Imaging of dorsal wrist pain

Abstract

Pain on the dorsal side of the wrist is a common clinical presentation, comparable to pain experienced on the ulnar and radial aspects of the wrist. The dorsal wrist region has distinct anatomical features and is associated with a wide spectrum of pathologies, including conditions affecting the bones, cartilage, ligaments, and tendons. Accurate diagnosis often depends on imaging techniques such as radiographs and ultrasound, with a growing trend towards the use of magnetic resonance imaging (MRI) for more detailed assessment of complex cases. The role of imaging in diagnosing dorsal wrist pain is expected to expand further in the future. To the best of our knowledge, there has not been a comprehensive review paper that specifically addresses the imaging findings related to dorsal wrist pain. This review aims to fill that gap by discussing the imaging characteristics of both common and uncommon pathologies that can cause dorsal wrist pain. It provides an overview of the most appropriate imaging modalities to evaluate various causes of dorsal wrist pain, highlights key imaging findings, and discusses differential diagnoses. By doing so, this review seeks to enhance the understanding and interpretation of imaging results, ultimately aiding in the accurate diagnosis and management of dorsal wrist pain. This comprehensive approach underscores the critical role of advanced imaging in contemporary clinical practice.

Keywords: Dorsal wrist pain; imaging findings; pathology; review.

Figure 1

A 28-year-old male patient presented with dorsal wrist pain for eight months. (A) Frontal radiograph of the wrist shows mixed lytic and sclerotic changes in the lunate bone (arrowheads), predominantly at the proximal ulnar aspect of the lunate. (B) Reformatted coronal CT image shows lytic change in the proximal lunate bone with mild collapse (arrow) and cortical fracture (block arrow). The distal portion of the lunate is sclerotic (black arrow). Features are compatible with Kienbock’s disease. (C) Coronal T1-weighted MR image of the same wrist shows homogeneous diffuse low signal intensity throughout the lunate (arrowheads), suggestive of loss of the fat marrow. There is ulnar negative variance (black arrow). Features are typical appearances of the AVN. The small areas of hypointensity in the capitate bone are due to subcortical cysts (black arrowheads). (D) Dynamic contrast-enhanced MRI of same wrist. Regions of interest have been put over the lunate (orange circle), distal radius (blue circle), scaphoid (red circle) and capitate (white circle). There is hyper-perfusion of the lunate with increased upslope (arrows) of the time-intensity curve compared to the normal low perfusion of the distal radius (blue block arrow), scaphoid (red block arrow) and capitate (white block arrow). This re-perfusion is thought to represent a reparative process secondary to bone ischemia. CT, computed tomography; MR, magnetic resonance; AVN, avascular necrosis; MRI, magnetic resonance imaging.

Figure 2

A 22-year-old male patient with dorsal wrist pain for one year. (A) Lateral wrist radiograph shows an additional osseous body articulating with the base of the 3^rd metacarpal base, suggestive of a “carpal boss” at the 3^rd CMC joint (solid arrow). (B) Sagittal proton-density fat suppression MR image of the same region shows a carpal boss articulating with the posterior aspect base 3^rd metacarpal bone (block arrow). Premature osteoarthritis with mild marrow oedema and a tiny subchondral cyst (arrowhead) is present. CMC, carpometacarpal; MR, magnetic resonance.

Figure 3

A 35-year-old male with severe dorsal wrist pain after fall during a football match. (A) Lateral wrist radiograph shows a small sharply demarcated osseous body (arrow) on the dorsal aspect of the carpus indicative of an acute triquetral fracture. (B) Sagittal T2-weighted fat suppressed MR of the same wrist shows how the low signal intensity cortical fracture fragment (block arrow) is barely visible. Associated severe sprain of dorsal intercarpal (black arrow) and radiocarpal (arrowhead) ligaments is seen with severe oedema and thickening of these ligaments. P, pisiform; T, triquetrum; L, lunate; MR, magnetic resonance.

Figure 4

A 41-year-old male patient with intermittent dorsal wrist pain for 8 months following a wrist sprain two years earlier. (A) Coronal T2-fat suppressed gradient echo MR image showing moderate widening of the scapholunate interval (double arrow), suggestive of scapholunate ligament tear. Secondary osteoarthritis with moderate cartilage thinning radial aspect of lunate fossa (arrow) distal radius. (B) Sagittal gradient echo MR image showing cartilage thinning (arrowheads) on the dorsal aspect of the lunate fossa. The cartilage thickness on the ventral aspect of the lunate fossa is normal (block arrows). MR, magnetic resonance.

Figure 5

A 55-year-old female with dorsal wrist pain for one year and no history of trauma. (A) Coronal proton density fat-suppressed MR image of right wrist shows a type 2 lunate with an additional facet for articulation with the hamate. Moderate subarticular bone marrow oedema (solid arrows) is present of the hamatolunate joint with complete loss of articular cartilage focally (arrowhead). Features are compatible with hamatolunate impaction syndrome with severe osteoarthritis. (B) Normal subject with type 2 lunate (block arrow) and no hamatolunate impaction for comparison. MR, magnetic resonance.

Figure 6

A 47-year-old female with unilateral right wrist pain for ten months, predominantly on the dorsal aspect of the wrist. (A) Frontal radiograph of the wrist is normal. (B) Coronal T2-weighted fat suppressed MR image shows moderate synovial proliferation in the pre-styloid recess (block arrow) and distal radio-ulnar joint (arrowhead). Subtle erosion of the ulnar styloid process (solid arrow) is present with mild bone marrow oedema of the capitate (asterisk). Features are indicative of early rheumatoid arthritis. MR, magnetic resonance.

Figure 7

Another 56-year-old female patient with more severe pain and swelling for more than half a year. (A) Longitudinal ultrasound of wrist shows severe synovial proliferation (solid arrows) on the dorsal aspect of the ulnar head with a medium-sized underlying erosion (block arrow). (B) Colour Doppler ultrasound shows severe synovial hyperaemia indicative of active disease.

Figure 8

A 57-year-old male patient with dorsal wrist pain for one year. (A) Frontal radiograph shows multiple well-defined erosions in the carpal bones, distal ulna and radius (solid arrows) indicative of an erosive arthropathy. (B) Longitudinal ultrasound shows mild synovial proliferation (block arrows) containing small echogenic foci (arrowheads), suggestive of crystal aggregates. Overall features are highly suspicious of a crystal arthropathy, more likely due to gout rather than CPPD. CPPD, calcium pyrophosphate deposition disease.

Figure 9

A 35-year-old female patient presented with acute dorsal wrist pain after slipped and fell. (A) Coronal T2-weighted fat suppression MR image shows severe thickening and oedema of the dorsal intercarpal (arrows) and dorsal radiocarpal ligaments (block arrows) suggestive of sprain ligament. The ligament is still in continuity. (B) Normal appearance of the dorsal ligaments on the same sequence of another subject was used for comparison. Dorsal intercarpal (arrowheads) and dorsal radiocarpal ligament (block arrowheads) show low T2-weighted signal intensity with smaller in calibre. MR, magnetic resonance.

Figure 10

A 41-year-old patient slipped and fell 4 months ago with diagnosis of triquetral fracture. He suffered from persistent dorsal wrist pain and swelling. (A) Sagittal T1-weighted and (B) T2-weighted fat suppression MRI images of the same patient show a small osseous body with rim of hypointense T1- and T2-weight signal suggestive of well corticated margin at dorsal side of the T, suggestive of a non-united fracture (arrow). There is associated soft tissue thickenings with low T1W (arrowheads) and low T2W signal intensity at around the fracture which suggests hypertrophic scars. T, triquetrum; MRI, magnetic resonance imaging; T2W, T2-weighted; T1W, T1-weighted.

Figure 11

A 51-year-old female with dorsal wrist pain for half a year and a clinically vague thickening of the capitolunate joint area. (A) Longitudinal ultrasound shows focal nodular thickening of the radiolunate interval (arrows) associated with a small ganglion cyst (arrowhead) suggestive of chronic sprain ligament. (B) Sagittal T2-weighted fat suppressed MR image confirms focal ligament thickening and oedema of the dorsal radiocarpal ligament (block arrow) and a small ganglion cyst (arrowhead). MR, magnetic resonance.

Figure 12

Two male patients presented with dorsal wrist pain after wrist injury. (A) Coronal proton-density fat suppressed MR image shows severe swelling and disruption of the SL ligament indicative of tear with scar formation (arrows). (B) Coronal proton-density fat suppressed MRI image of another patient shows slit-like full-thickness tear of the membranous component of the SL ligament (arrowhead). C, capitate; S, scaphoid; L, lunate; MR, magnetic resonance; SL, scapholunate; MRI, magnetic resonance imaging.

Figure 13

A 38-year-old patient with dorsal wrist pain and swelling for one year after a wrist sprain. (A) Axial proton-density fat suppressed MR image showing a full-thickness tear of the dorsal component SL ligament (arrow). (B) More distally, there is a small ganglion cyst extending through this tear (block arrow). (C) Coronal proton-density image dorsum of wrist shows the multiloculated ganglion cyst (arrowheads). S, scaphoid; L, lunate; R, radius; MR, magnetic resonance; SL, scapholunate.

Figure 14

A 35-year-old patient with dorsal wrist pain and swelling for one month. (A) Axial proton-density fat suppressed MR image shows a small ganglion cyst located between the dorsal component scapholunate ligament (solid arrowhead) and dorsal radiocarpal ligament (solid arrow). The dorsal component of the scapholunate ligament is normal. (B) Sagittal T2-weighted fat suppressed image shows fluid (block arrows) deep to the dorsal radiocarpal ligament (block arrowheads), suggestive of dorsal capsular septum tear. S, scaphoid; L, lunate; R, radius; C, capitate; MR, magnetic resonance.

Figure 15

A 68-year-old male patient with dorsal wrist redness and swelling and restriction of finger extension. (A) Transverse ultrasound shows severe tenosynovial thickening (arrows) of EDC with moderate tendon thickening (block arrows). There are multiple small echogenic foci (arrowheads) within both the thickened tenosynovium and the thickened extensor tendons, indicative of gouty tenosynovitis. (B) Colour Doppler ultrasound shows severe tenosynovial hyperaemia indicative of active inflammation. EDC, extensor digitorum communis.

Figure 16

A 46-year-old female patient with dog bite several weeks previously followed by slowly progressive swelling dorsum of wrist. (A) Transverse ultrasound shows moderate tenosynovial thickening (arrows) of EDC. The extensor digitorum tendons (arrowheads) are mildly swollen and surrounded by moderately thickened tenosynovium. (B) Colour Doppler ultrasound shows severe tenosynovial hyperaemia indicative of active inflammation. In this clinical context, features are suggestive of infective tenosynovitis (microbiology confirmed). EDC, extensor digitorum communis.

Figure 17

A 58-year-old female patient with dorsal wrist pain and swelling. (A) Transverse ultrasound shows well-defined anechoic cyst (solid arrows) present under the clinically palpable swelling deep to the EDC (arrowheads), indicative of a ganglion cyst. (B) Longitudinal ultrasound of the same area shows a tract extending from the ganglion to the scaphocapitate articulation (block arrows) indicative of a ganglion cyst arising from the dorsal aspect of this joint. C, capitate; S, scaphoid; EDC, extensor digitorum communis.

Figure 18

A 49-year-old male patient with dorsal wrist pain for a few months and no clinical swelling. (A) Sagittal T2W fat-suppressed MR image showing a small multiloculated cystic lesion (solid arrow) on the dorsal aspect of the mid-carpus deep to the extensor digitorum communis and superficial to the dorsal component of the SL ligament (arrowhead). Features are indicative of an occult ganglion. (B) Axial T2W fat-suppressed MR image shows the ganglion (block arrow) lying superficial to the intact SL ligament (arrowhead). No tear was seen. This is suggestive of a cyst arising from the DCSS. T2W, T2-weighted; MR, magnetic resonance; SL, scapholunate; DCSS, dorsal capsulo-scapholunate septum.

Figure 19

Two male patients with dorsal wrist pain and swelling. (A) Axial T2W fat suppressed MR image shows a solid partially hyperintense mass (solid arrows) encasing the ECRB (arrowhead). GCTTS is the most likely consideration, which was confirmed histologically. (B) Axial T2W fat suppressed MR image of another patient shows a similar mass (block arrows) encasing the ECRB and the index finger extensor digitorum tendons (*). Although the MR appearances were suggestive of GCTTS, the histological diagnosis was sarcoma. T2W, T2-weighted; MR, magnetic resonance; ECRB, extensor carpi radialis brevis; GCTTS, giant cell tumour of tendon sheath.