sep 2009

Was bedeutet der handsurgeon wissen wollen?

Xray Measurements

• Carpal height• Ulnar variance• Radial inclination• Radial length• Palmar tilt• Radial shift

Position

• Neutral PA• Neutral Lat

Position

• Neutral PA• Neutral Lat

Position: PA

• Wrist and elbow shoulder height• radius and ulna parallel

Extensor carpi ulnaris groove

• Radial to mid styloid

Extensor carpi ulnaris groove

• Radial to mid styloid

Position: Lateral

• Elbow adducted• Shoulder elbow wrist in 1 plane

Lateral CCC

• Radius• Lunate• Scaphoid

Lateral CCC

• Radius• Lunate• Scaphoid

Lateral CCC

• Scaphoid• Pisiform• Capitate

Lateral CCC

• Scaphoid• Pisiform• Capitate

CCC OK!

Lunate dislocation

CCC niet OK.

Shape Lunate

Scaphoid shape

Ext Uln. deviation

Scaphoid flex / radial deviation

flexrad deviation

Scaphoid axis

Lunate axis

Capitate axis

Oblique

trapezo-trapezoid

Oblique

trapezo-trapezoid

Carpal height

• Base MC3• Radiocarpal• Collapse

– RA– SL collapse– Lunatomalacie

Carpal height

• Ratio– MC3 (0.54)– Capitate (1.57)

Carpal height

• Ratio– MC3 (0.54)– Capitate (1.57)

Ulnar variance

Ulnar variance

• Load transfer• Growth disorder• Post trauma

Ulnar variance

• Association– SL instable– Ulnocarpal impaction– TFCC

• Normal + 3 mmMid

Radial inclination

• Fracture: – <5° poor outcome

• Madelung steep • Normal 16-28°

Radial inclination

• Fracture: – <5° poor outcome

• Madelung steep • Normal 16-28°

Mid

1878 O. W. Madelung: Die spontane Subluxation der Hand nach Vorne.

Radial length

• Styloid length• Shortening after #• Compare L-R• Normal 10-18 mm

Radial length

• Styloid length• Shortening after #• Compare L-R• Normal 10-18 mm

Mid

Palmar tilt

• Volar ligaments• Dorsal bony ridge• Residual deformity

– 200% load ulnocarpal

• Normal 0-22 °

Palmar tilt

• Volar ligaments• Dorsal bony ridge• Residual deformity

– 200% load ulnocarpal

• Normal 0-22 °

Mid

Radial shift

• # dislocation• PA• Styloid• Midshaft• Compare L-R

– max 1mm

Radial shift

• # dislocation• PA• Styloid• Midshaft• Compare L-R

– max 1mm

Width

Mid

Wrist conditions

• Carpal instability• Scapholunate Collapse• Ulnar translocation• Ulnocarpal impaction• Radio-Ulnar impingement

Carpal instability

• SL - scapholunate• LT - lunotriquete• SLT - Combined• Ligaments intact?

Arc I

LT

Arc II

SL LT

Arc III

CH

DISI

Dorsal intercalated segment instability

DISI (pathology)

Dorsal ... instabilityLunatum kijkt naar posterior

A A

VISI

Volar intercalated segment instability

VISI (variant)

Volar .. instabilityLunatum kijkt naar anterior

A A

VISI

LT Collapse

Instability

LT CollapseArc 1 Short ScaphoidParallel

VISI

Palmar tilt ScaphoidLunate

VISI

Palmar tilt ScaphoidLunate

VISI

Palmar tilt ScaphoidLunate

VISI

SL angle < 30 °

Scapho lunate advanced collapse

• Progressive• Clinical & Radiological• Narrowing• Sclerosis• Osteophyte• CPPD deposition• Non union

SLAC

SLAC

• a

Ulnar translocation

• Clinical & Radiological• Disruption R-C lig.• Instability• Ulnar displacement

– Scaphoid-Styloid– Hamate-Ulna

Ulnar translocation

Scaphoid-Styloid

Ulnar translocation

Ulna - Hamate

Ulnocarpal impaction

• U-L-T Joint degeneration • Compressive forces • Ulna +

Ulnocarpal impaction

• U-L-T Joint degeneration • Compressive forces • Ulna +

U

T L

Radio-Ulnar impingement

• ulna -, concave radius, convergence

TFCC

Intact #

Cases

Parallel joints OverlapCarpal ArcsShape Fracture

Case 1

Case 1

• Lunate not parallel• Arc 1 en 2• Triangular lunate• Dislocated!

Case 2

Case 2

TL, HL overlapParallel

R,L,prox S, prox CTriq,H,dist S, dist H, Trap

# H, S

Case 2

TL, HL overlapParallel

R,L,prox S, prox CTriq,H,dist S, dist H, Trap

# H, STrans scaphoid and capitate perinlunate

#dislocation

Case 2

Case 2

Case 3

Case 3

LT not parallelArc 1, 2 brokenSL tilted

VISI LT dissociation

Case 4

Case 4

All parallelSL wideScaphoid tiltLunate tiltArthrosis RS CL

SLAC (SL tear)

SLAC (CPPD)

Approach

CCC and CCCParallel joints OverlapCarpal ArcsShape Fracture

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