Extrinsic and Intrinsic Ligaments of the Wrist

Abstract

Carpal stability depends on the integrity of both intra-articular and intracapsular carpal ligaments. In this review, the role of the radial-sided and ulnar-sided extrinsic and intrinsic ligaments is described, as well as their advanced imaging using magnetic resonance arthrography (MRA) and contrast-enhanced magnetic resonance imaging (MRI) with three-dimensional (3D) scapholunate complex sequences and thin slices. In the last decade, the new concept of a so-called “scapholunate complex” has emerged among hand surgeons, just as the triangular ligament became known as the triangular fibrocartilage complex (TFCC).

The scapholunate ligament complex comprises the intrinsic scapholunate (SL), the extrinsic palmar radiocarpal: radioscaphocapitate (RSC), long radiolunate (LRL), short radiolunate (SRL) ligaments, the extrinsic dorsal radiocarpal (DRC) ligament, the dorsal intercarpal (DIC) ligament, as well as the dorsal capsular scapholunate septum (DCSS), a more recently described anatomical structure, and the intrinsic palmar midcarpal scaphotrapeziotrapezoid (STT) ligament complex. The scapholunate (SL) ligament complex is one of the most involved in wrist injuries. Its stability depends on primary (SL ligament) and secondary (RSC, DRC, DIC, STT ligaments) stabilizers.

The gold standard for carpal ligament assessment is still diagnostic arthroscopy for many hand surgeons. To avoid surgery as a diagnostic procedure, advanced MRI is needed to detect associated lesions (sprains, midsubstance tears, avulsions and chronic fibrous infiltrations) of the extrinsic, midcarpal and intrinsic wrist ligaments, which are demonstrated in this article using 3D and two-dimensional sequences with thin slices (0.4 and 2 mm thick, respectively).

Keywords

scapholunate complex - extrinsic and intrinsic wrist ligament tears - carpal instability - 3D magnetic resonance imaging and arthrography

Publication History

Article published online:
09 August 2021

• References

• 1 Feipel V, Rooze M. The capsular ligaments of the wrist: morphology, morphometry and clinical applications. Surg Radiol Anat 1999; 21 (03) 175-180
• 2 Schmitt R, Froehner S, Coblenz G, Christopoulos G. Carpal instability. Eur Radiol 2006; 16 (10) 2161-2178
• 3 Dautel G. Normal wrist arthroscopy. In: Camus E, Van Overstraeten L. eds. Ligamentous Surgery of the Wrist. Berlin, Germany: Springer; 2013: 99-107
• 4 Theumann NH, Etechami G, Duvoisin B. et al. Association between extrinsic and intrinsic carpal ligament injuries at MR arthrography and carpal instability at radiography: initial observations. Radiology 2006; 238 (03) 950-957
• 5 Camus E. Carpal biomechanics: application to ligamentous injuries. In: Camus E, Van Overstraeten L. eds. Carpal Ligament Surgery. Paris, France: Springer; 2013: 19-37
• 6 Van Overstraeten L. Arthroscopic anatomy and lesions of the extrinsic ligaments. In: Camus E, Van Overstraeten L. eds. Carpal Ligament Surgery. Paris, France: Springer; 2013: 119-131
• 7 Van Overstraeten L, Camus EJ. A systematic method of arthroscopic testing of extrinsic carpal ligaments: implication in carpal stability. Tech Hand Up Extrem Surg 2013; 17 (04) 202-206
• 8 Van Overstraeten L, Camus EJ. The role of extrinsic ligaments in maintaining carpal stability—a prospective statistical analysis of 85 arthroscopic cases. Hand Surg Rehabil 2016; 35 (01) 10-15
• 9 Linscheid RL, Dobyns JH, Beabout JW, Bryan RS. Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. J Bone Joint Surg Am 1972; 54 (08) 1612-1632
• 10 Grunz JP, Gietzen CH, Grunz K, Bley T, Schmitt R. Imaging of carpal instabilities. Röfo Fortschr Geb Röntgenstr Nuklearmed 2021; 193 (02) 139-150
• 11 Garcia-Elias M. The non-dissociative clunking wrist: a personal view. J Hand Surg Eur Vol 2008; 33 (06) 698-711
• 12 Viegas SF, Patterson RM, Ward K. Extrinsic wrist ligaments in the pathomechanics of ulnar translation instability. J Hand Surg Am 1995; 20 (02) 312-318
• 13 Viegas SF, Patterson RM, Hokanson JA, Davis J. Wrist anatomy: incidence, distribution, and correlation of anatomic variations, tears, and arthrosis. J Hand Surg Am 1993; 18 (03) 463-475
• 14 Overstraeten LV, Camus EJ, Wahegaonkar A. et al. Anatomical description of the dorsal capsulo-scapholunate septum (DCSS). Arthroscopic staging of scapholunate instability after DCSS sectioning. J Wrist Surg 2013; 2 (02) 149-154
• 15 Shahabpour M, Staelens B, Van Overstraeten L. et al. Advanced imaging of the scapholunate ligamentous complex. Skeletal Radiol 2015; 44 (12) 1709-1725
• 16 Shahabpour M, Van Overstraeten L, De Maeseneer M. Anatomy and injuries of the extrinsic and midcarpal ligaments. In: Shahabpour et al, eds. MRI Wrist and Hand. Vienna, Austria: Breitenseher; 2021: 113-132
• 17 Short WH, Werner FW, Green JK, Sutton LG, Brutus JP. Biomechanical evaluation of the ligamentous stabilizers of the scaphoid and lunate: part III. J Hand Surg Am 2007; 32 (03) 297-309
• 18 Berger RA. The anatomy of the ligaments of the wrist and distal radioulnar joints. Clin Orthop Relat Res 2001; (383) 32-40
• 19 Berger RA. The gross and histologic anatomy of the scapholunate interosseous ligament. J Hand Surg Am 1996; 21 (02) 170-178
• 20 Short WH, Werner FW, Green JK, Masaoka S. Biomechanical evaluation of the ligamentous stabilizers of the scaphoid and lunate: Part II. J Hand Surg Am 2005; 30 (01) 24-34
• 21 Short WH, Werner FW, Green JK, Masaoka S. Biomechanical evaluation of ligamentous stabilizers of the scaphoid and lunate. J Hand Surg Am 2002; 27 (06) 991-1002
• 22 Burns JE, Tanaka T, Ueno T, Nakamura T, Yoshioka H. Pitfalls that may mimic injuries of the triangular fibrocartilage and proximal intrinsic wrist ligaments at MR imaging. Radiographics 2011; 31 (01) 63-78
• 23 Totterman SM, Miller R, Wasserman B, Blebea JS, Rubens DJ. Intrinsic and extrinsic carpal ligaments: evaluation by three-dimensional Fourier transform MR imaging. AJR Am J Roentgenol 1993; 160 (01) 117-123
• 24 Rominger MB, Bernreuter WK, Kenney PJ, Lee DH. MR imaging of anatomy and tears of wrist ligaments. Radiographics 1993; 13 (06) 1233-1246 ; discussion 1247–1248
• 25 Cerezal L, de Dios Berná-Mestre J, Canga A. et al. MR and CT arthrography of the wrist. Semin Musculoskelet Radiol 2012; 16 (01) 27-41
• 26 Ringler MD, Murthy NS. MR imaging of wrist ligaments. Magn Reson Imaging Clin N Am 2015; 23 (03) 367-391
• 27 Moser T, Dosch JC, Moussaoui A, Buy X, Gangi A, Dietemann JL. Multidetector CT arthrography of the wrist joint: how to do it. Radiographics 2008; 28 (03) 787-800 ; quiz 911
• 28 Hafezi-Nejad N, Carrino JA, Eng J. et al. Scapholunate interosseous ligament tears: diagnostic performance of 1.5 T, 3 T MRI, and MR arthrography—a systematic review and meta-analysis. Acad Radiol 2016; 23 (09) 1091-1103
• 29 Schmid MR, Schertler T, Pfirrmann CW. et al. Interosseous ligament tears of the wrist: comparison of multi-detector row CT arthrography and MR imaging. Radiology 2005; 237 (03) 1008-1013
• 30 Moser T, Dosch JC, Moussaoui A, Dietemann JL. Wrist ligament tears: evaluation of MRI and combined MDCT and MR arthrography. AJR Am J Roentgenol 2007; 188 (05) 1278-1286
• 31 Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique. J Hand Surg Am 2006; 31 (01) 125-134
• 32 Messina JC, Van Overstraeten L, Luchetti R, Fairplay T, Mathoulin CL. The EWAS classification of scapholunate tears: an anatomical arthroscopic study. J Wrist Surg 2013; 2 (02) 105-109
• 33 Smith DK. Volar carpal ligaments of the wrist: normal appearance on multiplanar reconstructions of three-dimensional Fourier transform MR imaging. AJR Am J Roentgenol 1993; 161 (02) 353-357
• 34 Theumann NH, Pfirrmann CW, Antonio GE. et al. Extrinsic carpal ligaments: normal MR arthrographic appearance in cadavers. Radiology 2003; 226 (01) 171-179
• 35 Timins ME, Jahnke JP, Krah SF, Erickson SJ, Carrera GF. MR imaging of the major carpal stabilizing ligaments: normal anatomy and clinical examples. Radiographics 1995; 15 (03) 575-587
• 36 Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am 1996; 78 (03) 357-365
• 37 Berger RA, Landsmeer JM. The palmar radiocarpal ligaments: a study of adult and fetal human wrist joints. J Hand Surg Am 1990; 15 (06) 847-854
• 38 Shahabpour M, De Maeseneer M, Pouders C. et al. MR imaging of normal extrinsic wrist ligaments using thin slices with clinical and surgical correlation. Eur J Radiol 2011; 77 (02) 196-201
• 39 Shahabpour M, Van Overstraeten L, Ceuterick P. et al. Pathology of extrinsic ligaments: a pictorial essay. Semin Musculoskelet Radiol 2012; 16 (02) 115-128
• 40 Berger RA, Kauer JM, Landsmeer JM. Radioscapholunate ligament: a gross anatomic and histologic study of fetal and adult wrists. J Hand Surg Am 1991; 16 (02) 350-355
• 41 Taneja AK, Bredella MA, Chang CY, Joseph Simeone F, Kattapuram SV, Torriani M. Extrinsic wrist ligaments: prevalence of injury by magnetic resonance imaging and association with intrinsic ligament tears. J Comput Assist Tomogr 2013; 37 (05) 783-789
• 42 Mak WH, Szabo RM, Myo GK. Assessment of volar radiocarpal ligaments: MR arthrographic and arthroscopic correlation. AJR Am J Roentgenol 2012; 198 (02) 423-427
• 43 Scheck RJ, Romagnolo A, Hierner R, Pfluger T, Wilhelm K, Hahn K. The carpal ligaments in MR arthrography of the wrist: correlation with standard MRI and wrist arthroscopy. J Magn Reson Imaging 1999; 9 (03) 468-474
• 44 Spaans AJ, Minnen Pv, Prins HJ, Korteweg MA, Schuurman AH. The value of 3.0-tesla MRI in diagnosing scapholunate ligament injury. J Wrist Surg 2013; 2 (01) 69-72
• 45 Hajek PC, Sartoris DJ, Gylys-Morin V. et al. The effect of intra-articular gadolinium-DTPA on synovial membrane and cartilage. Invest Radiol 1990; 25 (02) 179-183
• 46 Mitsuyasu H, Patterson RM, Shah MA, Buford WL, Iwamoto Y, Viegas SF. The role of the dorsal intercarpal ligament in dynamic and static scapholunate instability. J Hand Surg Am 2004; 29 (02) 279-288
• 47 Elsaidi GA, Ruch DS, Kuzma GR, Smith BP. Dorsal wrist ligament insertions stabilize the scapholunate interval: cadaver study. Clin Orthop Relat Res 2004; (425) 152-157
• 48 Slutsky DJ. Incidence of dorsal radiocarpal ligament tears in the presence of other intercarpal derangements. Arthroscopy 2008; 24 (05) 526-533
• 49 Becce F, Theumann N, Bollmann C. et al. Dorsal fractures of the triquetrum: MRI findings with an emphasis on dorsal carpal ligament injuries. AJR Am J Roentgenol 2013; 200 (03) 608-617
• 50 Smith DK. Dorsal carpal ligaments of the wrist: normal appearance on multiplanar reconstructions of three-dimensional Fourier transform MR imaging. AJR Am J Roentgenol 1993; 161 (01) 119-125
• 51 Özkan S, Kheterpal A, Palmer WE, Chen NC. Dorsal extrinsic ligament injury and static scapholunate diastasis on magnetic resonance imaging scans. J Hand Surg Am 2019; 44 (08) 641-648
• 52 Swann RP, Noureldin M, Kakar S. Dorsal radiotriquetral ligament snapping wrist syndrome—a novel presentation and review of literature: case report. J Hand Surg Am 2016; 41 (03) 344-7.e2
• 53 Brown RR, Fliszar E, Cotten A, Trudell D, Resnick D. Extrinsic and intrinsic ligaments of the wrist: normal and pathologic anatomy at MR arthrography with three-compartment enhancement. Radiographics 1998; 18 (03) 667-674
• 54 Tommasini Carrara de Sambuy M, Burgess TM, Cambon-Binder A, Mathoulin CL. The anatomy of the dorsal capsulo-scapholunate septum: a cadaveric study. J Wrist Surg 2017; 6 (03) 244-247
• 55 Van Overstraeten L, Camus EJ. Arthroscopic classification of the lesions of the dorsal capsulo-scapholunate septum (DCSS) of the wrist. Tech Hand Up Extrem Surg 2016; 20 (03) 125-128
• 56 Mathoulin C, Gras M. Role of wrist arthroscopy in scapholunate dissociation. Orthop Traumatol Surg Res 2020; 106 (1S): S89-S99
• 57 Morimoto H, Viegas SF, Nakamura K. et al. The scaphotrapeziotrapezoidal joint. Part 1: an anatomic and radiographic study. J Hand Surg Am 2000; 25A: 899-910
• 58 Moritomo H, Viegas SF, Elder K, Nakamura K, Dasilva MF, Patterson RM. The scaphotrapezio-trapezoidal joint. Part 2: A kinematic study. J Hand Surg Am 2000; 25 (05) 911-920
• 59 Lichtman DM, Wroten ES. Understanding midcarpal instability. J Hand Surg Am 2006; 31 (03) 491-498
• 60 Lichtman DM, Bruckner JD, Culp RW, Alexander CE. Palmar midcarpal instability: results of surgical reconstruction. J Hand Surg Am 1993; 18 (02) 307-315
• 61 Toms AP, Chojnowski A, Cahir JG. Midcarpal instability: a radiological perspective. Skeletal Radiol 2011; 40 (05) 533-541
• 62 Sennwald GR, Zdravkovic V, Oberlin C. The anatomy of the palmar scaphotriquetral ligament. J Bone Joint Surg Br 1994; 76 (01) 147-149
• 63 Chang W, Peduto AJ, Aguiar RO, Trudell DJ, Resnick DL. Arcuate ligament of the wrist: normal MR appearance and its relationship to palmar midcarpal instability: a cadaveric study. Skeletal Radiol 2007; 36 (07) 641-645
• 64 Yoshioka H, Tanaka T, Ueno T. et al. High-resolution MR imaging of the proximal zone of the lunotriquetral ligament with a microscopy coil. Skeletal Radiol 2006; 35 (05) 288-294
• 65 Ishii S, Palmer AK, Werner FW, Short WH, Fortino MD. An anatomic study of the ligamentous structure of the triangular fibrocartilage complex. J Hand Surg Am 1998; 23 (06) 977-985
• 66 Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989; 14 (04) 594-606
• 67 Tay SC, Berger RA, Parker WL. Longitudinal split tears of the ulnotriquetral ligament. Hand Clin 2010; 26 (04) 495-501
• 68 Zhan H, Zhang H, Bai R. et al. High-resolution 3-T MRI of the triangular fibrocartilage complex in the wrist: injury pattern and MR features. Skeletal Radiol 2017; 46 (12) 1695-1706
• 69 Theumann N, Kamel EM, Bollmann C, Sturzenegger M, Becce F. Bucket-handle tear of the triangular fibrocartilage complex: case report of a complex peripheral injury with separation of the distal radioulnar ligaments from the articular disc. Skeletal Radiol 2011; 40 (12) 1617-1621
• 70 Yoshioka H, Burns JE. Magnetic resonance imaging of triangular fibrocartilage. J Magn Reson Imaging 2012; 35 (04) 764-778
• 71 Ringler MD, Howe BM, Amrami KK, Hagen CE, Berger RA. Utility of magnetic resonance imaging for detection of longitudinal split tear of the ulnotriquetral ligament. J Hand Surg Am 2013; 38 (09) 1723-1727
• 72 Anderson ML, Skinner JA, Felmlee JP, Berger RA, Amrami KK. Diagnostic comparison of 1.5 Tesla and 3.0 Tesla preoperative MRI of the wrist in patients with ulnar-sided wrist pain. J Hand Surg Am 2008; 33 (07) 1153-1159
• 73 Sandman E, Boily M, Martineau PA. “Hockey wrist”: dorsal ulnotriquetral ligament injury. Can J Surg 2018; 61 (06) 398-404
• 74 Smith DK, Snearly WN. Lunotriquetral interosseous ligament of the wrist: MR appearances in asymptomatic volunteers and arthrographically normal wrists. Radiology 1994; 191 (01) 199-202
• 75 Lee RK, Griffith JF, Ng AW. et al. Intrinsic carpal ligaments on MR and multidetector CT arthrography: comparison of axial and axial oblique planes. Eur Radiol 2017; 27 (03) 1277-1285
• 76 Garcia-Elias M. What about injury of the lunotriquetral complex: treatment principles. Chir Main 2003; 22: 57-64
• 77 Wagner ER, Elhassan BT, Rizzo M. Diagnosis and treatment of chronic lunotriquetral ligament injuries. Hand Clin 2015; 31 (03) 477-486