舟状骨骨折影像学诊断

ScaphoidScaphoid FracturesFractures Bill Bill SchlossSchloss Harvard Medical School, YearHarvard Medical School, Year-- IVIV Gillian Lieberman, MDGillian Lieberman, MD Bill Schloss Gillian Lieberman, MD January 2001 Mr. FMr. F „„ 23 year23 year--old man with old man with rollerblading injuryrollerblading injury „„ Fell backwards, Fell backwards, breaking fall with breaking fall with outstretched handsoutstretched hands „„ Presents with radialPresents with radial-- sided left wrist pain, sided left wrist pain, snuffbox tendernesssnuffbox tenderness www.geocities.com/pipeline/halfpipe/4583/pictures/scott4.jpg 2 Bill Schloss Gillian Lieberman, MD Clinical differential diagnosisClinical differential diagnosis „„ ScaphoidScaphoid FractureFracture „„ ScapholunateScapholunate InstabilityInstability „„ LunateLunate Dislocation or Dislocation or FractureFracture „„ Rupture of Flexor Rupture of Flexor Carpi Carpi RadialisRadialis TendonTendon „„ Radial Radial StyloidStyloid FractureFracture „„ Trapezium FractureTrapezium Fracture „„ Extensor Carpi Extensor Carpi RadialisRadialis LongusLongus AvulsionAvulsion „„ Extensor Carpi Extensor Carpi RadialisRadialis BrevisBrevis AvulsionAvulsion „„ OsteochondralOsteochondral Fracture of Distal Fracture of Distal RadiusRadius „„ DeQuervain’sDeQuervain’s TenosynovitisTenosynovitis „„ Basilar Joint (CMC) Basilar Joint (CMC) ArthrosisArthrosis 3 Bill Schloss Gillian Lieberman, MD Menu of tests available to image Menu of tests available to image traumatic wrist injuriestraumatic wrist injuries „„ Routine plain filmsRoutine plain films „„ Specialty plain film series (Specialty plain film series (egeg scaphoidscaphoid view)view) „„ CTCT „„ MRIMRI „„ Bone ScanBone Scan „„ UltrasoundUltrasound 4 Bill Schloss Gillian Lieberman, MD Our patient’s plain films, left wristOur patient’s plain films, left wrist 5 Film Film findings:findings: Subtle linear Subtle linear lucencylucency across the across the waist of the waist of the scaphoidscaphoid suggesting suggesting scaphoidscaphoid fracturefracture Courtesy of BIDMC files Bill Schloss Gillian Lieberman, MD 6 Courtesy of BIDMC files Our patient’s Our patient’s scaphoidscaphoid viewsviews Film findings:Film findings: ?? Subtle Subtle scaphoidscaphoid fracturefracture Bill Schloss Gillian Lieberman, MD A closer look at A closer look at the AP view…the AP view… 7 Film findings:Film findings: Highly suggestive of an Highly suggestive of an acute acute scaphoidscaphoid fracturefracture Courtesy of BIDMC files Bill Schloss Gillian Lieberman, MD Our Our patient’s patient’s wrist CTwrist CT 8Courtesy of BIDMC files Film findings:Film findings: Lucent line through Lucent line through scaphoidscaphoid confirms confirms acute fractureacute fracture Bill Schloss Gillian Lieberman, MD Our patient Our patient was treated was treated with internal with internal fixationfixation 9 Courtesy of BIDMC files Bill Schloss Gillian Lieberman, MD For our discussionFor our discussion We will first review the typical history, We will first review the typical history, anatomy, and physical findings associated anatomy, and physical findings associated with with scaphoidscaphoid fracturesfractures 10 Bill Schloss Gillian Lieberman, MD HistoryHistory „„ History of wrist History of wrist dorsiflexiondorsiflexion injuryinjury „„ 95% males95% males „„ Average age 25 yearsAverage age 25 years „„ Sporting injuries, motorcycle accidentsSporting injuries, motorcycle accidents „„ Previous trauma?: second injury may be trivial Previous trauma?: second injury may be trivial but may convert asymptomatic fracture to a but may convert asymptomatic fracture to a symptomatic fracturesymptomatic fracture 11 Bill Schloss Gillian Lieberman, MD Dorsal landmarksDorsal landmarks „„ A, Radial A, Radial styloidstyloid „„ B, Extensor B, Extensor pollicispollicis brevisbrevis tendontendon „„ C, Anatomic snuffboxC, Anatomic snuffbox „„ D, Extensor D, Extensor pollicispollicis longuslongus tendontendon „„ E, Lister’s tubercleE, Lister’s tubercle „„ F, Dorsal wrist F, Dorsal wrist depressiondepression „„ G, G, UlnarUlnar styloidstyloid Ritchie, JV, Munter, DW. Emer Med Clin N Amer, 1999 Nov; 17(4): 823-42, vi 12 Bill Schloss Gillian Lieberman, MD Bone anatomyBone anatomy „„ D, D, ScaphoidScaphoid „„ Proximal row: Proximal row: scaphoidscaphoid (D), (D), lunatelunate (F), (F), triquetrumtriquetrum (G), (G), pisiformpisiform (H)(H) „„ Distal row: trapezium Distal row: trapezium (B), trapezoid (K), (B), trapezoid (K), capitatecapitate (I), (I), hamatehamate (J)(J) Ritchie, JV, Munter, DW. Emer Med Clin N Amer, 1999 Nov; 17(4): 823-42, vi 13 Bill Schloss Gillian Lieberman, MD The The scaphoidscaphoid has a precarious has a precarious blood supplyblood supply „„ 67% have arterial foramina 67% have arterial foramina throughout lengththroughout length „„ 13% supplied 13% supplied predominantly by distal 1/3predominantly by distal 1/3 „„ 20% supplied by middle 20% supplied by middle 1/31/3 „„ 1/3 of fractures in proximal 1/3 of fractures in proximal third at risk for third at risk for avascularavascular necrosisnecrosis www.amirmd.com/Images/scaphoidfx3.gif 14 Bill Schloss Gillian Lieberman, MD Physical examinationPhysical examination „„ Tenderness on palpation of anatomic snuffboxTenderness on palpation of anatomic snuffbox „„ Minimal or gross swelling Minimal or gross swelling „„ Pain with Pain with dorsiflexiondorsiflexion, radial deviation, radial deviation „„ Pain with longitudinal compression/tension on Pain with longitudinal compression/tension on thumb metacarpalthumb metacarpal „„ Palpable deformity distal to radial Palpable deformity distal to radial styloidstyloid „„ Check for compartment syndromeCheck for compartment syndrome 15 Bill Schloss Gillian Lieberman, MD ScaphoidScaphoid fractures can be subtle and fractures can be subtle and therefore the imaging algorithm therefore the imaging algorithm may include some of the following:may include some of the following: „„ Plain filmsPlain films „„ Bone scanBone scan „„ UltrasoundUltrasound „„ CTCT „„ MRIMRI 16 Bill Schloss Gillian Lieberman, MD Plain film evaluationPlain film evaluation AP Lateral Pronated oblique Scaphoid view Schreibman, KL, et al, Orth Clin North Am, 1997 Oct; 28(4): 537-582; Ritchie, HV, Munter, DW, Emer Med Clin N Amer, 1999 Nov; 17(4): 823-42, vi 17 Bill Schloss Gillian Lieberman, MD ScaphoidScaphoid viewview „„ UlnarUlnar deviationdeviation „„ Distracts Distracts scaphoidscaphoid, , enhances visualization enhances visualization of fractureof fracture Rettig, ME, et al, Clin in Sports Med, 1998 Jul; 17(3): 469-89 Ritchie, JV, Munter, DW, Emer Med Clin N Amer, 1999 Nov; 17(4); 823-42, vi 18 fracture fracture Bill Schloss Gillian Lieberman, MD Bone scanBone scan „„ Increased tracer Increased tracer uptake in region of uptake in region of scaphoidscaphoid may suggest may suggest occult fractureoccult fracture Rockwood & Green’s Fractures in Adults, 4th ed., 1996Eustace, S, et al., Rad Clin North Am, 1999 Sept; 37(5): 975-94, vi 19 Left hand Right hand Fingers Bill Schloss Gillian Lieberman, MD UltrasoundUltrasound „„ Top: normal Top: normal scaphoidscaphoid (small arrows), flexor (small arrows), flexor carpicarpi radialisradialis tendon tendon (curved arrow)(curved arrow) „„ Bottom: Bottom: scaphoidscaphoid waist fracture waist fracture (arrows), compared to (arrows), compared to normal normal scaphoidscaphoid Jacobson, JA, Orthop Clin North Am, 1998 Jan; 29(1): 135-67 20 Bill Schloss Gillian Lieberman, MD Computed Computed tomographytomography „„ Focuses on plane Focuses on plane of of scaphoidscaphoid „„ Assessment of Assessment of displacement, displacement, angulationangulation Rettig, ME, et al., Clin in Sports Med, 1998 Jul; 17(3): 469-89 21 Scaphoid fracture Growth plate Radius Bill Schloss Gillian Lieberman, MD Plain film MRIPlain film MRI www.scar.rad.washington.edu/radcourse/wrist.html 22 Fracture? Bill Schloss Gillian Lieberman, MD MRI (cont)MRI (cont) „„ Coronal Coronal STIR MR STIR MR confirming confirming marrow marrow edema and edema and scaphoidscaphoid injury injury www.scar.rad.washington.edu/radcourse/wrist.html 23 Bill Schloss Gillian Lieberman, MD Types of Types of scaphoidscaphoid fracturefracture „„ 65% Waist65% Waist „„ 15% Proximal pole15% Proximal pole „„ 10% Distal body10% Distal body „„ 8% 8% TuberosityTuberosity „„ 2% Distal 2% Distal articulararticular surfacesurface Rockwood & Green’s Fractures in Adults, 4th ed., 1996 24 Bill Schloss Gillian Lieberman, MD ClassificationClassification Herbert ClassificationHerbert Classification „„ A: Acute, stableA: Acute, stable –– A1: TubercleA1: Tubercle –– A2: A2: NondisplacedNondisplaced crack in crack in waistwaist „„ B: Acute, unstableB: Acute, unstable –– B1: Oblique, distal 1/3B1: Oblique, distal 1/3 –– B2: Displaced or mobile, waistB2: Displaced or mobile, waist –– B3: Proximal poleB3: Proximal pole –– B4: FractureB4: Fracture--dislocationdislocation –– B5: ComminutedB5: Comminuted „„ C: Delayed UnionC: Delayed Union „„ D: Established NonunionD: Established Nonunion –– D1: FibrousD1: Fibrous –– D2: ScleroticD2: Sclerotic Simple Anatomic Simple Anatomic ClassificationClassification „„ I: Proximal thirdI: Proximal third „„ II: Middle thirdII: Middle third „„ III: Distal thirdIII: Distal third 25 Bill Schloss Gillian Lieberman, MD Unstable Unstable fracturefracture „„ Greater than 1 mm Greater than 1 mm stepoffstepoff „„ LunocapitateLunocapitate angulationangulation > 15 > 15 degrees (lateral)degrees (lateral) „„ ScapholunateScapholunate angulationangulation > 70 > 70 degrees (lateral)degrees (lateral) Schreibman, KL, et al., Orthop Clin North Am, 1997 Oct; 28(4): 537-582 26 Bill Schloss Gillian Lieberman, MD ComplicationsComplications „„ NonunionNonunion „„ AvascularAvascular necrosisnecrosis „„ ScapholunateScapholunate advanced collapse advanced collapse (SLAC)(SLAC) 27 Bill Schloss Gillian Lieberman, MD NonunionNonunion www.medmedia.com/image5/i1/scphn1.jpg 28 Bill Schloss Gillian Lieberman, MD AvascularAvascular necrosisnecrosis www.e-hand.com/jpgwww.e-hand.com/jpg 29 Sclerotic on plain filmSclerotic on plain film Low signal on MRILow signal on MRI Bill Schloss Gillian Lieberman, MD ScapholunateScapholunate advanced advanced collapse collapse (SLAC)(SLAC) www.medmedia.com/image4/i1/slac1.jpg 30 Lunate Scaphoid Bill Schloss Gillian Lieberman, MD TreatmentTreatment „„ UndisplacedUndisplaced, stable, stable –– Splint, short/long arm Splint, short/long arm thumb thumb spicaspica cast (6cast (6--12 12 weeks)weeks) „„ Displaced, unstableDisplaced, unstable –– Longitudinal traction Longitudinal traction along thumb, along thumb, compression of compression of carpuscarpus, , then splint and castthen splint and cast –– SurgerySurgery »» Closed reduction, Closed reduction, percutaneouspercutaneous pinningpinning »» Open reduction, internal Open reduction, internal fixationfixation „„ NonunionNonunion –– Excision of fragmentsExcision of fragments –– StyloidectomyStyloidectomy –– Radial graftRadial graft –– Proximal row Proximal row carpectomycarpectomy –– Partial/total Partial/total arthrodesisarthrodesis of wristof wrist 31 Bill Schloss Gillian Lieberman, MD SurgerySurgery „„ Displaced Displaced scaphoidscaphoid fracture treated by fracture treated by ORIF, Herbert ORIF, Herbert screw fixation, screw fixation, radial bone grafting radial bone grafting for for comminutioncomminution Rettig, ME, et al., Clin in Sports Med, 1998 Jul; 17(3): 469-89 32 Bill Schloss Gillian Lieberman, MD Four corner Four corner fusionfusion www.medmedia.com/image4/i1/scp4.jpg 33 Bill Schloss Gillian Lieberman, MD A history and examination typical A history and examination typical for for scaphoidscaphoid fractures may result fractures may result from other injuriesfrom other injuries 34 Bill Schloss Gillian Lieberman, MD Distal radius Distal radius fracturefracture „„ Coronal fast Coronal fast spin echo spin echo MRMR „„ Distal radius Distal radius fracture in fracture in patient with patient with snuffbox snuffbox tenderness, tenderness, negative AP negative AP filmfilm www.scar.rad.washington.edu/radcourse/wrist.html 35Bill Schloss Gillian Lieberman, MD DdxDdx for clinical for clinical presentation of presentation of scaphoidscaphoid fracture:fracture: „„ TransscaphoidTransscaphoid perilunarperilunar dislocationdislocation „„ Trapezium fractureTrapezium fracture „„ Bennett fractureBennett fracture „„ Radial head fractureRadial head fracture „„ Distal radius fractureDistal radius fracture „„ LunateLunate dislocationdislocation Ritchie, JV, Munter, DW, EmerMed Clin N Amer, 1999 Nov; 17(4): 823-42, vi www.aafp.org/afp/980301ap/ shearman.html 36 PerilunatePerilunate dislocationdislocation LunateLunate dislocationdislocation Bill Schloss Gillian Lieberman, MD ReferencesReferences „„ BiondettiBiondetti, PR, et al: Wrist: Coronal and , PR, et al: Wrist: Coronal and transaxialtransaxial CT scanning. CT scanning. Radiology. 1987; 163(1): 149Radiology. 1987; 163(1): 149--151.151. „„ Bush, CH, et al: HighBush, CH, et al: High--resolution CT of the wrist: Initial experience resolution CT of the wrist: Initial experience with with scaphoidscaphoid disorders and surgical fusions. disorders and surgical fusions. AJRAJR. 1987 Oct; 149: . 1987 Oct; 149: 757757--760.760. „„ CanaleCanale. . Campbell’s Operative Campbell’s Operative OrthopaedicsOrthopaedics. 9. 9thth eded, 1998: 3455, 1998: 3455-- 3480.3480. „„ Eustace, S, et al: Emergency MR imaging of orthopedic trauma. Eustace, S, et al: Emergency MR imaging of orthopedic trauma. RadRad ClinClin N AmerN Amer. 1999 Sep; 37(5): 975. 1999 Sep; 37(5): 975--94, vi.94, vi. „„ TaleisnikTaleisnik, J: Fractures of the carpal bones. , J: Fractures of the carpal bones. Operative Hand SurgeryOperative Hand Surgery. . 22ndnd eded, 1988: 813, 1988: 813--873.873. „„ Herbert, TJ: Herbert, TJ: The Fractured The Fractured ScaphoidScaphoid. . St.LouisSt.Louis: 1990. : 1990. „„ HodgkinsonHodgkinson, DW: , DW: ScaphoidScaphoid fracture: A new method of assessment. fracture: A new method of assessment. ClinClin RadiolRadiol. 1993 Dec; 48(6): 398. 1993 Dec; 48(6): 398--401.401. „„ Hunter, JC, et al: MR imaging of clinically suspected Hunter, JC, et al: MR imaging of clinically suspected scaphoidscaphoid fractures. fractures. AJRAJR. 1997 May; 168: 1287. 1997 May; 168: 1287--1293.1293. „„ ImaedaImaeda, T, et al: Magnetic resonance imaging in , T, et al: Magnetic resonance imaging in scaphoidscaphoid fractures. fractures. J Hand SurgJ Hand Surg. 1992 Feb; 17B(1): 20. 1992 Feb; 17B(1): 20--27.27. „„ Jacobson, JA: Musculoskeletal Jacobson, JA: Musculoskeletal ultrasonographyultrasonography. . OrthOrth ClinClin N AmerN Amer. . 1998 Jan; 29(1): 1351998 Jan; 29(1): 135--67.67. „„ LepistoLepisto, J, et al: Low field MRI and , J, et al: Low field MRI and scaphoidscaphoid fracture. fracture. J Hand SurgJ Hand Surg. . 1995 Aug; 20B(4): 5391995 Aug; 20B(4): 539--542.542. www.geocities.com/pipeline/halfpipe/ 4583/pictures/spizer5.jpg 37 Bill Schloss Gillian Lieberman, MD ReferencesReferences „„ MatityahuMatityahu, A: , A: ScaphoidScaphoid fractures. fractures. www.amirmd.com/orthowww.amirmd.com/ortho-- info/scafoidfx.htmlinfo/scafoidfx.html „„ PehPeh, WCG, et al: Detection of occult wrist fractures by magnetic , WCG, et al: Detection of occult wrist fractures by magnetic resonance imaging. resonance imaging. ClinClin RadiolRadiol. 1996, 51: 285. 1996, 51: 285--292.292. „„ RettigRettig, ME, et al: Hand and wrist injuries. , ME, et al: Hand and wrist injuries. ClinClin in Sports Medin Sports Med. 1998 . 1998 Jul; 17(3): 469Jul; 17(3): 469--89.89. „„ Richardson, ML: Interpretation of radiographic images: Snuffbox Richardson, ML: Interpretation of radiographic images: Snuffbox tenderness following trauma. 1997. tenderness following trauma. 1997. www.scar.rad.washington.edu/radcourse/wrist.htmlwww.scar.rad.washington.edu/radcourse/wrist.html „„ Ritchie, JV, Ritchie, JV, MunterMunter, DW: Orthopedic emergencies, emergency , DW: Orthopedic emergencies, emergency department evaluation and treatment of wrist injuries. department evaluation and treatment of wrist injuries. EmerEmer Med Med ClinClin N AmerN Amer. 1999 Nov; 17(4): 823. 1999 Nov; 17(4): 823--42.42. „„ Rockwood & Green’s Fractures in AdultsRockwood & Green’s Fractures in Adults. 4. 4thth eded, 1996: 826, 1996: 826--867.867. „„ SchreibmanSchreibman, KL, et al.: Imaging of the hand and wrist. , KL, et al.: Imaging of the hand and wrist. OrthOrth ClinClin N N AmerAmer. 1997 Oct; 28(4): 537. 1997 Oct; 28(4): 537--582.582. „„ Shearman, CM, ElShearman, CM, El--KhouryKhoury, GY: Pitfalls in radiologic evaluation of , GY: Pitfalls in radiologic evaluation of upper extremity trauma. www.aafp.org/afp/980301ap/shearman.htmlupper extremity trauma. www.aafp.org/afp/980301ap/shearman.html „„ WheelessWheeless’ Textbook of ’ Textbook of OrthopaedicsOrthopaedics. . www.medmedia.com/orthoo/41.htmwww.medmedia.com/orthoo/41.htm www.geocities.com/pipeline/ halfpipe/4583/pictures/kruse2.jpg 38Bill Schloss Gillian Lieberman, MD AcknowledgmentsAcknowledgments „„ Daniel Daniel SaurbornSaurborn „„ BeverleeBeverlee TurnerTurner „„ HaldonHaldon BryerBryer „„ Larry Barbaras and Larry Barbaras and Ben Crandall our Ben Crandall our webmasterswebmasters www.geocities.com/pipeline/halfpipe/4583/pictures/kruse.jpg 39 Bill Schloss Gillian Lieberman, MD Scaphoid Fractures Mr. F Clinical differential diagnosis Menu of tests available to image traumatic wrist injuries Our patient’s plain films, left wrist Slide Number 6 A closer look at the AP view… Our patient’s wrist CT Our patient was treated with internal fixation For our discussion History Dorsal landmarks Bone anatomy The scaphoid has a precarious blood supply Physical examination Scaphoid fractures can be subtle and therefore the imaging algorithm may include some of the following: Plain film evaluation Scaphoid view Bone scan Ultrasound Computed �tomography Plain film MRI MRI (cont) Types of �scaphoid fracture Classification Unstable fracture Complications Nonunion Avascular necrosis Scapholunate advanced collapse (SLAC) Treatment Surgery Four corner fusion A history and examination typical for scaphoid fractures may result from other injuries Distal radius fracture Ddx for clinical presentation of scaphoid fracture: References References Acknowledgments