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Objectives The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique. Methods Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors’ clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of ‘0’, ‘5’ and ‘10’ reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of ‘8’ or higher for 80% or more of the panellists. Results Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available. Conclusions Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability. Key Points • Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability . • Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability . • Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects .

Background Scaphoid fractures are the most common carpal fractures. They often need to be treated by surgery, where the use of a compression screw is the globally accepted gold standard. Surgeons may choose between different implant materials including titanium alloys, which remain in the body or are removed after healing. An alternative are biodegradable magnesium-based implants. Properties of magnesium alloys include high stability, osteoconductivity, potential reduction of infections and few artifacts in magnetic resonance imaging (MRI). The aim of this trial is to demonstrate non-inferiority of magnesium-based compression screws compared with titanium Herbert screws for scaphoid fractures. Methods The trial is designed as a multicenter, blinded observer, randomized controlled parallel two-group post market trial. Approximately 190 patients will be randomized (1:1) with stratification by center either to titanium or magnesium-based compression screws. Follow-up is 1 year per patient. Surgical procedures and aftercare will be performed according to the German treatment guideline for scaphoid fractures. The first primary endpoint is the patient-rated wrist evaluation (PRWE) score after 6 months. The second primary endpoint is a composite safety endpoint including bone union until 6 months, no adverse device effect (ADE) during surgery or wound healing and no serious ADE or reoperation within 1 year. The third primary endpoint is the difference in change MRI artifacts over time. Non-inferiority will be investigated for primary endpoints 1 (t-test confidence interval) and 2 (Wilson’s score interval) using both the full analysis set (FAS) and the per protocol population at the one-sided 2.5% test-level. Superiority of magnesium over titanium screws will be established using the FAS at the two-sided 5% test-level (Welch test) only if non-inferiority has been established for both primary endpoints. Secondary endpoints include quality of life. Discussion This study will inform care providers whether biodegradable magnesium-based implants are non-inferior to standard titanium Herbert screws for the treatment of scaphoid fractures in terms of wrist function and safety. Furthermore, superiority of magnesium-based implants may be demonstrated using MRI, which is used as surrogate endpoint for screw degradation. Trial registration DRKS, DRKS00013368 . Registered Dec 04, 2017.

ObjectiveTo investigate whether an intensive early rheumatoid arthritis (RA) treat-to-target (T2T) strategy could be improved through the use of musculoskeletal ultrasound (MSUS) assessment of disease activity.Methods111 newly diagnosed patients with RA or undifferentiated arthritis (symptom duration <1 year) were randomised to strategies that aimed to attain either DAS28-erythrocyte sedimentation rate (ESR)<3.2 (control) or a total power Doppler joint count≤1 during a combined DAS28-ESR/MSUS assessment (intervention). MSUS examination was indicated if: DAS28-ESR<3.2 or DAS28-ESR≥3.2 with two swollen joints. Step-up disease-modifying antirheumatic drug (DMARD) escalation was standardised: methotrexate monotherapy, triple therapy and then etanercept/triple therapy. American College of Rheumatology (ACR) core-set variables were assessed 3 monthly by a metrologist blinded to group allocation. MRI of dominant hand and wrist, and plain radiographs of hands and feet were undertaken at baseline and 18 months for grading by two readers using the Outcome Measures in Rheumatology (OMERACT) Rheumatoid Arthritis MRI Scoring System (RAMRIS) and van der Heijde/Sharp Score, respectively. The coprimary outcomes were mean change from baseline of DAS44 and RAMRIS erosion score.ResultsGroups were matched for baseline clinical, demographic and radiographic features. The intervention group received more intensive DMARD therapy. Both groups demonstrated significant improvements in DAS44 (mean change: control −2.58, intervention −2.69; 95% CI difference between groups −0.70 to 0.48; p=0.72). There were no significant between-group differences for any ACR core-set variables, except DAS44 remission after 18 months (control 43%, intervention 66%; p=0.03). There was minimal progression of MRI and radiographic erosions and no difference in imaging outcomes or serious adverse event rates.ConclusionsIn early RA, a MSUS-driven T2T strategy led to more intensive treatment, but was not associated with significantly better clinical or imaging outcomes than a DAS28-driven strategy.Trial registration numberNCT00920478.

IntroductionThe purpose of this study was to arthroscopically verify MRI diagnostic accuracy for triangular fibrocartilage complex (TFCC) lesions in a regular clinical environment.MethodsA total of 859 patients' data with both preoperative MRI of the wrist and additional wrist arthroscopy were retrospectively reviewed. Two board-certified hand surgeons and one orthopaedic surgeon executed wrist arthroscopy, whereas more than 100 radiologists examined the MRI of the wrist. The accordance of TFCC lesion classification using MRI in comparison to wrist arthroscopy and diagnostic precision of the former depending on technical details were evaluated.ResultsDiagnostic accuracy of MRI for TFCC lesions is poor in comparison to wrist arthroscopy as the reference standard. Technical specifications for MRI of the wrist are heterogeneous among the radiologists. These parameters have not improved accuracy of TFCC evaluation at large.ConclusionThe accuracy of MRI in a regular clinical environment still remains inferior to wrist arthroscopy for detection of TFCC lesions. Development of a standard MRI protocol may be implemented on a regular basis and application of the Palmer classification for TFCC lesion should be sought.

Background Triangular fibrocartilage complex (TFCC) lesions commonly cause ulnar-sided wrist pain and instability of the distal radioulnar joint. Due to its triangular shape, discontinuity of the TFCC is oftentimes difficult to visualize in radiological standard planes. Radial multiplanar reconstructions (MPR) may have the potential to simplify diagnosis in CT wrist arthrography. The objective of this study was to assess diagnostic advantages provided by radial MPR over standard planes for TFCC lesions in CT arthrography. Methods One hundred six patients (49 women, 57 men; mean age 44.2 ± 15.8 years) underwent CT imaging after wrist arthrography. Two radiologists (R1, R2) retrospectively analyzed three randomized datasets for each CT arthrography. One set contained axial, coronal and sagittal planes (MPR Standard ), while the other two included an additional radial reconstruction with the rotating center either atop the ulnar styloid (MPR Styloid ) or in the ulnar fovea (MPR Fovea ). Readers evaluated TFCC differentiability and condition. Suspected lesions were categorized using Palmer’s and Atzei’s classification and diagnostic confidence was stated on a five-point Likert scale. Results Compared to standard planes, differentiability of the superficial and deep TFCC layer was superior in radial reconstructions (R1/R2; MPR Fovea : p  < 0.001; MPR Styloid : p  ≤ 0.007). Palmer and Atzei lesions were present in 86.8% (92/106) and 52.8% (56/106) of patients, respectively. Specificity, sensitivity and accuracy for central Palmer lesions did not differ in radial and standard MPR. For peripheral Atzei lesions, sensitivity (MPR Standard 78.6%/80.4%, MPR Styloid 94.6%/94.6%, MPR Fovea 91.1%/89.3%) and accuracy (MPR Standard 86.8%/86.8%, MPR Styloid 96.2%/96.2%, MPR Fovea 94.3%/93.4%) improved with additional styloid-centered ( p  = 0.004/0.008) and fovea-centered ( p  = 0.039/0.125) reconstructions. No substantial difference was observed between both radial MPR ( p  = 0.688/0.250). Interrater agreement was almost perfect for each dataset ( κ Standard  = 0.876, κ Styloid  = 0.894, κ Fovea  = 0.949). Diagnostic confidence increased with addition of either radial MPR ( p  < 0.001). Conclusions Ancillary radial planes improve accuracy and diagnostic confidence for detection of peripheral TFCC lesions in CT arthrography of the wrist.

Context: Successful arterial cannulation requires wide and patent arterial lumen. A recent study has shown that success rate of radial arterial cannulation at first attempt is more at 45 angle of wrist extension in both young and elderly patients. No study has reasoned whether these high success rates at 45 is because of less compression of the radial artery at this particular angle of wrist extension. Hence, we attempted to study whether the radial artery dimensions changes with increasing angles of wrist extension in young, healthy female volunteers using ultrasound examination. Aim: To investigate the effect of increasing angle of wrist extension of 0, 15, 30, 45, 60, and 75 on radial artery dimensions at the level of the wrist joint using ultrasound examination. Settings and Design: A prospective single blinded study in volunteers. Subjects and Methods: Sonographic measurements of radial artery dimension at the wrist level were performed in 48 young, healthy female subjects. Height (anteroposterior in mm), width (mediolateral in mm) and depth (skin to artery) were measured at wrist extension of 0, 15, 30, 45, 60, and 75. The dimensions at each angle are compared with 0 as the control and statistical analysis done. Statistical Analysis: One-way analysis of variance test. Results: No statistically significant change in dimension of the radial artery is observed with increasing angle of wrist extension. Conclusion: Ultrasound evaluation showed that increasing angle of wrist extension does not significantly change the dimensions of radial artery at the wrist joint level in young healthy female volunteers.

Wrist Fracture is the most common type of fracture with a high incidence rate. Conventional radiography (i.e. X-ray imaging) is used for wrist fracture detection routinely, but occasionally fracture delineation poses issues and an additional confirmation by computed tomography (CT) is needed for diagnosis. Recent advances in the field of Deep Learning (DL), a subfield of Artificial Intelligence (AI), have shown that wrist fracture detection can be automated using Convolutional Neural Networks. However, previous studies did not pay close attention to the difficult cases which can only be confirmed via CT imaging. In this study, we have developed and analyzed a state-of-the-art DL-based pipeline for wrist (distal radius) fracture detection—DeepWrist, and evaluated it against one general population test set, and one challenging test set comprising only cases requiring confirmation by CT. Our results reveal that a typical state-of-the-art approach, such as DeepWrist, while having a near-perfect performance on the general independent test set, has a substantially lower performance on the challenging test set—average precision of 0.99 (0.99–0.99) versus 0.64 (0.46–0.83), respectively. Similarly, the area under the ROC curve was of 0.99 (0.98–0.99) versus 0.84 (0.72–0.93), respectively. Our findings highlight the importance of a meticulous analysis of DL-based models before clinical use, and unearth the need for more challenging settings for testing medical AI systems.

Timely and accurate diagnosis of wrist abnormalities, especially distal radius and ulna fractures, is critical in children and adolescents, yet complicated by skeletal immaturity, overlapping anatomy, and low-contrast fracture lines. To address these challenges, we propose MFSD-YOLO, a multi-scale detection model for pediatric wrist abnormality analysis. The model integrates a Cross-Stage Partial Progressive Multi-Scale Feature Aggregation (CSP_PMSFA) module inspired by GhostNet that applies lightweight multi-scale convolutions on partial channels with partial convolution and residual connections to reduce redundancy and enhance shallow texture and subtle fracture sensitivity. The Feature Pyramid Shared Convolution (FPSConv) module replaces pooling with shared dilated convolutions to expand the receptive field and capture multi-scale context without added cost. The C2 Bi-Level Routing Attention (C2BRA) module, based on C2PSA, uses regional routing and local enhancement to refine focus on relevant areas while balancing accuracy and speed. The Recursive Gradient Dynamic Feature Pyramid Network (RepGDFPN) optimizes top-down and bottom-up multi-scale fusion, reducing semantic loss and improving robustness. Finally, the Sliding Weight Adaptive Loss (SlideLoss) addresses class imbalance, enhancing detection of rare targets. Evaluated on the GRAZPEDWRI-DX dataset, MFSD-YOLO achieves 69.7% mAP@0.5, representing a 5.3% improvement over the baseline YOLOv11, while maintaining 10.8M parameters and 3.2 ms inference speed. These results validate the model’s effectiveness and its potential for real-world deployment in clinical pediatric radiographic analysis.

Objectives To assess radiopalmar ganglion cysts’ (RPG) prevalence, morphology, and clinical significance in consecutive patients. Materials and methods In this retrospective single-center study, two radiologists assessed the presence of RPG and morphologic features on wrist MRI. Radiopalmar complaints and scapholunate ligament (SLL) tears were evaluated. Results A total of 1053 wrists in 909 patients (mean age 43.4 ± 15.5 years, 602 females) were evaluated. All 308 RPG (Group 1; 308 patients, 29.2%) originated from the palmar capsule; 49 were unilocular, 95 oligolocular, and 164 multilocular; 745 wrists had no RPG (Group 2; 601 patients). One hundred and twenty-six RPG showed internal debris. The mean diameter was 8.5 ± 5.6 mm (cranio-caudal) (1.0–32.9 mm), 8.0 ± 4.1 mm (medio-lateral) (1.0–31.9 mm), and 3.7 ± 2.3 mm (dorso-palmar) (0.4–16.0 mm). 168 RPG showed direct contact with the radial vascular bundle, 24 with the flexor carpi radialis tendon, and 123 with the flexor pollicis longus tendon. In Group 1, significantly more patients showed partial (82/308) [group 2: 45/745, p  < 0.001] or complete SLL tears (22/308) [group 2: 20/745, p  < 0.001]. Of the patients with RPG, 15.3% presented with radiopalmar complaints. Only the dorso-palmar RPG diameter was positively correlated with radiopalmar complaints (for readers 1 and 2: r s  = 0.66/0.61, p  < 0.001, respectively), and the best dorso-palmar diameter cut-off value for the probability of having radiopalmar complaints was defined at 3 mm (area under the curve (AUC) 0.74). Other morphologic features were not eligible to discriminate symptomatic patients (AUC range 0.53–0.61). Conclusion This study found RPG in 29% of patients, most of them asymptomatic. However, a dorso-palmar cyst diameter > 3 mm may be clinically significant. Clinical relevance statement Radiopalmar ganglion cysts, observed in 29% of wrist MR examinations, are mostly asymptomatic, but those with a larger dorso-palmar diameter may be associated with radiopalmar complaints. Key Points Radiopalmar ganglion cysts are found in 29% of patients undergoing wrist MRI. Most patients with evidence of radiopalmar ganglion cysts do not show radiopalmar symptoms (85%). A dorso-palmar cyst diameter > 3   mm may be associated with radiopalmar complaints.

We read with great interest the study of Di Matteo et al,1 which highlighted the association between ultrasound (US)-detected subclinical synovitis and bone erosion with the development of inflammatory arthritis. We agree with the authors that the second and fifth metacarpophalangeal joints and the fifth metatarsophalangeal joints are the most frequent site of US-detected bone erosion.2 However, MRI studies have reported that in rheumatoid arthritis (RA), carpal joints were affected by synovitis and erosions more frequently than metacarpophalangeal joints.3 4 The ulnar aspect of the radiocarpal joint and the pisotriquetral joint (PTJ) are the most involved by synovitis.5 Moreover, triquetrum is among the most frequent erosion-affected bone3 and, according to a recent MRI investigation, seems to be the first morphological site to be affected by RA.4