Radiographic Examination of the Wrist
Igo Goldberg M.D, Hand Surgeon
Tel-Aviv, Israel
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
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)
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)
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
LAT NEUTRAL
LAT in EXTENSION
LAT in FLEXION
Scaphoid:
35 extension
Lunate:
further 30
Scaphoid:
75 flexion
Lunate:
50 flexion
‫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 !
CESAREA MARITTIMA