Musculoskeletal Trauma of the Wrist
Murat Akalin, Harvard Medical School, Year- IVGillian Lieberman, MD
September 2000
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The Wrist
• Most common site of injury in entire skeleton
• Distal radius and ulna fractures are 10 times more common than carpal bone fractures
• Mechanism of injury is most often “Fall On OutStretched Hand”
FOOSH
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The Wrist
• Complex anatomy makes identification of abnormalities difficult
• Dislocations are easy to overlook• Complications are significant so these fractures are
among the “MUST NOT MISS”radiologic diagnoses
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Anatomy
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Anatomy
Radiographic Anatomy of the Skeleton Michael L.Richardson, M.D. http://www.scar.rad.washington.edu/RadAnatomy.html
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Anatomy
Modified from Radiographic Anatomy of the Skeleton Michael L.Richardson, M.D.
http://www.scar.rad.washington.edu/RadAnatomy.html
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Anatomycapitate
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Zone of Vulnerability
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Standard Imaging Studies for Suspected wrist trauma or
complications• Wrist series
– PA, lateral, and oblique plain films• Special views
– usually of scaphoid• CT scan
– useful for occult fractures, fragments, nonunion, osteonecrosis
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Other Imaging Studies (Less Useful in Evaluation of Acute Injury)
• MRI– Early/occult
osteonecrosis– cartilaginous and
ligamentous injuries– marrow processes
• Arthrogram– disruption of
ligamentous compartments
• Flouroscopy– Carpal instability with
reproducible symptoms
• Bone scintigraphy– Occult fractures– Osteomyelitis
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Common Wrist Fractures
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Case 1: 23 Year Old with FOOSH
Fracture
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Scaphoid (navicular) Fracture
• Most commonly fractured carpal
• Difficult to detect• Frequently occult,
becoming evident only over time (5-10 days)
• If there is “snuff box” tenderness, special scaphoid view(s) should be requested
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Scaphoid View
• Ulnar flexion– Better visualisation of radial
surface of scaphoid, where fractures often occur
– “Fourth view” often added to standard wrist series
• Variety of other special scaphoid views
Image from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995.
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Multiple Scaphoid Views
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Osteonecrosis of the Scaphoid• 5-15% of scaphoid
fractures• Increased radiodensity
over proximal pole • Take weeks to appear • Likelihood depends on
location of fracture line• Other complications:
nonunion, instabilty, DJD• Complications increase
with delayed diagnosis and treatment Electronic Journal of Hand Surgery
http://www.eatonhand.com/img/IMG00016.htm
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Wrist CT
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CT Reconstruction
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Scaphoid Fracture s/p ORIF
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n pearl pearl Scaphoid Fracture
• Common• Difficult to detect• Especially prone to complications• May become radiographically evident only over
time• Therefore…
If scaphoid views are requested, the patient MUST be followed-up radiographically, even if initial studies are negative
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Case 2: 60 Year Old with FOOSH
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Colles’ Fracture
• Transverse fracture of distal radius
• Distal fragment angulated dorsally
• Often comminuted• Often impacted• 60% have associated
ulnar styloid fracture
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Case 3: 6 Year Old with FOOSH
Radiology Cases in Pediatric Emergency Medicine, (1) 18.
http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
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Greenstick Fracture
• Children• Greater bone elasticity• Break in 1 cortex• Usually angulated• Usually not subtle
Radiology Cases in Pediatric Emergency Medicine, (1) 18.
http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
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Case 4: 6 Year Old with FOOSH
Radiology Cases in Pediatric Emergency Medicine, (1) 18.
http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
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Torus Fracture
• Children• Buckling of 1 cortex• Variant of greenstick• Little or no angulation• Often subtle and easily
missed
Radiology Cases in Pediatric Emergency Medicine, (1) 18.
http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
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Case 5: 16 Year Old with FOOSH
Radiology Cases in Pediatric Emergency Medicine, (1) 18.
http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
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Salter-Harris Fracture• Involves growth plate• Risk of premature fusion
and deformity• S-H classification
predicts risk• May be impossible to
detect radiographically
• Therefore…tenderness at growth plate should be treated as S-H fracture, even in absence of radiographic evidence
Radiology Cases in Pediatric Emergency Medicine, (1) 18.
http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
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Salter-Harris Classification
American Family Physician Vol. (46), number 4
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Common Wrist FracturesKids:•Greenstick Fracture
•Torus Fracture
•Salter-Harris Fracture
Adults:•Scaphoid Fracture
•Colles Fracture
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Wrist Dislocations
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Dislocations of Wrist
• Less common than fractures, but still comprise about 10% of carpal injuries
• Anatomy may be confusing at first,but a few simple tips will make it easy
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On the Frontal View…
• Look for Three Arcs– Clear, smooth, and
continuous– Spaces should be 2mm
or less
• Disruption in any one of these arcs signifies dislocation
Arc 1
Arc 2Arc 3
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On the Lateral View…• Look to see that the
radius + lunate and lunate + capitate articulate
• Like an apple in a cup in a saucer
• If the cup is empty, there is a dislocation
Image from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995.
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Lunate Dislocation
• Most common dislocation• Best seen on lateral view
• On frontal view, Arcs 2 and 3 disrupted and “pie sign” is present
• Treatment is traction and closed reduction vs ORIF and ligamentous repair
Image from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995.
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Perilunate Dislocation
• Best seen on lateral view
• On frontal view, again, Arcs 2 and 3 are disrupted
• Often associated with scaphoid fracture
Image from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995.
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Navicular Subluxation (Scaphoid Dislocation
AKA Scapholunate Dissociation)• Second most frequent
carpal dislocation• Subluxation, not a full
dislocation• “David Letterman” sign
(aka “Terry Thomas” sign)• “Ring” sign• Arcs 1 2 & 3 disrupted• Often associated with
radius fractureImage from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995.
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Common Wrist Dislocations
•Lunate dislocation : pie sign
•Perilunate dislocation
•Navicular subluxationi:
David Letterman/Terry Thomas Sign
Ring Sign
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Summary
• Common fractures may be predicted from the age of patient:
Child GreenstickTeen Salter-HarrisAdult ScaphoidOlder Colles’
• Particular vigilance required for scaphoid fractures
• CT is modality of choice for detecting occult fractures
• Dislocations may be detected with knowledge of normal carpal relations
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References
Chew F. Skeletal Radiology: The Bare Bones. 1st edition, 1989.
Dee R, Mango E, Hurst L. Principles of Orthopaedic Practice. 1998.
Eisenberg R. Clinical Imaging: An Atlas of Differential Diagnosis. 3rd edition. 1998.
Hodge J, Gilula L. Imaging of the Wrist and Hand www.sma.org/soa/jsoawt96/jsoawt6.htm
Rogers L. Radiology of Skeletal Trauma. 2nd edition, 1992.
Raby N, Berman L, de Lacey G. Accident and Emergency Radiology. 1995.
Brown J., Deluca S. Growth Plate Injuries: Salter Harris Classification American Family Physician Volume(46), number 4, Figure 2.
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Acknowledgements
Beverlee Turner
Larry Barbaras
The end.
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