Igo Goldberg M.D, Hand Surgeon

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Radiographic Examination of the Wrist
Igo Goldberg M.D, Hand Surgeon Tel-Aviv, Israel
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CAPITATE
HAMATE
TRAPEZOID
TRIQUETRUM
TRAPEZIUM
PISIFORMIS
LUNATE
SCAPHOID
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Carpometacarpal joints
Micarpal joint
Ulnocarpal joint

• Radiocarpal joint
• Radioscaphoid
• radiolunate

Distal Radio Ulnar Joint )DRUJ(
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Force transmission across the wrist
LOAD
RS 50-56
Ul 10-21
RL 29-35
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Imaging investigations

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

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Which radiographic views should be obtained in
the evaluation of every patient with wrist injury?
Routine Wrist Radiography
PA PRONATED OBLIQUE LAT
SUPINATED OBLIQUE
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How should the standard (PA) radiogram for the
examination of the wrist be obtained?
90-90 position

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1

• (?? ?????? ?? ?? ???? ???????? ??????).
• ?????? ?? ????????? ??????? ???? ??? ?????? ????
  ?????? PA ?? AP .
• ????? ????? ?? ECU ??????? ????????? ?????? ????
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• Scaphoid fat pad

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5
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2
3
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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 patients side
  usually makes the ulna more positive.

PA with forearm pronation and firm grip
PA
Conventional PA
AP
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NO !
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What are we looking for on PA views?
L2
L3
L1
radial inclination Normal 16-30 Mean22
radial length Normal 9 mm
carpal height L1/L2 normal 0.54 /- 0.03
carpal translation L3/L2 normal 0.3 /- 0.03
Gilulas arcs
Modified carpal height ratio L3/L2 normal 1.57
(/- 0.05
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1.RADIAL LENGTH INCLINATION
radial inclination Normal 16-30 Mean22 deg.
radial length Normal 9 mm
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2.GILULAS ARCS
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3. CARPAL HEIGHT CARPAL TRANSLATION RATIO
L1
L1
carpal height ratio L2/L1 normal 0.54 /- 0.03
L3
L2
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carpal translation ratio L3/L1 normal 0.3
/- 0.03
L1
L1
L1
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CARPAL HEIGH RATIO - modified
L3
L2
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modified carpal height ratio L2/L3 Normal
1.57 (/- 0.05)
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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

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What are the three methods of measuring ulnar
variance?
Project-a-line technique
Concentric circle method
Method of perpendiculars
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5. IMPACTION SYNDROMES
U.S.P.I C-B/A0.21/-0.07
Ulnar styloid impaction syndrome
Ulnar impaction syndrome
Ulnar impingement syndrome
Ulnocarpal impaction syndrome 2ndary to ulnar
styloid nonunion
Hamatolunate impaction syndrome
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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

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Adequacy of the projection the
scaphopisocapitate (SPC) relationship
the ulna should be within 3 mm of the radial
cortex

• The volar-most edge of the pisiformis is within
  the boundaries of the scaphoid and volar-most
  edge of the capitate

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SPC relationship in LAT projection
True Lat
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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

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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
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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 0 - 15
• Radioscaphoid 120 -150
• Scapholunate angle 30 - 60

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• Carpal instability angles radiolunate angle

R
L
10 deg. either volar or dorsal lunate angulation
gt 10 deg. susp.DISI lt -10 deg. Susp.VISI
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• Carpal instability angles capitolunate angle

0-15 deg.
L
C
VISI
DISI
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• Carpal instability angles radioscaphoid angle

R
120 150 deg.
S
S
C pattern
V pattern (S-L dissociation)
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Rotatory instability of scaphoid
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• Carpal instability angles scapholunate angle

S
L
DISI Lunate dorsiflexed Scaphoid palmarflexed
VISI Lunate volarflexed Scaphoid palmarflexed
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Example of combination of PA and LAT views
Disrupted Gilulas arc at L-T joint volarflexed
lunate and scaphoid
Lunotriquetral lig. disruption (VISI)
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LUNATE DISLOCATION
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3.INTRASCAPHOID ANGLES
Posteroanterior intrascaphoid angle

• Lateral
• intrascaphoid angle

Normal angles lt 35 deg. gt 45 deg.
Increased risk for OA changes
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Routine wrist radiography
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OBLIQUE SUPINE
PA
LAT
OBLIQUE
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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

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CLENCHED- FIST AP
The intercarpal spaces of a normal wrist will not
appear different than on a nonstressed AP
projection
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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
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PA NEUTRAL
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PA RADIAL- DEVIATION
PA ULNAR-DEVIATION
Proximal raw dorsiflexes
Proximal raw palmarflexes
SCAPHOID
foreshortened
elongated
LUNATE
quadrangular
triangular
TRIQUETRUM
Proximal (high position)
Distal (low position)
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VISI
DISI
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MONEIMS VIEW ?????? S-L
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PA UD
AP UD
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SLAC WRIST
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LAT NEUTRAL
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LAT in FLEXION
LAT in EXTENSION
Scaphoid 75 flexion
Scaphoid 35 extension
Lunate 50 flexion
Lunate further 30
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• MOBILITY FORCE

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The saddle joint
dorsal
palmar
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Compression forces in the thumb ray
3 kg
5,4 kg
1 kg
FPL
12 kg
AP
APL
APB

• Dorsal subluxation force is inherent with each
  pinch because of weak ligaments on the radial
  side of the joint and is resisted by AOL

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Roberts view
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Clements-Nakayama Position
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RADIOLOGICAL STAGING OF THE DISEASE
1987

• Menon 1997

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Stage I

• Painful joint instability after injury or
  congenital

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Eaton Stress Thumb Position
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WRONG !!
WRIGHT!!
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Stage II
S/P Eaton-Littler operation
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Stage III
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Stage IV
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• Scaphoid 79
• Triquetrum 14
• Trapezium 2.3
• Hamate 1.5
• Lunate 1
• Capitate 1
• Trapezoid 0.2

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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)

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Fractures of the scaphoid are the most commonly
missed fractures of the upper limb yet , early
diagnosis is essential for successful treatment
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The simplest and most commonly used
classification 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.
Most frequent in children
80 of adults
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20
10
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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
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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.

RSC
RL
Scaphoid to occur Wrist dorsiflexiongt95
deg. Wrist radial deviationgt10 deg
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What is navicular fat stripe sign?
Radiolucent line Fracture leads to radial
displacement or (usually) obliteration of the fat
stripe
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Stecher Position
Scaphoid Position
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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

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Occult scaphoid fracture
Initial Rx
6 m later
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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 gt 10 degrees
• Fracture comminution

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Unstable,displaced fracture of scaphoid
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Scaphoid Collapse (Amadio JHS 1989)
PA intra- scaphoid angle
LA intra-scaphoid angle
An angle gt 40 suggest scaphoid
collapse/malunion and an increased rate of DJD
(SNAC WRIST)
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Scaphoid Collapse
Sagittal CT is best to measure intrascaphoid angle
. Angle gt 40 suggest collapse
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SNAC WRIST(Scaphoid Nonunion Advanced Collapse)
How do scaphoid fractures contribute to wrist
arthritis?
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TRIQUETRUM
14 of carpal fractures
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HOOK OF HAMATE
Papilion Hook of Hamate Position
Carpal Tunnel View
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Hook Of Hamate
Trapezium ridge
Pisiformis
Trapezoid
Capitate
50 of fractures of hook of hamate detected in
this position
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PISIFORMIS
Supinated Oblique View
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CARPAL BRIDGE POSITION
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CARPAL BOSS POSITION
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EXPLODED VIEWS
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Lunotriquetral coalition
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2
2
2
2
1
1
6
7
12
1
3
5
4
1
6
90
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• A1 radial angulation
• 120-125 deg.
• A2 ulnar deviation of the fingers
• Pathological gt25 deg.
• L2/L1 carpal heigh
• 0.54/-0.03
• L3/L1 ulnar translocation
• 0.30/-0.03

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arthritis
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arthritis
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Thank You!
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ARTHROGRAPHY VS. ARTHROSCOPY

• Roth Haddad (1986)
• Koman et al (1990)
• Kelly Stanley (1990)
• Levinshon et al (1991
• Adolfson (1992)
• Vanden et al (1994)
• Weiss et al (1996)
• Only 69 of SL tears and 86 of LT tears were
  seen on arthrography
• A negative arthrogram does not exclude a wrist
  pathology because in 92 of those patients a
  lesion can be found on arthroscopy

• An arthroscopy is indicated on clinical
  suspicion, even when the arthrogram is negative

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MRI vs. ARTHROGRAPHY VS. ARTHROSCOPY

• Golimbu (1989)
• Zlatkin (1989)
• Metz et al (1996)
• Linkous Gilula (1998)
• MRI is the gold standard for the diagnosis of
  osteonecrosis (eg Kioenbocks disease)
• MRI is shown to be both sensitive and specific in
  identifying pathology in the TFCC
• MRI is more sensitive (86 for SL, 50 for TL)
  and more specific (100 for SL and TL) than
  arthrography

• MRI may replace arthrography in evaluating the
  painful wrist as the technique is refined and
  becomes more cost-effective.
• Arthroscopy defines better the nature of ligament
  (Geisslers classification) and TFCC lesion
  (Palmers classification) and enables surgery
  accordingly