Upper Extremity Imaging Hand

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Upper ExtremityImaging- Hand
Wren V. McCallister, MD
Surgery of the Hand Upper Extremity
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Edmonds Orthopedic CenterEdmonds,
Washington425-673-3900
Jeffrey P. Remington, MD Brian D. Cameron,
MD James R. Alberts, MD Wren V. McCallister,
MD
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Upper Extremity Imaging-Hand

• Arthritis-Thumb carpometacarpal (CMC) joint
• Avulsion FDS tendon insertion
• Avulsion fracture extensor tendon at distal
  phalanx
• Boutonniere deformity
• Carpometacarpal (CMC) joint dislocation
• Finger dislocation
• Fracture-Metacarpals
• Fracture-Phalanges
• Fracture-Thumb metacarpal

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Upper Extremity Imaging-Hand

• Thumb ulnar collateral ligament injury

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Arthritis-Thumb CMC joint

• What else is it called?
• Basal joint arthritis
• What is it?
• Osteoarthritis of thumb carpometacarpal joint.
  Often associated with subluxation of CMC joint.
• What studies to order?
• PA and LAT Thumb plain radiographs
• Demonstrate degenerative changes in joint and
  subluxation
• Robert view
• Demonstrates metacarpal-trapezial joint

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Arthritis-Thumb CMC joint

• LAT view, showing isolated
• metacarpo-trapezial arthritis
• (black arrow)

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Arthritis-Thumb CMC joint

• PA view, showing
• pan-trapezial arthritis
• (black arrow
• metacarpo-trapezial joint
• white arrow
• scapho-trapezial joint)

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Arthritis-Thumb CMC joint

• Robert view, showing
• narrowed
• metacarpo-trapezial joint
• (white arrow)

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Avulsion FDS tendon insertion

• What else is it called?
• Jersey finger
• What is it?
• Disruption (either bony or soft tissue) of the
  flexor digitorum profundus (FDS) tendon at its
  insertion on the distal phalanx
• What studies to order?
• PA and LAT Finger plain radiographs
• Lateral view shows bony fragment, which may be
  retracted more proximal along the course of the
  FDS tendon

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Avulsion FDS tendon insertion

• MRI
• For suspected soft tissue avulsions when plain
  radiographs do not demonstrate a bony fragment.
• Lateral plain radiograph
  demonstrating bony avulsion
• with proximal migration.

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Avulsion fracture extensor tendon at distal
phalanx

• What else is it called?
• Mallet finger
• Baseball finger
• What is it?
• Disruption (bony or soft tissue) of the insertion
  of the extensor mechanism on the base of the
  distal phalanx
• What studies to order?
• PA and LAT Finger plain radiographs
• Sufficient to make diagnosis

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Avulsion fracture extensor tendon at distal
phalanx

• PA views, mallet deformity suggested by narrowed
  DIP joint space

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Avulsion fracture extensor tendon at distal
phalanx

• LAT views, line x shows reduced DIP joint
  (intersects mid-condyle of distal middle phalanx)

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Boutonniere deformity

• What else is it called?
• Buttonhole deformity
• What is it?
• Disruption of the extensor tendon central slip at
  its insertion onto the base of the middle phalanx
• Results in the lateral bands moving volar to axis
  of PIP joint rotation
• End result flexion PIP joint, extension DIP
  joint
• End result paradoxical flexion of PIP joint
  with attempted extension

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Boutonniere deformity

• What studies to order?
• PA and LAT Finger
• plain radiographs
• Can identify
• associated fracture
• Difficult to visualize
• PIP joint space
• due to flexion
• deformity (AP view)

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CMC joint dislocation

• What is it?
• Loss of articular congruity of the
  carpometacarpal joints, either a single joint or
  multiple joints.
• What studies to order?
• PA and LAT Hand plain radiographs
• Do not always demonstrate this injury
• 30 Pronated Oblique view of hand
• Demonstrates 5th CMC joint
• CT scan
• Can identify associated carpal bone fractures as
  well as CMC joint congruity

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CMC joint dislocation

• PA, LAT and OBLIQUE plain radiographs
• CMC
• joints

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CMC joint dislocation

• Multiple views demonstrating associated fracture
  of hamate (arrow black far left, white far
  right)

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Finger dislocation

• What is it?
• Disruption of articular congruity at finger joint
  (MCP, PIP, DIP)
• What studies to order?
• PA and LAT Hand or Finger plain radiographs
• Will demonstrate obvious dislocation, most often
  dorsal
• OBLIQUE view
• Will show more subtle fracture-dislocations

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Finger dislocation

• PA view, PIP joint dislocation (white arrow)

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Finger dislocation

• LAT view, PIP joint dislocation (white arrow)

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Fracture-Metacarpals

• What else is it called?
• Boxers fracture
• What is it?
• Disruption of cortical continuity of metacarpal
  bone anywhere along its length
• Boxers fracture disruption of 4th or 5th
  metacarpal neck cortical continuity
• What studies to order?
• PA, LAT and OBLIQUE Hand plain radiographs
• All 3 views necessary to help identify hand
  fractures

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Fracture-Metacarpals

• What studies to order?additional views
• Brewerton view, plain radiograph
• Demonstrates metacarpal head and associated
  fractures or bony fragments associated with
  collateral ligament avulsion
• Skyline view, plain radiograph
• Demonstrates metacarpal head in profile and shows
  articular surface fracture (for fractures
  resulting from injury to a closed fist)

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Fracture-Metacarpals

• PA views Boxers fracture and metacarpal shaft
  fracture

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Fracture-Phalanges

• What is it?
• Disruption of cortical continuity of either
  proximal, middle or distal phalanx anywhere along
  their length (base, shaft, neck or head/condyles)
• What studies to order?
• PA, LAT and OBLIQUE Finger plain radiographs
• All 3 views necessary to help identify hand
  fractures
• CT scan
• To evaluate articular fractures

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Fracture-Phalanges

• PA views
• Intra-articular
• fracture, base
• middle phalanx
• Oblique fracture
• proximal phalanx
• shaft

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Fracture-Phalanges

• LAT views
• Distal phalanx
• shaft
• Oblique fracture
• proximal phalanx
• shaft

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Fracture-Thumb metacarpal

• What else is it called?
• Bennetts fracture
• Rolandos fracture
• What is it?
• Disruption of cortical continuity of thumb
  metacarpal anywhere along its length. Divided
  into extra-articular (transverse or oblique) and
  intra-articular (Bennetts and Rolandos
  fractures)
• Bennets fracture intra-articular fracture with
  large dorsal fragment displaced by pull of
  abductor pollicis longus tendon insertion and
  smaller volar fragment anchored to trapezium by
  anterior oblique ligament

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Fracture-Thumb metacarpal

• What is it?
• Rolandos fracture comminuted fracture of base
  of thumb metacarpal (historically, 3-part
  fracture with T- or Y-shaped pattern)
• What studies to order?
• PA and LAT Thumb plain radiographs
• Usually all that is needed to make diagnosis

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Fracture-Thumb metacarpal

• PA and LAT
• views thumb,
• Bennetts
• fracture

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Fracture-Thumb metacarpal

• PA and LAT views thumb, Rolandos fracture

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Thumb ulnar collateral ligament

• What else is it called?
• Gamekeepers thumb
• Skiers thumb
• What is it?
• Disruption of the thumb ulnar collateral ligament
  (with or without bony avulsion) at its insertion
  onto the ulnar base of the proximal phalanx
• What studies to order?
• PA and LAT Thumb plain radiographs
• May show bony avulsion or be normal if pure
  soft tissue disruption

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Thumb ulnar collateral ligament

• What studies to order?additional views
• Stress PA view, plain radiograph
• May show bony avulsion or be normal if pure
  soft tissue disruption
• MRI
• Can make diagnosis in the absence of a stress
  view (which may require local anaesthetic)
• Aids in estimating degree of retraction

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Thumb ulnar collateral ligament

• PA view (left thumb) shows bony
• defect (black arrow) in base of
• proximal phalanx and avulsed
• fragment attached to ulnar
• collateral ligament (white arrow)

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Thumb ulnar collateral ligament

• Stress view (left thumb)
• demonstrates
• instability associated
• with disruption of
• ulnar collateral ligament

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www.AskEdmondsHand.com
Edmonds Orthopedic Center
Wren V. McCallister, MD