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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