Anatomy is king (or queen) in this wrist case

This 45-year-old male has pain around the scaphoid after an accident.

Q1 – What is wrong with the scaphoid?

On the two water-weighted images (image 1, proton density fat suppression; image 2, three-dimensional additive gradient echo or ADAGE), attempt to identify the structures labeled red, blue and green. This is a real challenge unless you are doing a fair amount of hand and wrist imaging or are a hand surgeon.

Hint: The red arrows point to two different structures, one thicker and one thinner.

  • Coronal PD

    Coronal T2

A1 – Nothing is wrong with the scaphoid.

The thicker structure that is highlighted by the red arrow represents the superficial anterior oblique ligament of the first carpometacarpal junction. The red arrow pointing to the thinner ligament is its deep layer, also known as the beak ligament. Both are swollen and clearly injured with the deeper one slightly corrugated (image 2) or “crimped”. The blue arrow highlights the torn medial scaphotrapezial ligament. Finally, this patient’s symptoms most likely are emanating from the torn radial collateral ligament of the first carpometacarpal (CMC) junction (green arrows). Another important stabilizer of the first CMC, the dorsomedial posterior ligament, is not specifically shown.

Check out MRI Online for more case review.

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