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X-Ray RoundsX-Ray Rounds
Wrist
Mark Scott Nov. 8, 2007
Wrist
Mark Scott Nov. 8, 2007
Systematic ApproachSystematic Approach
Fracture Identification, Look for:• Mal-alignment• Discontinuity• Radio-lucency / radio-opacity• Fat pads
Fracture Identification, Look for:• Mal-alignment• Discontinuity• Radio-lucency / radio-opacity• Fat pads
11-22-11 Rule11-22-11 Rule
• Radius tilted ~110 volar on Lat. • Radius tilted ~220 ulnar on AP• Radial Styloid ~11mm distal to
ulna
• Radius tilted ~110 volar on Lat. • Radius tilted ~220 ulnar on AP• Radial Styloid ~11mm distal to
ulna
2211mm11mm
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3 C’s Rule3 C’s Rule
• Distal Radius Lunate Capitate appears as 3 C’s on lateral
• Distal Radius Lunate Capitate appears as 3 C’s on lateral
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Distal Radial #Distal Radial #
• Apply 11-22-11 rule• Ortho referral for open, comminuted,
unstable or failure to reduce, DRUJ, and NV compromise3
• Generally, Smith # (volar angl.) more unstable than Colles #
• Research study4
• Apply 11-22-11 rule• Ortho referral for open, comminuted,
unstable or failure to reduce, DRUJ, and NV compromise3
• Generally, Smith # (volar angl.) more unstable than Colles #
• Research study4
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Dorsal Barton’s Fracture
Barton’s FractureBarton’s Fracture
• Intra-articular Shearing injury of dorsal (or volar) radial lip.
• Require ortho referral due to high-degree of instability (insertion of Brachioradialis tendon)
• Intra-articular Shearing injury of dorsal (or volar) radial lip.
• Require ortho referral due to high-degree of instability (insertion of Brachioradialis tendon)
Scaphoid #Scaphoid #
• Most commonly # carpal bone (60-70%)• Axial loading 70-100% sensitive (better
than snuff box tenderness)• Evidence suggests below elbow cast
with neutral wrist & thumb free is adequate3
• Refer if >1mm displaced or comminuted• Follow up within 1 week is crucial.
• Most commonly # carpal bone (60-70%)• Axial loading 70-100% sensitive (better
than snuff box tenderness)• Evidence suggests below elbow cast
with neutral wrist & thumb free is adequate3
• Refer if >1mm displaced or comminuted• Follow up within 1 week is crucial.
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CT vs MRI vs Bone Scan for Scaphoid #
CT vs MRI vs Bone Scan for Scaphoid #
• Radiographs miss 10-20% of scaphoid #
• CT more sensitive and readily available3
• MRI more info re: ligamentous injury but ties up MRI time.
• Bone scan very sensitive (72hrs - 2 weeks) but non-specific3
• High resolution US may be imaging modality of choice in future (Sn100%, Sp98%)
• Radiographs miss 10-20% of scaphoid #
• CT more sensitive and readily available3
• MRI more info re: ligamentous injury but ties up MRI time.
• Bone scan very sensitive (72hrs - 2 weeks) but non-specific3
• High resolution US may be imaging modality of choice in future (Sn100%, Sp98%)
Scapho-lunate DissociationScapho-lunate Dissociation
• Forceful hyper-ext of the wrist• Tenderness immediately distal to Lister’s
tubercle• Terry Thomas Sign or signet ring sign• Ortho referral and look for
Lunate/Perilunate dislocation
• Forceful hyper-ext of the wrist• Tenderness immediately distal to Lister’s
tubercle• Terry Thomas Sign or signet ring sign• Ortho referral and look for
Lunate/Perilunate dislocation
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SummarySummary• Clinical Scaphoid CT if can’t
immobilize or cast & f/u bone scan in 3-5 days.4
• Gross reduction of Colles # is adequate to prevent negative sequelae.1
• Stability: Colles > Smith’s > Barton’s• Obtain multiple views and use 11-
22-11 and 3 C’s rules.
• Clinical Scaphoid CT if can’t immobilize or cast & f/u bone scan in 3-5 days.4
• Gross reduction of Colles # is adequate to prevent negative sequelae.1
• Stability: Colles > Smith’s > Barton’s• Obtain multiple views and use 11-
22-11 and 3 C’s rules.
ReferencesReferences1. Jaremko JL et Al. Do radiographic indices of distal radius fracture
reduction predict outcomes in older adults receiving conservative treatment?Clinical Radiology. 62(1):65-72, 2007 Jan.
2. McRae, R. Pocketbook of orthopaedics and fractures [2nd ed.]. Churchill Livingstone Elsevier, 2006.
3. Ritchie JV. Emergency Emerg Med Clin North Am - 01-NOV-1999; 17(4): 823-42
4. Seitz et al. Fractures and dislocations of the wrist. Rockwell and Green’s Fractures in Adults [5 ed]. Lippincott, Williams & Wilkins, 2002.
5. Tintnelli, JE. Emergency medicine: a comprehensive study guide [6th ed]. American College of Emergency Physicians / McGraw-Hill, New York, 2004. Pp. 1674-84.
1. Jaremko JL et Al. Do radiographic indices of distal radius fracture reduction predict outcomes in older adults receiving conservative treatment?Clinical Radiology. 62(1):65-72, 2007 Jan.
2. McRae, R. Pocketbook of orthopaedics and fractures [2nd ed.]. Churchill Livingstone Elsevier, 2006.
3. Ritchie JV. Emergency Emerg Med Clin North Am - 01-NOV-1999; 17(4): 823-42
4. Seitz et al. Fractures and dislocations of the wrist. Rockwell and Green’s Fractures in Adults [5 ed]. Lippincott, Williams & Wilkins, 2002.
5. Tintnelli, JE. Emergency medicine: a comprehensive study guide [6th ed]. American College of Emergency Physicians / McGraw-Hill, New York, 2004. Pp. 1674-84.
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Thank You
