Igo Goldberg M.D, Hand Surgeon

Tel-Aviv, Israel

Radiographic Examination of the Wrist

TRAPEZIUM

TRAPEZOID

CAPITATE

HAMATE

TRIQUETRUM

PISIFORMIS

LUNATESCAPHOID

הגרמי הפיגום

הפיגום הגרמי

Radiocarpal joint:

•Radioscaphoid•radiolunate

Ulnocarpal joint

Distal Radio Ulnar Joint

)DRUJ(

Micarpal joint

Carpometacarpal joints

Force transmission across the wrist

RS: 50-56%

LOAD

RL: 29-35%Ul: 10-21%

מה הפתולוגיה שניתן להדגים בעזרת צילומי רנטגן?

שברים•

פריקות•

פגיעה ברצועות•

מחלות דלקתיות•

מחלות מולדות•

Imaging investigations

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

PA PRONATED OBLIQUE LAT SUPINATED OBLIQUE

Which radiographic views should be obtained in the evaluation of every patient with wrist injury?

“Routine Wrist Radiography”

How should the standard (PA) radiogram for the examination of the wrist be obtained?

“90-90 position”

מע', כף היד (ולא שורש היד) 90 מע', מרפק בכיפוף ל-90כתף באבדוקציה ל-•שטוחה על הקסטה (ללא כיפוף,יישור או הטיות לצדדים).

הקרן המרכזית של הרנטגן מאונכת לקסטה ומרוכזת על ראש עצם הקפיטטום•

(קסטה גדולה מספיק בכדי להדגים את מלוא אורכן של עצמות המסרק).•

קריטריונים לצילום נכון:

(יש להדגים את כל אורך המטקרפוס 1.השלישי).

המיקום של הסטילואיד האולנרי מראה האם 2. .AP או PAהצילום נעשה בתנוחת

רדיאלית לסטילואיד ECUהופעת התעלה של 3.אולנרי מראה שהמרפק היה בגובה הכתף

בזמן הצילום, כפי שאכן צריך להיות.

ציר האורך של עצם המסרק צריך להיות בקו 4.ישר להמשך ציר האורך של הרדיוס, מה

שמצביע שלא היו הטיות לצדדים בזמן הצילום.

צריכים 2-5קווי הפרקים הקרפומטקרפלים 5.להיות מקבילים שאם לא כן שורש היד היה

בכיפוף או ביישור.

.6Scaphoid fat pad

1

23

4

5

6

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 patient’s side

usually makes the ulna more positive .

Conventional PAPA with forearm pronation

and firm gripPAAP

NO !

What are we looking for on PA views ?

radial inclinationNormal = 16-30

Mean=22

radial lengthNormal = 9 mm

carpal height = L1/L2normal = 0.54

+/- 0.03

carpal translation = L3/L2normal = 0.3

+/- 0.03

Gilula’s arcs

L2

L1

L3

Modified carpal height ratio= L3/L2 normal = 1.57 (+/- 0.05

1.RADIAL LENGTH & INCLINATION

radial inclinationNormal =16-30 Mean=22 deg.

radial lengthNormal = 9 mm

2.GILULA’S ARCS

ככל שהיחס קטן –התמט של שורש היד גדל

3 .CARPAL HEIGHT & CARPAL TRANSLATION RATIO

carpal height ratio = L2/L1normal = 0.54 +/- 0.03

carpal translation ratio = L3/L1normal = 0.3 +/- 0.03

L1

L2

L3

L1

L1

L1’L1’’

ככל שהיחס קטן – התמט של שורש היד גדל

CARPAL HEIGH RATIO - modified

modified carpal height ratio = L2/L3Normal = 1.57 (+/- 0.05)

L2L3

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

What are the three methods of measuring ulnar variance?

Project-a-line technique Concentric circle method

Method of perpendiculars

5. IMPACTION SYNDROMES

U.S.P.I =C-B/A=0.21+/-0.07

Ulnar impaction syndrome

Ulnar impingement syndrome Ulnocarpal impaction syndrome 2ndary to ulnar styloid nonunion

Hamatolunate impaction syndrome

Ulnar styloid impaction syndrome

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

Adequacy of the projection: the scaphopisocapitate (SPC) relationship

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

the ulna should bewithin 3 mm

of the radial cortex

SPC relationship in LAT projection

True Lat

What are we looking for on LAT views?

1. PALMAR TILT2. CARPAL INSTABILITY ANGLES3. INTRASCAPHOID ANGLES4. RELATIONSHIP BETWEEN THE SCAPHOID & LUNATE IN

FLEXION & EXTENSION OF THE WRIST

1.PALMAR TILT

90 deg. – the tilt is zero degrees.Palmar tilt is identified by (+) signDorsal tilt is identified by (-) sign

Normal = +11 deg

2.CARPAL INSTABILITY ANGLES

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

Collinear alignment of the radius, lunate and capitate:Lines are perpendicular to radiolunate and lunocapitate articulations

Carpal instability angles: radiolunate angle

10 deg. either volar or dorsal lunate angulation

> +10 deg. susp.DISI

< -10 deg. Susp.VISI

RL

Carpal instability angles: capitolunate angle

0-15 deg.

CL

DISI

VISI

Carpal instability angles: radioscaphoid angle

120 – 150 deg.

C pattern V pattern

(S-L dissociation)

R

SS’

Rotatory instability of scaphoid

Carpal instability angles: scapholunate angle

DISI

Lunate dorsiflexed

Scaphoid palmarflexed

VISI

Lunate volarflexed

Scaphoid palmarflexed

S

L

Example of combination of PA and LAT views:……

Lunotriquetral lig. disruption (VISI)

Disrupted Gilula’s arc at L-T joint volarflexed lunate and scaphoid

LUNATE DISLOCATION

סימן "ספל תה ההפוך"

3.INTRASCAPHOID ANGLES

Lateral intrascaphoid angle

Posteroanterior intrascaphoid angle

Normal angles < 35 deg.

> 45 deg. Increased risk for OA changes

“Routine wrist radiography”

PA LAT OBLIQUEOBLIQUE SUPINE

כף היד צ"ל שטוחה על הקסטה

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: neutraldorsiflexionvolarflexion

CLENCHED- FIST AP

The intercarpal spaces of a normal wrist will not appear different than on a nonstressed AP projection

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

PA NEUTRAL

quadrangular

Distal “)low position(”

Proximal (“high position”)

LUNATE

TRIQUETRUM

PA ULNAR-DEVIATION

Proximal raw palmarflexes

Proximal raw dorsiflexes

SCAPHOID

triangular

foreshortened elongated

PA RADIAL- DEVIATION

VISI

DISI

MONEIM’S VIEW למרווח S-L

תקין

פתולוגי

קרן מאונכת 1.

הצד האולנרי של שורש 2. מע' 20היד מורם ב-

מהקסטה

PA

UD

AP

UD

SLAC WRIST

LAT NEUTRAL

LAT in FLEXIONLAT in EXTENSION

Scaphoid:75 flexion

Scaphoid:35 extension

Lunate:50 flexion

Lunate:further 30

הערכה רנטגנית של פרק טרפזיו-מטקרפלי

CMC1( (

דורזלי

פלמרי

מה מייחד את כף היד האנושית ?

של האגודלהאופוזיציהתנועת

:אופוזיציה

הבאת כרית הגליל הרחיקני של האגודל במגע עם הכריות של האצבעות האחרות במטרה לבצע

צביטה

אופוזיציה של האגודל מול האצבעות

ע"י בעיקרמתאפשרת

שרירים אינטרינסיים של האגודל CMC1 פרק

MOBILITY FORCE

dorsalpalmar

“The saddle joint”

APFPL

APLAPB

1 kg

3 kg5,4 kg

12 kg

Compression forces in the thumb ray

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

Robert’s view

Clements-Nakayama Position

RADIOLOGICAL STAGING OF THE DISEASE

Menon 1997

1987

Stage I

Painful joint instability after injury or congenital

Eaton Stress Thumb Position

חובה ללחוץ את האגודלים בכוח אחד כנגד השני !

WRONG!! WRIGHT!!

Stage II

S/P Eaton-Littler operation

Stage III

Stage IV

הערכה רנטגנית של עצמות קרפליות

שכיחות השברים בעצמות שורש היד

Scaphoid 79%

Triquetrum 14%

Trapezium 2.3%

Hamate 1.5%

Lunate 1%

Capitate 1%Trapezoid 0.2%

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…)

Fractures of the scaphoid are the most commonly missed fractures of the upper limb;

yet, early diagnosis is essential for

successful treatment

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.

80% of

adults

Most frequent in children

70% 20%10%

What is the role of the scaphoid in the wrist?

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

Stabilizing bridge between PCR and DCR

RSC RL

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.

MECHANISM

Scaphoid # to occur:

Wrist dorsiflexion>95 deg.

Wrist radial deviation>10 deg

What is navicular fat stripe sign?

Radiolucent line

Fracture leads to radial displacement or (usually) obliteration of the fat stripe

צילומים לסקפואיד

Stecher Position

אגרוף קמוץ והטיה אולנרית קלה

Scaphoid Position

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

Initial Rx 6 m later

Occult scaphoid fracture

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 > 10 degrees

• Fracture comminution

Unstable,displaced fracture of scaphoid

An angle > 40° suggest scaphoid collapse/malunionand an increased rate of DJD (SNAC WRIST)

Scaphoid Collapse (Amadio JHS 1989)

PA intra- scaphoid angle LA intra-scaphoid angle

Scaphoid Collapse

Sagittal CT is best to measure intrascaphoidangle.

Angle > 40° suggestcollapse

SNAC WRIST(Scaphoid Nonunion Advanced Collapse)

How do scaphoid fractures contribute to wrist arthritis?

TRIQUETRUM

14% of carpal fractures

HOOK OF HAMATE

Papilion Hook of Hamate Position

Carpal Tunnel View

Hook

Of

Hamate

Trapezium ridge

Pisiformis

TrapezoidCapitate

50% of fractures of hook of hamate detected in this position

PISIFORMIS

Supinated Oblique View

CARPAL BRIDGE POSITION

גב שורש היד על הקסטה

CARPAL BOSS POSITION

“EXPLODED VIEWS”

מה האבחנה?

Lunotriquetral coalition

מה האבחנה?

מרכזי צמיחה

11

34

5

6 7 12

1 6

1

2

2

2

2

הערכה רנטגנית של שורש היד וכף היד

A1= “radial angulation”

120-125 deg.

A2= ulnar deviation of the fingers

Pathological >25 deg.

L2/L1= “carpal heigh”

0.54+/-0.03

L3/L1= “ulnar translocation”

0.30+/-0.03

הערכה רנטגנית של שורש היד וכף היד:Rheumatoid arthritis

הערכה רנטגנית של

שורש היד וכף היד:

Rheumatoid arthritis

Thank You!