Upper Extremity Trauma: page 1 of 14 Wrist...Ulnar Variance Ulna shorter than Radius “Negative...
Transcript of Upper Extremity Trauma: page 1 of 14 Wrist...Ulnar Variance Ulna shorter than Radius “Negative...
©Ken L Schreibman, PhD/MD 10/27/15 www.schreibman.info
page 1 of 14Upper Extremity Trauma:Wrist
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Upper Extremity Trauma Wrist
Slide 1 of 84
3D Wrist CT
Frontalview
Ulna sideview
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Slide 2 of 84
Ulna sideview
Radius:
Frontalview
RadialStyloid
Arm:Radius rotates around ulna(radial head)
Lister’s Tubercle (dorsal)
Wrist: Radius is the foundation upon which the carpal bones reside
Looking down onarticular surface
LunateFossa
ScaphoidFossa
Anterior
Normal anterior (volar) (palmar) tilt of distal radius
Long axis of radius
Perpen-dicular to long axis
Normal2-20°volar
R R
[L] “ray”
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Scaphoid:
Frontalview
Ulna sideview
aka “Navicular of hand”(confusing Navicular in foot)
ScaphoidFossa
Waist
Distal pole sticks out anteriorly
ProximalPole
Scaphoid bridges the proximal and distal carpal rows
ProximalPole
DistalPoleDistal
Pole
R R
S S
[Gr]“boat”
Waist
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TFC
Lunate:
Frontalview
Ulna sideview
LunateFossa
R R
S S
L L
Should have opening upLike a teacup holding tea
Lunate sits ½ over radius (lunate fossa),½ over Triangular Fibro Cartilage (TFC)Lunate is nearly surrounded by cartilage
Lunate susceptible to AVN (Kienböck)
Onesmall artery anterior
Onesmallarteryposterior
[L] “moon”
ScaphoidFossa
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TFC
Proximal Carpal Row: (S+L+Tq+P)
Frontalview
Ulna sideviewR R
S
L L
PTq
PTq
Triquetrum (Tq): [L] “three-cornered”Pisiform (P): [L] “pea”
Radio-CarpalJoint
SL JtLT Jt
PT Jt
Pisiformstick outanterior
DistalPole
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Upper Extremity Trauma Wrist
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Ulna major component of elbow, forearmRole at wrist is limitedDoesn’t even normally touch carpal bones
½ Radius fxs have Ulnar styloid fxs**Often remain
ununitedSeldom require
surgery(If DRUJ stable)TFC
Ulna:
Frontalview
Ulna sideviewR UU
S
L L
PTq
PTq
UlnaStyloid
[L] “arm”… related to “ell”, “cubit” *Unit of length equal to the forearm
*www.etymonline.com
DRUJ
Forms theDistalRadio-UlnarJoint
UlnaStyloid
**orthopedics.about.com
[L] “elbow”
©Ken L Schreibman, PhD/MD 10/27/15 www.schreibman.info
page 2 of 14Upper Extremity Trauma:Wrist
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© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Wrist
Slide 7 of 84
TFC
Frontalview R U
S
L
PTq
PTq
C
UUlna side
view
L
C
Capitate: Head-shaped round proximal endsits inside open end of the lunate
R
CapitateLunateRadiusform a straight stack
[L] “head”AnatomyRadiographs
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Slide 8 of 84
TFC
Hamate:
Frontalview
Ulna sideviewR UU
S
L L
PTq
PTq
HC
Hook-shaped process (H)sticks out anterior
Pisiform
DistalPole
Hook of Hamatesticks outanteriorH
[L] “hook”
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Upper Extremity Trauma Wrist
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TFC
Metacarpals
Frontalview
Ulna sideviewR UU
S
L L
PTq
PTq
HHC
Capitate articulates with Long finger MCHamate articulates with Ring & Small finger
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Upper Extremity Trauma Wrist
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TFC
aka “Lesser Multangular”
Frontalview
Trapezoid:
Ulna sideviewR UU
S
L L
PTq
PTq
HHC
2 parallel sides
Trapezoid articulates with index finger MC
Td
[Gr] “table shaped”
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aka “Greater Multangular”
TFC
Trapezium:
Frontalview
Ulna sideviewR UU
S
L L
PTq
PTq
C HHTm Tm
no parallelsides
TrapeziUMarticulates
with the ThUMb
Td
[Gr] “little table”AnatomyRadiographs
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Upper Extremity Trauma Wrist
Slide 12 of 84
Carpal Tunnel
S PHTm
Walls of the carpal tunnel are made of the carpal bones that stick out anteriorly
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page 3 of 14Upper Extremity Trauma:Wrist
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Upper Extremity Trauma Wrist
Slide 13 of 84
Hand ≠ Wrist
R,A 27yoM, fell off bike
HandPA
HandLat
HandObl
All Negative
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Hand ≠ Wrist
R,A 27yoM, fell off bike
Hand ≠ WristWristPA
WristObl
WristLat
WristUl Dev
Bennett Fracture!
Still Negative…
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Upper Extremity Trauma Wrist
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Hand ≠ Wrist
G,M 44yoM
PA Hand
?
PA Wrist (next day)
!
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Upper Extremity Trauma Wrist
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Hand vs Wrist: X-ray BeamHand radiographs:X-ray beam centered
@ 3rd MC head
G,M 44yoM
Wrist radiographs:X-ray beam
centered @ capitate
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Upper Extremity Trauma Wrist
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Wrist: PA = Standard View
Marty age 15
Elbow @ shoulder height
Elbow @ 90°
Lowchair
Raise cassette
ShieldX-rays
X-ray beamPosteriorAnterior
= “PA”
X-ray beam centered on Capitate
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Upper Extremity Trauma Wrist
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PA: Standard view
Wrist: PA ViewCarpal AlignmentProximal Carpal Row
Joint AlignmentRadio-Carpal JointCarpal-Metacarpal JtDistal Radio-Ulnar Jt
Ulnar LengthNormally, Ulna same
length as Radius
DRUJ
Ulna shorter
than Radius
R-C Jt
C-MC
D,H 21yoF
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page 4 of 14Upper Extremity Trauma:Wrist
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© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Wrist
Slide 19 of 84
Ulnar VarianceUlna shorter than Radius“Negative Ulnar Variance”Risk AVN Lunate (Kienböck)
Ulna longer than Radius“Positive Ulnar Variance”Ulna can punch hole in TFCUlna can impact upon Lunate
“Ulna Abutment Syndrome”
S,Z 18yoM
Ulna is only slightly shorter
than Radius
AVN Lunate with collapse
Radius shorteningT,C 14yoM
2 y earlier, normal unfused growth plates
Premature fusion radius,
continued ulna growth UV
Compared to normal side
Treated with ulna
shortening osteotomy
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Upper Extremity Trauma Wrist
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Wrist: Lateral View
R
L
C,S 48yoM
CC
RAnterior
L
Normal2-20°volar
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Upper Extremity Trauma Wrist
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Can see most carpal bones on Lateral
C,S 48yoM
C
R
L
SS
R
L
C
P
Hard to see Ulna as it overlaps Radius on a
good lateral view
U
PTq
Can’t see Triquetrum on lateral view…
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Upper Extremity Trauma Wrist
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Triquetral FractureClassically presents
as a tiny avulsion fracture dorsal to the mid-carpus
There are no normal ossicles dorsal to the carpal bonesIf you see a small bone
back there, it’s a fractureMay be old, as these tiny
fractures don’t always healM,G 50yoM
Fx
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Upper Extremity Trauma Wrist
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Wrist: Standard 3 ViewsPA View Lateral View
ThumbDown Thumb
Up
Oblique View
ThumbHalfway
Between
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Upper Extremity Trauma Wrist
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Wrist: Oblique ViewBest view of:STT jointThumb C-MC jointCommon sites for OA
Additional view of:Carpals (scaphoid)MetacarpalsRadius (styloid)Sometimes a fracture is
seen only on this view
K,M 20yoF
S
Tm TdMC
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page 5 of 14Upper Extremity Trauma:Wrist
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Upper Extremity Trauma Wrist
Slide 25 of 84
Scaphoid (Ulnar Deviation) View
S,B 21yoF
Patient holds wrist in ulnar deviation
Yields an elongated view of the scaphoid.
Helps when looking for fractures.
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Upper Extremity Trauma Wrist
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4 View Series for Scaphoid Fracture
K,T 32yoF
Lateral View
PA View Oblique View Scaphoid View
Doesn’t show scaphoid well
Dorsalswelling
Negative Negative? Positive!scaphoid waist fx
?
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Upper Extremity Trauma Wrist
Slide 27 of 84
Wrist: CTGood for complex fracturesAid in surgical planningGood to assess fracture healingEven in the presence of metal
E,A 18yoM
PA view Scaphoid view
CT:Coronal Acutrak®
screwCT:Obl Sag
Fx?
Fx
Fx! S LTq
HCTd
CT:Obl Sag
R
Fx! S
R
Tm
Healed!
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Upper Extremity Trauma Wrist
Slide 28 of 84
Wrist CT: Positioning
We don’t scan patients with their wrist down at their sideExcess radiation across torsoX-ray scatter decreases res.
We scan patients with their wrist over the head
No excess radiation to bodyNo x-ray scatter
Mighty MousePosition
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Upper Extremity Trauma Wrist
Slide 29 of 84
Wrist: CTNOT good for occult fracturesFractures non-displaced on radiographs…
…are non-displaced on CT
L,N 21yoF
PA viewScaphoid view
No fracture
CT: Coronal MR: T1 Coronal
Blackfractureline
MR: T2fs Coronal Acutrak® screw
No fracture
Marrow edema
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Upper Extremity Trauma Wrist
Slide 30 of 84
Wrist MR: Positioning
Wrist coil
We scan patients with their wrist over the head
In a wrist coil Functions best in the center of
the magnetic field
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page 6 of 14Upper Extremity Trauma:Wrist
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Upper Extremity Trauma Wrist
Slide 31 of 84
Fall On Out-Stretched Hand (FOOSH)Most injuries to the wrist are due to one
common mechanismPerhaps THE most common injury
1-in-6 ER fractures occur in the distal radius*Humans are a clumsy speciesWe walk uprightWe’re top heavyWhen falling, we instinctively protect our head, byExtending our armStriking the ground with our hand
This mechanism of injury is perhaps UNIQUE to humans
*orthopedics.about.com
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Upper Extremity Trauma Wrist
Slide 32 of 84
The most famous penguin on the Internet
www.youtube.comwww.youtube.com
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Upper Extremity Trauma Wrist
Slide 33 of 84Marty age 8½
HANDS
ULNA
RADIUS
Fall On Out-Stretched Hand (FOOSH)
FOOSH
HyperextendWrist
HyperextendWrist
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Upper Extremity Trauma Wrist
Slide 34 of 84
Fall On Out-Stretched Hand (FOOSH)Hyperextension of wrist Hyperextensive forces on:RadiusColles fractureTorus fracture (children)
Carpal bonesBarton fractureScaphoid fractureLunate/perilunate dislocations
S
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Upper Extremity Trauma Wrist
Slide 35 of 84
Transverse Fx distal radiusHyperextension forces cause:Dorsal angulation± Dorsal displacement
Colles Fracture
S
Fx
R,C 92yoF O,M 20yoM
DORSAL ANGULATIONALWAYS ABNORMAL!
Lateral view Lateral view
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Upper Extremity Trauma Wrist
Slide 36 of 84
Dorsal Angulation is BadTo measure angle:Draw line along
distal radiusFrom front cornerTo back corner
Draw line along shaft of radiusPerpendicular to this
Measure this angleNormal is VOLAR2-20°
Dorsal = Abnormal
R,C 92yoF
Lateral view
5°Dorsal
20°Dorsal
2 weeks later…
The ligaments are not designed to support carpal
bones on a dorsal sloped radius
Lateral view
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page 7 of 14Upper Extremity Trauma:Wrist
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Upper Extremity Trauma Wrist
Slide 37 of 84
Must reduce angle to heal right
M,D 59yoF
ER lateral view:Marked dorsal angulation
Following reduction & casting in ER:
Volar angulation
6 weeks later:Healing, normal
volar angulation
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Upper Extremity Trauma Wrist
Slide 38 of 84
Colles fractures very commonIn childrenFall a lotTorus fracture
In womenOsteopenia2 women in
my life…
In the media…
Secretary Judy Wife Lynn
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Upper Extremity Trauma Wrist
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Colles vs Smith Fracture
Anatomically impossible?
Season 15, Episode 2original air date 9/22/04
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Upper Extremity Trauma Wrist
Slide 40 of 84
S
Colles:Hyper-
extensionDORSAL
angulation
Smith:Hyper-
flexionVOLAR
angulation
Smith Fracture = Reverse Colles
S,K 51yoF
Lateral view:Too much volar angulation
Reduction & cast:Normal volar angulation
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Upper Extremity Trauma Wrist
Slide 41 of 84
FOOSHColles:Hyper-
extensionDORSAL
angulation
Mechanisms: Colles vs SmithAnatomyRadiographs
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Upper Extremity Trauma Wrist
Slide 42 of 84
Mechanisms: Colles vs Smith
FOOSH Hyperextension Colleswhether fall Forwards or Backwards
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Upper Extremity Trauma Wrist
Slide 43 of 84
Mechanisms: Colles vs SmithFall onto Back of handHyper-
flexionSmith FxVOLAR
angulation
Colles:Hyper-
extensionDORSAL
angulation
Smith fracture
is much less
common than
Colles
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Upper Extremity Trauma Wrist
Slide 44 of 84
Abraham Colles (1773-1843)
“The injury to which I wish to direct the attention ofsurgeons, had not, as far as I know, been described byany author.”
“I should consider this as by far the most commoninjury to which the wrist or carpal extremities of theradius and ulnar are exposed.”
babel.hathitrust.org
(81 years before
Roentgen)
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Slide 45 of 84
Robert William Smith (1807-1873)
google.combooks.google.com
(1847?) MDCCCL=1850
Page 162
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Upper Extremity Trauma Wrist
Slide 49 of 84
RADIUS
PowerPoint ModelAdult Lateral
Fractures in Children
A
RADIUS
PowerPoint ModelChild Lateral
Epiphysis
physis(growth plate)
Metaphysis
Diaphysis
K,V 2yoM
Lateral PA view AnatomyRadiographs
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Upper Extremity Trauma Wrist
Slide 50 of 84
FOOSH Fractures in ChildrenAdult bones: BrittleSnap under forceChild bones: SoftBend under forceFOOSH Hyperextension distal
radial metaphysisBuckling metaphysis-
diaphysis junctionBuckle Fracture“Torus Fracture”
RADIUS
PowerPoint ModelChild Lateral
RADIUS
A
G,A 5yoM
Lateral
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Upper Extremity Trauma Wrist
Slide 51 of 84
Torus Fractures: Lateral ViewCortex buckles INFOOSH (Colles)Dorsal cortex
Fall on back of wrist (Smith)Volar cortex
Nature does not make angles…Nature makes smooth curvesIf you see cortex angulation ina child that should be smooth,
it’s likely a torus fracture!
RADIUS
S,A 5yoF
Lateral
Cortex of radius & ulna overlap
A,C 6yoM
Lateral AnatomyRadiographs
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Upper Extremity Trauma Wrist
Slide 52 of 84
Torus Fractures: PA View
FOOSH
AxialLoad
RADIUS
AxialLoad
RADIUS
AxialLoad
Cortex bucklesOUTWARD
PowerPoint ModelChild PA View
PA view
H,T 8yoF
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Upper Extremity Trauma Wrist
Slide 53 of 84
Torus Fractures: Common…Run eyes along cortexFocus on
metaphysisPA viewBuckles
outwardNot sure?Compare to
normal sideUse other
views!
Subtle
A,B 14yoF
PA viewSymptomatic side
PA viewAsymptomatic side
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Upper Extremity Trauma Wrist
Slide 54 of 84
Torus Fractures: Common…Run eyes along cortexFocus on
metaphysisLat viewBuckles
inwardNot sure?Compare to
normal sideUse other
views!
SubtlePA viewSymptomatic side
Lat viewAsympt.
Lat viewSympt.
A,B 14yoF
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Upper Extremity Trauma Wrist
Slide 55 of 84
“Torus”Capital
S
h
a
f
t
BasePlinth
Torus
RadioGraphics 2004; 24:p1025
[L]:“swelling,protuberance,bulge”[Architecture]:A large convex molding, semicircular in cross section, at base of a classical column.
Wisconsin State Capitol
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Upper Extremity Trauma Wrist
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Fall On Out-Stretched Hand (FOOSH)Hyperextension of wrist Hyperextensive forces on:RadiusColles fractureTorus fracture (children)
Carpal bones(Proximal carpal row)Barton fracture
S
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Upper Extremity Trauma Wrist
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Barton FractureHyperextension of wrist Impaction of carpal bones on radius dorsal rim Fracture radius rimIntra-articular fracturePotentially more serious than Colles
(extra-articular fracture)May require surgical fixationSurgeon may order CT for planning
S
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Upper Extremity Trauma Wrist
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Dorsal Barton FractureDorsal BartonDue to FOOSHis much more common than
Volar BartonDue to blow to
back of wrist
(Just as Colles is much more common than Smith fracture)
S
S,G 37yoM
Lateral view
M,M 58yoF
Lateral view
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© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Wrist
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Volar Barton Fracture
S
Lateral view
A,D 43yoM
CT: Sagittal OpenReductionInternalFixation
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Upper Extremity Trauma Wrist
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John Rhea Barton (1794-1871)
www.kmle.co.krThe Medical ExaminerNov 7, 1838; 1, 23; p 365-8
It was said that Barton was ambidextrous and that once he had positioned himself for an operation, he did not move about.
whonamedit.com
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Upper Extremity Trauma Wrist
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Fall On Out-Stretched Hand (FOOSH)Hyperextension of wrist Hyperextensive forces on:RadiusColles fractureTorus fracture (children)Carpal bones
(Proximal carpal row)Barton fracture(Distal carpal row)Scaphoid fracture
S
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© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Wrist
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Scaphoid FracturesScaphoid THE most common
carpal bone to be fractured.
71% of all carpal fxs*Scaphoid bridges
the carpal rowsTraumatic shear forces
between the rows …shearing fracture across the scaphoid
*emedicine.com
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Upper Extremity Trauma Wrist
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Scaphoid Fractures Locations
S,A 24yoM
PA View Wrist
Scaphoid Waist70% of scaphoid fractures
occur at the waist
www.gentili.netB,J 21yoM
Scaphoid Proximal Pole20% occur at scaphoid proximal poleIncreased risk of non-union/AVN
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Upper Extremity Trauma Wrist
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Scaphoid Fractures LocationsPA View Wrist
Scaphoid Distal Pole10% occur at distal pole
These are usually uneventful*
PA View Wrist
Scaphoid TubercleRare, usually uncomplicated.If nonunion, usually asympt.*
*emedicine.comB,T 44yoMT,B 20yoM
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Upper Extremity Trauma Wrist
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Scaphoid & Radius FracturesSame common mechanism (FOOSH)Distal Radius FractureScaphoid Fracture…BOTH!
Watch out for “satisfaction of search”“Aha, I found the fracture… I’d done looking”
Old Radiology Axiom:The hardest fracture to find is the 2nd fracture
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Upper Extremity Trauma Wrist
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Scaphoid with Radius Fracture
W,M 19yoF
PA View Wrist Obl View Wrist PA View Wrist
Colles
UlnaStyloid
Proximal Pole
Plate fixates Colles
fracture
Screw fixates
scaphoid fracture
©Ken L Schreibman, PhD/MD 10/27/15 www.schreibman.info
page 12 of 14Upper Extremity Trauma:Wrist
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Upper Extremity Trauma Wrist
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22yo M03:00Unbelted passengerHigh speed MVCT-boned by minivanAir bags deployedTook 20 minutes to
extract from car
Intubated
Scaphoid doesn’t heal as well as other bones
V,G 22yoM
FB
…
Acetabularfracture
PA View Hand 2 months later…Healing
FB
OK
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© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Wrist
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Scaphoid doesn’t heal as well as other bonesafter 4 months…
FB
OK
CT: Coronal
OK
FBCT: SagittalOblique
Non-union scaphoid
waistV,G 22yoM
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© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Wrist
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Scaphoid has a tenuous blood supplyRadial artery
supplies:Distal Pole (DP)
of Scaphoid (S) Not Proximal Pole (PP)
The more proximalthe fracture, the
greater the risk of non-union.
The more distracted the fracture, the
greater the risk of non-union.
PAHandOblHand
S
DP
PP
RadialArtery
S
Heavy arterial calcificationPt w/ diabetes, renal failure
L,T 60yoM
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Scaphoid Non-Union AVN
Q,B 62yoF
PA View Wrist CT: Coronal CT: SagittalOblique
Non-union scaphoid waist fx
Collapse & fragmentation
PP = AVN
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Upper Extremity Trauma Wrist
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Proximal Row CarpectomyLateral View WristPA View Wrist
Resection: Scaphoid, Lunate, TriquetrumRadius articulates with Capitate (distal row)Only treatment for fragmented scaphoid AVN
R
C
Q,B 62yoF
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Upper Extremity Trauma Wrist
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To avoid non-unionAVNPRCAll scaphoid fxs require early treatment!Probably with a screw if displacedAt least with a splint or cast if non-displaced
But non-displaced fractures are hard to see because they are non-displaced
So how do we know if a patient has a non-displaced scaphoid fracture?
SNUFFBOX TENDERNESS =PRESUMED SCAPHOID FRACTURE
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page 13 of 14Upper Extremity Trauma:Wrist
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Upper Extremity Trauma Wrist
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Anatomical Snuffbox
Extensor Pollicis Longus Tendon
Extensor Pollicis Brevis Tendon
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Snuffbox Tenderness= PRESUMED SCAPHOID FRACTUREWhat if the radiographs are normal?Beautiful! Then it’s a non-displaced fractureTreat anyway with a cast/splintMake sure radiologist agrees they’re negative
Have patient follow-up in 2 weeksRe-examine… if still tender… back into the splintGet repeat radiographs (out of the cast/splint)We’re taught occult fxs become visible after 1-2 weeks
from bone resorption at fx margins… I’m not sure it’s true…
If you really need to know…MRI (we don’t miss fractures on MRI)
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Upper Extremity Trauma Wrist
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Resorbtion of Fracture Margins?
M,D 55yoM, cutting tree branches, FOOSH 15ft
Scaphoid View Oblique View
No scaphoid fx No scaphoid fx No scaphoid fx…
Radius fracturesImportance of multiple views!
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Resorbtion of Fracture Margins?
M,D 55yoM, cutting tree branches, FOOSH 15ft
PA View8 days laterStill snuffbox tenderness
Still noscaphoid fx
MRI: 19 days after injuryCoronal T1 Coronal T2fs
Bone marrow edema in Radius
Blackfx line
Blackfx line
Bone marrow edema in Scaphoid
Blackfx line
Occult scaphoid fracture!
No resorbtion scaphoidfracture margins
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Upper Extremity Trauma Wrist
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Resorbtion of Fracture Margins?
M,D 55yoM, cutting tree branches, FOOSH 15ft
Scaphoid View Oblique ViewPA Viewafter 29 days…
Still see lucent radius fractures
Still no resorbtion scaphoidfracture margins
Negative radiographs do not exclude a scaphoid fractureSnuffbox Tenderness = Presumed Scaphoid Fracture!
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Upper Extremity Trauma Wrist
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Anatomical Snuffbox?snuffhouse.org
www.snuffstore.co.uk schmalzlerfranzl.de
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Wrist: What to Order When (WOW)Radiographs:
Trauma PainArthritis (Hand radiographs)
CTSurgical planning known fracturesMROccult fractures (scaphoid)Synovitis (w/Gd) (Usually includes MCPs ± IPs) …pain?
RG95% CT
2%
MR3%
UW data 2005 & 2014
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Wrist: What to Order When (WOW)Wrist Radiographs (95%)3-view wrist seriesPA (not AP)LateralOblique
If snuffbox tenderness, add 4th viewScaphoid (ulnar deviation)
If snuffbox tenderness+negative radiographsTREAT AS PRESUMED SCAPHOID FRACTURECast/splint, follow-up in 2 weeksIf still has snuffbox tenderness, keep treating
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© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Wrist
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Wrist: What to Order When (WOW)Wrist CTPredominantly used for surgical planning of
known radius/carpal bone fracturesOrdered by Orthopedics from ER or clinic
Assess healing of known scaphoid fractureWith or without prior screw fixationSmall screws cause virtually no CT artifacts
We always reformat in 3 orthogonal planesFor scaphoid, we add oblique sagittal
We have a specialized protocol for DRUJ instabilityAll protocols at: www.radiology.wisc.edu
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© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Wrist
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Wrist: What to Order When (WOW)Wrist MROccult fractures (scaphoid)Persistent symptoms despite negative radiographs
Synovitis (RA)Needs IV contrastNormal synovium does not enhanceVascularized pannus greatly enhances
Ordering provider should specify area of concernJust intercarpal jointsAlso Metacarpal-phalangeal jointsAlso Interphalangeal joints
Field of View = Resolution
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© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Wrist
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Wrist: What to Order When (WOW)Wrist ChargesWrist Radiographs 3 views = 4 views = $137It costs nothing to add the scaphoid view to a 3 view series
1 view = 2 views = $128Going from 2 views to 4 views adds only $9 (7%)
Wrist CT (without contrast) = $1,460
Wrist MR (without contrast) = $2,921 (with contrast) = $3,377
UWMF charges 2012
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Upper Extremity Trauma Wrist
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That’s all we have on wrists…
Marty age 7