Musculoskeletal Trauma
of the Wrist
Murat Akalin, Harvard Medical School, Year- IV
Gillian Lieberman, MD
September 2000
2
The Wrist
• Most common site of injury in entire
skeleton
• Distal radius and ulna fractures are 10 times
more common than carpal bone fractures
• Mechanism of injury is most often
“Fall On OutStretched Hand”
FOOSH
3
The Wrist
• Complex anatomy makes identification of
abnormalities difficult
• Dislocations are easy to overlook
• Complications are significant so these fractures are
among the “MUST NOT MISS”radiologic
diagnoses
4
Anatomy
5
Anatomy
Radiographic Anatomy of the Skeleton Michael L.Richardson, M.D. http://www.scar.rad.washington.edu/RadAnatomy.html
6
Anatomy
Modified from Radiographic Anatomy of the Skeleton Michael L.Richardson, M.D.
http://www.scar.rad.washington.edu/RadAnatomy.html
7
Anatomy
capitate
8
Zone of Vulnerability
9
Standard Imaging Studies for
Suspected wrist trauma or
complications
• Wrist series
– PA, lateral, and oblique plain films
• Special views
– usually of scaphoid
• CT scan
– useful for occult fractures, fragments,
nonunion, osteonecrosis
10
Other Imaging Studies
(Less Useful in Evaluation of Acute Injury)
• MRI
– Early/occult
osteonecrosis
– cartilaginous and
ligamentous injuries
– marrow processes
• Arthrogram
– disruption of
ligamentous
compartments
• Flouroscopy
– Carpal instability with
reproducible symptoms
• Bone scintigraphy
– Occult fractures
– Osteomyelitis
11
Common Wrist
Fractures
12
Case 1: 23 Year Old with FOOSH
Fracture
13
Scaphoid (navicular) Fracture
• Most commonly fractured
carpal
• Difficult to detect
• Frequently occult,
becoming evident only
over time (5-10 days)
• If there is “snuff box”
tenderness, special
scaphoid view(s) should
be requested
14
Scaphoid View
• Ulnar flexion
– Better visualisation of radial
surface of scaphoid, where
fractures often occur
– “Fourth view” often added
to standard wrist series
• Variety of other special
scaphoid views
Image from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995.
15
Multiple Scaphoid Views
16
Osteonecrosis of the Scaphoid
• 5-15% of scaphoid
fractures
• Increased radiodensity
over proximal pole
• Take weeks to appear
• Likelihood depends on
location of fracture line
• Other complications:
nonunion, instabilty, DJD
• Complications increase
with delayed diagnosis
and treatment Electronic Journal of Hand Surgery
http://www.eatonhand.com/img/IMG00016.htm
17
Wrist CT
18
CT Reconstruction
19
Scaphoid Fracture s/p ORIF
20
n pearl pearl Scaphoid Fracture
• Common
• Difficult to detect
• Especially prone to complications
• May become radiographically evident only over
time
• Therefore…
If scaphoid views are requested, the patient MUST
be followed-up radiographically, even if initial
studies are negative
21
Case 2: 60 Year Old with FOOSH
22
Colles’ Fracture
• Transverse fracture of
distal radius
• Distal fragment
angulated dorsally
• Often comminuted
• Often impacted
• 60% have associated
ulnar styloid fracture
23
Case 3:
6 Year Old with
FOOSH
Radiology Cases in Pediatric Emergency Medicine, (1) 18.
http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
24
Greenstick Fracture
• Children
• Greater bone elasticity
• Break in 1 cortex
• Usually angulated
• Usually not subtle
Radiology Cases in Pediatric Emergency Medicine, (1) 18.
http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
25
Case 4: 6 Year Old with FOOSH
Radiology Cases in Pediatric Emergency Medicine, (1) 18.
http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
26
Torus Fracture
• Children
• Buckling of 1 cortex
• Variant of greenstick
• Little or no angulation
• Often subtle and easily
missed
Radiology Cases in Pediatric Emergency Medicine, (1) 18.
http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
27
Case 5: 16 Year Old with FOOSH
Radiology Cases in Pediatric Emergency Medicine, (1) 18.
http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
28
Salter-Harris Fracture
• Involves growth plate
• Risk of premature fusion
and deformity
• S-H classification
predicts risk
• May be impossible to
detect radiographically
• Therefore…
tenderness at growth plate
should be treated as S-H
fracture, even in absence
of radiographic evidence
Radiology Cases in Pediatric Emergency Medicine, (1) 18.
http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
29
Salter-Harris Classification
American Family Physician Vol. (46), number 4
30
Common Wrist Fractures
Kids:
•Greenstick Fracture
•Torus Fracture
•Salter-Harris Fracture
Adults:
•Scaphoid Fracture
•Colles Fracture
31
Wrist Dislocations
32
Dislocations of Wrist
• Less common than fractures, but still
comprise about 10% of carpal injuries
• Anatomy may be confusing at first,
but a few simple tips will make it easy
33
On the Frontal View…
• Look for Three Arcs
– Clear, smooth, and
continuous
– Spaces should be 2mm
or less
• Disruption in any one
of these arcs signifies
dislocation
Arc 1
Arc 2
Arc 3
34
On the Lateral View…
• Look to see that the
radius + lunate and
lunate + capitate
articulate
• Like an apple in a
cup in a saucer
• If the cup is empty,
there is a
dislocation
Image from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995.
35
Lunate Dislocation
• Most common dislocation
• Best seen on lateral view
• On frontal view, Arcs 2
and 3 disrupted and “pie
sign” is present
• Treatment is traction and
closed reduction vs ORIF
and ligamentous repair
Image from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995.
36
Perilunate Dislocation
• Best seen on lateral view
• On frontal view, again,
Arcs 2 and 3 are disrupted
• Often associated with
scaphoid fracture
Image from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995.
37
Navicular Subluxation
(Scaphoid Dislocation
AKA Scapholunate
Dissociation)
• Second most frequent
carpal dislocation
• Subluxation, not a full
dislocation
• “David Letterman” sign
(aka “Terry Thomas” sign)
• “Ring” sign
• Arcs 1 2 & 3 disrupted
• Often associated with
radius fractureImage from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995.
38
Common Wrist Dislocations
•Lunate dislocation : pie sign
•Perilunate dislocation
•Navicular subluxationi:
David Letterman/Terry Thomas Sign
Ring Sign
39
Summary
• Common fractures
may be predicted from
the age of patient:
Child Æ Greenstick
Teen Æ Salter-Harris
Adult Æ Scaphoid
Older Æ Colles’
• Particular vigilance
required for scaphoid
fractures
• CT is modality of choice
for detecting occult
fractures
• Dislocations may be
detected with knowledge
of normal carpal relations
40
References
Chew F. Skeletal Radiology: The Bare Bones. 1st edition, 1989.
Dee R, Mango E, Hurst L. Principles of Orthopaedic Practice. 1998.
Eisenberg R. Clinical Imaging: An Atlas of Differential Diagnosis. 3rd edition. 1998.
Hodge J, Gilula L. Imaging of the Wrist and Hand www.sma.org/soa/jsoawt96/jsoawt6.htm
Rogers L. Radiology of Skeletal Trauma. 2nd edition, 1992.
Raby N, Berman L, de Lacey G. Accident and Emergency Radiology. 1995.
Brown J., Deluca S. Growth Plate Injuries: Salter Harris Classification American Family
Physician Volume(46), number 4, Figure 2.
41
Acknowledgements
Beverlee Turner
Larry Barbaras
The end.
Musculoskeletal Trauma �of the Wrist
The Wrist
The Wrist
Anatomy
Anatomy
Anatomy
Anatomy
Zone of Vulnerability
Standard Imaging Studies for Suspected wrist trauma or complications
Other Imaging Studies�(Less Useful in Evaluation of Acute Injury)
Common Wrist Fractures
Case 1: 23 Year Old with FOOSH
Scaphoid (navicular) Fracture
Scaphoid View
Multiple Scaphoid Views
Osteonecrosis of the Scaphoid
Wrist CT
CT Reconstruction
Scaphoid Fracture s/p ORIF
pearl Scaphoid Fracture
Case 2: 60 Year Old with FOOSH
Colles’ Fracture
�Case 3: �6 Year Old with�FOOSH
Greenstick Fracture
Case 4: 6 Year Old with FOOSH
Torus Fracture
Case 5: 16 Year Old with FOOSH
Salter-Harris Fracture
Salter-Harris Classification
Common Wrist Fractures
Wrist Dislocations
Dislocations of Wrist
On the Frontal View…
On the Lateral View…
Lunate Dislocation
Perilunate Dislocation
Navicular Subluxation�(Scaphoid Dislocation�AKA Scapholunate Dissociation)
Common Wrist Dislocations
Summary
References
Acknowledgements
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