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Project: Ghana Emergency Medicine Collaborative Document Title: Radiology: X-rays of the Hand and Wrist Author(s): Christian Jacobus MD, Maine Medical Center, 2007 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/

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Radiology: X-rays of the Hand and Wrist

Christian Jacobus, MD April 11, 2007

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Overview

n  Brief review of normal radiographic anatomy

n  Cases n  I give you mechanism, complaint, and X-ray n  You give me diagnosis, treatment, and

eponym

n  Shameless unrelated entertainment

4

I Will not Cover…

n  Phalanx fractures n  Soft tissue injuries (except that can be

detected on plain film) n  Cross sectional imaging

5

Carpal Bones

6 Source undetermined

Normal Wrist PA

7

Source undetermined

Normal Wrist Lateral

8 Source undetermined

Normal Hand PA

9 Source undetermined

Normal Hand Lateral

10 Source undetermined

Case 1

n  Hyperextension n  Tender and swollen

thumb

11 Source undetermined

Case 1

n  Bennett Fracture n  Fx-Disloc of base of

thumb MC n  APL tendon

n  Splint, Hand referral n  Will need OR

12

Source undetermined

Case 2

n  FOOSH, wrist pain n  Deformity to dorsal wrist n  Decreased sensation to volar palm

13

Case 2

14 Source undetermined Source undetermined

Case 2

n  Peri-lunate dislocation n  Lunate remains articulated with radius n  Distal carpal bones translate dorsally n  Emergent Hand consult

15

Case 3 n  FOOSH, pain in wrist

16 Source undetermined Source undetermined

Case 3

n  Lunate dislocation n  Disruption of all lunate ligaments n  Emergent Hand consultation

17 E-Hand.com, eatonhand.com

Case 4

n  FOOSH n  Pain in wrist

18

Case 4

19 Source undetermined

Source undetermined

Case 4

n  Colles fracture

20

Sletuffe, Wikimedia Commons Abigor, Wikimedia Commons

Case 4

n  Colles fracture n  Distal metaphysis of the radius n  Dorsal displacement and shortening

n  Silver fork deformity

n  Reduction, splinting n  Be alert for elbow and scaphoid injuries

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Case 5

n  Skier n  Tender and swollen

thumb

22 Source undetermined

Case 5

n  Gamekeeper’s Thumb/Skier’s Thumb/ Breakdancer’s Thumb n  Disruption of the UCL of the thumb MCP n  Only visible on plain film when avulsion fx is

present

n  Splint, Hand Referral n  Will likely need OR

23

Case 5

24

Source undetermined

3-Point Products, 3pointproducts.com

Case 6

n  Punched a wall n  Wrist pain

25 Source undetermined

Case 6

n  Die-punch or lunate load fracture

n  Axial force along hand n  Splint, urgent referral

26 Source undetermined

Case 7

n  FOOSH n  Pain and

tenderness to base of thumb and radial wrist

27 Source undetermined

Case 7

n  Scapho-lunate dissociation n  Terry Thomas/David Letterman sign

n  Scapho-lunate space >4mm

n  Splint n  Urgent f/u

28

Source undetermined

Case 7

29 Source undetermined

Case 8

n  Assaulted with bat n  Wrist pain

30

Source undetermined

Case 8

n  Chauffeur's/Backfire/Hutchinson Fracture n  Direct blow to distal edge of radius n  Often scapholunate dissociation n  Splint, urgent referral

31

Case 9

n  13 yo, FOOSH n  Pain to radial wrist

32 Source undetermined

Case 9

n  Scaphoid fracture n  Frequently missed n  High litigation n  Splint, urgent hand

33 Houston Methodist Orthopedics & Sport Medicine, methodistorthopedics.com

Case 9

34

Source undetermined Source undetermined

Case 9

n  Scapholunate Advance Collapse

35

Source undetermined Source undetermined

Case 10

n  Punched a wall n  Hand pain

36 Source undetermined

Case 10

n  Boxer's fracture n  Splint n  Hand referral

37

Source undetermined

Case 10

n  Displacement in metacarpal fractures n  Reduce

n  > 10° in 2 and 3 n  > 30° in 4 and 5 n  Any rotation

38

Case 11

n  FOOSH n  Dorsal wrist pain

39 Source undetermined

Case 11

n  Triquetrum fracture n  Most dorsal bone on lateral n  Dorsal fracture most common n  Splint, referral

40

Case 12

n  14 yo boy n  Basketball injury n  Wrist pain

41

Source undetermined

Case 12

n  Normal adolescent wrist n  Partially closed physes n  Splint

42

Case 13

n  Thumb hyper-extension

n  Tender and swollen thumb

43 Source undetermined

Case 13

n  Rolando Fracture n  AKA double-Bennett

n  Splint, Hand referral n  Will need OR

44 Source undetermined

Case 14

n  Tried to catch falling wine glass

45 Source undetermined

Case 14

n  Hand foreign body n  Significant litigation

46

Case 15

n  Nightstick injury

47 Source undetermined

Case 15

n  Chauffeur fracture n  Splint, routine Hand referral

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Case 16

n  Punched a wall n  Wrist pain

49 Source undetermined

Case 16

n  Die-punch/Lunate load fracture n  Splint, urgent Hand referral

50

Case 17

n  FOOSH n  Wrist pain

51

Source undetermined

Case 17

n  Scaphoid fracture n  Thumb spica splint n  Urgent Hand referral

52

Case 18

n  Nintendo Wii accident n  Thumb pain

53 Source undetermined

Case 18

n  Gamekeeper's thumb n  Thumb spica n  Urgent Hand referral

54

Case 19

n  Barfight n  Hand pain

55 Source undetermined

Case 19

n  Spiral fracture of second metacarpal n  Splint, referral

56

Case 20

n  MVC n  Hand pain n  Lateral?

57 Source undetermined

Case 20

n  Lateral:

58 Source undetermined

Case 20

n  Dislocation of MCC joints 3-5 n  Hand consultation, reduction

59

Case 21

n  Punched a bouncer

n  Hand pain

60 Source undetermined

Case 22

n  5th MC body fracture n  Reduction? n  Splint

61

Case 23

n  Fall on supinated hand

n  Wrist pain

62

Source undetermined

Case 23

n  Smith's fracture (aka reversed Colles) n  Distal radius n  Impaction and volar displacement n  Reduction, splint

63

Case 24

n  FOOSH n  Wrist pain n  Lateral?

64 Source undetermined

Case 24

n  Lateral:

65 Source undetermined

Case 24

n  Peri-lunate dislocation n  Emergent Hand consultation

66

Case 25

n  FOOSH n  Wrist pain n  Lateral?

67 Source undetermined

Case 25

n  Lateral:

68 Source undetermined

Case 25

n  Triquetral dorsal chip fracture n  Splint n  Urgent Hand referral

69

Case 26

n  FOOSH n  Wrist pain

70 Source undetermined

Case 26

n  Scaphoid fracture n  Thumb spica splint n  Urgent Hand referral

71