Here's how we do a three-compartment wrist arthrogram:

1. The three sites of injection in a tricompartmental wrist arthrogram:
   1. the midcarpal space
   2. the distal radioulnar joint
   3. the radiocarpal joint
2. Place a towel roll or bolster to position the wrist in slight flexion.
3. Obtain a scout fluoroscopic view.
4. Use a radiopaque instrument to localize and mark the planned sites of injection for all three joint spaces.
5. We perform the midcarpal injection at the "four corners" area, at the junction between the capitate, lunate, hamate and triquetrum.
6. Prepare the overlying skin with antiseptic solution and place sterile drapes over the area.
7. Prepare the buffered lidocaine anesthetic solution.
8. Prepare the MR arthrography contrast solution.
9. Anesthetize the planned needle tract with buffered lidocaine solution.
10. For wrist arthrography, we use a 25 gauge butterfly needle with attached extension tubing.
    Midcarpal Joint
    1. Advance the needle directly into the midcarpal space, and check needle position fluoroscopically.
    2. We image our injections with cinefluoroscopy at 1 frame/second.
    3. Inject contrast slowly. Contrast should flow freely away from the needle tip, with little resistance to injection.
    4. Observe contrast extending to the level of the carpometacarpal joints.
    5. Remove the needle and then gently stress the wrist under fluoroscopic observation. Observe fluoroscopically to determine if contrast extends through ligamentous defects into the radiocarpal space during stress.
    6. If contrast remains confined to the midcarpal space by the proximal intercarpal ligaments, it is time to move on to the next joint injection.
    Distal Radioulnar Joint (DRUJ)
    1. Recheck your original localization of the DRUJ.
    2. Anesthetize the DRUJ injection site.
    3. Advance the needle into the joint. Check needle position fluoroscopically.
    4. Inject contrast slowly to opacify the DRUJ, again imaging at 1 frame/second.
    5. Remove the needle and then gently stress the wrist under fluoroscopic observation. Observe fluoroscopically to determine if contrast extends through ligamentous defects into the radiocarpal space during stress.
    6. Look for extravasation through a torn triangular fibrocartilage complex (TFCC) into the radiocarpal space.
    7. If contrast remains confined to the DRUJ joint space by the TFCC, it is time to move on to the final joint injection into the radiocarpal joint.
    Radiocarpal Joint
    1. Recheck your original localization of the radiocarpal joint.
    2. Anesthetize the injection site.
    3. Enter the skin in the region of the proximal scaphoid pole.
    4. Advance the needle until the tip contacts the proximal scaphoid.
    5. Inject contrast slowly to opacify the radiocarpal space. There should be no resistance to the injection. As before, document document your injection by imaging at 1 frame/second.