X-Ray Rounds

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X-Ray Rounds

• Wrist
• Mark Scott
• Nov. 8, 2007

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Systematic Approach

• Fracture Identification, Look for
• Mal-alignment
• Discontinuity
• Radio-lucency / radio-opacity
• Fat pads

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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 Cs Rule

• Distal Radius ? Lunate ? Capitate appears as 3
  Cs 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 Bartons Fracture
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Bartons Fracture

• Intra-articular Shearing injury of dorsal (or
  volar) radial lip.
• Require ortho referral due to high-degree of
  instability (insertion of Brachioradialis tendon)

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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 gt1mm 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)

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Scapho-lunate Dissociation

• Forceful hyper-ext of the wrist
• Tenderness immediately distal to Listers
  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 cant 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 gt Smiths gt Bartons
• Obtain multiple views and use 11-22-11 and 3 Cs
  rules.

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References

1. 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.
2. McRae, R. Pocketbook of orthopaedics and
   fractures 2nd ed.. Churchill Livingstone
   Elsevier, 2006.
3. Ritchie JV. Emergency Emerg Med Clin North Am -
   01-NOV-1999 17(4) 823-42
4. Seitz et al. Fractures and dislocations of the
   wrist. Rockwell and Greens Fractures in Adults
   5 ed. Lippincott, Williams Wilkins, 2002.
5. Tintnelli, JE. Emergency medicine a
   comprehensive study guide 6th ed. American
   College of Emergency Physicians / McGraw-Hill,
   New York, 2004. Pp. 1674-84.

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Thank You
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