MRI of a painful carpal boss: variations at the extensor carpi radialis brevis insertion and imaging findings in regional traumatic and overuse injuries

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Abstract

Objective

To report patterns of MRI findings involving carpal boss and extensor carpi radialis brevis (ECRB) tendon insertion in individuals with overuse-related or post-traumatic wrist pain.

Materials and Methods

Eighty-four MRI cases with carpal bossing between December 2006 and June 2015 were analyzed by two fellowship-trained musculoskeletal radiologists. The following MRI findings were reviewed: type of carpal bossing (bony prominence, partial coalition, os styloideum), insertion of ECRB tendon (to the 3rd metacarpal, to carpal boss or to both), bone marrow edema (BME), insertion site, and tenosynovitis/tendinosis of ECRB tendon. Clinical information on wrist pain was available on 68 patients.

Results

Fused carpal bossing was detected in 21%, partial coalition in 35%, and os styloideum in 44% of the cases. Regional BME was observed in 64% of the cases. When BME specifically at the carpal boss was assessed, 78% of stable and 50% of unstable bosses showed BME ( p = 0.035). ECRB tendon inserted on a carpal boss in 20%, on the 3rd metacarpal bone in 35%, and on both sites in 45% of the cases. As BME at the carpal boss was assessed, BME was detected at the respective insertion sites in 71%, 35%, and 66% of the cases ( p = 0.015). Dorsal wrist pain was associated with BME as 75% of the patients had regional BME in the vicinity of the carpal boss ( p = 0.006).

Conclusion

A spectrum ranging from complete fusion of a boss to an entirely unfused os styloideum exists with a variable ECRB insertional anatomy. BME at the carpal boss is a consistent MRI finding.

Related collections

Most cited references 15

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The carpal boss: review of diagnosis and treatment.

Min J Park, Surena Namdari, Arnold-Peter Weiss (2008)

It is not uncommon to find a protruding mass at the dorsum of the wrist. The carpal boss is a commonly overlooked condition of unclear etiology. Minor trauma and persisting os styloideum are among the suspected causes of the condition. Long-standing carpal boss can lead to osteoarthritic damage in some patients. Many diagnostic tools, such as a "carpal boss view" radiographic study or a technetium bone scan, are available to help differentiate carpal boss from other, more common, masses of the dorsal aspect of wrist. For years, excision of the mass has been a commonly described treatment, because conservative treatment does not always give relief of symptoms. However, the benefits of wide excision must be balanced by the risks of instability at the involved joints, leading to persistent, and potentially worsened, symptoms.

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W Conway, J Destouet, L Gilula … (1985)

The carpal boss, an unmovable bony protuberance, is located on the dorsum of the wrist at the base of the second and third metacarpals adjacent to the capitate and trapezoid bones. This bony prominence may represent degenerative osteophyte formation and/or the presence of an os styloideum, an accessory ossification center that occurs during embryonic development. When this condition is symptomatic, patients present with complaints of pain and limitation of motion of the affected hand. The symptoms of carpal boss may result from an overlying ganglion or bursitis, an exterior tendon slipping over this bony prominence, or from osteoarthritic changes at this site. Radiographically, the view that best profiles the separate os styloideum is a lateral view utilizing 30 degrees of supination and ulnar deviation of the wrist. Once a diagnosis has been made, treatment can range from the use of nonsteroidal antiinflammatory medication and limited use of the wrist to surgical excision of the anatomic abnormality.

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A detailed and comprehensive study of the anatomy of the 2nd through 5th carpometacarpal (CMC) joints and adjacent structures and clinical relevance is reported. Multiple dorsal ligaments were identified, including 2 from the 5th metacarpal (MC), 2 from the 4th, 3 from the 3rd, and 2 from the 2nd. There were also multiple volar ligaments, 1 from the 5th MC, 1 from the 4th, 4 from the 3rd, and 1 from the 2nd. There was only 1 intra-articular ligament, which was located between the 3rd/4th MC and the capitate/hamate and provided stability even when the dorsal and volar CMC ligaments were cut. There was more variability and often multiple distinct joint surfaces or facets forming the articulations between adjacent MCs and/or adjacent distal carpal bones. The joint surfaces between the 4th MC and the capitate and/or the hamate were also variable and had 5 different types of articulation. The area of the 2nd and 3rd CMC joints was found to have the highest incidence (18%) of carpal coalition, and when present there was a dorsal bone prominence and an absence of the normal dorsal ligament anatomy.

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Author and article information

Contributors

Mika T. Nevalainen: +358-83152011 , mika.nevalainen@oulu.fi

Journal

Journal ID (nlm-ta): Skeletal Radiol

Journal ID (iso-abbrev): Skeletal Radiol

Title: Skeletal Radiology

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0364-2348

ISSN (Electronic): 1432-2161

Publication date (Electronic): 12 January 2019

Publication date PMC-release: 12 January 2019

Publication date (Print): 2019

Volume: 48

Issue: 7

Pages: 1079-1085

Affiliations

[1 ]ISNI 0000 0001 2166 5843, GRID grid.265008.9, Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Thomas Jefferson University Hospitals, , Sidney Kimmel Medical College at Thomas Jefferson University, ; 132 South 10th Street, Philadelphia, PA 19107 USA

[2 ]ISNI 0000 0004 4685 4917, GRID grid.412326.0, Department of Diagnostic Radiology, , Oulu University Hospital, ; PO Box 50, 90029 Oulu, Finland

[3 ]ISNI 0000 0001 0941 4873, GRID grid.10858.34, Medical Research Center Oulu, , University of Oulu, ; PO Box 8000, Oulu, Finland

[4 ]ISNI 0000 0001 0941 4873, GRID grid.10858.34, Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, , University of Oulu, ; PO Box 5000, 90014 Oulu, Finland

Article

Publisher ID: 3136

DOI: 10.1007/s00256-018-3136-9

PMC ID: 6525668

PubMed ID: 30637474

SO-VID: 6594d7c0-f7c4-4b03-b6fc-0df38e7266af

License:

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 24 September 2018

Date revision received : 24 November 2018

Date accepted : 11 December 2018

Funding

Funded by: University of Oulu including Oulu University Hospital

Open Access :

Open access funding provided by University of Oulu including Oulu University Hospital.

Custom metadata

ScienceOpen disciplines: Radiology & Imaging

Keywords: bone marrow edema,carpal boss,extensor carpi radialis brevis,magnetic resonance imaging,os styloideum

Data availability:

ScienceOpen disciplines: Radiology & Imaging

Keywords: bone marrow edema, carpal boss, extensor carpi radialis brevis, magnetic resonance imaging, os styloideum