Role of radionuclidewrist pain

imaging in the evaluation of

The cause of hand and wrist pain can be ditficuit to determine, especially when standard ra-diographs are normal or show only nonspec~ic changes. This study reports the effectiveness of

radionuclide imaging in the evaluation of patients with hand and wrist pain of uncertain cause.Eighty-eight patients with hand and wrist pa~a and initially normal standard radiographs wereevaluated prospectively by additional radiographic methods including the following: routinetomography, wrist arthrography, computerized tomography, or magnetic resonance imaging.Each patient also had bone scintigraphy. The diagnosis established by clinical assessment andby other imaging methods was then compared with the scintigraphic findings. The presence orabsence of focal scintigraphic abnormalities correlated with the presence or absence of focalpathology definable by the conventional methods in 88% of patients. As expected, scintigraphywas chiefly of value in defining the locus of an injury or other process in the wrist, rather thanthe nature of an abnormality. Th~~ma! in 95% of cases involving complete

intrinsic ligament ruptures and fractures and were normal in 96% of patients with no_dg.fi_~able

inju~ry. Scintigraphic findings correlated poorly with partial intrinsic ligament injuries and incases of synovitis. Radionuclide imaging is a sensitive means of detecting focal lesions in patientswith hand and wrist pain (~f unknown cause. (J HA~D SURG 1988;13A:810-14.)

Paul G. Pin, MD, Janice W. Semenkovi!ch, MD, V. Leroy Young, MD,

Thomas Bartell, MD, R. Evan Crandall. MD, Louis A. Gilula, MD, Katherine Reed, MD,

Paul M. Weeks, MD, and Barry A. Siegel, MD, St. Louis, Mo.

he cause of hand and wrist pain can bedifficult to diagnose and the selection of proper therapyis often delayed, particularly when conventional radi-ography reveals no abnormalities. Conservative man-agement results in gradual resolution of symptoms insome patients. However, pain persists in others and

they. are often labeled empirically as having sprains,strains, synovitis, or even arthritis. Treatment with non-

steroidal, anti-inflammatory agents, physical therapyand/or immobilization for weeks or months will resultin little or no improvement. The role of wrist arthrog-

From the Division of Plastic and Reconstructive Surgery, and theMaltinckrodt Institute of Radiology, Washington University Schoolof Medicine, St. Louis, Mo.

Received for publication Dec. 21, 1987; accepted in revised formApril 6, 1988. " "

No benefi~ in any form have been received or will be received froma commercial party related directly or indirectly to the subject ofthis article.

Reprint requests: Paul G. Pin, MD. Division of Plastic and Recon-structive Surgery, Washington University School of Medicine,4949 Bam~s Hospital Plaza, Suite 17424, St. Louis, MO 63110.

810 THE JOURNAL OF HAND SURGERY

raphy in evaluating these patients has been empha-~" sized. ~3 Scintigraphic evaluation has also been

ommended by several investigators. 4-7 The purposethis study was to determine the potential effectivenessof radionuclide imaging in guiding the further-e-valua-tion of patients with hand and wrist pain of unknowncause.

Materials and methods --

"Between January 1982 and February 1986, 88tients with normal conventional radiographs andplained hand and wrist pain were evaluatedtively. Conventional radiographs consisted .ofviews: lateral, oblique, posteroanterior, and scaphoid.

Further testing of these 88 patients variably includedwrist arthrography, fluoroscopy, tomography, spotfilms, magnetic resonance imaging (MRI), andputed tomography (CT) to establish the dia

"dionuclide imaging of the hands and wrists was also ~performed in each of the 88 patients. Scinfigraphy wa~done by administering 20 mCi of Tc 99m methylen~ii

_ diphosphate as a bolus by rapid intravenous injectioninto the antecubital vein of the opposite extremity.

November 1988 Radionuclide imaging in evaluation of wrist pain 811

of

, MD,

aging was obtained in three phases as follows: (1) ra-dionuclide angiography in either palmar or dorsal pro-jection, (2) immediate postinjection static ("bloodpo~9") imaging in both palmar and dorsal projections,

....and (3) delayed imaging at 2 hours. Magmficanon-

....delayed images ~n palmar and dorsal projections wereobtained with converging collimation for 10 minutesper view (yielding 250,000 to 300,000 counts). Ad-ditional projections and/or pinhole magnification im-ages were obtained as indicated by the initial clinicalor scintxgraph~c findings. The sclnngraph~c ~mages wereevaluated for evidence of increased or decreased activityrelative to the normal side and relative to the expectedn¢~nal scintigraphic appearance of the hand and wrist.

-~n the basis of the composite information from theclinical history, physical examination, wrist arthrog-raphy, spot films, tomography, MRI, and/or CT, eachpatient was assigned to one of the following nine di-agnostic categories: (1) no evidence of significant pa-thology, (2) asymptomatic intrinsic ligamentous abnor-malities, (3) incomplete intrinsic ligamentous tears, (4)complete intrinsic ligamentous tears, (5) capsular extrinsic tigamentous tears, (6) fracture, (7) soft tissueini,=u, (8) synovitis, and (9) reflex sympathetic dystro-pt:? ’. This final diagnosis was then compared with thefindings of bone scintigraphy (Fig. 1).

empha-~enrpose of:tiveness ~!:.

No evidence of significant pathology. Twenty-sixhad no clinically or radiographically demon-

strable abnormalities. Twenty-five of these patients hadscintigrams. One patient had unexplained ac-

over the triquetrum, which did not correspond tolocation of his point tenderness on examination.

.nknown 26 patients were all followed for at least 6:::i, !~}!:;~:. months, and ~n no case d~d the dmgnosls change.: ~:~,!~: ~:i?:. Asymptomatic abnormalities. Ten patients had; : ? ::;~:~asymotomatic abnormalities on arthrography The term

,88

.ncludedy~-

~d~sis.vas also’:

phy was ~i,

is used because the locus of the patient’sdid not correspond with the location of the ab-

seen by arthrography. There were seven tri-complex (TFCC) perforations and

lunotriquetral perforations. Nine of these 10 pa-had normal bone scintigrams, while one asymp-

..tomatic lunotriquetral ligament tear was associated withincreased activity.

Incomplete intrinsic ligamentous tears. Five pa-had incomplete intrinsic ligamentous tears dem-

0nstrated arthrographically. There were three scapho-tears, one TFCC tear, and one lunotriquetral

ligament tear. Three patients had abnormal scintigramscorrelating with the site of ligament rupture. Of the two

METHODS

88 Patients

Normal FourView Plain Films

Spot FilmsTomographyArthrographyCTI MRI

Diagnosis

Comparison

FindingsBone Scan,

Fig. 1. All of the patients in this study had normal conven-tional radiographs. The diagnosis obtained by further testingwas compared with the findings of scintigraphy.

patients with normal scans, one had an incompletescapholunate tear and one had a small tear of the TFCC.

Complete intrinsic iigamentous tears. Completein~insic ligamentous tears were found on arthrography__-’

in 13 patients (Fig. 2). Two patients each had completetears of two separate intrinsic ligaments. There werenine, scapholunate tears, five lunotriquetral tears, andone TFCC tear. Twelve of 13 patients had abnormalsciratigrams. Ten had focally increased activity at thesite of the injury, and two had diffusely increased uptakeof the radiopharmaceutical throughout the carpus. Onepatient with a complete lunotriquetral tear had a normalscintigraphic study.

Capsular or extrinsic ligamentous tears. T.hree pa-tients had symptomatic capsular or extrinsic ligamen-tous tears by arthrography. :All had abnormal bonescans. One patient had intense focal activity over theradiocarpal joint (the Site of tear), and the other twohad. diffusely increased ~ctivity throughout the wrist.

Fractures. Ten patients had occult fractures not vi-sualized on routine films but subsequently documentedby tomography (Fig. 3). All I0 bone scintigrams dem-

812 Pin et al. The Journal ofHAND SURGERY

R DORSALFig. 2. Ligamentous injury. This 47-year-old man injured his right wrist and has persistent pain.Palmar and dorsal delayed scintigrams show mild, diffusely increased activity in the right carpus.with slight focally greater increased activity in the lunate regxon. A lunotriquetral ligament tearwas confirmed by arthrography.

Table I. Frequency of scintigraphic abnormalities

Injury Normal

No demonstrated pathology*Asymptomatic abnormalities*Symptomatic incomplete intrinsic ligamentous tearsSymptomatic complete intrinsic ligamentous tearsCapsular or extrinsic ligamentous tearsFracturesSoft tissue injury.SynovitisReflex sympathetic dystrophy

TOTAL ,

Abnormal

25 1-" 9 1

2 31 120 30 100 45 91 2

43 45

% agreementwith diagnosis

96906093100100 --1006467

(77/88) * In these two diagnostic categories, a normal scintigraphic study was considered to be in agreement with the final diagnosis. In all other categories, an

abnormalstudy was considered to be in agreement.

onstrated intense, focally increased activity at the siteof the fracture. The trapezium was fractured in fivecases. There were single fractures involving the scaph-oid, hamate, capitate, distal ulna, and distal radius.¯ -Soft tissue injuries. Four patients had sustained

crush injuries with no demonstrable pathology otherthan soft tissue swelling. All four bone scintigramsshowed multiple areas of increased activity. No frac-tures were detected. The arthrograms were normal.

Synovitis. Fourteen patients with wrist pain, swell-ing, and/or tenderness on physical examination andwith normal films were diagnosed as having synovitis.

Nine patients had abnormal bone scintigrams showingdiffusely increased uptake. This was often niore prom-inent on the "blood-pool" images than on the delayedimages as would be expected with an inflammatory~process chiefly of periarticular soft tissues. The fivepatients with normal studies were judged clinically t011have mild synovitis. ..... i

Reflex sympathetic dystrophy. Three patients werediagnosed as having classic reflex sympathetic dystro-. !phy. Two had diffusely abnormal bone scans with find-ings typical of reflex sympathetic dystrophy. These find-ings included diffuse hyperperfusion of the hand and

ae Journal of) SURGERY¯

merit

rnosis

~, an abnormal

ore.e

ammatory~,iThe

.entsicwith find-h~sehand and

November 1988 Radionuclide imaging in evaluation of wrist pain 813

Fig. 3. Hook of hamate fracture. This 37-year-old man fell and injured his right wrist 3 weeksago. Plain radiographs at the time of the injury were negative, but he continued to have persistentpain, swelling, and tenderness over the hook of the harnate. Dorsal and palmar delayed scintigramsshow moderately intense, focally increased activity in the region of the right hamate. A medialprojection (not shown) confirmed that the increased activity was in the hook of the hamate.

v,,cist on the radionuclide angiogram, corresponding dif-t::;e hyperemia on the "blood-pool" image, and dif- WRIST PAIN ALGORITHMfusely increased osseous activity with periarticular ac-centuation on the delayed images The third had in-creased activity in the distal radius £nd mildly increased

~i~-. activity in the carpus on the delayed images. There wasneither hyperfusion nor hyperemia of the hand andwrist, nor was there increased activity in the hand on

These findings were believed not to be

[ CAREFUL HBP ]

14"VIEW Xo RAYSI

As a result of our experience, bone scintigraphy hasassumed an important role in our evaluation of unex-plained wrist pain (Fig. 4).8 Bone scintigraphy iden-tifies areas with altered bone blood flow, active new

Fig. 4. Strategy for eva.luating unexplained wrist pain. "Fur-¯ ter evaluation" consists of one or more of the following:instability series, spot films, magnified views, fluoroscopy,CT. and MRI.

814 Pin et al. The Journal ofHAND SURGERY

bone formation, or both. In areas of intense, focallyincreased tracer uptake, an occult fracture must be ex-.cluded with spot films or tomography.9 Mildly increased.focal activity suggests a ligamentous injury and the needfor arthrography.1° Alternatively, these abnormalitiesmay be further examined by wrist arthroscopy.~t Themechanism for increased tracer accumulation in suchcases may be related to periosteal reaction secondaryto ligamentous avulsion, early degenerative disease, orbone remodeling accompanying altered stress. A non-specific increase in activity may be obtained in thepresence of an inflammatory process)V In this event,laboratory screening (chemistry profile, hematologicprofile, erythrocyte sedimentation rate, rheumatoid fac-tor, and anti-nuclear antibody) should be performed toexclude the presence of a rheumatologic disorder. Anyabnormality should be pursued by further testing andpossibly medical consultation. A normal scintigram ar-gues against major osseous pathology and can be usedto avoid unnecessary immobilization and further di-agnostic tests)3 However, in no case should the scin-tigraphic result supercede clinical judgement. A normalstudy should be discounted if pathology is clinicallyapparent.

When used early in the diagnostic course, radionu-clide imaging appears to be a sensitive method for eval-uating patients with unexplained hand and wrist pain.It can reliably separate those patients who need furtherevaluation from those without demonstrable pathology.However, it appears that, after an indeterminate timefollowing an injury, the sensitivity of scintigraphy maydecrease. In the three patients with symptomatic in-trinsic ligamentous tears who had normal scintigrams,the average duration of symptoms was 21.8 months,compared with an average of 9.0 months in patientswith similar pathology and positive scintigrams. Bonescintigraphy seems to be less reliable in evaluating theseremote injuries.

Finally, it must be emphasized that the scintigraphicresult must be evaluated in conjunction with clinicalinformation. With the exception of the intensely in-creased focal activity associated with an occult fracture,abnormal scintigraphic findings are generally nonspe-

cific, and there is much overlap in the scintigraphicappearances of various disorders associated with wristpain. Although a negative result may permit cessationof diagnostic efforts, a positive study warrants clinicalcorrelation and further radiographic evaluation, withparticular attention to the locus of scintigraphicallydemonstrated abnormalities.

REFERENCES1. Levinsohn EM, Palmer AK. Arthrography of the t~au-

matized wrist. Radiology 1983;146:647-65t..2. Ganel A, Engel J, Ditzian R, Farin I, Militeanu J. Ar-

thrography as a method of diagnosing soft-tissue injuriesof the wrist. J Trauma 1979;19:376-80.

3. Palmer AK, Levinsohn EM, Kuzma GR. Arthrographyof the wrist. J HAND SURG 1983;8:15-23.

4. Belsole RJ, Eikman EA, Muroff LR. Bone scintigraphyin trauma of the hand and wrist. J Trauma t981;21:163-6.

5. Maurer AH, Holder LE, Espinola DA, et ai. Three-phaseradionuclide scintigraphy of the hand. Radiology 1983;146:761-75.

6. Stein F, Miaie A, Jr, Stein A. Enhanced diagnosis of handand wrist disorders by triple phase radionuclide boneimaging. Bull Hosp Jt Dis Orthop Inst 1984;44:477-84.

7. Lecklitner ML, Douglas KP. Skeletal scintigraphy of thehands and wrists: trauma, tumors, infections, and otherinflammation. In: Freeman LM. Weissmann HS. eds.Nuclear medicine annual 1986. New York: Raven Press,1986:247-283.

8. Gilula LA, Destouet JM, Weeks PM, et al. Roentgen-ographic diagnosis of the painful wrist. Clin Orthop1984; 187:52-64.

9. Batillas J, Vasilas A, Pizzi WF, et al. Bone scanning inthe detection of occult fractures. J Trauma--1981;21:564-9.

10. Gilula LA, Weeks PM. Post traumatic ligamentous in-stabilities of the wrist. Radiology 1978;129:641-51.

11. Whipple TL, Marotta J J, Powell JH lII. Techniques ofwrist arthroscopy. Arthro~copy 1986;2:244-52.

12.Brown DE, Lichtman DM The evaluation of chronicwrist pain. Orthop Clin North Am 1984; 15:183-92.

13.Taleisnik J. Pain on the ulnar side of the wrist. In: Tal-eisnik J, ed. Management of wrist problems. Philadel-phia: WB Saunders, 1987:51-68.

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