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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!