Radiographic Examination of the Wrist

Igo Goldberg M.D, Hand Surgeon Tel-Aviv, Israel

ימרגה םוגיפה CAPITATE TRAPEZOID TRAPEZIUM SCAPHOID HAMATE TRIQUETRUM PISIFORMIS LUNATE

ימרגה םוגיפה Radiocarpal joint:

•Radioscaphoid •radiolunate

Carpometac arpal joints Micarpal joint Ulnocarpal joint Distal Radio Ulnar Joint

)

DRUJ (

Force transmission across the wrist LOAD

Ul: 10-21% RS: 50-56% RL: 29-35%

?

ןגטנר ימוליצ תרזעב םיגדהל ןתינש היגולותפה המ

םירבש תוקירפ תועוצרב העיגפ תויתקלד תולחמ תודלומ תולחמ • • • • •

Imaging investigations

• • • • • • •

Routine (screening) radiographic examination Specialized radiographic projections Scintigraphic examination Arthrography CT MRI Diagnostic arthroscopy (ARS)

Which radiographic views should be obtained in the evaluation of every patient with wrist injury?

“Routine Wrist Radiography”

PA PRONATED OBLIQUE LAT SUPINATED OBLIQUE

How should the standard (PA) radiogram for the examination of the wrist be obtained?

“90-90 position” ) דיה שרוש אלו ( דיה ףכ .) ,' עמ 90 ל ףופיכב קפרמ ,' עמ םידדצל תויטה וא רושיי , 90 ףופיכ אלל ( ל היצקודבאב ףתכ הטסקה לע החוטש

•

םוטטיפקה םצע שאר לע תזכורמו הטסקל תכנואמ ןגטנרה לש תיזכרמה ןרקה

•

.) קרסמה תומצע לש ןכרוא אולמ תא םיגדהל ידכב קיפסמ הלודג הטסק (

•

6 4 1 3

: ןוכנ םוליצל םינוירטירק

5 2 .) ישילשה סופרקטמה ךרוא לכ תא םיגדהל שי ( םאה הארמ ירנלואה דיאוליטסה לש םוקימה .

AP וא PA תחונתב השענ םוליצה דיאוליטסל תילאידר ןמזב ףתכה הבוגב היה קפרמהש הארמ ירנלוא .

ECU לש הלעתה תעפוה תויהל ךירצ ןכאש יפכ , םוליצה רשי וקב תויהל ךירצ קרסמה םצע לש ךרואה ריצ אלש עיבצמש המ .

, סוידרה לש ךרואה ריצ ךשמהל םוליצה ןמזב םידדצל תויטה ויה תויהל םיכירצ 2-5 םילפרקטמופרקה םיקרפה יווק וא ףופיכב היה דיה שרוש ןכ אל םאש םיליבקמ .

רושייב Scaphoid fat pad .1

.2

.3

.4

.5

.6

Why is it important to obtain adequate PA view of the wrist?

Ulnar variance measurements should not be made on a PA view of the wrist that does not meet the above criteria because there is a difference in the ulnar length on different position of the forearm and elbow: pronation gives the impression of positive ulnar variance and supination gives the impression of negative ulnar variance; adduction of the elbow towards the patient ’s side usually makes the ulna more positive.

AP PA Conventional PA PA with forearm pronation and firm grip

NO !

What are we looking for on PA views?

L2 L3 L1

radial inclination

Normal = 16-30 Mean=22

radial length

Normal = 9 mm

Gilula ’s arcs carpal height

= L1/L2 normal = 0.54

+/- 0.03

carpal translation

= L3/L2 normal = 0.3

+/- 0.03

Modified carpal height ratio= L3/L2 normal = 1.57 (+/- 0.05

1.RADIAL LENGTH & INCLINATION

radial inclination

Normal =16-30 Mean=22 deg.

radial length

Normal = 9 mm

2.GILULA

’S ARCS

3. CARPAL HEIGHT & CARPAL TRANSLATION RATIO

L1

carpal height ratio

= L2/L1 normal = 0.54 +/- 0.03

L1 L3 L2

– ןטק סחיהש לככ לדג דיה שרוש לש טמתה carpal translation ratio

= L3/L1 normal = 0.3 +/- 0.03

L1 L1 ’ L1 ’’

CARPAL HEIGH RATIO - modified

L3 L2

modified carpal height ratio = L2/L3 Normal = 1.57 (+/- 0.05)

– ןטק סחיהש לככ לדג דיה שרוש לש טמתה

4.ULNAR VARIANCE

The relationship between the distal articular surfaces of the radius and ulna as seen on a standardized PA view of the wrist

What are the three methods of measuring ulnar variance?

Project-a-line technique Concentric circle method Method of perpendiculars

5. IMPACTION SYNDROMES

Ulnar impaction syndrome

U.S.P.I =C-B/A=0.21+/-0.07

Ulnar styloid impaction syndrome Ulnar impingement syndrome Ulnocarpal impaction syndrome 2ndary to ulnar styloid nonunion Hamatolunate impaction syndrome

How should the standard lateral view of the wrist be obtained?

• • • •

Elbow flexed to 90 deg. and adducted against the trunk No flexion or extension of the wrist The pronator quadratus fat pad is seen and is straight.

Scaphopisocapitate (SPC) relationship

Adequacy of the projection:

the scaphopisocapitate (SPC) relationship The volar-most edge of the pisiformis is within the boundaries of the scaphoid and volar-most edge of the capitate

the ulna should be within 3 mm of the radial cortex

SPC relationship in LAT projection

True Lat

What are we looking for on LAT views? 1. PALMAR TILT 2. CARPAL INSTABILITY ANGLES 3. INTRASCAPHOID ANGLES 4. RELATIONSHIP BETWEEN THE SCAPHOID & LUNATE IN FLEXION & EXTENSION OF THE WRIST

1.PALMAR TILT

90 deg. – the tilt is zero degrees.

Palmar tilt is identified by (+) sign Dorsal tilt is identified by (-) sign Normal = +11 deg

2.CARPAL INSTABILITY ANGLES

Collinear alignment

of the radius, lunate and capitate: Lines are perpendicular to radiolunate and lunocapitate articulations • • • •

Intercarpal angles of carpal instability Radiolunate angle = 0 - 10

(either volar or dorsal lunate angulation)

Capitolunate angle Radioscaphoid Scapholunate angle = 0 - 15 = 120 -150 = 30 - 60

Carpal instability angles:

radiolunate angle R L 10 deg. either volar or dorsal lunate angulation

> +10 deg. susp.DISI

< -10 deg. Susp.VISI

Carpal instability angles:

capitolunate angle 0-15 deg.

L C VISI DISI

Carpal instability angles:

radioscaphoid angle R 120 – 150 deg.

S ’ S

C pattern V pattern (S-L dissociation)

Rotatory instability of scaphoid

Carpal instability angles:

scapholunate angle S L DISI

Lunate dorsiflexed Scaphoid palmarflexed

VISI

Lunate volarflexed Scaphoid palmarflexed

Example of combination of PA and LAT views: ……

Disrupted Gilula ’s arc at L-T joint volarflexed lunate and scaphoid Lunotriquetral lig. disruption (VISI)

LUNATE DISLOCATION

" ךופהה הת לפס " ןמיס

3.INTRASCAPHOID ANGLES

Posteroanterior intrascaphoid angle Lateral intrascaphoid angle

Normal angles < 35 deg.

> 45 deg. Increased risk for OA changes

“Routine wrist radiography” ל " צ דיה ףכ הטסקה לע החוטש PA LAT OBLIQUE OBLIQUE SUPINE

Of which radiographic views consists the “wrist instability series” described by Gilula?

“Routine wrist radiography”

• PA • LAT • Oblique • Supinated Oblique

“Wrist motion view series”

• Clenched-fist AP (Clenched-fist PA with UD) • PA view in:

neutral radial deviation ulnar deviation

• LAT view in:

neutral dorsiflexion volarflexion

CLENCHED- FIST AP The intercarpal spaces of a normal wrist will not appear different than on a nonstressed AP projection

CLENCHED - FIST PA (a matter of personal preference) The intercarpal spaces of a normal wrist will not appear different than on a nonstressed AP projection

PA NEUTRAL

PA RADIAL- DEVIATION PA ULNAR-DEVIATION Proximal raw palmarflexes SCAPHOID foreshortened elongated LUNATE triangular Proximal ( “high position

”)

TRIQUETRUM quadrangular Distal ( “low position”) Proximal raw dorsiflexes

VISI DISI

S-L חוורמל MONEIM ’S VIEW תכנואמ ןרק .1

דיה שרוש לש ירנלואה דצה הטסקהמ ' עמ 20 ב םרומ .2

PA UD AP UD

SLAC WRIST

LAT NEUTRAL

LAT in EXTENSION LAT in FLEXION Scaphoid: 35 extension Scaphoid: 75 flexion Lunate: further 30 Lunate: 50 flexion

ילפרקטמ ויזפרט קרפ לש תינגטנר הכרעה ) CMC1)

ירמלפ ילזרוד

?

תישונאה דיה ףכ תא דחיימ המ

לדוגאה לש

היציזופואה

תעונת

: היציזופוא

םע עגמב לדוגאה לש ינקיחרה לילגה תירכ תאבה הטיבצ עצבל הרטמב תורחאה תועבצאה לש תוירכה

תועבצאה לומ לדוגאה לש היציזופוא י " ע

רקיעב

תרשפאתמ

לדוגאה לש םייסנירטניא םירירש

FORCE

CMC1 קרפ

MOBILITY

“The saddle joint”

palmar dorsal

Compression forces in the thumb ray 1 kg 3 kg FPL AP 5,4 kg 12 kg APB APL Dorsal subluxation force is inherent with each pinch because of weak ligaments on the radial side of the joint and is resisted by AOL

Robert ’s view

Clements-Nakayama Position

RADIOLOGICAL STAGING OF THE DISEASE

Menon 1997

1987

Stage I

Painful joint instability after injury or congenital

םילדוגאה תא ץוחלל הבוח !

ינשה דגנכ דחא חוכב

Eaton Stress Thumb Position

WRONG !!

WRIGHT!!

Stage II

S/P Eaton Littler operation

Stage III

Stage IV

תוילפרק תומצע לש תינגטנר הכרעה

דיה שרוש תומצעב םירבשה תוחיכש

Scaphoid 79% Triquetrum 14% Trapezium 2.3% Hamate Lunate Capitate Trapezoid 1.5% 1% 1% 0.2%

FRACTURES OF THE SCAPHOID

• 80% of carpal bones fractures • Second to distal radius fractures • 43 fractures per 100,000 population (3225 fractures for 7.5 million – Israel…)

Fractures of the scaphoid are the most commonly missed fractures of the upper limb; yet , early diagnosis is essential for successful treatment

The simplest and most commonly used classification:

Most frequent in children

80% of adults The fairly benign scaphoid tubercle fractures The scaphoid waist fractures benign but with propensity for carpal collapse with subsequent malunion and arthritis.

Proximal pole fractures can result in an avascular proximal segment that will not heal, ultimately causing degenerative arthritis over time if not properly treated.

10% 70% 20%

What is the role of the scaphoid in the wrist? Stabilizing bridge between PCR and DCR The scaphoid connects proximally to the lunate (S-L lig) and distally to the capitate and trapezium & trapezoid: S-L dissociation # waist of scaphoid with humpback deformity

MECHANISM

Most injuries to the carpus occur in wrist extension. The contact point of the injury determines the type of fracture/dislocation pattern that occurs: •Injuries with a contact occurring at the

distal radius

produce distal radius fractures.

•Injuries with a contact occurring over the

carpus

, carpal fracture and dislocations occur.

•When the contact point is more distal, fractures and dislocations at the

CMC joints

occur.

Scaphoid # to occur: Wrist dorsiflexion>95 deg.

Wrist radial deviation>10 deg

What is navicular fat stripe sign?

Radiolucent line Fracture leads to radial displacement or (usually) obliteration of the fat stripe

Stecher Position דיאופקסל םימוליצ Scaphoid Position

הלק תירנלוא היטהו ץומק ףורגא

What is an occult scaphoid fracture?

1. Completely undisplaced fracture that may not appear on plain films initially.

2. 2-3 weeks needed for resorption to occur at the fracture site 3. Clinical examination positive 4. Casting until definite diagnosis

Occult scaphoid fracture Initial Rx 6 m later

What are the criteria for classifying the scaphoid fracture as displaced?

• 1 mm of displacement (gapping) on any radiographic view Non-union rates climb 10-20-fold • Angular displacement > 10 degrees • Fracture comminution

Unstable,displaced fracture of scaphoid

Scaphoid Collapse (Amadio JHS 1989) PA intra- scaphoid angle LA intra-scaphoid angle An angle > 40 ° suggest scaphoid collapse/malunion and an increased rate of DJD (SNAC WRIST)

Scaphoid Collapse

Sagittal CT is best to measure intrascaphoid angle.

Angle > 40 ° suggest collapse

How do scaphoid fractures contribute to wrist arthritis?

SNAC WRIST

(

S

caphoid

N

onunion

A

dvanced

C

ollapse)

TRIQUETRUM 14% of carpal fractures

Papilion Hook of Hamate Position

HOOK OF HAMATE

Carpal Tunnel View

Pisiformis Hook Of Hamate Trapezium ridge Capitate Trapezoid 50% of fractures of hook of hamate detected in this position

Supinated Oblique View

PISIFORMIS

CARPAL BRIDGE POSITION

הטסקה לע דיה שרוש בג

CARPAL BOSS POSITION

?

הנחבאה המ

“EXPLODED VIEWS”

?

הנחבאה המ

Lunotriquetral coalition

2 2 2 2 החימצ יזכרמ 1 6 5 7 1 4 1 3 1 6 12

דיה ףכו דיה שרוש לש תינגטנר הכרעה A1= “radial angulation” 120-125 deg.

A2= ulnar deviation of the fingers Pathological >25 deg.

L2/L1= “carpal heigh” 0.54+/-0.03

L3/L1= “ulnar translocation” 0.30+/-0.03

: דיה ףכו דיה שרוש לש תינגטנר הכרעה Rheumatoid arthritis

תינגטנר הכרעה דיה שרוש לש : דיה ףכו Rheumatoid arthritis

Thank

You!