Radiological diagnosis of injuries following fall on outstretched hand

Radiological diagnosis of injuries following Fall on outstretched hand (FOOSH)

Ziad Obermeyer, MS4 Gillian Lieberman, MD

18 September 2006

Core Radiology Clerkship Beth Israel Deaconess Medical Center

snap to grid

HAND INJURIES ARE VERY COMMON IN ED, AND FALL IS ONE OF THE MOST IMPORTANT MECHANISMS

Hand injuries: mechanisms (meta-analysis)*

Location AVG Dk (2) UK (3) N Ir (4) Nl/Dk (1)Year 1991 1991 1995 1997-8N 535800 50272 2655 4873 478000Cut/bite 31 46 28.7 17.3 31Fall 22 23 29 15 -Punch/ assault 17 27 22 2.6 -Sport 16 - 19 15 15

Body surface area Injuries presenting to ED

Palm: 1% of TBSA Hands: ~4-8% of

TBSA

Hands: 29% of all injuries treated in ED (Dutch & Danish surveillance data [1])

* Averages not weighted to correct for sampling bias of individual studies. (1) Larsen CF, Mulder S, Johansen AM, Stam C. The epidemiology of hand injuries in the Netherlands and Denmark. Eur J Epi 2004; 19.323-327. (2) Angermann P, Lohmann M. Injuries to the hand and wrist: A study of 50,272 injuries. J Hand Surg (Br) 1993; 18B.5:642-4. (3) Packer GJ, Shaheen MA. Patterns of hand fractures and dislocations in a district general hospital. J Hand Surg (Br)1993; 18B.5:511-514. (4) Hill C, Riaz M, Mozzam A, Brennen MD. A regional audit of hand and wrist injuries. J Hand Surg (Br); 23B.2: 196-200.

Falls account for 22 percent of all visits to ED for hand injuries

Images from http://www.anatomyatlases.org/atlasofanatomy/index.shtml: Bocks Handbuch der Anatomie des Menschen (1841), tr. Bergman RA, Afifi AK.

http://www.anatomyatlases.org/atlasofanatomy/index.shtml

BEFORE WE CONTINUE, A QUICK GLIMPSE OF WHAT WERE NOT COVERING: DISTAL INJURIES A SELECTION OF BOSTON SEASONAL VARIANTS

Distal hand fractures most common site of injury in epidemiological studies Straightforward diagnosis and treatment wheres the challenge? Lets move on to wrist fractures

Winter: Snowblowing the drivewaySummer: Foul ball at Fenway

Oblique fx of 4th DP

Volar displace- ment

Comminuted fx of R 2nd, 3rd, 4th MPs and DPs

3rd MP displaced radially

Associated soft tissue defects

BIDMC, PACS

OUTLINE: WRIST FRACTURES RESULTING FROM FALLS

1. Differential diagnosis of wrist pain following FOOSH Colles Scaphoid fx SL lig tear Trangular fibrocartilage complex (TFCC) tear

2. Case presentations: radiological involvement in each diagnosis Highlights of normal anatomy Whats at stake: importance of early diagnosis and treatment 1st line imaging and tricks Backup imaging

OUTLINE: WRIST FRACTURES RESULTING FROM FALLS


2. Case presentations: radiological involvement & imaging for each diagnosis Highlights of normal anatomy Whats at stake: importance of early diagnosis and treatment 1st line imaging and tricks Backup imaging

ACCURATE AND TIMELY DIAGNOSIS AND TREATMENT CAN AVOID COMPLICATIONS OF HAND & WRIST FRACTURES

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sue

Potential complications

1st line imaging modality

2nd line imaging modality

1. Distal radius fracture (Colles)

2. Scaphoid fracture

3. Scapholunate ligamentous tear

4. Trangular fibrocartilage complex (TFCC) tear

OA Strength deficit,

instability

OA Avascular

necrosis Malunion

OA Wrist instability Scapholunate

advanced collapse

OA

Plain film

Plain film

Plain film

Arthroscopy Arthrography

CT MRI

CT MRI

Arthroscopy Arthrography

(none)

Goldfarb CA, Yin Y, Giluta LA, Boyer, MI. Wrist fractures: What the clinician wants to know. Radiology 2001; 219:11-28

NORMAL HAND AND WRIST ANATOMY IS CONFUSING, AND CHARACTERISED BY UNHELPFUL MNEMONICS

Bones How can a mnemonic with

eight letters have three Ts? TriQuetrumUlna Trapeziumnear the

thumb Only Trapezoid is left

Thumb is missing a Ligaments

Any permutation you can imagine

Strength ligaments volar Arteries

Ulnar Radial

Nerves Median Ulnar Radial

Normal PA film Normal lateral film Notes

BIDMC, PACS

OUTLINE


2. Case presentations: radiological involvement & imaging for each diagnosis Highlights of normal anatomy Whats at stake: importance of early diagnosis and treatment 1st line imaging and tricks Backup imaging

PATIENT 1: FALL DOWN STAIRS

Patient 1s PA hand film

65F Pain in my

hand Had 1/2

glass of wine and fell down stairs

PMH: HTN Meds: ASA,

HCTZ, black cohosh

SHx: menopause

FHx: n/c

PE: tender prox to wrist

Patient 1 Normal comparison PA film

COLLES FRACTURE

Distal radius fracture Ulnar styloid avulsed

BIDMC, PACS

RELEVANT ANATOMY: DISTAL RADIUS AND RADIO-CARPAL JOINT HAS SEVERAL INTERESTING BONY AND SOFT TISSUE FEATURES

1. Metaphyseal widening 2cm from joint:

less cortical, more cancellous bone

Anatomical featuresPathological features following fracture

Normal hand: PA film

4. TFCC cartilage Joins radius to

ulnar styloid

2. Radius longer than ulna Radius bears 80%

of strain

3. Triangles Volar tilt (11) Ulnar inclination:

loads radius

Goldfarb CA, Yin Y, Giluta LA, Boyer, MI. Wrist fractures: What the clinician wants to know. Radiology 2001; 219:11-28

Normal hand: lateral film

1. Less density is fracture set up Osteoporosis

screening

2. Shortened radius Ulnar loading, OA Muscle spasm

3. Triangles Dorsal

angulation in Colles fx loads ulna

4. TFCC cartilage Frequent

avulsion of ulnar styloid

FOR COMPLEX INTRA-ARTICULAR FRACTURES OF DISTAL RADIUS, 2D CT RECONSTRUCTION CAN BE VALUABLE

Companion case: 2D CT reconstructionCompanion case: CT slices

Coronal reconstruction shows clear scaphoid fracture

and sagittal shows small associated lunate fracture.

Coronal SagittalLeft to right, top to down

BIDMC, PACS

AND 3D CT RECONSTRUCTION CAN SIGNIFICANTLY INCREASE DIAGNOSIC ACCURACY, AND CHANGE SURGICAL DECISION-MAKING

leading to complex internal fixationCompanion case: PA & lat films, 3DCT reconstructn

(1) Harness NG, Ring D, Zurakowski D, Harris GJ, Jupiter JB. The influence of 3D CT reconstructions on the characterization and treatment of distal radius fractures. JBJS (Am) 2006; 88.6:1315-23. Images reproduced from (1).

Increases reliability and diagnostic accuracy

Significantly changes surgical decision-making vs plain films (1)

Multiple intra-articular fractures

PATIENT 2: FALL WHILE HORSEPLAYING

Patient 2

27M Pain in my

hand Had one

beer, was discussing baseball with friend from NYC

PMH: none Meds: none SHx: painter FHx: n/c PE: tender

snuffbox

Patient 2

Images courtesy of Dr Jim Wu, BIDMC Radiology

PATIENT 2: CORRECT VIEWS EXPOSE

High degree of clinical suspicion required to diagnose occult fractures Correct views also required! (request scaphoid views, not wrist) If still unsure, can cast and re-image in 2 weeks, to avoid additional imaging

PA hand film (as seen in previous slide) PA hand film with ulnar deviation

VS


OCCULT SCAPHOID FRACTURE

SCAPHOID ANATOMY: ORIENTED OBLIQUELY, WITH VASCULAR SUPPLY EXEMPLIFYING LESS-THAN-INTELLIGENT DESIGN

1. Bony orientation of scaphoid Not parallel to plane of palm Radial side volar, ulnar side

dorsal Need oblique views!

2. Vasculature 80% of supply from dorsal

branches of radial artery, entering at scaphoid waist

20% from palmar branches entering at distal pole

Negligible supply from SL ligament, SRL ligament

AVN risk increases with more proximal fracture location, approaching 100% with proximal pole fractures

NotesScaphoid orientation & vasculature

Image reproduced from www.eorthopod.comGoldfarb CA, Yin Y, Giluta LA, Boyer, MI. Wrist fractures: What the clinician wants to know. Radiology 2001; 219:11-28

http://www.eorthopod.com/

PATIENT 3: WRIST PAIN SEVERAL DAYS FOLLOWING FALL

Patient 3s PA hand film

42F Pain in my

hand At a cocktail

party, was pushed by agent from competing real estate agency

PMH: none Meds: none SHx: smokes

half pack x20y

FHx: n/c

PE: tender snuffbox

Patient 3 Normal comparison


DIAGNOSIS OF AVASCULAR NECROSIS IS CHALLENGING

Patient 3s MRIDoes Patient 3 have AVN? (PA film)

Fat subtraction shows blood filling distal to fracture, but filling defect proximal

Diagnostic of avascular necrosis


PATIENT 4: SPORTS INJURY

67M Pain in my

hand Bicyclist struck

by car and thrown, used hand to break fall

PMH: none Meds: MVI SHx: n/c FHx: mother,

father with OA

PE: +Watson test (painful snap w/ volar scaphoid pressure, uln to rad dev)

Patient 4

SCAPHOLUNATE LIGAMENT TEAR

MR ARTHROGRAPHY CAN DIAGNOSE SUBTLE LIGAMENTOUS TEARS, THOUGH FALSE POSITIVES ARE COMMON

TFCC tearMR arthrograph with gadolinium injection

(1) Schadel-Hopfner M, Iwinska-Zelder J, Braus T, et al. MRI versus arthroscopy in the diagnosis of scapholunate ligament injury. J Hand Surg (Br) 2001; 26B.1:17-21. (2) Sahin G, Demirtas M. An overview of MR arthrography with emphasis on the current technique and applicational hints and tips. Eur J Radiol 2006; 58:416-430.

Scapholunate ligament tearMR arthrograph with gadolinium injection

Evaluation based on visualization of contrast in compartments of hand Indirect MR arthrography is not superior to traditional arthrography (1) However, difficult to differentiate clinically irrelevant pinhole communications vs real tear (2)

Radiocarpal gadolinium

injection

Gadolinium diffuses out of radiocarpal compartment

Indicates ligamentous disruption

SUMMARY

1. Radiology plays a critical role in establishing diagnosis of wrist pain following FOOSH, and directing treatment plan Clinical differentiation among various etiologies nearly impossible given

similarities of symptoms

2. Fractures of the distal radius are common, particularly in the elderly, and can have debilitating consequences Osteoporosis screening Associated injuries 3D CT reconstruction is promising way to characterize complex intra-

articular fractures

3. Scaphoid fractures are easy to miss one of the most common causes of litigation vs radiologists and can lead to avascular necrosis of the proximal pole Correct views are essential MR can aid in diagnosis of AVN

4. Ligamentous tears can be difficult to diagnose with non-invasive means, but early diagnosis and treatment can help to avoid late complications

THANK YOU

Dr Gillian Liebermann Pamela Lepkowski Dr Jim Wu Dr Justin Kung Larry Barbaras

Dr Charles Day Dr Andetta Hunsaker Dr Rajan Agarwal Dr M Vincent Makhlouf

Radiology, BIDMCRadiology, BIDMCRadiology, BIDMCRadiology, BIDMCRadiology, BIDMC

Orthopedics, BIDMCRadiology, BWHRadiology, UPMCPlastic Surgery

Radiological diagnosis of injuries following Fall on outstretched hand (FOOSH)HAND INJURIES ARE VERY COMMON IN ED, AND FALL IS ONE OF THE MOST IMPORTANT MECHANISMSBEFORE WE CONTINUE, A QUICK GLIMPSE OF WHAT WERE NOT COVERING: DISTAL INJURIES A SELECTION OF BOSTON SEASONAL VARIANTSOUTLINE: WRIST FRACTURES RESULTING FROM FALLS OUTLINE: WRIST FRACTURES RESULTING FROM FALLS ACCURATE AND TIMELY DIAGNOSIS AND TREATMENT CAN AVOID COMPLICATIONS OF HAND & WRIST FRACTURESNORMAL HAND AND WRIST ANATOMY IS CONFUSING, AND CHARACTERISED BY UNHELPFUL MNEMONICSOUTLINEPATIENT 1: FALL DOWN STAIRSRELEVANT ANATOMY: DISTAL RADIUS AND RADIO-CARPAL JOINT HAS SEVERAL INTERESTING BONY AND SOFT TISSUE FEATURESFOR COMPLEX INTRA-ARTICULAR FRACTURES OF DISTAL RADIUS, 2D CT RECONSTRUCTION CAN BE VALUABLE AND 3D CT RECONSTRUCTION CAN SIGNIFICANTLY INCREASE DIAGNOSIC ACCURACY, AND CHANGE SURGICAL DECISION-MAKINGPATIENT 2: FALL WHILE HORSEPLAYINGPATIENT 2: CORRECT VIEWS EXPOSESCAPHOID ANATOMY: ORIENTED OBLIQUELY, WITH VASCULAR SUPPLY EXEMPLIFYING LESS-THAN-INTELLIGENT DESIGN PATIENT 3: WRIST PAIN SEVERAL DAYS FOLLOWING FALLDIAGNOSIS OF AVASCULAR NECROSIS IS CHALLENGINGPATIENT 4: SPORTS INJURYMR ARTHROGRAPHY CAN DIAGNOSE SUBTLE LIGAMENTOUS TEARS, THOUGH FALSE POSITIVES ARE COMMONSUMMARYTHANK YOU

Radiological diagnosis of injuries following fall on outstretched hand

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