Transcript Document 7813456

X-Ray Rounds
Wrist
Mark Scott
Nov. 8, 2007
Systematic Approach
Fracture Identification, Look for:
• Mal-alignment
• Discontinuity
• Radio-lucency / radio-opacity
• Fat pads
11-22-11 Rule
• Radius tilted ~110 volar on Lat.
• Radius tilted ~220 ulnar on AP
• Radial Styloid ~11mm distal to ulna
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11mm
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3 C’s Rule
• Distal Radius  Lunate  Capitate
appears as 3 C’s on lateral
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Distal Radial #
• Apply 11-22-11 rule
• Ortho referral for open, comminuted,
unstable or failure to reduce, DRUJ, and
NV compromise3
• Generally, Smith # (volar angl.) more
unstable than Colles #
• Research study4
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Dorsal Barton’s Fracture
Barton’s Fracture
• Intra-articular Shearing injury of dorsal
(or volar) radial lip.
• Require ortho referral due to high-degree
of instability (insertion of Brachioradialis
tendon)
Scaphoid #
• Most commonly # carpal bone (60-70%)
• Axial loading 70-100% sensitive (better
than snuff box tenderness)
• Evidence suggests below elbow cast with
neutral wrist & thumb free is adequate3
• Refer if >1mm displaced or comminuted
• Follow up within 1 week is crucial.
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CT vs MRI vs Bone Scan for Scaphoid #
• Radiographs miss 10-20% of scaphoid #
• CT more sensitive and readily available3
• MRI more info re: ligamentous injury but
ties up MRI time.
• Bone scan very sensitive (72hrs - 2
weeks) but non-specific3
• High resolution US may be imaging
modality of choice in future (Sn100%,
Sp98%)
Scapho-lunate Dissociation
• Forceful hyper-ext of the wrist
• Tenderness immediately distal to Lister’s
tubercle
• Terry Thomas Sign or signet ring sign
• Ortho referral and look for Lunate/Perilunate
dislocation
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Summary
• Clinical Scaphoid CT if can’t immobilize
or cast & f/u bone scan in 3-5 days.4
• Gross reduction of Colles # is adequate
to prevent negative sequelae.1
• Stability: Colles > Smith’s > Barton’s
• Obtain multiple views and use 11-22-11
and 3 C’s rules.
References
1.
2.
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4.
5.
Jaremko JL et Al. Do radiographic indices of distal radius fracture
reduction predict outcomes in older adults receiving conservative
treatment?Clinical Radiology. 62(1):65-72, 2007 Jan.
McRae, R. Pocketbook of orthopaedics and fractures [2nd ed.].
Churchill Livingstone Elsevier, 2006.
Ritchie JV. Emergency Emerg Med Clin North Am - 01-NOV-1999;
17(4): 823-42
Seitz et al. Fractures and dislocations of the wrist. Rockwell and
Green’s Fractures in Adults [5 ed]. Lippincott, Williams & Wilkins,
2002.
Tintnelli, JE. Emergency medicine: a comprehensive study guide [6th
ed]. American College of Emergency Physicians / McGraw-Hill, New
York, 2004. Pp. 1674-84.
Thank You
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