Upper Extremity Trauma: page 1 of 22 Wrist...©Ken L Schreibman, PhD/MD 2/15/12 Upper Extremity Trauma: page 2 of 22 Wrist Anatomy Radiographs 4 Views Other Views CT/MR FOOSH Colles

©Ken L Schreibman, PhD/MD 2/15/12 www.schreibman.info

page 1 of 22Upper Extremity Trauma:Wrist

AnatomyRadiographs

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CT/MRFOOSH

CollesTorusBartonScaphoidDislocations

VISI/DISIWOW

© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info

Upper Extremity Trauma Wrist

Slide 1 of 131

3D Wrist CT

Frontalview

Ulna sideview

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Slide 2 of 131

Ulna sideview

Radius:

Frontalview

RadialStyloid

Arm:Radius rotates around ulna(radial head)

Lister’s Tubercle (dorsal)

Wrist: Radius is the foundation upon which the carpal bones reside

Looking down onarticular surface

LunateFossa

ScaphoidFossa

Anterior

Normal anterior (volar) (palmar) tilt of distal radius

Long axis of radius

Perpen-dicular to long axis

Normal2-20°volar

R R

[L] “ray”

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Slide 3 of 131

Scaphoid:

Frontalview

Ulna sideview

aka “Navicular of hand”(confusing Navicular in foot)

ScaphoidFossa

Waist

Distal pole sticks out anteriorly

ProximalPole

Scaphoid bridges the proximal and distal carpal rows

ProximalPole

DistalPoleDistal

Pole

R R

S S

[Gr]“boat”

Waist

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Slide 4 of 131

TFC

Lunate:

Frontalview

Ulna sideview

LunateFossa

R R

S S

L L

Should have opening upLike a teacup holding tea

Lunate sits ½ over radius (lunate fossa),½ over Triangular Fibro Cartilage (TFC)Lunate is nearly surrounded by cartilage

Lunate susceptible to AVN (Kienböck)

Onesmall artery anterior

Onesmallarteryposterior

[L] “moon”

ScaphoidFossa

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Slide 5 of 131

TFC

Proximal Carpal Row: (S+L+Tq+P)

Frontalview

Ulna sideviewR R

S

L L

PTq

PTq

Triquetrum (Tq): [L] “three-cornered”Pisiform (P): [L] “pea”

Radio-CarpalJoint

SL JtLT Jt

PT Jt

Pisiformstick outanterior

DistalPole

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Slide 6 of 131

Ulna major component of elbow, forearmRole at wrist is limitedDoesn’t even normally touch carpal bones

½ Radius fxs have Ulnar styloid fxs**Often remain

ununitedSeldom require

surgery(If DRUJ stable)TFC

Ulna:

Frontalview

Ulna sideviewR UU

S

L L

PTq

PTq

UlnaStyloid

[L] “arm”… related to “ell”, “cubit” *Unit of length equal to the forearm

*www.etymonline.com

DRUJ

Forms theDistalRadio-UlnarJoint

UlnaStyloid

**orthopedics.about.com

[L] “elbow”

http://www.schreibman.info/






http://www.etymonline.com/index.php?search=ulna

http://orthopedics.about.com/od/handwristfractures/f/styloidtreatment.htm



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Slide 7 of 131

TFC

Frontalview R U

S

L

PTq

PTq

C

UUlna side

view

L

C

Capitate: Head-shaped round proximal endsits inside open end of the lunate

R

CapitateLunateRadiusform a straight stack

[L] “head”AnatomyRadiographs

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Slide 8 of 131

TFC

Hamate:

Frontalview

Ulna sideviewR UU

S

L L

PTq

PTq

HC

Hook-shaped process (H)sticks out anterior

Pisiform

DistalPole

Hook of Hamatesticks outanteriorH

[L] “hook”

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Slide 9 of 131

TFC

Metacarpals

Frontalview

Ulna sideviewR UU

S

L L

PTq

PTq

HHC

Capitate articulates with Long finger MCHamate articulates with Ring & Small finger

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Slide 10 of 131

TFC

aka “Lesser Multangular”

Frontalview

Trapezoid:

Ulna sideviewR UU

S

L L

PTq

PTq

HHC

2 parallel sides

Trapezoid articulates with index finger MC

Td

[Gr] “table shaped”

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Slide 11 of 131

aka “Greater Multangular”

TFC

Trapezium:

Frontalview

Ulna sideviewR UU

S

L L

PTq

PTq

C HHTm Tm

no parallelsides

TrapeziUMarticulates

with the ThUMb

Td

[Gr] “little table”AnatomyRadiographs

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Slide 12 of 131

Carpal Tunnel

S PHTm

Walls of the carpal tunnel are made of the carpal bones that stick out anteriorly









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Slide 13 of 131

Hand ≠ Wrist

R,A 27yoM, fell off bike

HandPA

HandLat

HandObl

All Negative

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Slide 14 of 131

Hand ≠ Wrist

R,A 27yoM, fell off bike

Hand ≠ WristWristPA

WristObl

WristLat

WristUl Dev

Bennett Fracture!

Still Negative…

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Slide 15 of 131

Hand ≠ Wrist

G,M 44yoM

PA Hand

?

PA Wrist (next day)

!

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Slide 16 of 131

Hand vs Wrist: X-ray BeamHand radiographs:X-ray beam centered

@ 3rd MC head

G,M 44yoM

Wrist radiographs:X-ray beam

centered @ capitate

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Slide 17 of 131

Wrist: PA = Standard View

Marty age 15

Elbow @ shoulder height

Elbow @ 90°

Lowchair

Raise cassette

ShieldX-rays

X-ray beamPosteriorAnterior

= “PA”

X-ray beam centered on Capitate

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Slide 18 of 131

PA: Standard view

Wrist: PA ViewCarpal AlignmentProximal Carpal Row

Joint AlignmentRadio-Carpal JointCarpal-Metacarpal JtDistal Radio-Ulnar Jt

Ulnar LengthNormally, Ulna same

length as Radius

DRUJ

Ulna shorter

than Radius

R-C Jt

C-MC

D,H 21yoF









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Slide 19 of 131

Ulnar VarianceUlna shorter than Radius“Negative Ulnar Variance”Risk AVN Lunate (Kienböck)

Ulna longer than Radius“Positive Ulnar Variance”Ulna can punch hole in TFCUlna can impact upon Lunate

“Ulna Abutment Syndrome”

S,Z 18yoM

Ulna is only slightly shorter

than Radius

AVN Lunate with collapse

Radius shorteningT,C 14yoM

2 y earlier, normal unfused growth plates

Premature fusion radius,

continued ulna growth UV

Compared to normal side

Treated with ulna

shortening osteotomy

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Slide 20 of 131

Wrist: Lateral View

R

L

C,S 48yoM

CC

RAnterior

L

Normal2-20°volar

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Slide 21 of 131

Can see most carpal bones on Lateral

C,S 48yoM

C

R

L

SS

R

L

C

P

Hard to see Ulna as it overlaps Radius on a

good lateral view

U

PTq

Can’t see Triquetrum on lateral view…

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Slide 22 of 131

Triquetral FractureClassically presents

as a tiny avulsion fracture dorsal to the mid-carpus

There are no normal ossicles dorsal to the carpal bonesIf you see a small bone

back there, it’s a fractureMay be old, as these tiny

fractures don’t always healM,G 50yoM

Fx

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Slide 23 of 131

Wrist: Standard 3 ViewsPA View Lateral View

ThumbDown Thumb

Up

Oblique View

ThumbHalfway

Between

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Slide 24 of 131

Wrist: Oblique ViewBest view of:STT jointThumb C-MC jointCommon sites for OA

Additional view of:Carpals (scaphoid)MetacarpalsRadius (styloid)Sometimes a fracture is

seen only on this view

K,M 20yoF

S

Tm TdMC









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Slide 25 of 131

Scaphoid (Ulnar Deviation) View

S,B 21yoF

Patient holds wrist in ulnar deviation

Yields an elongated view of the scaphoid.

Helps when looking for fractures.

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Slide 26 of 131

4 View Series for Scaphoid Fracture

K,T 32yoF

Lateral View

PA View Oblique View Scaphoid View

Doesn’t show scaphoid well

Dorsalswelling

Negative Negative? Positive!scaphoid waist fx

?





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Slide 31 of 131

Wrist: Standard 3 View Series1. PA ViewShows alignment of all bones & joints

2. Lateral ViewImportant for Radius fracturesImportant for Carpal alignment/dislocations

3. Oblique ViewShows STT joint (OA, Scaphoid fractures)------------------------------------------------------4. Scaphoid (Ulnar Deviation) ViewElongates Scaphoid (helps to find fractures)

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Slide 32 of 131

Wrist: Additional ViewsNOT part of standard wrist series

(Ordered only in specialized circumstances)

Reverse Oblique (Piso-Triquetral View)Shows Piso-Triquetral joint

Carpal Tunnel (Hook of Hamate) ViewI find this view not particularly helpfulCT better to show Hook of Hamate fractures

Clenched Fist AP ViewLooking for Scapho-Lunate widening (diastasis)

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Slide 33 of 131

Reverse Oblique (Piso-Triquetral View)

L,D 45yoM

ReverseOblique View

Thumb rotated past up

Profiles:P-Tq jointPisiform

Thumb halfway between down/up

Oblique View

Profiles:STTThumb C-MC

We rarely do this view

S,D 18yoM

Fx?

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Slide 34 of 131

Carpal Tunnel (Hook of Hamate) View

PHH

Tm

We rarely do this view

S,D 18yoM

Tm

HH

P

Fx!

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Slide 35 of 131

Wrist: PA ≠ APChest: PA ≠ APChest:PA is

standard

Marty age 13

X-raytube

PosteriorAnterior= “PA”

Portable Chest = AP

X-raytube

AnteriorPosterior = “AP”

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Slide 36 of 131

Wrist: PA ≠ AP

T,A 16yoM

PA: Standard view AP: Non-standard view

Ulna styloid off the ulnar side of the ulna

Ulna styloid off the middleof the ulna

Can’t assess ulnar variance on AP

AP view tends to profile SL

PA view often doesn’t profile SL

SL joint appears WIDERthan other joints on AP









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Slide 37 of 131

Wrist: AP Clenched Fist ViewTo look for an

abnormally wide SL joint

(diastasis)SL joint always

appears wide on AP viewc/w standard PA

Clenched fist forces Capitate down between S & LFurther widening

Need to compare with other side

Very specialized

view

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Slide 38 of 131

Wrist: AP Clenched Fist View

R,T 33yoF

Left wristAP clenched fist

Right wristAP clenched fist

SupinatedRadius outside

Ulna inside

SL wider than other joints

SL wider than other joints…but same as contralateral

side

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Slide 39 of 131

We don’t do PA clenched fist views

R,T 33yoF

Left wristPA clenched fist

Right wristPA clenched fist

PronatedRadius insideUlna outside

SL notprofiled

SL notprofiled

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Slide 40 of 131

Scapho-Lunate Diastasis

P,L 39yoM

PA view Ulnar DeviationRadial Deviation

Normal SL width

Marked SL diastasis= Disruption SL lig.

Normal SL width

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Slide 41 of 131

Scapho-Lunate Diastasis

P,J 32yoM

PA view PA view: Post-operative

Proximal pole dislocated out of scaphoid fossa

K-wires stabilize proximal carpal row

Suture anchors repair SL ligament

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Slide 42 of 131

Wrist ImagingRadiographs:

Trauma PainArthritis (Hand radiographs)

CTSurgical planning known fracturesMROccult fractures (scaphoid)Synovitis (w/Gd) (Usually includes MCPs ± IPs) …pain?

RG95% CT

2%

MR3%

UW data 2005









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Slide 43 of 131

Wrist: CTGood for complex fracturesAid in surgical planningGood to assess fracture healingEven in the presence of metal

E,A 18yoM

PA view Scaphoid view

CT:Coronal Acutrak®

screwCT:Obl Sag

Fx?

Fx

Fx! S LTq

HCTd

CT:Obl Sag

R

Fx! S

R

Tm

Healed!

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Slide 44 of 131

Wrist CT: Positioning

We don’t scan patients with their wrist down at their sideExcess radiation across torsoX-ray scatter decreases res.

We scan patients with their wrist over the head

No excess radiation to bodyNo x-ray scatter

Mighty MousePosition

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Slide 45 of 131

Wrist: CTNOT good for occult fracturesFractures non-displaced on radiographs…

…are non-displaced on CT

L,N 21yoF

PA viewScaphoid view

No fracture

CT: Coronal MR: T1 Coronal

Blackfractureline

MR: T2fs Coronal Acutrak® screw

No fracture

Marrow edema

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Slide 46 of 131

Wrist MR: Positioning

Wrist coil

We scan patients with their wrist over the head

In a wrist coil Functions best in the center of

the magnetic field

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Slide 47 of 131

Wrist: MRGood for occult fracturesWe don’t miss fractures with MR!

Good for synovitis, infectionNeeds IV contrast to show pannus, abscess

Good for masses, tumors, cysts, …Needs IV contrast to show vascularity

Tears? (SL/LT ligaments, TFCC)Arthrogram-MR: Intra-articular contrastI find tears better seen on the arthrogram

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Slide 48 of 131

Wrist: Arthrogram-MR

25g Needle in DRUJContrast flowing in DRUJContrast flowing in DRUJContrast flowing in DRUJContrast flowing in DRUJRadial deviation

No contrast communicating through TFC into RCJ

Ulnar deviation

Contrast communicating through TFC…

…into RCJ

Patient has TFC tear!

C,A 19yoM

After further manipulation

Can seeTFC tear

No contrast communicating through SL or LT into MCJ

25g Needle in MCJ

MR after arthrogram: Coronal T2fs

Contrast flowing thru MCJContrast flowing thru MCJContrast flowing thru MCJ

Contrast flowing through LT tear

into RCJ

Manipulation under fluoro

Fluoroscopy

TFC Tear

LT Tear

SL Intact









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Slide 49 of 131

Fall On Out-Stretched Hand (FOOSH)Most injuries to the wrist are due to one

common mechanismPerhaps THE most common injury

1-in-6 ER fractures occur in the distal radius*Humans are a clumsy speciesWe walk uprightWe’re top heavyWhen falling, we instinctively protect our head, byExtending our armStriking the ground with our hand

This mechanism of injury is perhaps UNIQUE to humans

*orthopedics.about.com

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Slide 50 of 131

The most famous penguin on the Internet

www.youtube.comwww.youtube.com

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Slide 51 of 131Marty age 8½

HANDS

ULNA

RADIUS

Fall On Out-Stretched Hand (FOOSH)

FOOSH

HyperextendWrist

HyperextendWrist

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Slide 52 of 131

Fall On Out-Stretched Hand (FOOSH)Hyperextension of wrist Hyperextensive forces on:RadiusColles fractureTorus fracture (children)

Carpal bonesBarton fractureScaphoid fractureLunate/perilunate dislocations

S

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Slide 53 of 131

Transverse Fx distal radiusHyperextension forces cause:Dorsal angulation± Dorsal displacement

Colles Fracture

S

Fx

R,C 92yoF O,M 20yoM

DORSAL ANGULATIONALWAYS ABNORMAL!

Lateral view Lateral view

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Slide 54 of 131

Dorsal Angulation is BadTo measure angle:Draw line along

distal radiusFrom front cornerTo back corner

Draw line along shaft of radiusPerpendicular to this

Measure this angleNormal is VOLAR2-20°

Dorsal = Abnormal

R,C 92yoF

Lateral view

5°Dorsal

20°Dorsal

2 weeks later…

The ligaments are not designed to support carpal

bones on a dorsal sloped radius

Lateral view


http://orthopedics.about.com/od/handwristfractures/f/styloidtreatment.htm


http://www.youtube.com/watch?v=UtLiQFtKVj8&NR=1

http://www.youtube.com/watch?v=kGy_7gY4f1o







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Slide 55 of 131

Must reduce angle to heal right

M,D 59yoF

ER lateral view:Marked dorsal angulation

Following reduction & casting in ER:

Volar angulation

6 weeks later:Healing, normal

volar angulation

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Slide 56 of 131

Colles fractures very commonIn childrenFall a lotTorus fracture

In womenOsteopenia2 women in

my life…

In the media…

Secretary Judy Wife Lynn

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Slide 57 of 131

Colles vs Smith Fracture

Anatomically impossible?

Season 15, Episode 2original air date 9/22/04

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Slide 58 of 131

S

Colles:Hyper-

extensionDORSAL

angulation

Smith:Hyper-

flexionVOLAR

angulation

Smith Fracture = Reverse Colles

S,K 51yoF

Lateral view:Too much volar angulation

Reduction & cast:Normal volar angulation

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Slide 59 of 131

FOOSHColles:Hyper-

extensionDORSAL

angulation

Mechanisms: Colles vs SmithAnatomyRadiographs

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Slide 60 of 131

Mechanisms: Colles vs Smith

FOOSH Hyperextension Colleswhether fall Forwards or Backwards




http://www.imdb.com/title/tt0629232/






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Slide 61 of 131

Mechanisms: Colles vs SmithFall onto Back of handHyper-

flexionSmith FxVOLAR

angulation

Colles:Hyper-

extensionDORSAL

angulation

Smith fracture

is much less

common than

Colles

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Slide 62 of 131

Abraham Colles (1773-1843)

“The injury to which I wish to direct the attention ofsurgeons, had not, as far as I know, been described byany author.”

“I should consider this as by far the most commoninjury to which the wrist or carpal extremities of theradius and ulnar are exposed.”

babel.hathitrust.org

(81 years before

Roentgen)

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Slide 63 of 131

Robert William Smith (1807-1873)

google.combooks.google.com

(1847?) MDCCCL=1850

Page 162



http://babel.hathitrust.org/cgi/pt?u=1&num=182&seq=1&view=image&size=100&id=mdp.39015020923374


http://www.worldortho.com/dev/index.php?option=com_content&view=article&catid=&id=149:foundations-of-modern-orthopaedics

http://books.google.com/books?id=DjgAAAAAQAAJ&printsec=frontcover&source=gbs_ge_summary_r&cad=0



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Slide 67 of 131

RADIUS

PowerPoint ModelAdult Lateral

Fractures in Children

A

RADIUS

PowerPoint ModelChild Lateral

Epiphysis

physis(growth plate)

Metaphysis

Diaphysis

K,V 2yoM

Lateral PA view AnatomyRadiographs

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Slide 68 of 131

FOOSH Fractures in ChildrenAdult bones: BrittleSnap under forceChild bones: SoftBend under forceFOOSH Hyperextension distal

radial metaphysisBuckling metaphysis-

diaphysis junctionBuckle Fracture“Torus Fracture”

RADIUS

PowerPoint ModelChild Lateral

RADIUS

A

G,A 5yoM

Lateral

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Slide 69 of 131

Torus Fractures: Lateral ViewCortex buckles INFOOSH (Colles)Dorsal cortex

Fall on back of wrist (Smith)Volar cortex

Nature does not make angles…Nature makes smooth curvesIf you see cortex angulation ina child that should be smooth,

it’s likely a torus fracture!

RADIUS

S,A 5yoF

Lateral

Cortex of radius & ulna overlap

A,C 6yoM

Lateral AnatomyRadiographs

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Slide 70 of 131

Torus Fractures: PA View

FOOSH

AxialLoad

RADIUS

AxialLoad

RADIUS

AxialLoad

Cortex bucklesOUTWARD

PowerPoint ModelChild PA View

PA view

H,T 8yoF

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Slide 71 of 131

Torus Fractures: Common…Run eyes along cortexFocus on

metaphysisPA viewBuckles

outwardNot sure?Compare to

normal sideUse other

views!

Subtle

A,B 14yoF

PA viewSymptomatic side

PA viewAsymptomatic side

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Slide 72 of 131

Torus Fractures: Common…Run eyes along cortexFocus on

metaphysisLat viewBuckles

inwardNot sure?Compare to

normal sideUse other

views!

SubtlePA viewSymptomatic side

Lat viewAsympt.

Lat viewSympt.

A,B 14yoF









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Slide 73 of 131

“Torus”Capital

S

h

a

f

t

BasePlinth

Torus

RadioGraphics 2004; 24:p1025

[L]:“swelling,protuberance,bulge”[Architecture]:A large convex molding, semicircular in cross section, at base of a classical column.

Wisconsin State Capitol

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Slide 74 of 131

Fall On Out-Stretched Hand (FOOSH)Hyperextension of wrist Hyperextensive forces on:RadiusColles fractureTorus fracture (children)

Carpal bones(Proximal carpal row)Barton fracture

S

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Slide 75 of 131

Barton FractureHyperextension of wrist Impaction of carpal bones on radius dorsal rim Fracture radius rimIntra-articular fracturePotentially more serious than Colles

(extra-articular fracture)May require surgical fixationSurgeon may order CT for planning

S

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Slide 76 of 131

Dorsal Barton FractureDorsal BartonDue to FOOSHis much more common than

Volar BartonDue to blow to

back of wrist

(Just as Colles is much more common than Smith fracture)

S

S,G 37yoM

Lateral view

M,M 58yoF

Lateral view

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Slide 77 of 131

Volar Barton Fracture

S

Lateral view

A,D 43yoM

CT: Sagittal OpenReductionInternalFixation

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Slide 78 of 131

John Rhea Barton (1794-1871)

www.kmle.co.krThe Medical ExaminerNov 7, 1838; 1, 23; p 365-8

It was said that Barton was ambidextrous and that once he had positioned himself for an operation, he did not move about.

whonamedit.com


http://radiographics.rsna.org/content/24/4/1009.full.pdf






http://www.kmle.co.kr/search.php?Search=Barton, John Rhea

http://search.proquest.com.ezproxy.library.wisc.edu/docview/136837731/1341E9D945F5C7B6F36/4?accountid=465

http://www.whonamedit.com/doctor.cfm/2416.html



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Slide 79 of 131

Fall On Out-Stretched Hand (FOOSH)Hyperextension of wrist Hyperextensive forces on:RadiusColles fractureTorus fracture (children)Carpal bones

(Proximal carpal row)Barton fracture(Distal carpal row)Scaphoid fracture

S

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Slide 80 of 131

Scaphoid FracturesScaphoid THE most common

carpal bone to be fractured.

71% of all carpal fxs*Scaphoid bridges

the carpal rowsTraumatic shear forces

between the rows …shearing fracture across the scaphoid

*emedicine.com

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Slide 81 of 131

Scaphoid Fractures Locations

S,A 24yoM

PA View Wrist

Scaphoid Waist70% of scaphoid fractures

occur at the waist

www.gentili.netB,J 21yoM

Scaphoid Proximal Pole20% occur at scaphoid proximal poleIncreased risk of non-union/AVN

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Slide 82 of 131

Scaphoid Fractures LocationsPA View Wrist

Scaphoid Distal Pole10% occur at distal pole

These are usually uneventful*

PA View Wrist

Scaphoid TubercleRare, usually uncomplicated.If nonunion, usually asympt.*

*emedicine.comB,T 44yoMT,B 20yoM

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Slide 83 of 131

Scaphoid & Radius FracturesSame common mechanism (FOOSH)Distal Radius FractureScaphoid Fracture…BOTH!

Watch out for “satisfaction of search”“Aha, I found the fracture… I’d done looking”

Old Radiology Axiom:The hardest fracture to find is the 2nd fracture

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Slide 84 of 131

Scaphoid with Radius Fracture

W,M 19yoF

PA View Wrist Obl View Wrist PA View Wrist

Colles

UlnaStyloid

Proximal Pole

Plate fixates Colles

fracture

Screw fixates

scaphoid fracture



http://emedicine.medscape.com/article/397230-overview


http://www.gentili.net/fracture.asp?ID=104







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Slide 85 of 131

22yo M03:00Unbelted passengerHigh speed MVCT-boned by minivanAir bags deployedTook 20 minutes to

extract from car

Intubated

Scaphoid doesn’t heal as well as other bones

V,G 22yoM

FB

…

Acetabularfracture

PA View Hand 2 months later…Healing

FB

OK

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Slide 86 of 131

Scaphoid doesn’t heal as well as other bonesafter 4 months…

FB

OK

CT: Coronal

OK

FBCT: SagittalOblique

Non-union scaphoid

waistV,G 22yoM

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Slide 87 of 131

Scaphoid has a tenuous blood supplyRadial artery

supplies:Distal Pole (DP)

of Scaphoid (S) Not Proximal Pole (PP)

The more proximalthe fracture, the

greater the risk of non-union.

The more distracted the fracture, the

greater the risk of non-union.

PAHandOblHand

S

DP

PP

RadialArtery

S

Heavy arterial calcificationPt w/ diabetes, renal failure

L,T 60yoM

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Slide 88 of 131

Scaphoid Non-Union AVN

Q,B 62yoF

PA View Wrist CT: Coronal CT: SagittalOblique

Non-union scaphoid waist fx

Collapse & fragmentation

PP = AVN

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Slide 89 of 131

Proximal Row CarpectomyLateral View WristPA View Wrist

Resection: Scaphoid, Lunate, TriquetrumRadius articulates with Capitate (distal row)Only treatment for fragmented scaphoid AVN

R

C

Q,B 62yoF

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Slide 90 of 131

To avoid non-unionAVNPRCAll scaphoid fxs require early treatment!Probably with a screw if displacedAt least with a splint or cast if non-displaced

But non-displaced fractures are hard to see because they are non-displaced

So how do we know if a patient has a non-displaced scaphoid fracture?

SNUFFBOX TENDERNESS =PRESUMED SCAPHOID FRACTURE









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Slide 91 of 131

Anatomical Snuffbox

Extensor Pollicis Longus Tendon

Extensor Pollicis Brevis Tendon

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Slide 92 of 131

Snuffbox Tenderness= PRESUMED SCAPHOID FRACTUREWhat if the radiographs are normal?Beautiful! Then it’s a non-displaced fractureTreat anyway with a cast/splintMake sure radiologist agrees they’re negative

Have patient follow-up in 2 weeksGet repeat radiographs (out of the cast/splint)We’re taught occult fxs become visible after 1-2 weeks

from bone resorption at fx margins… I’m not sure it’s true…

Re-examine… if still tender… back into the splintIf you really need to know…MRI (we don’t miss fractures on MRI)

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Slide 93 of 131

Resorbtion of Fracture Margins?

M,D 55yoM, cutting tree branches, FOOSH 15ft

Scaphoid View Oblique View

No scaphoid fx No scaphoid fx No scaphoid fx…

Radius fracturesImportance of multiple views!

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Slide 94 of 131



PA View8 days laterStill snuffbox tenderness

Still noscaphoid fx

MRI: 19 days after injuryCoronal T1 Coronal T2fs

Bone marrow edema in Radius

Blackfx line

Blackfx line

Bone marrow edema in Scaphoid

Blackfx line

Occult scaphoid fracture!

No resorbtion scaphoidfracture margins

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Slide 95 of 131



Scaphoid View Oblique ViewPA Viewafter 29 days…

Still see lucent radius fractures

Still no resorbtion scaphoidfracture margins

Negative radiographs do not exclude a scaphoid fractureSnuffbox Tenderness = Presumed Scaphoid Fracture!

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Slide 96 of 131

Anatomical Snuffbox?snuffhouse.org

www.snuffstore.co.uk schmalzlerfranzl.de







http://snuffhouse.org/discussion/1112/jaxons-english-toffee-mccrystals-mild-lemon

http://www.snuffstore.co.uk/news/2008/04/06/snuff-snow/

http://www.schmalzlerfranzl.de/module.php5?am=3&fid=7&ident=1&mod=vorlagen



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Slide 97 of 131

Normal Carpal Alignment

R

L

C C

R

L

C

L

R

Capitate sits on/in cupped Lunate

Lunate sits on/in cupped Radius

Lateral View3D CT PowerPoint Model AnatomyRadiographs

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Slide 98 of 131

FOOSH Carpal Dislocation

HyperextendWrist

C

L

R

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Slide 99 of 131

Dorsal Dislocation of the Carpus

C

L

R

R,J 20yoM

C

LR

20 yo Male

Riding ATV

Breaks locked

Flew overhandlebars

Very rare injury

(I’ve seen this twice in 20 years)

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Slide 100 of 131

If the hyperextensive forces are applied to the distal carpal rowCapitate (& distal carpal row)

dislocates dorsal to the Lunate (& proximal carpal row)

Capitate (& distal carpal row)

then gets stuck dorsal to theLunate (& proximal carpal row)

FOOSH Carpal Dislocation

C

L

R

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Slide 101 of 131

Perilunate DislocationLunate NOT dislocated.

Carpal bones around lunate(perilunate bones)dislocated.CAPITATE

DISLOCATES

C

R

R,S 56yoM

C

R


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Slide 102 of 131

Perilunate Dislocation becomes…Sometimes the perilunate bones will relocate…shoving the Lunate volar.

This is how a perilunatedislocation becomes a Lunate Dislocation

C

R









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Slide 103 of 131D,D 18yoM

C

R

Lunate Dislocation

C

R

Lunate IS dislocated Capitate

NOT dislocated


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Slide 104 of 131

C

R

L,H 38yoM

C?

R

Occasionally Lunate VERY Dislocated

R

Lateral View PA View

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Slide 105 of 131

Lunate vs Perilunate Dislocations

C

L

R

Vola

r R

adia

l Lin

e

Dors

al R

adia

l Lin

e

C

R

C

R

Carpals should be between the lines

Lunate dislocated beyond volar

radial line

Capitate dislocated beyond dorsal

radial line

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Slide 106 of 131

Continuance of Same Injury

C

R

C

R

C

R

Mid-Carpal Dislocation

Lunate Dislocation

Perilunate Dislocation

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Slide 107 of 131


C

R


B,J 26yoM

Lateral View

C

R

PA View

Hard to appreciate these dislocations on the PA views

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Slide 108 of 131

PA View

Dislocations: Lateral vs PA ViewsEasy to detect

on Lateral viewAlignment of

L & C to RHarder to detect

on PA viewOrientation

of LunateTipped

(Pie-shaped)║ Lack of

Parallelism B,J 26yoM

Lateral View

C

R









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Slide 109 of 131

The Importance of the Lateral View

C

R

Lateral ViewLunate Disloc

D,D 18yoM

C

R

L

LateralReduced

PA ViewLunate Disloc

PA ViewReduced

Normal Lunate Orientation

(Cup-shaped)

Lunate Tipped (Pie-shaped)

Parallel articular surfaces

Lack of parallelism

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Slide 110 of 131

Lunate/Perilunate/Mid-Carpal DislocationsComprise ~10% of all wrist injuries “Because the subtlety of wrist injuries often is not

appreciated fully, many believe that perilunate injuries in general are underdiagnosed.”

I maintain they shouldn’t be underdiagnosed if recognize the importance of the lateral view!

61% also have scaphoid fracturesSCAPHOID BRIDGES CARPAL ROWS! “Trans-Scaphoid Perilunate Fracture Dislocation”Anytime we see one of these carpal dislocations,

need to look for the accompanying scaphoid fx!emedicine.com

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Slide 111 of 131

Trans-Scaphoid Perilunate Fracture Dislocation

P,T 19yoM

PA View

R

Lateral View

DP

Scaphoidwaist fracture

CLack of

parallelism between

C & LC

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Slide 112 of 131

Volar Perilunate Dislocation

C

R R

Result of wrist hyper-extension

Most Perilunate dislocations are dorsal

Blow to the back of the wrist

(likefrom anight-stick)

can result in a VOLAR Perilunate dislocation

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Slide 113 of 131

R

Volar Perilunate Dislocation

H,J 52yoM

R

PA ViewLateral View AnatomyRadiographs

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Slide 114 of 131

C-MC Dislocations

H,C 25yoM

LateralReduced

PA ViewReduced

Lateral PA View

MC bases articulating w/ nothing

Lack of parallelism between MC bases

and distal carpal row

Parallelism restored along C-MC joints

C-MC joints aligned










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Slide 115 of 131

Lunate Tilting (Volar/Dorsal)

V,D 64yoF

H HHCTd

TmTq

P

Lunate

DPPP

PA View Lateral AnatomyRadiographs

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Slide 116 of 131

VISI & DISI

Intercalated:[L]“interposed”, “inserted”Applied to the proximal carpal row…

the Lunate is the intercalated segment (IS)between the Scaphoid and Triquetrum.

VISI=Lunate tipped forwardDISI=Lunate tipped backward

VolarIntercalatedSegmentalInstability

DorsalIntercalatedSegmentalInstability

SL

Tq

IS

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Slide 117 of 131

Measuring VISI/DISILateral ViewDraw 3 LinesLunate long axisScaphoid long axisCapitate long axisMeasure 2 AnglesCapito-Lunate angle Normally between 0-30°Scapho-Lunate angle Normally between 30-60°

S C

L

R

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Slide 118 of 131

Measuring VISI/DISILateral ViewDraw 3 LinesLunate long axisFirst draw SHORT axis, between

● Dorsal distal corner● Volar distal corner

Long axis perpendicular to short● On our PACS, I use the

Cobb angle to draw these lines

L

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Slide 119 of 131

Measuring VISI/DISILateral ViewDraw 3 LinesLunate long axisScaphoid long axisBetween

● Volar proximal edge● Volar distal edge

S

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Slide 120 of 131

Measuring VISI/DISILateral ViewDraw 3 LinesLunate long axisScaphoid long axisCapitate long axisJust eyeball it

C









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Slide 121 of 131

Measuring VISI/DISIMeasurement valid only for lateral wrist radiographNot CTNot MR

Needs to be a “True Lateral”S-P-C Lateral

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Slide 122 of 131

S-P-C Lateral

C,S 48yoM

SC

P

Pisiform should be between Capitate and distal pole of Scaphoid

K,M 20yoF

P S C

True Lateral View Off-Lateral Repeat

S

P C

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Slide 123 of 131

Measuring VISI/DISITrue Lateral ViewDraw 3 LinesLunate long axisScaphoid long axisCapitate long axisMeasure 2 AnglesCapito-Lunate angle Normally between 0-30°Scapho-Lunate angle Normally between 30-60°

L

K,M 20yoF

S

S

C

S-L=57°

C-L=11°

60°

30° 90°

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Slide 124 of 131

VISI (Lunate Tipped Forward)

B,J 56yoM

S C

L

R

True LateralPA View


PS C

C-L=47°(>30°)

Lunate Tipped Forward

S-L=21°(<30°)

R

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Slide 125 of 131

S C

L

RR

DISI (Lunate Tipped Backward)

M,C 56yoF

PA View True Lateral

PSC


Lunate Tipped Backward

S-L=101°(<<60°)

C-L?

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Slide 126 of 131

S C

L

Normal DISIVISI

30°<S-L<60°0°<C-L<30°

S-L<30°C-L>30°

S-L>80°

Lunate tips VolarS-L decreasesC-L increases

C-L doesn’t matter

Lunate tips DorsalS-L increasesC-L backwards

60°

30° 90°

S-L 60-80°

gray zone

VISI/DISI Numbers









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Slide 127 of 131

Wrist: What to Order When (WOW)Wrist Radiographs (95%)3-view wrist seriesPA (not AP)LateralOblique

If snuffbox tenderness, add 4th viewScaphoid (ulnar deviation)

If snuffbox tenderness+negative radiographsTREAT AS PRESUMED SCAPHOID FRACTURECast/splint, follow-up in 2 weeksIf still has snuffbox tenderness, keep treating

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Slide 128 of 131

Wrist: What to Order When (WOW)Wrist CTPredominantly used for surgical planning of

known radius/carpal bone fracturesOrdered by Orthopedics from ER or clinic

Assess healing of known scaphoid fractureWith or without prior screw fixationSmall screws cause virtually no CT artifacts

We always reformat in 3 orthogonal planesFor scaphoid, we add oblique sagittal

We have a specialized protocol for DRUJ instabilityAll protocols at: www.radiology.wisc.edu

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Slide 129 of 131

Wrist: What to Order When (WOW)Wrist MROccult fractures (scaphoid)Persistent symptoms despite negative radiographs

Synovitis (RA)Needs IV contrastNormal synovium does not enhanceVascularized pannus greatly enhances

Ordering provider should specify area of concernJust intercarpal jointsAlso Metacarpal-phalangeal jointsAlso Interphalangeal joints

Field of View = Resolution

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Slide 130 of 131

Wrist: What to Order When (WOW)Wrist ChargesWrist Radiographs 3 views = 4 views = $137It costs nothing to add the scaphoid view to a 3 view series

1 view = 2 views = $128Going from 2 views to 4 views adds only $9 (7%)

Wrist CT (without contrast) = $1,460

Wrist MR (without contrast) = $2,921 (with contrast) = $3,377

UWMF charges 2012

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Slide 131 of 131

That’s all we have on wrists…

Marty age 7



http://www.radiology.wisc.edu/

http://www.radiology.wisc.edu/




Upper Extremity Trauma: page 1 of 22 Wrist...©Ken L Schreibman, PhD/MD 2/15/12 Upper Extremity Trauma: page 2 of 22 Wrist Anatomy Radiographs 4 Views Other Views CT/MR FOOSH Colles

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