(Plain) Radiographic Evaluation of the Hand and Wrist

1
(Plain) Radiographic Evaluation of the Hand and
Wrist

• Garry W. K. Ho, M.D.
• Sports Medicine Fellow -VCU / Fairfax Family
  Practice
• April 2007

2
Function of the Hand Wrist

• Multiple functions
• Delicate, fine motions
• Powerful, grasping tasks
• Support / transfer force for changing positions
• Sensory organ perception of surroundings
• Communication / express emotions
• Complex anatomical structure
• Structure follows function

3
Anatomy - Wrist

• Bones
• Distal radius
• Distal ulna
• Carpus (8 individual bones)
• Joints
• Radiocarpal joint
• Distal radioulnar joint (DRUJ)
• Intercarpal midcarpal joints
• Ligaments

4
Anatomy - Wrist

• Distal radius
• Metaphysis primarily cancellous bone
• Proximal ? distal cortical bone thickness over
  cancellous bone decreases
• Predisposed to Fx
• Radial (lateral) styloid
• Listers tubercle
• Level of scapho-lunate joint
• Bears 80 axial load

5
Anatomy - Wrist

• Distal radius (Continued)
• Articular surfaces
• Biconcave, radio-carpal surface 2 facets, 1
  ridge
• Scaphoid lunate fossae
• Notched, radio-ulnar surface
• Sigmoid notch

6
Anatomy - Wrist

• Distal ulna
• Ulnar (medial) styloid
• Triangular fibrocartilage complex (TFCC)

7
Anatomy - Wrist

• Triangular fibrocartilage complex (TFCC)
• Attaches to ulnar styloid, ulnar radius, 5th MC
• Major stabilizer of ulnar carpus DRUJ
• Bears 20 axial load
• Components
• Radiotriquetral ligament (meniscal homologue)
• Articular disk
• Ulnolunate ligament
• Ulnar collateral ligament (UCL)
• Prestyloid recess
• Dorsal volar radio-ulnar ligaments (transverse
  fibers)

8
Anatomy - Wrist

• Carpus (8 carpal bones) SLTP-TTCH
• Distal row (4)
• Trapezium (aka Greater Mutilangular)
• Trapezoid (aka Lesser Mutilangular)
• Capitate (aka Os Magnum) largest carpal bone
• Hamate (aka Unciform) - Hook
• Protrude volarly (flexor
• retinaculum)

• Carpus (8 carpal bones) SLTP-TTCH
• Proximal row (4)
• Scaphoid (aka Navicular) spans both rows
• Lunate - keystone of the wrist
• Triquetrum (aka Triangular)
• Pisiform a sesamoid bone
• Protrude volarly (flexor
• retinaculum)

9
Anatomy - Wrist

• Scaphoid (aka Navicular)
• Oblique strut
• Spans both rows
• Proximal distal poles
• Tubercle
• Waist
• 80 covered w/ articular cartilage
• 1 supplied by radial artery
• Volar branches ? distal 20-30
• Dorsal (ridge) branches ? proximal 70-80
• Fxs at scaphoid waist or prox 1/3 depend of fx
  union for revascularization (risk of AVN)
• Protrude volarly (flexor retinaculum)

10
Anatomy - Wrist

• Lunate - AKA Semilunar bone
• Lunate fossa
• Keystone of the wrist
• Convex head of capitate
• Interosseous ligaments ? scaphoid triquetrum
• 80 pts both volar and dorsal supply
• 20 have only a volar blood supply

11
Anatomy - Wrist

• Inter-carpal joints
• Mid-carpal joint b/w proximal and distal rows
• Distal row attached to one another metacarpals
  via very strong, stiff ligaments
• Relatively immobile

12
Anatomy - Wrist

• Ligaments
• Many ligaments ? ligamentotaxis for distal
  radius Fxs
• Intrinsic ligaments
• Carpal bone ? carpal bone
• Extrinisic ligaments
• Radius ? carpus ? metacarpals

13
Anatomy - Wrist

• Extrinsic ligaments
• Ulnar collateral ligament (UCL)
• Radial collateral ligament (RCL)
• Volar dorsal radio-carpal ligaments
• Dorsal ligaments weaker
• Stronger, volar ligaments
• ? more stability to radio-carpal joint

• Volar radio-carpal ligaments
• Radio-scapho-capitate
• Guides scaphoid kinematics
• Radio-scapho-lunate
• Radio-luno-triquetral
• Supports proximal row
• Stabilizes radio-lunate luno-triquetral joints

14
Anatomy - Wrist

• Space of Poirier
• Ligament-free area in volar capito-lunate space
• Allows concomitant midcarpal extension w/
  radiocarpal extension
• Area of potential weakness
• Expands in dorsiflexion disappears in palmar
  flexion
• Rips open during hyperextension ? defect
• Lunate / perilunate dislocations

15
Anatomy - Hand

• Volar hand
• Major digital nerves blood vessels
• Flexor tendons muscles
• Dorsal hand
• Nerves, vessels, extensor tendons muscles
• Bones
• Metacarpals
• Phalanges
• Sesamoids
• Joints
• Ligaments

16
Anatomy - Hand

• Metacarpal bones (5)
• Head
• N eck
• Shaft (Body)
• Triangular cross-section
• Dorsal (posterior)
• Medial (ulnar)
• Lateral (radial)
• Base

17
Anatomy - Hand

• Phalanges (14)
• 3 phalanges per finger (digits 2-5)
• Proximal, middle, distal
• 2 phalanges for the thumb (digit 1)
• Proximal, distal
• 1st MC a primordial phalanx
• Head (condyle tubercle)
• Neck
• Shaft (Body)
• Base

18
Anatomy - Hand

• Sesamoids
• Volar /palmar surface
• MCP 1 (constant)
• 2 sesamoids (medial gt lateral)
• MCP 2 (frequent)
• 1 or 2 sasamoids
• MCP 5 (frequent)
• 1 sesamoid
• MCP 3 4, IP 1, DIP 2 (occasionally to
  infrequently)

19
Anatomy - Hand

• Joints
• Carpo-metacarpal joints (5 CMC)
• 1st CMC highly mobile saddle joint
• Inter-metacarpal joints (3 IMC)
• Metacarpo-phalangeal joints (5 MCP)
• Proximal interphalangeal joints (4 PIP)
• Distal interphalangeal joints (41 DIP)

20
Anatomy - Hand

• Rays
• Unit comprised of an entire structural chain of a
  particular digit
• All the phalanges of a given digit its
  associated metacarpal

21
Anatomy - Hand

• Ligaments
• Palmar metacarpal transverse metacarpal
  ligaments
• Joint capsule (MCP, PIP, DIP)
• Volar (palmar) plate (MCP, PIP, DIP)
• Collateral ligaments (MCP, PIP, DIP)
• Ulnar radial

22
Biomechanics - Hand

• MCP collateral ligaments
• Relaxed in extension
• Permitting lateral motion
• Taut when MCP fully flexed
• Due to cam-shaped MC head
• Distance b/w MC pivot point to phalanx in
  extension lt distance in flexion

23
Anatomy - Pediatrics

• Open physes
• Bony fractures rare
• Higher incidence of Salter-Harris type injuries
• As child matures, a critical bone-to-cartilage
  ratio is reached in pre-adolescence
• Incidence of physeal injuries decrease
• Incidence of fractures increase

24
Biomechanics Hand Wrist

• Arches of the hand
• Longitudinal arch
• Proximal transverse arch
• Distal transverse arch
• Position of function, position of safety
• MCP 45 of flexion
• PIP 30 of flexion
• DIP slight flexion

25
PA View - Hand

• Hand PA View

26
PA View - Hand

• Hand PA View
• Phalanges
• DIP / IP jt
• PIP jt
• Metacarpals
• MCP jt
• Sesamoids
• Distal radius
• Distal Ulna
• Carpal bones
• Soft tissue edema
• Best visualized in dedicated views

27
PA View - Wrist

• Wrist PA View

28
PA View - Wrist

• Wrist PA View
• Metacarpals
• MCP jt
• Sesamoids
• Distal radius
• Distal Ulna
• Carpal bones
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
• Trapezium
• Trapezoid
• Capitate
• Hamate
• Soft tissue edema
• Best visualized in dedicated views

• Wrist PA View
• Should profile E CU tendon groove
• _at_ or radial to base of ulnar styloid

29
PA View - Wrist

• Radial length (Radial height)
• Distance (D-E ) between
• Line (Z) perpendicular to long axis of radius (X)
  through distal tip of sigmoid notch (C)
• Line (Y) b/w distal tip of the radial styloid (D)
  and sigmoid notch (C)
• Averages 1013 mm

• Radial inclination
• (Radial angle)
• Angle between
• Line (Y) connecting the radial styloid tip (D)
  and the ulnar aspect of the distal radius (C)
• Line (Z) perpendicular to the longitudinal axis
  of the radius (X)
• Ranges b/w 21 and 25

30
PA View - Wrist

• Radio-carpal load
• 80 axial load ? distal radius
• 20 axial load ? distal ulna / TFCC
• Abn volar tilt of dital radius
• Load transfer to ulna / TFCC
• Ecentric load to radius, concentrated ? dorsal
  scaphoid
• Plus ulnar variance
• Load transfer to ulna / TFCC
• Minus ulnar variance
• Load transfer to radius

• Ulnar variance
• Longitudinal difference b/w
• Transverse line at level of lunate fossa
• Transverse line at level of the ulnar head
• Mean 0.9 mm (range 4 - 2 mm)
• Minus ulnar variance
• Kienbock's disease
• Positive ulnar variance
• Ligament tears
• Carpal dislocations
• ulnar impaction syndrome
• triangular fibrocartilage
• "stress related changes" (child gymnasts)

31
PA View - Wrist

• Carpal height
• Distance b/w distal capitate distal radius
• Carpal height ratio
• Carpal height / length of 3rd MC
• Avg 53
• Range 45-60
• Decrd carpal height ratio ? carpal collapse
• Used to follow
• Progression of degen dz
• Carpal instability
• Osteonecrosis
• Osteoarthrosis

32
Lateral View - Hand

• Hand lateral view

• Phalanges
• DIP / IP jt
• PIP jt
• Metacarpals
• MCP jt
• Sesamoids
• Distal radius
• Distal Ulna
• Carpal bones
• Soft tissue edema
• Best visualized in dedicated views

33
Lateral View - Wrist

• Wrist lateral view

34
Lateral View - Wrist

• Wrist Lateral View
• Metacarpals
• MCP jt
• Sesamoids
• Distal radius
• Distal Ulna
• Carpal bones
• Scaphoid
• Lunate
• Triquetrum (/-)
• Pisiform
• Trapezium
• Trapezoid
• Capitate
• Hamate
• Soft tissue edema

• Wrist Lateral View
• Scaphopisocapitate relationship
• palmar pisiform should overlie central 1/3 of
  interval b/w palmar scaphoid palmar capitate
• Dorsal metacarpals distal radius
• Straight line

35
Lateral View - Wrist
Biomechanics - Wrist

• Radio-carpal load
• 80 axial load ? distal radius
• 20 axial load ? dital ulna / TFCC
• Abn volar tilt of dital radius
• Load transfer to ulna / TFCC
• Ecentric load to radius, concentrated ? dorsal
  scaphoid

• Volar (palmar) tilt
• Angle (Z) between
• Line perpendicular to the longitudinal axis (X)
  of radius at joint margin
• Line (Y) along the distal radial articular
  surface
• Averages 11
• Ranges between 220

36
Lateral View - Wrist

• Capitolunate angle
• Angle b/w
• Long axis of capitate
• Midplane axis of lunate
• Normally lt 20 (10-30)
• (Depends)
• Usually co-linear
• Scaphoid fracture
• More dorsally tilted lunate strongly suggests a
  scaphoid fracture
• Dorsal tilting of proximal scaphoid fragment
• (More later)

37
Lateral View - Wrist

• Scapholunate angle
• Angle b/w
• Long axis of scaphoid
• Midplane axis of lunate
• Normally b/w 3060
• Angle gt 80 or lt 30
• Instability pattern
• Dorsal tilting of proximal scaphoid fracture
  fragment
• (more on next slide)

38
Biomechanics - Wrist

• Wrist kinematics complicated
• Complex articulations and ligamentous
  connections
• Radius, lunate, capitate central link of the
  wrist
• Scaphoid (along w/ triquetrum) connecting
  strut
• Rests on Radioscaphocapitate ligament _at_ its waist
• Ligament axis
• Scaphoid rotates volar-flexed, perpendicular ?
  dorsiflexed longitudinal position
• Flexion at the scaphoid ?? extension at the
  triquetrum

39
Biomechanics - Wrist

• DISI
• (Dorsal intercalated segmental instability)
• Scaphoid destabilized (Fx, ligament disruption)
• Lunate triquetrum ? excessively dorsiflexed
• Scapholunate angle
• gt 60

40
Biomechanics - Wrist

• VISI
• (Volar intercalated segmental instability)
• Triquetrum destabilized (Fx, ligament disruption)
• Lunate ? volar-flexed
• Scapholunate angle
• lt 30

41
30 (45) Pronated Oblique View

• Obtained w/ radial side of wrist elevated to 30
  (or 45) angle off table / film
• Only view that demonstrates trapeziotrapezoidal
  jt
• Also demonstrates waist of the scaphoid

42
30 (45) Supinated Oblique View(AKA Reverse
Oblique View)

• Obtained w/ ulnar side of wrist elevated to 30
  (or 45) angle off table / film
• Used to image pisiform pisotriquetral joint

43
Scaphoid Views

• PA view w/ ulnar deviated wrist
• Elongates the scaphoid
• Improves detection of subtle scaphoid fractures
• Cephalad tube angle view
• 30 of cephalad beam angulation
• Wrist positioned in 10-15 ulnar deviation
• /- clenched fist

44
Carpal Tunnel View

• Obtained with
• Hand maximally passively dorsiflexed
• Palmar surface of wrist / forearm on cassette
• Beam directed twds cup of palm at 15 deg angle
• Axial view of carpal canal
• Particular attention to
• Hook of the hamate
• Pisiform

45
Phalangeal Views

• Dedicated finger views
• PA
• Lateral
• ER oblique
• IR oblique

46
Views

• Radiographs of contralateral wrist are often
  valuable
• Large range of normal variation in these
  measurements

47
Indications

• American College of Radiology (ACR)
  Appropiateness Criteria for Musculoskeletal
  Imaging in Acute Hand and Wrist Trauma
• Developed in 1998, revised in 2005
• 3-View Series (PA, lateral, 45 pronated oblique
  views)
• Recommended as first study in acute trauma
• 45 supinated oblique view
• Optional may increase yield for distal radius
  Fxs

48
Indications

• ACR Appropiateness Criteria for Acute Hand and
  Wrist Trauma (continued)
• Suspected acute scaphoid fracture
• 3-View Series (PA, lateral, 45 pronated oblique)
• 45 supinated oblique /or cephalad tube angle
  views
• Suspected DRUJ subluxation
• 3-View Series (PA, lateral, 45 pronated oblique)
• CT wrist (bilateral, pronated, supinated)
• Suspected hook of hamate fracture
• 3-View Series (PA, lateral, 45 pronated oblique)
• 45 supinated oblique view
• Carpal tunnel view
• CT wrist (if radiographs normal suspicion still
  high)

49
Indications

• ACR Appropiateness Criteria for Acute Hand and
  Wrist Trauma (continued)
• Suspected metacarpal or phalangeal fracture or
  dislocation
• Hand or finger PA, lateral, ER oblique, IR
  oblique views
• Suspected gamekeeper injury (MCP 1 UCL injury)
• Thumb PA, lateral views (bony avulsion)
• Thumb MRI (bony avulsion)
• Valgus stress PA view compared to contralateral
  limb (controversial accuracy / Steners lesion)

50
Indications

• Equivocal initial radiographs, high suspicion
  despite normal plain films, intra-articular or
  comminuted Fxs
• Further imaging may be appropriate
• Additional plain radiographic projections
• Sonogram (less common expertise required)
• Bone scintigraphy (occult fracture)
• CT scan (comminution, intra-articular)
• MRI (occult fracture, TFCC injury)
• Arthrogram (TFCC inury)
• Initial immobilization w/ follow-up radiographs
  in 2 weeks may be appropiate
• Consider specialist consultation

51
Indications

• Other indications
• Suspicion of instability
• The patient cannot communicate (altered mental
  status, alcohol intoxication, or other)
• Persistent pain or decreased ROM
• Anytime your history and physical dont give you
  enough information

52
PA lateral view of L wrist Normal study
53
Hx FOOSH, wrist pn PA lateral views R
wrist Distal radius Fx Dorsal displacement Dorsal
(apex volar) angulation (loss of volar
tilt) Radial shift Radial shortening Dx
(eponym)? Colles Fx Tx Trial of non-operative
tx Ortho referral if signif displaced or unstable
54
Hx FOOSH, wrist pn PA lateral views L
wrist Distal radius Fx Volar displacement Volar
(apex dorsal) angulation Radial shortening Dx
(eponym)? Smith Fx AKA Reverse Colles
Fx Notoriously unstable Tx ORIF
55
Hx FOOSH, wrist pn PA lateral views R
wrist Distal radius Fx with intraarticular
extension involving volar rim Fx-dislocation Dx
(eponym)? Volar Barton Fx Tx ORIF w/ buttress
plate
56
Hx FOOSH , wrist pn PA lateral views L
wrist Distal radius Fx with intraarticular
extension involving radial styloid Normal
scapholunate angle Dx (eponym)? Radial styloid Fx
(AKA Chauffeur Fx, Backfire Fx, Hutchinson
Fx) Tx Needs a screw!
57
Distal Radius Fractures

• Successful treatment
• Reestablish radial length, inclination, and tilt
• Restoration of articular surfaces
• Adequate reduction
• lt 2 mm step-off of distal radial articular
  surface necessary for good long-term outcome
• Smith, Barton (volar / dorsal), and Chauffeur
  fractures
• Unstable
• Consider surgical referral

58
Hx FOOSH, wrist pn PE snuff-box TTP PA and PA
w/ ulnar dev. views - L wrist Scaphoid
Fx Lateral supinated oblique views Scaphoid
Fx Scapholunate angle 58 Dx? Displaced scaphoid
Fx Tx
ORIF
59
Scaphoid Fractures

• Notoriously difficult to see on initial
  radiographs
• Up to 20 radiographically occult
• Suspected scaphoid fxs w/ nl initial radiographs
• Apply cast (presumptive casting)
• Repeat clinical exam and radiographs in 1014
  days
• Resorption at Fx line may make Fx more visible
• If exam / X-rays still equivocal, consider bone
  scan, CT, or MRI
• ORIF for displaced scaphoid fractures
• As little as 1 mm displacement ? higher rate of
  nonunion AVN
• Dorsal tilting of lunate on lateral views
• May be indirect sign of scaphoid fracture
  displacement

60
Hx Just took my black belt test hand
hurts PA view of metacarpals R hand Minimally
(lt1mm) to non-displaced oblique Fx of 4th MC
shaft No angulation Tx? Splint in position of
safety
61
Metacarpal Shaft Fractures

• Minimally displaced / angulated fxs
• Closed reduction, ulnar gutter splint
• Position of function, position of safety
• MCP 45 of flexion
• PIP 30 of flexion
• DIP slight flexion
• Max tolerated angulation for non-op tx
• MC 2, 3 10
• MC 4, 5 20

62
Hx Chronic wrist pain Lateral PA views L
wrist distal forearm Abn lunate radiodensity
contour with collapse possible fx Pronated
supinated oblique views Same Abn carpal height Dx
(eponym)? Kienbock disease Tx Surgerize!
63
Kienbock Disease

• AVN of lunate
• Risk factors
• manual labor w/ h/o trauma
• Minus ulnar variance (75)
• 20-40 years old
• Si/Sx
• Wrist pn / swelling
• unilateral or bilateral
• Etiology
• Vulnerable blood supply
• Fixed wrist position

• Radiographic findings
• Initially normal maybe linear or compression fx
• Then, incrd density altered shape
• Finally, collapse
• MRI to confirm suspicion
• Treatment
• Based on staging

64
Kienbock Disease
Kienbock's Disease - Radiographic staging Kienbock's Disease - Radiographic staging
I Normal
II Lunate sclerosis
III Lunate collapse
IV Carpal arthritis

• Treatment
• Based on staging
• I NSAIDs, splinting
• II-IV Surgery
• (Ulnar lengthening, radial shortening, lunate
  replacement, prox carpectomy, fusion)

65
Hx jammed finger PA view L hand Lateral view
little (5th) finger Dorsal PIP
dislocation Dx (eponym)? Coachs
finger Tx? Attempted CR and splinting
66
Coachs Finger

• Dislocation of finger PIP
• Most commonly dislocated joint
• Severity often underestimated
• Improper Tx ? morbidity
• Direction usually dorsal, but lateral and volar
  (rare) dislocations occur
• Dorsal PIP dislocation ? injure volar plate or
  middle phalanx avulsion fx
• During sporting event, can attempt reduction
  without XR
• PIP should be splinted after reduction
• Buddy taping PIP in slight flexion
• Must re-eval in office w/ XR
• Treatment should focus on soft tissue damage and
  include follow-up radiography

67
Coachs Finger

• Dorsal dislocation
• Reduction
• Gently applying distal traction
• Volarly directed pressure to middle phalanx
• If ineffective, add hyperextension of distal
  portion to "unlock" the joint
• Lateral dislocation
• Reduction
• Pressure to deviated distal portion (middle
  phalanx)
• Stabilizing proximal portion (proximal phalanx)
• If XR large fx fragment, or reduction
  unsuccessful
• Surgical referral
• Volar dislocation
• May cause tear in central slip of extensor tendon
• Button holing" of proximal phalanx through
  central slip
• Reduction
• Should only be attempted once
• Hyperflexing distal segment (middle phalanx) to
  "unlock" joint
• Apply gentle traction

68
Hx FOOSH, wrist pain Lateral, pronated oblique,
PA views R wrist Minimally displaced pisiform
Fx Carpal tunnel view R wrist Pisiform
Fx Tx? Tx splint / cast x 6 weeks (if
displaced, refer)
69
Hx punched wall ? hand pn PA lateral views R
hand Fx at neck of 5th MC, w/ apex dorsal
angulation Dx (eponym)? Boxers Fx Tx? Surgical
referral (given extent of angulation)
70
Hx sudden ulnar sided wrist pn during kendo
(kumdo) sparring without mitts PA lateral views
R wrist Possible lucent line in hamate Carpal
tunnel view R wrist Nondisplaced oblique fx of
Hook of Hamate Tx? Short-arm cast x 6 weeks
71
Hx Jammed finger playing basketball, weak
finger extension PA lateral views R 5
finger Dorsal lip Fx at base of distal phalanx Dx
(eponym)? Mallet Fx Tx? Splint in extension x
6-8 wks If jt subluxed Refer
72
Hx got finger caught while grabbing a judo
opponent during a match Lateral view of middle
(3) finger Volar lip fx at base of distal
phalanx Dx (eponym)? Jersey finger Tx? Primary
repair (go see Dr. Miller)
73
Hx ski pole got caught during a fall on the
slopes Lateral view of thumb radial
wrist Intraarticular volar lip fx at base of 1st
MC with lateral-proximal displacement Dx
(eponym)? Bennett fracture Tx? Surgerize !
74
Hx ski pole got caught during a fall on the
slopes Lateral view of thumb radial
wrist Intraarticular volar / dorsal lip fx at
base of 1st MC with Y or T comminution Dx
(eponym)? Rolando fracture Tx? Surgerize !
75
Hx FOOSH PA lateral view R distal radius /
wrist Subtle abn cortical contour along radial
volar surface of radius Dx (eponym)? Buckle
(Torus) Fx Tx? Short arm cast x 3 weeks
76
Hx FOOSH PA lateral view L distal
wrist Radial shaft fx b/w middle distal
thirds Shortened Ulnar dorsal displacement
angulation DRUJ dislocation Dx
(eponym)? Galeazzi (Piedmont) Fx Tx? ORIF
77
Hx chronic finger pain, AMS, fatigue, Cr 3.5,
Calcium 12.0 PA view L hand Radiolucent lytic
appearing bone lesion in proximal body of 4th
prox phalanx Dx (eponym)? Brown tumor CRF w/
secondary hyperPTH Tx? Surgical referral for
currettage ? path Renal consult
78
Hx FOOSH, wrist pain PA lateral views of L
wrist No obvious fx Widened scapholunate space (gt
3mm) Cortical (signet) ring sign Abn scapholunate
angle Dx? Scapholunate DISI Dissociation Tx? Reduc
tion cast x 8 weeks, or refer
79
Summary

• Know what views to order when
• Know how to describe what you see
• Importance of anatomy
• Many injuries can be managed conservatively
• When in doubt, immobilize refer

80
Thank You
Questions ?
81
view