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DOI: 10.1148/radiol.2361040377
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(Radiology 2005;236:231-236.)
© RSNA, 2005

Musculoskeletal Imaging

Reactive Carpal Synovitis: Initial Experience with MR Imaging1

Mohamed S. Barakat, MD, Mark E. Schweitzer, MD, William B. Morisson, MD, Randall W. Culp, MD and Marcelo Bordalo-Rodrigues, MD

1 From the Department of Radiology, New York University Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003 (M.S.B., M.E.S., M.B.R.); Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pa (W.B.M.); and Department of Orthopedic Surgery, Philadelphia Hand Center, King of Prussia, Pa (R.W.C.). Received March 3, 2004; revision requested May 13; revision received September 21; accepted September 28. Address correspondence to M.E.S. (e-mail: mark.schweitzer{at}nyumc.org).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
PURPOSE: To retrospectively evaluate the accuracy of various magnetic resonance (MR) imaging findings in the diagnosis of reactive carpal synovitis.

MATERIALS AND METHODS: Institutional review board approval was obtained, and the need for informed consent was waived. This study was compliant with the Health Insurance Portability and Accountability Act. Thirty-five consecutive patients (19 male and 16 female patients; age range, 13–57 years) who underwent arthroscopy and MR imaging within 4 weeks of surgery were evaluated by two reviewers for the following potential findings of synovitis: (a) distention of the pisotriquetral recess by fluid, (b) distention of the radial and/or prestyloid recess, (c) synovial enhancement (in patients who received contrast material), (d) amount of dorsal capsule distention, and (e) the location of bone marrow edema, if any. The {chi}2 and paired t tests were used to assess these findings in patients with and patients without arthroscopically proved synovitis. The sensitivity, specificity, positive and negative predictive values, and accuracy of these findings in the detection of synovitis were calculated.

RESULTS: Fluid in the pisotriquetral recess was seen in nine of the 14 patients with synovitis and five of the 21 patients without synovitis (P = .018). Distention of the radial and/or prestyloid recess was observed in six of the 14 patients with synovitis and two of the 21 patients without synovitis (P = .027). Among the 24 patients who received contrast material, synovial enhancement was seen in seven of eight patients with synovitis and three of 16 patients without synovitis (P = .002). The dorsal capsule measured 1–7 mm (mean, 3.07 mm) in the 14 patients with synovitis and 2–7 mm (mean, 3.76 mm) in the 21 patients without synovitis (P = .193). Although bone marrow edema was seen globally in similar frequencies (nine of 14 patients with synovitis, nine of 21 patients without synovitis), pisotriquetral bone marrow edema was seen only in patients with synovitis (two of nine patients).

CONCLUSION: Fluid in the pisotriquetral recess, enhancing synovium, and, less commonly, pisotriquetral bone marrow edema are MR imaging findings that may help in the diagnosis of reactive carpal synovitis.

© RSNA, 2005


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Synovitis is a common articular phenomenon that may be a manifestation of either an infectious or an inflammatory process or, most commonly, a reaction to either an internal derangement or a degenerative process (1,2). Most imaging research has concentrated on synovitis related to inflammatory arthritis, and detailed magnetic resonance (MR) imaging and ultrasonographic (US) descriptions are available, often including the value of contrast material enhancement (3–5). In the general orthopedic clinical population, however, synovitis usually accompanies degenerative processes, and the presence of reactive synovitis may be indicative of articular inflammation secondary to an internal derangement (6–8). Synovitis is often conjectured to be the symptom generator that causes the patient with an internal derangement to seek medical attention (9,10). Consequently, it is desirable to conduct a noninvasive evaluation to determine if synovitis is present in patients without inflammatory arthropathy. This is particularly important in the wrist, where synovitis accompanying internal derangement is fairly common (6–8,11). Thus, the purpose of our study was to retrospectively evaluate the accuracy of various MR imaging findings in the diagnosis of reactive carpal synovitis.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Population
This study was compliant with the Health Insurance Portability and Accountability Act. After institutional review board approval and with waiver of informed consent for this retrospective study, we evaluated 35 consecutive patients who underwent wrist arthroscopy and MR imaging of the wrist within 8 weeks before surgery (mean, 24 days; range, 5–60 days). MR images were obtained between January 1999 and November 2002. Initial indications for surgery were triangular fibrocartilage tear in 20 patients, scapholunate ligament tear in seven patients, lunatotriquetral ligament tear in six patients, and dorsal ganglion cyst in two patients. In each patient, the internal derangement was believed to be the major clinical problem; there was no evidence of inflammatory synovitis. Findings of rheumatoid factor tests were negative in all patients.

Patients ranged in age from 13 to 57 years, with a mean age of 36 years. There were 19 male (mean age, 37 years; age range, 16–57 years) and 16 female (mean age, 35 years; age range, 13–56 years) patients. There was no statistically significant difference in age between male and female patients (P = .26).

Surgical Report Review
Surgery was performed by a board-certified orthopedic hand surgeon (R.W.C.) with 12 years of experience. Surgical reports were reviewed for the presence and location of synovitis by two authors (M.E.S., M.S.B.). The presence of synovitis was determined at surgery by means of focal frondlike synovial proliferation and increased blood flow (hyperemia). Synovitis in the radiocarpal compartment is routinely evaluated and reported by the surgeon.

Imaging
Imaging was performed with a 1.5-T superconducting MR imager (Signa; GE Medical Systems, Milwaukee, Wis) and either a dedicated quadrature wrist coil (ICG Medical Advances, Milwaukee, Wis) or two 3-inch (7-cm) round surface coils (GE Medical Systems). The following pulse sequences were used: coronal T1-weighted spin-echo (SE) imaging with a repetition time of 400–900 msec, an echo time of 10–30 msec (400–900/10–30), and two signals acquired; coronal intermediate-weighted fast SE imaging with 4000/40 and two signals acquired; coronal T2-weighted fast SE imaging with fat saturation, 2500/48–78, and four signals acquired; and coronal three-dimensional gradient-echo imaging with 45/15, two signals acquired, and a 10°–20° flip angle. Transverse T1-weighted SE imaging and T2-weighted fast SE imaging were performed with protocols similar to those used with coronal T1-weighted SE imaging and coronal T2-weighted fast SE imaging, except that the former was performed without fat suppression. The field of view was 10 cm. Other imaging parameters included a matrix of 256 x 256, a section thickness of 3 mm (except for the gradient-echo sequence, in which the section thickness was 1.2 mm), and a 1-mm intersection gap.

Twenty-four patients received 0.1 mmol per kilogram of body weight intravenous gadopentate dimeglumine (Magnevist; Berlex, Wayne, Pa) by means of hand injection. In these patients, supplemental transverse T1-weighted SE images were obtained with fat saturation before and 1–5 minutes after contrast material administration. Patients were selected for contrast material–enhanced imaging on the basis of availability of a physician to administer the contrast material.

Image Analysis
Two experienced musculoskeletal radiologists (M.E.S. and W.B.M.), working in consensus and blinded to the initial MR readings, surgical results, and patient demographics, separately evaluated images for the following potential findings of synovitis.

1. The presence of fluid in the pisotriquetral recess and the amount of distention. The long and short axes were measured with electronic calipers on anterior coronal T2-weighted images. Area was calculated on the basis of these measurements.

2. Amount of distention of the radial recess, prestyloid recess, or both, which are visible on coronal T2-weighted MR images obtained at the level of the midcarpus. Although there may be physiologic fluid in these recesses, we believed that physiologic fluid would appear as a thin sheet similar to that seen in other joints (12); therefore, distention was diagnosed when these recesses had a fusiform shape.

3. Synovial enhancement, as compared with that of other articulations visible on the images (13).

4. Amount of dorsal capsule distention, with measurement of the joint performed with modification of the criteria of Backhaus et al (14). We measured the posterior distance from the dorsal cortex of the bone to the outer margin of the joint capsule of the wrist. If this distance was more than 4 mm, it was considered consistent with synovitis. This measurement was made with electronic calipers on a transverse image at the midcapitate level and at the midline of this image (capitate cortex).

5. The presence and location of subchondral bone marrow edema, cysts, or erosions. Bone marrow edema was defined as an ill-defined area of high signal intensity on T2-weighted images with corresponding low signal intensity on T1-weighted images. A subchondral cyst was defined as a well-defined, sharply marginated subchondral area of trabecular loss without a visible cortical break. Erosion was defined as a sharply marginated bone defect with a cortical break seen in at least one imaging plane (15).

Findings 1 and 2 were evaluated to determine whether there was a relationship between effusion and synovitis. Findings 3–5 were believed to enable a more direct assessment of synovial proliferation.

Statistical Analysis
The {chi}2 test was used to assess findings 1, 2, 3, and 5 in patients with and patients without arthroscopically proved synovitis. For statistical analysis, fluid in the pisotriquetral recess was graded only as present or absent. A paired t test was used to compare the amount of dorsal capsule distention (finding 4) in patients with and patients without synovitis and the age between male and female patients. A P value of less than .05 was considered to indicate a statistically significant difference. The sensitivity, specificity, positive and negative predictive values, and accuracy were calculated for each potential finding of wrist synovitis.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Surgical Findings
Synovitis was diagnosed with arthroscopy in 14 of the 35 patients. At surgery, synovitis was localized to the ulnar side in 13 of the 14 patients (Fig 1). In one patient, synovitis was diffuse.



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  		Figure 1a. MR images obtained in an 18-year-old man with synovitis related to a triangular fibrocartilage complex tear. (a) Transverse unenhanced three-dimensional gradient-echo image (45/15, 10° flip angle) demonstrates no substantial abnormality in the pisotriquetral recess (arrows). (b) Transverse three-dimensional gradient-echo image (45/15, 10° flip angle) obtained immediately after the intravenous administration of paramagnetic gadopentetate dimeglumine demonstrates enhancement of the pisotriquetral recess (arrows). (c) Coronal T2-weighted image (2500/50) shows bone marrow edema within the triquetrum (arrowheads) and increased signal intensity in the triangular fibrocartilage complex (arrows). (d) Coronal three-dimensional gradient-echo image (45/15, 10° flip angle) obtained after the intravenous administration of paramagnetic gadopentetate dimeglumine demonstrates marrow enhancement in the triquetrum (arrowheads) and a peripheral cleft in the triangular fibrocartilage complex (arrows).

 


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  		Figure 1b. MR images obtained in an 18-year-old man with synovitis related to a triangular fibrocartilage complex tear. (a) Transverse unenhanced three-dimensional gradient-echo image (45/15, 10° flip angle) demonstrates no substantial abnormality in the pisotriquetral recess (arrows). (b) Transverse three-dimensional gradient-echo image (45/15, 10° flip angle) obtained immediately after the intravenous administration of paramagnetic gadopentetate dimeglumine demonstrates enhancement of the pisotriquetral recess (arrows). (c) Coronal T2-weighted image (2500/50) shows bone marrow edema within the triquetrum (arrowheads) and increased signal intensity in the triangular fibrocartilage complex (arrows). (d) Coronal three-dimensional gradient-echo image (45/15, 10° flip angle) obtained after the intravenous administration of paramagnetic gadopentetate dimeglumine demonstrates marrow enhancement in the triquetrum (arrowheads) and a peripheral cleft in the triangular fibrocartilage complex (arrows).

 


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  		Figure 1c. MR images obtained in an 18-year-old man with synovitis related to a triangular fibrocartilage complex tear. (a) Transverse unenhanced three-dimensional gradient-echo image (45/15, 10° flip angle) demonstrates no substantial abnormality in the pisotriquetral recess (arrows). (b) Transverse three-dimensional gradient-echo image (45/15, 10° flip angle) obtained immediately after the intravenous administration of paramagnetic gadopentetate dimeglumine demonstrates enhancement of the pisotriquetral recess (arrows). (c) Coronal T2-weighted image (2500/50) shows bone marrow edema within the triquetrum (arrowheads) and increased signal intensity in the triangular fibrocartilage complex (arrows). (d) Coronal three-dimensional gradient-echo image (45/15, 10° flip angle) obtained after the intravenous administration of paramagnetic gadopentetate dimeglumine demonstrates marrow enhancement in the triquetrum (arrowheads) and a peripheral cleft in the triangular fibrocartilage complex (arrows).

 


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  		Figure 1d. MR images obtained in an 18-year-old man with synovitis related to a triangular fibrocartilage complex tear. (a) Transverse unenhanced three-dimensional gradient-echo image (45/15, 10° flip angle) demonstrates no substantial abnormality in the pisotriquetral recess (arrows). (b) Transverse three-dimensional gradient-echo image (45/15, 10° flip angle) obtained immediately after the intravenous administration of paramagnetic gadopentetate dimeglumine demonstrates enhancement of the pisotriquetral recess (arrows). (c) Coronal T2-weighted image (2500/50) shows bone marrow edema within the triquetrum (arrowheads) and increased signal intensity in the triangular fibrocartilage complex (arrows). (d) Coronal three-dimensional gradient-echo image (45/15, 10° flip angle) obtained after the intravenous administration of paramagnetic gadopentetate dimeglumine demonstrates marrow enhancement in the triquetrum (arrowheads) and a peripheral cleft in the triangular fibrocartilage complex (arrows).

 
Recesses
Fluid in the pisotriquetral recess was visible in nine of the 14 patients with synovitis and five of the 21 patients without synovitis (Fig 2). Recess sizes were larger in patients with synovitis, with a range of 6–56 mm2 (mean, 20.4 mm2; median, 12 mm2) in patients with synovitis and 5–15 mm2 (mean, 8.2 mm2; median, 6 mm2) in patients without synovitis (Table 1). Distention of the radial and/or prestyloid recess was observed in six of the 14 patients with synovitis and two of the 21 patients without synovitis (Fig 3).



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  		Figure 2a. MR images in a 54-year-old woman with synovitis. (a) Anterior coronal T2-weighted image obtained with fat saturation (2500/50) shows distention of the pisotriquetral recess (arrow). P = pisiform. (b) Transverse T2-weighted image obtained with fat saturation (2500/50) shows focal subchondral cysts with surrounding edema in the pisiform (arrowhead) and triquetrum (arrow) bones.

 


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  		Figure 2b. MR images in a 54-year-old woman with synovitis. (a) Anterior coronal T2-weighted image obtained with fat saturation (2500/50) shows distention of the pisotriquetral recess (arrow). P = pisiform. (b) Transverse T2-weighted image obtained with fat saturation (2500/50) shows focal subchondral cysts with surrounding edema in the pisiform (arrowhead) and triquetrum (arrow) bones.

 

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  		TABLE 1. Measurements of Pisotriquetral Recess Size and Dorsal Capsular Distention

 


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  		Figure 3a. MR images obtained in a 52-year-old man with synovitis. Coronal T1-weighted (a) and T2- weighted (b) images (400/10 and 2500/50, respectively) demonstrate distention of the radial-sided recess (black arrowheads), extrinsic erosion with adjacent subchondral marrow edema in the distal scaphoid (arrows), and the radial styloid (white arrowhead). (c) Transverse coronal three-dimensional gradient-echo image (45/15, 10° flip angle) obtained after the intravenous administration of gadopentetate dimeglumine demonstrates focal enhancement of the synovium along the dorsal aspect of the wrist (arrows).

 


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  		Figure 3b. MR images obtained in a 52-year-old man with synovitis. Coronal T1-weighted (a) and T2- weighted (b) images (400/10 and 2500/50, respectively) demonstrate distention of the radial-sided recess (black arrowheads), extrinsic erosion with adjacent subchondral marrow edema in the distal scaphoid (arrows), and the radial styloid (white arrowhead). (c) Transverse coronal three-dimensional gradient-echo image (45/15, 10° flip angle) obtained after the intravenous administration of gadopentetate dimeglumine demonstrates focal enhancement of the synovium along the dorsal aspect of the wrist (arrows).

 


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  		Figure 3c. MR images obtained in a 52-year-old man with synovitis. Coronal T1-weighted (a) and T2- weighted (b) images (400/10 and 2500/50, respectively) demonstrate distention of the radial-sided recess (black arrowheads), extrinsic erosion with adjacent subchondral marrow edema in the distal scaphoid (arrows), and the radial styloid (white arrowhead). (c) Transverse coronal three-dimensional gradient-echo image (45/15, 10° flip angle) obtained after the intravenous administration of gadopentetate dimeglumine demonstrates focal enhancement of the synovium along the dorsal aspect of the wrist (arrows).

 
Synovial Enhancement and Dorsal Capsule Distention
Twenty-four patients received contrast material. Diffuse synovial enhancement was seen in seven of eight patients with synovitis and three of 16 patients without synovitis (Figs 1, 3).

Dorsal capsular distention ranged from 1 to 7 mm (mean, 3.07 mm) in the 14 patients with synovitis and from 2 to 7 mm (mean, 3.76 mm) in the 21 patients without synovitis (P = .193) (Fig 3, Table 1).

Marrow Edema
Marrow edema was seen in nine of the 14 patients with synovitis and nine of the 21 patients without synovitis. Two of the patients without synovitis also had cysts. In patients without synovitis, marrow edema was seen in the lunate (n = 3), scaphoid (n = 2), capitate (n = 2), ulnar styloid (n = 1), and radial styloid (n = 1). In patients with synovitis, marrow edema was seen in the lunate (n = 5), ulnar styloid (n = 1), and radial styloid (n = 1). In one of these patients with synovitis, there was also an extrinsic erosion of the radial aspect of the scaphoid (Fig 3). Pisotriquetral marrow edema, however, was seen only in patients with synovitis (n = 2) (Fig 2).

Statistical Analysis
The sensitivity, specificity, positive and negative predictive values, accuracy, and P values for the MR imaging findings in the detection of synovitis are given in Table 2.


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  		TABLE 2. Sensitivity, Specificity, Positive Predictive Values, Negative Predictive Values, and Accuracy of MR Imaging Findings in the Detection of Synovitis

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
A number of articular disorders are characterized by marked inflammation of the synovial membrane (1,2). Among these, rheumatoid arthritis and seronegative spondyloarthropathies are the most commonly described (3,16). Frequent involvement of the synovium, however, is seen in osteoarthritis, a disorder characterized by deterioration of articular cartilage and marginal new bone formation (17).

The early stages of osteoarthritis are often accompanied by an inflammatory response of the synovium and adjacent soft tissues (18). Most authors believe that inflammation is a secondary event that occurs as a consequence of the release and phagocytosis of cartilage breakdown products (19,20). Stimulated synovium releases pain-related mediators, especially bradykinin-inducing vasodilatation, extravasation of blood-borne proteins, activation of immune cells, induction of leukocyte chemotaxis, and activation of nociceptive neurons (9,21). Thus, although synovitis is a secondary phenomenon in osteoarthritis, it is an important symptom generator and may accelerate the progression of disease (22).

The ability to noninvasively evaluate synovitis has long been desired (6,14). Although conventional radiography may show early joint space widening with displacement of nearby periarticular fat planes, it is exceptionally insensitive in the detection of this disorder (23). Although radiocarpal arthrography is minimally invasive, it may demonstrate fronds of proliferative synovium or outpouchings of contrast material (24,25). Visibly enhancing or nodular synovium is the MR imaging correlate of these arthrographic findings (6,13). Singson and Zalduondo (26) first described visible synovium as a sign of synovitis in the knee. This sign is difficult to visualize in small joints such as the wrist.

Doppler US is another noninvasive mechanism with potential to aid in the evaluation of synovitis by showing increased blood flow (27). Although classically used in patients with rheumatoid arthritis, the synovial volume at MR imaging has been proved to show correlation with synovial inflammatory activity in knee osteoarthritis (13). In a similar way, Doppler US demonstration of synovial hypervascularity correlates with vascular enhancement. In our study, we found that almost all patients with synovitis showed enhancement. We believe that this likely is related to synovial hyperemia and increased diffusion through the basement membrane (28). It should be noted that small degrees of enhancement may be seen in nonsynovitic joints, partly depending on the temporal delay of imaging (29).

Backhaus et al (14) suggested that early arthritis may be diagnosed with the detection of a small joint effusion. They measured the anterior distance between the bone and the joint capsule, and, if this distance was more than 4 mm, a definite diagnosis of synovitis or effusion was made. We measured the posterior capsule because it is more capacious, and there is a less indirect effect from carpal tunnel contents (30). Our posterior measurements, however, did not show any statistically significant differences between capsular thickness in patients with and patients without synovitis.

Several other authors (7,31,32) have used the presence of joint fluid as an MR imaging marker of synovitis in the shoulder, knee, ankle, or temporomandibular joint. Although the presence of fluid is physiologic in many joints (33), we were interested in the presence of recess distention (34). In this study, we found pisotriquetral recess distention in three-quarters of the patients with synovitis and one-quarter of the patients without synovitis. The amount of fluid distention was significantly higher in patients with synovitis.

Looking specifically at the normally visualized radial and prestyloid recesses, we found less helpful results, with distention seen in only half of the patients with synovitis. In this group, therefore, effusions did not frequently accompany reactive synovitis. This is quite different then that seen with inflammatory synovitis (3). Distention of these recesses, however, was seen in only 10% of patients without synovitis. Thus, in this pilot study, radiocarpal recess distention appears to be a fairly specific, but somewhat insensitive, sign of carpal synovitis.

It has been suggested that the presence of bone marrow edema is indicative of increased cartilage loss in the knee (35). In our study, the frequency of marrow edema was similar for patients with and patients without synovitis. This may be because there are disparate causes of marrow edema in the wrist, many of which are not associated with synovitis (36). Two patients with synovitis and none without showed pisotriquetral bone marrow edema. Although this finding was unusual in our study, it merits further study to determine its relationship to carpal synovitis.

An interesting finding of this study was that the synovitis at surgery was most often localized, typically to the ulnar side of the wrist, and yet the MR imaging findings were somewhat diffuse in many patients. As previously stated, the reviewers were blinded to the surgical findings. A likely explanation of this is that even when the synovium is focally proliferative in patients with osteoarthritis and recognizable at surgery, it is often diffusely abnormal at histologic analysis (37). In addition, the absence of synovial enhancement is helpful for excluding reactive synovitis.

We acknowledge three additional limitations to this study. First, only half of the patients with synovitis received intravenous contrast material. In addition, this was a retrospective study. Because of our strict inclusion criteria, a somewhat limited patient population was studied. These were consecutive patients, with one observer using consistent criteria to determine whether synovitis was present. Although we could also have evaluated a "normal" control group, we chose not to use this method. Considering the fact that no asymptomatic volunteer can undergo arthroscopy, we would not be able to exclude cases of subtle or clinically occult wrist synovitis.

Despite these limitations, we conclude that MR imaging may show signs of reactive synovitis of the wrist. Pisotriquetral recess distention, synovial enhancement, and, less commonly, the presence of pisotriquetral marrow edema are MR findings that may help determine the presence of noninflammatory wrist synovitis. Our initial experience may provide some baseline data to be verified in future studies of the wrist and other articulations.


   FOOTNOTES
 

Abbreviations: SE = spin echo

Author contributions: Guarantor of integrity of entire study, M.E.S.; study concepts, M.E.S., W.B.M.; study design, M.E.S.; literature research, M.S.B., M.B.R.; clinical studies, R.W.C.; experimental studies, M.S.B., M.B.R.; data acquisition, M.S.B., M.B.R.; data analysis/interpretation, M.E.S., M.S.B., M.B.R.; statistical analysis, M.S.B., M.B.R.; manuscript preparation and definition of intellectual content, M.E.S., M.S.B., M.B.R., R.W.C.; manuscript editing, M.E.S., M.B.R.; manuscript revision/review, M.E.S.; manuscript final version approval, all authors


   References
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

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