Radiographic Examination of the Wrist
Igo Goldberg M.D, Hand Surgeon
Tel-Aviv, Israel
‫הפיגום הגרמי‬
CAPITATE
HAMATE
TRAPEZOID
TRIQUETRUM
TRAPEZIUM
PISIFORMIS
SCAPHOID
LUNATE
‫הפיגום הגרמי‬
Carpometac
arpal joints
Micarpal
joint
Ulnocarpal
joint
Radiocarpal
joint:
•Radioscaphoid
•radiolunate
Distal Radio
Ulnar Joint
)DRUJ (
Force transmission across the wrist
LOAD
RS: 50-56%
Ul: 10-21%
RL: 29-35%
‫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)
Which radiographic views should be obtained in the evaluation of
every patient with wrist injury?
“Routine Wrist Radiography”
PA
PRONATED OBLIQUE
LAT
SUPINATED OBLIQUE
‫‪How should the standard (PA) radiogram for the examination of‬‬
‫?‪the wrist be obtained‬‬
‫”‪“90-90 position‬‬
‫•‬
‫כתף באבדוקציה ל‪ 90-‬מע'‪ ,‬מרפק בכיפוף ל‪ 90-‬מע'‪ ,‬כף היד (ולא שורש היד)‬
‫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:‬‬
‫‪.1‬‬
‫(יש להדגים את כל אורך המטקרפוס השלישי)‪.‬‬
‫‪.2‬‬
‫המיקום של הסטילואיד האולנרי מראה האם‬
‫הצילום נעשה בתנוחת ‪ PA‬או ‪. AP‬‬
‫‪.3‬‬
‫הופעת התעלה של ‪ ECU‬רדיאלית לסטילואיד‬
‫אולנרי מראה שהמרפק היה בגובה הכתף בזמן‬
‫הצילום‪ ,‬כפי שאכן צריך להיות‪.‬‬
‫‪.4‬‬
‫ציר האורך של עצם המסרק צריך להיות בקו ישר‬
‫להמשך ציר האורך של הרדיוס‪ ,‬מה שמצביע שלא‬
‫היו הטיות לצדדים בזמן הצילום‪.‬‬
‫‪.5‬‬
‫קווי הפרקים הקרפומטקרפלים ‪ 2-5‬צריכים להיות‬
‫מקבילים שאם לא כן שורש היד היה בכיפוף או‬
‫ביישור‪.‬‬
‫‪.6‬‬
‫‪Scaphoid fat pad‬‬
‫‪1‬‬
‫‪4‬‬
‫‪5‬‬
‫‪6‬‬
‫‪2‬‬
‫‪3‬‬
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.
AP
PA
Conventional PA
PA with forearm
pronation and firm
grip
NO !
What are we looking for on PA views?
L2
L3
L1
radial inclination
Normal = 16-30
Mean=22
radial length
Normal = 9 mm
Gilula’s arcs
carpal height = L1/L2
normal = 0.54
+/- 0.03
carpal translation = L3/L2
normal = 0.3
+/- 0.03
Modified carpal height ratio= L3/L2
normal = 1.57 (+/- 0.05
1.RADIAL LENGTH & INCLINATION
radial inclination
Normal =16-30
Mean=22 deg.
radial length
Normal = 9 mm
2.GILULA’S ARCS
3. CARPAL HEIGHT & CARPAL TRANSLATION RATIO
L1
carpal height ratio = L2/L1
normal = 0.54 +/- 0.03
L1
L3
L2
– ‫ככל שהיחס קטן‬
‫התמט של שורש היד גדל‬
carpal translation ratio = L3/L1
normal = 0.3 +/- 0.03
L1
L1’
L1’’
CARPAL HEIGH RATIO - modified
L3
L2
modified carpal height ratio = L2/L3
Normal = 1.57 (+/- 0.05)
– ‫ככל שהיחס קטן‬
‫התמט של שורש היד גדל‬
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
Ulnar styloid impaction syndrome
Ulnocarpal impaction syndrome
2ndary to ulnar styloid nonunion
Hamatolunate 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 be
within 3 mm
of the radial cortex
SPC relationship in LAT projection
True Lat
What are we looking for on LAT views?
1.
2.
3.
4.
PALMAR TILT
CARPAL INSTABILITY ANGLES
INTRASCAPHOID ANGLES
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 (+) sign
Dorsal tilt is identified by (-) sign
Normal = +11 deg
2.CARPAL INSTABILITY ANGLES
Collinear alignment of the radius, lunate and capitate:
Lines are perpendicular to radiolunate and lunocapitate articulations
•
•
•
•
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
Carpal instability angles: radiolunate angle
R
L
10 deg. either volar or dorsal lunate angulation
> +10 deg. susp.DISI
< -10 deg. Susp.VISI
Carpal instability angles: capitolunate angle
0-15 deg.
L
C
VISI
DISI
Carpal instability angles: radioscaphoid angle
R
120 – 150 deg.
S’
C pattern
S
V pattern
(S-L dissociation)
Rotatory instability of scaphoid
Carpal instability angles: scapholunate angle
S
L
DISI
VISI
Lunate dorsiflexed
Lunate volarflexed
Scaphoid palmarflexed
Scaphoid palmarflexed
Example of combination of PA and LAT views:……
Disrupted Gilula’s arc at L-T joint
volarflexed lunate and scaphoid
Lunotriquetral lig. disruption
(VISI)
LUNATE DISLOCATION
"‫סימן "ספל תה ההפוך‬
3.INTRASCAPHOID ANGLES
Posteroanterior
intrascaphoid angle
Lateral
intrascaphoid angle
Normal angles < 35 deg.
> 45 deg.
Increased risk for OA changes
“Routine wrist radiography”
‫כף היד צ"ל‬
‫שטוחה על הקסטה‬
PA
LAT
OBLIQUE
OBLIQUE
SUPINE
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: neutral
dorsiflexion
volarflexion
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
PA RADIAL- DEVIATION
PA ULNAR-DEVIATION
Proximal raw
dorsiflexes
Proximal raw
palmarflexes
SCAPHOID
foreshortened
elongated
LUNATE
quadrangular
triangular
TRIQUETRUM
Proximal
)“high position”)
Distal
)“low position”(
VISI
DISI
‫‪ MONEIM’S VIEW‬למרווח ‪S-L‬‬
‫‪ .1‬קרן מאונכת‬
‫‪ .2‬הצד האולנרי של שורש היד‬
‫מורם ב‪ 20-‬מע' מהקסטה‬
PA
AP
UD
UD
SLAC WRIST
LAT NEUTRAL
LAT in EXTENSION
LAT in FLEXION
Scaphoid:
35 extension
Lunate:
further 30
Scaphoid:
75 flexion
Lunate:
50 flexion
‫הערכה רנטגנית של פרק טרפזיו‪-‬מטקרפלי‬
‫)‪) CMC1‬‬
‫דורזלי‬
‫פלמרי‬
‫מה מייחד את כף היד האנושית ?‬
‫תנועת האופוזיציה של האגודל‬
‫אופוזיציה‪:‬‬
‫הבאת כרית הגליל הרחיקני של האגודל במגע עם‬
‫הכריות של האצבעות האחרות במטרה לבצע צביטה‬
‫אופוזיציה של האגודל מול האצבעות‬
‫מתאפשרת בעיקר ע"י‬
‫פרק ‪CMC1‬‬
‫‪MOBILITY‬‬
‫שרירים אינטרינסיים של האגודל‬
‫‪FORCE‬‬
“The saddle joint”
palmar
dorsal
Compression forces in the thumb ray
3 kg
5,4 kg
1 kg
FPL
12 kg
AP
APL
APB
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
1987
Menon 1997
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 EatonLittler
operation
Stage III
Stage IV
‫הערכה רנטגנית של עצמות קרפליות‬
‫שכיחות השברים בעצמות שורש היד‬
Scaphoid
Triquetrum
Trapezium
Hamate
Lunate
Capitate
Trapezoid
79%
14%
2.3%
1.5%
1%
1%
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:
Most
frequent
in children
80%
of
adults
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.
10%
70%
20%
What is the role of the scaphoid in the wrist?
Stabilizing bridge between PCR and DCR
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
MECHANISM
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.
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
‫‪Scaphoid Position‬‬
‫אגרוף קמוץ והטיה אולנרית קלה‬
‫‪Stecher 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
Occult scaphoid fracture
Initial Rx
6 m later
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
Scaphoid Collapse
(Amadio JHS 1989)
PA intra- scaphoid angle
LA intra-scaphoid angle
An angle > 40° suggest scaphoid collapse/malunion
and an increased rate of DJD (SNAC WRIST)
Scaphoid Collapse
Sagittal CT is best to
measure intrascaphoid
angle.
Angle > 40° suggest
collapse
How do scaphoid fractures contribute
to wrist arthritis?
SNAC WRIST
(Scaphoid Nonunion
Advanced Collapse)
TRIQUETRUM
14% of carpal fractures
HOOK OF HAMATE
Papilion Hook of
Hamate Position
Carpal Tunnel View
Hook
Pisiformis
Of
Trapezium
ridge
Hamate
Capitate
Trapezoid
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
?‫מה האבחנה‬
“EXPLODED VIEWS”
?‫מה האבחנה‬
Lunotriquetral
coalition
‫מרכזי צמיחה‬
‫‪2‬‬
‫‪2‬‬
‫‪2‬‬
‫‪2‬‬
‫‪1‬‬
‫‪1‬‬
‫‪12‬‬
‫‪7‬‬
‫‪1‬‬
‫‪3‬‬
‫‪5‬‬
‫‪4‬‬
‫‪6‬‬
‫‪6‬‬
‫‪1‬‬
‫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!