by BMO (Fig. 10a, b). Even on standard views, the small cysts with discrete sclerosis at the borders may be visible (Fig. 10c) and are sharply delineated on MRI (Fig. 10d). Dynamic diastasis (Abou Arab et al. 2018; Dao et al. 2004; Grunz et al. 2021; Langner et al. 2015; Ramamurthy et al. 2016; Shaw et al. 2019; Sulkers et al. 2014) at the SSL joint space (Fig. 11a) remains due to an elongation of the SLL with very subtle signal changes of the SLL (Fig. 11b) and a discrete amount of fluid in the SL joint space with complete regression of the BMO (Fig. 11c versus Fig. 9c). SLL tears may or may not change (Garcia-Elias 2008) after an indefinite period of time. Besides the regression of the oedema, small tears often remain unchanged (Fig. 12). On the contrary, large SLL tears may be replaced by broad, ill defined, heterogenous scar tissue (Fig. 13).

Fig. 6

Cor T2-WI FS (a) and 3D GRE (b). The SLL will preferably tear at the S side with an irregular delineation

Fig. 7

Standard PA view (a) with clenched fist (b); Cor T2-WI FS (c) and T1-WI (d). Dynamic diastasis at the SL space (a, b). The SL pace is broadly widened, filled with fluid and the ligament is absent (c, d)

Fig. 8

Standard PA view with clenched fist (a); Cor 2D GRE (b). Dynamic diastasis at the SL space with a vacuum phenomenon (a). The SLL is torn (b)

Fig. 9

Standard PA view with clenched fist (a); Cor PD WI (b) and T2WI-FS (c). Dynamic diastasis at the SL space (a) with a laceration of the SLL (b). Juxta-articular BMO at the L side (c)

Fig. 10

Cor T1-WI (a) and T2-WI FS (b); Standard PA view (c) and Cor 2D GRE (d). At the insertion of the torn SLL on the L, subchondral cysts appear, surrounded by BMO (a, b). Even on standard views, the small cysts with discrete sclerosis at the borders are visible (c) and are sharply delineated on MRI (d)

Fig. 11

Standard PA view with clenched fist (a), Cor PD-WI (b), and Cor T2-WI FS (c). SL diastasis (a). Only a discrete signal increase remains at tip of the SLL (b) and a small amount of fluid in the SL joint space (c). The BMO has regressed completely (c versus Fig. 9c)

Fig. 12

Cor PD-WI (a, d), T1WI (b, e), and T2-WI FS (c, f). The aspect of this SLL tear (a, c) almost does not change over a period of 10 months (d–f). Posteriorly, there is a reduction of the limited oedema (a, d)

Fig. 13

Cor T1WI (a), 2D GRE (b), and T2-WI FS (c). The SLL is replaced by a broad, ill defined, heterogenous band of scar tissue with adjacent subchondral cysts (S and L)

MRI should always be considered as the first examination in order to evaluate the form, signal, and continuity of the SLL. MRA (Fig. 14) may be added in a second stage to evaluate very specific problems. False negative results are possible in case of an external continuity of the SL ligament (Fig. 14), due to significant—but internally limited—damage of the ligament, fibrous scar formation, local synovial proliferation, or even the valve phenomenon. The signal alteration is also less obvious (T1-WI FS) or less reliable (GRE). If only one compartment is injected, midcarpal arthrography should be preferred as this generally results in the best evaluations.

Fig. 14

Cor 3D GRE (a–f) and T1-WI FS (g–i). MRA (RC injection) shows no contrast leakage from the RC into de MC joint in fine 3D GRE, nor in T1-WI FS images

Arthrosynovial cysts are very frequently associated with SLL tears. They are also often the first sign of a SLL lesion and mainly detected by US (Fig. 15). The most frequent cysts are located superficially, between the tendons of the extensor compartment II (ecl, ecb) and IV (ed) (Fig. 15a). The stalk needs to be demonstrated until the SL joint (Fig. 15b). In detecting large cysts (Fig. 16), MRI does not have an advantage over US. However, small cysts are more likely to be discovered by MRI due to their obvious bright signal and the underlying SLL tear may be demonstrated as well (Fig. 17). In addition, the trajectory of the (fine and tortuous) stalks (Fig. 18) is easier to demonstrate on MRI (and to communicate visually to the clinician). This is certainly the case for radio-palmar cysts (Fig. 19), associated with SL lesions. The cysts develop and run through the space of Poirrier and surface just distal from the pronator quadratus (Fig. 19a). Proximal expansion may be superficial (Fig. 19b) and/or deep of the pronator quadratus (Fig. 19c).

Fig. 15

US transverse (a, b), sagittal at pathological (c) and normal side (d). US reveals an arthrosynovial cyst at the dorsal side between the tendons of the II and IV extensor compartments (a). In the depth, the stalk is followed to the SL space (b). Comparative imaging (c, d) shows the bilobular cyst at the right side, posteriorly from the C and L (c)

Fig. 16

Cor 2D GRE (a, c) and Ax T2-WI FS. Extensive SLL tear (a, c) with large deep dorsal ASC (d)

Fig. 17

Ax T2-WI FS; Cor 2D GRE (b) and T2-WI FS (c). Small cyst dorsal from the torn SLL

Fig. 18

Cor (a, b) and Ax T2-WI FS (c–g). Small ASC dorsally of the SLL with illustration of the trajectory of the stalk until the SLL

Fig. 19

Ax T2-WI FS (a, b) and Sag 3D GRE (c). ASC at the radio-palmar region

Detecting a tear of the strong SLL tear should spontaneously trigger a search for associated lesions. A bony erosion of the adjacent carpal bones may develop over time (Fig. 20). A similar image may be found in RA (Fig. 21a, b), but additional series with contrast will clearly define the aetiology (Fig. 21c). SLL tears may exist alongside S fractures (Fig. 22). A tear of the LTL may coexist as well (Figs. 22b, c and 23). Despite these important lesions, the mobility in ulnar and radial deviation may initially remain quite normal (Fig. 23e, f). Associated extrinsic ligament lesions have to be excluded (Fig. 24) in order to obtain a complete diagnosis, in function of the evaluation of the importance of the trauma and to guide the therapy. Even a pseudarthrosis may be associated with a SLL tear (Fig. 25). Accompanying traumatic TFCC tears (Fig. 26) may appear more obviously.

Fig. 20

Cor T2-WI (a, d), T1-WI (b, e), Cor (c) and Sag (f) T2-WI FS. SLL tear (a, c) with L bone erosion (d–f)

Fig. 21

Cor T1-WI (a), T2-WI FS (b), and T1-WI FS with contrast (c). SLL “lesion” with lunate erosion (a, b). CE at the SLL, the adjacent erosion, and the diffuse synovial proliferations as at diffuse bony (oedema) regions in RA

Fig. 22

Cor T1-WI (a), T2-WI (b), 2D GRE (c), and Standard PA view. SLL tear (a, c), fracture of the S (a, d) with already callus formation (d), and LTL tear (b, c)

Fig. 23

Standard PA (a), Lateral (b), Slightly oblique with clenched fist (c, d), PA with ulnar (e) and radial deviation (f) views; Cor T1-WI (g, i) and T2-WI FS (h, j). Normal standard PA and Lateral view (a, b) with diastasis SL (c) and LT (d). Mobility is not significantly reduced (e, f). Both ligaments SLL and LTL are torn with adjacent BMO (g–j)

Fig. 24

Standard PA view with clenched fist (a); Cor T2-WI FS (b), T1-WI (c), and PD-WI (d). Diastasis SL (a) due to a SLL tear (b). Associated laceration of the radial part of the palmar V with oedema and erasure of the striated pattern (c, d)

Fig. 25

Cor T2-WI FS (a); Cor (b, d) and Ax 3D GRE (c). Clear old SLL tear (a, c) with a hazardous discovery of a S pseudarthrosis

Fig. 26

Cor T2-WI FS (a); Cor 2D GRE (b), T2-WI FS (c), and 3D GRE (d). SLL tear (A-D) with diastasis and a TFCC tear Palmer type I A (B-D)

Early diagnosis of a SLL tear is important. Careful analysis of “normal” standard views (Fig. 27a, b) should avoid the further evolution of the S rotatory subluxation (Gelberman et al. 2001). Signet ring sign (Fig. 27c), an increased SL angle (Fig. 27d) and widening of the SL space in ulnar deviation (Fig. 27e) are obvious red alert signs in the early stage after trauma. Further increase of the signet ring sign (Fig. 27f), the SL angle (Fig. 27g) and of the widening of the SL space, even in neutral position (Fig. 27h), has to be avoided through early treatment. Treatment failure may otherwise lead to a carpal collapse with reduced height, resulting from proximal migration of the C (Fig. 27f) and thinning of the midcarpal cartilage (Fig. 27i–l) with surrounding BMO between S and C (Fig. 27i–k).

Fig. 27

Standard AP (a, c, f) with clenched fist (e, h) and Lateral (b, d, g) views; Cor T1-WI (i) with contrast (j), T2-WI FS (k), and 3D GRE (l, m). “Normal” standard views (a, b). Signet ring sign (c), increased SL angle (d) and widening of the SL space in ulnar deviation (e). Further increase of the signet ring sign (f), the SL angle (g) and of the widening of the SL space now even in neutral position (h). The C starts to migrate proximally (f). The midcarpal cartilage is thinned (i–l) with BMO between S and C (i–k). The SLL is torn (k–m) with SL diastasis

Standard views may give some idea about the post-operative status (Michelotti et al. 2018; Del Piñal 2013; Szabo 2008), depending on the technique used (Fig. 28). In case of the use of plugs, they should be continuous and fixed in the bone without apparent (sclerotic outlined) radiolucency around (Fig. 28b). However, increase of the SL angle (Fig. 28b) and the SL diastasis (Fig. 28c) are highly suspicious for (internal) rupture and/or elongation. The continuity of a fixed external ligamentous reconstruction as well as the scar tissue between S and L may be delineated on MRI. However, due to artefact, post-operative sequels and signal alterations, and a variable aspect of the scar formation, the interpretation remains doubtful (Fig. 29).

Fig. 28

Standard PA (a, c) and Lateral (b) views (b). Radio-opaque plugs indicating a reconstruction of the ligament (a, c). The SL angle remains about 80° (b). The SL diastasis is still present (c)

Fig. 29

Cor T1-WI and T2-WI FS from dorsal to palmar. The externally fixed ligamentous reconstruction and the scar tissue between S and L may be delineated

1.2 LT Ligament

A lesion of this even smaller intrinsic ligament may be strongly suspected on standard PA views. Indirect signs (Devilliers Minnaar 1952; Shin et al. 2000), such as sclerotic margins at the LT joint (Fig. 30a), indicate a reaction to the abnormal mobility. The additional MRI exam (Figs. 30b, c and 31) should always include T1 and T2-WI in order to not only evaluates the form and continuity of the LTL, but also the signal of the ligament on both sequences. The images need to cover the whole horseshoe-shaped ligament from dorsal to palmar. Fine images in at least two orthogonal directions may show the extent of the LTL lesion (Fig. 31). The LTL tear is observed on MRI (Ritt et al. 1998) (Figs. 30b and 31), as is the juxta-articular BMO (Figs. 30c and 31a–c, f). The ligament is mostly torn at the L side (Fig. 31b, c). The palmar part of the LTL is the most important one (Fig. 31d–e). As the ligament is small, MRI will miss more lesions of this intrinsic ligament and MRA or CTA (Fig. 32) will be needed to make a definite diagnosis (Fig. 32).

Fig. 30

Standard PA view (a); Cor 2D GRE (b); and T2-WI FS (c). Sclerotic borders at the LT joint (a). A tear of the LTL (b) is accompanied by BMO at the borders of the LT joint

Fig. 31

Cor T1WI (a) and T2-WI FS (b, c), Ax (d, e) and Cor (f) 3D GRE. LTL tear (a–f) with BMO at the L side (b, c, f). The dorsal part is not delineable (d, e) and the palmar part shows an internal high signal (d, e)

Fig. 32

Wrist arthrography (RC injection) (a); Cor (b–d) and Sag (e) CT images. Small LTL (a–d) and SLL (b) tear with an old fracture of the Tri (c–e)

The significance of an isolated LTL tear is still debated (Garn et al. 1971). Some authors state the need for an additional lesion of the extrinsic palmar radiolunotriquetral ligament for the LTL lesion to be significant. The classically associated VISI appears after an LTL tear with a palmar radiolunotriquetral and a dorsal radiotriquetral ligament tear. The coexistence with a SLL tear (Wolfe et al. 2012) has already been mentioned as well (Fig. 23). Other (bony) lesions may also be detected (Fig. 32c–e).

1.3 TFCC

TFCC (Luetkens et al. 2021; Magee 2009; Mannil et al. 2016; Matthews et al. 2019; Mikić 1989; Nakamura et al. 2001a; Oneson et al. 1997; Yoshioka et al. 2007) stands for triangular fibrocartilage complex, meaning that this structure is a unit of multiple and quite different parts. The location of the tear—most classically central (Mespreuve et al. 2015; Spies et al. 2022; Wang et al. 2023; Watanabe et al. 2010)—and its extent (Anderson et al. 2008; Iordache et al. 2012; Lindau et al. 2000; Chong and Kandathil 2013) (Fig. 33) are evaluated on at least two perpendicular images, usually coronal (Fig. 33a) and axial (Fig. 33b). A frequent pitfall on the first one is the brighter signal of the small zone of cartilage adjacent to the sigmoid notch (Nevalainen et al. 2023) (Fig. 33a), which should not be mistaken for a tear.

Fig. 33

Cor PD WI (a) and Ax T2-WI FS (b). Central tear of the TFCC (Palmer type I A)

The traumatic tears are classified using the Palmer classification (Palmer 1989, 1990; Palmer and Werner 1981; Palmer et al. 1985; Zhan et al. 2020; Zlatkin and Rosner 2006) (Fig. 34). A type I A tear (Fig. 33) may be very subtle and/or oblique (Fig. 35). Accompanying fluid in the DRUJ should be an alert sign (Figs. 33a and 35). A small high signal zone in the TFC on GRE (Fig. 36a) needs to be considered with caution and wrist arthrography (always combined with MRA or CTA) may be needed for the definite diagnosis (Fig. 36b). The forceful contrast injection may open a “valve” lesion with only a small step off in case of a I A type TFFC lesion (Fig. 37).

Fig. 34

Palmer classification of traumatic TFCC lesions

Fig. 35

Cor T2-WI FS (a, b). Palmer type I A TFCC tear with hydrops at the DRUJ

Fig. 36

Cor 2D GRE (a) and wrist arthrography (RC injection) (b). Palmer type I A slit-like TFCC tear with contrast leakage to the DRUJ

Fig. 37

Cor T1-WI FS wrist arthrography (RC injection). Palmer type I A slit-like TFCC tear with contrast leakage to the DRUJ and small step off

A type I B consists of an avulsion fracture of the double ulnar attachment (Fig. 38). More extended lesions (Fig. 39) may include a (sub)luxation of the disc (Figs. 39a and 40), laceration with tenosynovitis (Fig. 39e), and luxation (Fig. 39f) of the ECU, and a posterior ulna luxation (Fig. 40). A (large) arthrosynovial cyst (Fig. 41) may develop at the palmar side (Fig. 41c–e), starting from the region of the tear (Fig. 41b–d). This cyst should not be confused with a fluid accumulation extending between the meniscus homologue and the TFCC to the prestyloid recessus of the RC joint (Fig. 42a). A well delineated peritendinous cyst without stalk (Fig. 42b) of the ECU may also be confusing in this small region.

Fig. 38

Cor T2-WI FS (a) and 2D GRE (b). Palmer type I B tear of the TFCC (note: also a SL tear with diastasis)

Fig. 39

Sag (a) and Cor (b) 3D GRE; Cor T1-WI (c) and T2-WI FS (d–f), Ax 3D GRE (e) and T2-WI FS (f). Palmer type I B tear of the TFCC (a–d) with extension in the anteriorly subluxated disc (a), tenosynovitis of the ECU (e), and luxation of the ECU tendon (f)

Fig. 40

Sag 3D GRE (a) and T1-WI (b). Anteriorly luxated disc with posterior U displacement

Fig. 41

Cor T1-WI (a) and 3D GRE (b, c); Ax T2-WI FS (d, e). Palmer type I B tear of the TFCC (a, b) with large arthrosynovial cyst at the palmar side (c–e) starting from the region of the tear (b–d)

Fig. 42

Cor T2-WI FS. Prestyloid recessus filled with fluid (a) and peritendinous cyst of the ECU (b)

A rare, isolated lesion of the ulno-lunar and ulno-triquetral ligaments is categorized as type I C (Fig. 43). As these are very small structures and since these lesions are frequently associated with other “close vicinity” lesions (TFC; LT) (Fig. 44), the diagnosis is not always obvious, even with prominent hydrops.

Fig. 43

Cor T1-WI FS (a); T2-WI FS (b); 3D GRE (c), and 2d GRE (d). An isolated Palmer type I C lesion of the TFCC with deformed ulno-lunate and ruptured ulno-triquetral ligament

Fig. 44

T2-WI FS (a–c). Probable lesion Palmer I C type with LT and I A TFCC lesions with prominent tri-compartmental hydrops

The Palmer type I D lesion is the most exceptional one, touching the TFC at the ulnar border of the cartilage of the sigmoid notch (Fig. 45).

Fig. 45

Cor T1-WI FS (a); T2-WI FS (b, c); and 2D GRE (d). Palmer type I D lesion of the TFCC

Other components, such as the distal radio-ulnar ligaments (Ekenstam and Hagert 1985; Kim and Park 2008; Kim et al. 2012; Morrissy and Nalebuff 1979; Slattery et al. 2013; Reghunath et al. 2022) of the TFCC, may also rupture after (sub)luxation at the DRUJ (Adams and Berger 2002; Carlsen et al. 2010; Lo et al. 2001; May et al. 2002; McMurray and Muralikuttan 2008; Mikic 1995; Mino et al. 1983; Orbay et al. 2021; Rijal et al. 2023; Stuart et al. 2000; Viegas et al. 1990; Wechsler et al. 1987; Zannou et al. 2015) (Figs. 46 and 47). Traumatic sequels may be obvious (Fig. 46a, b) with a rupture of the rul (Gillis et al. 2019; Mulford and Axelrod 2007; Mulford et al. 2010; Nakamura 2012; Verhiel et al. 2022) (Fig. 46c). (Restored) normal relation at the DRUJ, however, may hide a clear lesion of the rul (Fig. 47c–e). The impression of the cortex that may remain after an anterior U luxation at the DRUJ is known as the second ulnar groove sign (Mespreuve and Coenen 2017) (Fig. 48).

Fig. 46

Standard PA (a) and Lateral (b) views; Ax T2- WI FS (c). Sequel of an impacted Pouteau fracture with radial shortening and distal luxation of the ulnar head (a, b). Rupture of the dorsal rul (c)

Fig. 47

Standard PA (a) and Lateral (b) views; (c) Cor (d) and Sag (e) 3D GRE. Reduced posterior U luxation with normal standard views (a, b). Rupture of the palmar rul with scar formation (c–e)

Fig. 48

Standard PA (a) and Lateral (b) views; Ax T2-WI FS (c, d). Sequels of a reduced anterior U luxation with a second ulnar groove sign (c, d) antero-radial form the ECU groove (d) and rupture of the palmer rul (d)

1.4 Others

The isolated rupture (Lichtman and Wroten 2006; Nakamura et al. 2001b; Theumann et al. 2002; Zancolli 2001; Zancolli et al. 1987) of the scaphotrapezial ligament (Fig. 49a, b) is a very rare finding. Here also, an arthrosynovial cyst may develop (Fig. 49c).

Fig. 49

Cor T2-WI FS (a, c). Sequels a rupture of the scaphotrapezial ligament (a, b) with small cyst formation (c)

1.5 General

Notice that, in general, even with the best MRI techniques used, some lesions of the ligaments will go unnoticed (Fig. 50a, b). The wrist arthrography (Cerezal et al. 2005; De Filippo et al. 2010; Lee et al. 2013b; Moneim and Omer 1983; Moser et al. 2007; Scheck et al. 1999; Schmid et al. 2005; Schmitt et al. 2003; Theumann et al. 2001, 2006; Zanetti et al. 1997)—always completed with CTA or MRA—remains a very valuable additional technique to exclude thin lesions (Fig. 50c) in case of clinical doubt.

Fig. 50

Cor 3d GRE (a) and T2-WI FS (b); wrist arthrography (RC joint injection). MRI reveals no lesion, but there is a small hydrops at the DRUJ. A very thin Palmer type I A lesion of the TFCC (c) is obvious

2 Extrinsic Ligaments

2.1 Palmar

The exact evaluation of these important multidirectional ligaments remains even more challenging (Andersson et al. 2015; Bencardino and Rosenberg 2006; Boutry et al. 2005; Davis and Blankenbaker 2010; Gilula and Weeks 1978; Girgis and Epstein 2000; Gitto et al. 2017; Lee and Elfar 2015; Loredo et al. 2005; Mayfield 1984; Pulos and Bozentka 2015; Ringler 2013; Ringler and Murthy 2015; Lacelli et al. 2008; Manley et al. 2013), also due to their anatomical location in the capsule (Zdravkovic et al. 1994). This makes arthrography also less suitable (Sennwald et al. 1994; Shahabpour et al. 2011).

At the radial component of the palmar V, composed of the radioscaphocapitate and the radiolunotriquetral ligament, the striped aspect is erased and replaced by a higher and more homogenous signal (Figs. 51a, b and 54a), eventually with small cystic components (Figs. 51c and 54a). Elongation and/or partial tears give rise to oedema between the low signal striations and/or with partial rupture of the low signal stripes (Fig. 52), respectively. A bony detachment may accompany the ligamentous lesion (Fig. 53). More frequently, a periosteal stripping at the carpal attachments results in focal BMO (Fig. 54b, c).

Fig. 51

Cor T1-WI (a); PD WI (b); and T2-WI FS (c). Tear at the radial part of the Palmar V (rsc and rlt)

Fig. 52

Cor T1-WI (a) and PD WI (b). Oedema between the low signal stripes at the radial part of the Palmar V

Fig. 53

Standard PA (a) and lateral (b) views; Cor 3D GRE (c); Ax T2-WI FS (d); and 3D GRE (e). A small translucency at the S (S) corresponds to a palmar, small broken S bone fragment (c–e) at the insertion point of the palmar V (d, e), which shows a higher signal zone (d)

Fig. 54

Cor PD WI (a, c). Higher signal with cyst formation along the trajectory of the rsc (a). Focal BMO along the trajectory of the rlt (b, c) due to periosteal stripping

The ulnar component of the palmar V (capitate-triquetral ligament) (Figs. 55, 56, and 57) rarely lacerates but—if extensive enough—it may lead to ulnar midcarpal instability (Anderson et al. 2008; Niacaris et al. 2015).

Fig. 55

Cor (a–c) and Ax (d) T2-WI FS. Laceration at the triquetral insertion of the ligament between C and Tri and extensive post-traumatic BMO at the Tri

Fig. 56

Cor (a, c) and Ax (b) T2-WI FS; Cor T1-WI (d–f). Periosteal stripping at the C (a, b, d, e) and the Tri (e) with an intact ligament (b, f) between C and Tri

Fig. 57

Cor (a) and Sag (b) 3D GRE; Ax T2-WI FS (c); and 3D GRE (d). Small laceration of the distal part of the ligament between the C and Tri with small internal cystic formations, probably not significant/extensive enough

(Diffuse) destruction of an extrinsic ligament should always be differentiated from destruction through infiltration by rheumatoid arthritis (Ochman et al. 2017) (Fig. 58).

Fig. 58

Cor T1-WI (a) and T1-WI FS with contrast (b). Extensive infiltration and destruction of the palmar ligaments (a) with diffuse CE (b) due to RA (a, b). The hydrops of the Tri-P joint and the CMC I joint with adjacent bone erosion (b) are additional arguments in favour of RA

The indirect effect of the palmar extrinsic ligaments in trauma may result in a manually non-reducible anterior luxation of the lunate, trapped in the space of Poirier between the rsc and rlt ligament (Fig. 59). In addition, the hump back deformity of the S after trauma (Fig. 60) is the result of the ligaments of the ulnar palmar V (rsc and rlt). The proximal part of the S tilts backward with the lunate (Fig. 60a, b), while the distal part has a natural tendency to tilt in the palmar direction (Fig. 60b) around the ligaments at the waist of the S (Fig. 60c).

Fig. 59

Standard Lateral (a) and PA (b) view; T2-WI FS (c). The lunate bone is luxated through the space of Poirier between the palmar rsc and rlt ligament

Fig. 60

Sag 3D GRE (a, b) and T1-WI FS with CE (c). The post-traumatic hump-back deformity of the S around the ulnar palmar V components (rsc and rlt) at the S waist

2.2 Dorsal

The same pattern as in the palmar ligaments will appear at the dorsal ligaments (Fig. 61) after a tear and/or an elongation (Özkan et al. 2019). An extreme elongation (Fig. 62a, b) combined with a palmar ligament lesion may lead to an ulnar translation (Metz et al. 1997) of the whole carpus (Fig. 62c, d). On the other hand, also an (old) fracture of the common triquetral insertion of the dorsal ligaments (Rubensson et al. 2018; Schmitt et al. 2006; Sulkers et al. 2018; Viegas et al. 1995; Theumann et al. 2003) (Fig. 63) may result in ulnar translation on the long term.

Fig. 61

Standard PA (a) and Lateral (b) views; Ax T2-WI FS (c) and 3D GRE (d); Cor T1-WI (e), T2-WI FS (f), and 3D GRE (g). The dorsal intercarpal ligament shows a higher signal infiltration with partial erasure of the longitudinal low signal stripes (c–g) and a periosteal stripping at the Tri side (d, f, g)

Fig. 62

Standard PA view (a); Cor T2-WI FS (b); and PD WI (c, d). The whole carpus is translated (type 1) to the ulnar side with an extensively degenerative RC joint (a). The dorsal ligaments are continuous, but elongated, flaccid, and deformed (b). The palmar ligaments are affected in the same way (c, d), all suggesting an old traumatic lesion

Fig. 63

Cor (a) and Sag (b) 3D GRE; Standard lateral view (c); Cor T2-WI FS (d, e). A small fragment posteriorly of the proximal carpal row (a, c) corresponds with a fracture at the dorsal side of the triquetral bone (c). The fragment and the depicted attached ligaments (S Triq and R Triq) are displaced radially versus the white line through the normal position (d, e) on the more dorsal image (e)