Updated: 6/10/2020

Wrist Trauma Radiographic Evaluation

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NORMAL ANATOMY
 Ossification
  • order of ossification (clockwise in a right hand starting at capitate): capitate, hamate, triquetrum, lunate, scaphoid, trapezium, trapezoid, pisiform 
 Osteology
  • Palmar/volar view
  • Dorsal view
 Ligaments
  • Palmar/volar view
  • Dorsal view
 Carpal (Gilula's) arcs
  • Proximal = proximal scaphoid + lunate + triquetrum
  • Middle = distal scaphoid + lunate + triquetrum
  • Distal = proximal capitate + hamate 
RADIOGRAPHIC VIEWS
 AP/PA view
  • Positioning
    • patient
      • shoulder abducted 90°+ elbow flexed 90° + forearm/hand supinated (AP) vs. pronated (PA)
    • beam
      • aim at mid-carpus
  • Indications
    • carpal joints = AP view preferred over PA view
    • radiocarpal joint
    • distal radius/ulnar fracture
  • Critique
    • foreshortened scaphoid
    • trapezoidal lunate
    • slight superimposition of distal radius + carpal bones
    • open 2nd-5th CMC joints
 Lateral view
  • Positioning
    • patient
      • shoulder adducted + elbow flexed 90° + forearm neutral
    • beam
      • aim at mid-carpus + 10° cephalad
  • Indications
    • alignment of bones/joints
    • carpal/lunate instability
  • Critique
    • volar cortex of pisiform + capitate within central 1/3 of volar scaphoid
    • visualization of ulnar styloid posteriorly
    • important to adduct shoulder to achieve adequate rotation of ulna
      • ulna does not rotate with pronation/supination
  Oblique view 
  • Positioning 
    • patient 
      • shoulder abducted 90°+ elbow flexed 90° 
        • IR oblique = forearm pronated 45°
        • ER oblique = forearm supinated 45°
    • beam
      • aim at mid-carpus
  • Indications
    • IR oblique = radial carpal bones
    • ER oblique = ulnar carpal bones
  • Critique
    • IR oblique
      • no superimposition of trapezoid + trapezium
      • slight superimposition of trapezoid + capitate
      • open trapezium-trapezoid + scaphotrapezium + 2nd CMC joints
    • ER oblique
      • no superimposition of triquetrum, lunate, or pisiform
 Ulnar/radial deviation view
  • Positioning
    • patient
      • shoulder abducted 90° + elbow flexed 90° + forearm pronated + hand ulnarly vs. radially deviated
    • beam
      • aim at scaphoid
  • Indications
    • ulnar deviation = lateral wrist + scaphoid fracture
    • radial deviation = medial wrist
  • Critique
    • characteristic movement of scaphoid/lunate
      • ulnar deviation = extends
      • radial deviation = flexes
 Carpal bridge/tunnel view
  • Positioning 
METHOD
PATIENT
BEAM
Original carpal bridge
elbow extended + forearm pronated + wrist flexed 4cm proximal to bend of wrist 45° caudad
Modified carpal bridge elbow flexed + wrist flexed 4cm proximal to bend of wrist 45° caudad
Carpal tunnel
elbow flexed + forearm pronated + wrist flexed 2.5cm distal to base of 3rd metacarpal
25-30° cephalad
  • Indications
    • pisiform fracture
    • trapezium fracture
    • hook of hamate fracture
  • Critique
    • visualization of carpal tunnel
 Clenched fist view
  • Positioning
    • patient
      • elbow flexed 90° + forearm supinated + wrist ulnarly deviated + hand clenched to move capitate proximally
    • beam
      • aim at mid-carpus
      • usually obtain bilateral wrists
  • Indications
    • SL injury
  • Critique
    • if obtaining bilateral wrists, symmetric positioning of bilateral wrists
 Scaphoid view
  • Positioning
    • patient 
      • elbow flexed + forearm pronated + wrist extended 30° and ulnarly deviated 20°
    • beam
      • aim at mid-wrist
  • Indications
    • scaphoid fracture
 Trapezium (Clements-Nakayama) view
  • Positioning
    • patient
      • elbow flexed + forearm pronated 45° + wrist ulnarly deviated
    • beam
      • aim at snuffbox/trapezium
      • if unable to ulnarly deviate wrist, aim 20° cephalad
  • Indications
    • trapezium fracture
NORMAL FINDINGS
  • Normal radiographic appearance
  •   PA view Lateral view Oblique view Scaphoid view
    Scaphoid
    Lunate
    Triquetrum
    Pisiform
    Trapezium        
    Trapezoid        
    Capitate        
    Hamate
  • Normal variants
    • lunula
      • located within TFCC between ulnar styloid + triquetrum
      • can be fused to ulnar styloid, resulting in elongated shape
    • os triangulare
      • located between ulnar styloid + lunate + triquetrum
    • os hamuli proprium
      • accessory bone resulting from failure of fusion of hook of hamate ossification center
    • os centrale carpi
      • located dorsally between scaphoid + trapezoid + capitate
    • os epilunate
      • located at dorsal aspect of lunocapitate joint
    • os styloideum
      • located between 2nd and 3rd metacarpal bases
    • os paratrapezium
      • located between distal radial aspect of radius + base of 1st metacarpal
    • os radiostyloideum
      • located near radial styloid process and lateral to mid-portion of scaphoid
CLINICAL PEARLS
 Amsterdam wrist rules
  • XRs are indicated if any of the following criteria are met 
    • increased age
    • wrist swelling
    • visible deformity
    • TTP at distal radius
    • if suspected distal radius fracture
      • pain with palmarflexion
      • pain with supination
      • painful radioulnar ballottement test
      • pain with ulnar deviation = decreased risk
    • if suspected wrist fracture
      • M > F
      • anatomical snuffbox swelling
      • pain with radial deviation
      • painful axial compression of thumb = decreased risk
 Wrist effusion
  • pronator quadratus fat pad sign
    • bowing of fascial covering of pronator quadratus
    • seen on lateral view
  • scaphoid fat pat sign
    • seen on ulnar deviation view
 Scaphoid fracture  
  • Classification
    • waist = 65%
    • proximal 1/3 = 25%
    • distal 1/3 = 10%
      • most common in peds due to ossification pattern
  • Recommended views
    • PA
      • visualizes the proximal pole but provides distorted image of waist and distal pole due to flexed position of scaphoid
    • lateral
      • visualizes the waist of scaphoid but is limited by overlap of carpal bones
    • scaphoid view
      • 30° wrist extension, 20° ulnar deviation
    • IR oblique
      • best view to see the waist and distal pole of scaphoid
    • if radiographs are negative and there is a high clinical suspicion, repeat radiographs in 14-21 days
  • Optional views
    • clenched fist
      • if concern for scapholunate ligament injury
  • Findings
    • unstable scaphoid fractures
      • humpback deformity
      • displacement > 1 mm on any view
      • scapholunate angle > 60°
      • radiolunate angle > 15°
      • intrascaphoid angle > 35°
  • Treatment criteria
    • nonoperative treatment acceptable if 
      • stable nondisplaced fracture (majority of fractures)
    •  
      • if patient has normal xrays but there is a high level of suspicion can immobilize in thumb spica and reevaluate in 12 to 21 days
    • ORIF if
    •  
      • unstable fractures
        • proximal pole fractures 
        • displacement > 1 mm
        • 15° scaphoid humpback deformity
        • radiolunate angle > 15° (DISI)
        • intrascaphoid angle of > 35°
        • scaphoid fractures associated with perilunate dislocation
        • comminuted fractures
        • unstable vertical or oblique fractures
    •  
      •  non-displaced waist fractures
 Lunate dislocation (perilunate dissociation)  
  • Classification = Mayfield
     
     Mayfield Classification
    Stage I  • scapholunate dissociation
    Stage II  • + lunocapitate disruption
    Stage III  • + lunotriquetral disruption, "perilunate"
    Stage IV  • lunate dislocated from lunate fossa (usually volar)
     • associated with median nerve compression

  • Recommended views
    • PA
    • lateral
  • Findings
    • PA
      • break in Gilula’s arc
      • overlap of lunate + capitate
      • "piece-of-pie sign"
        • triangular appearance of lunate
        • due to palmar rotation from dorsal force of carpus
    • lateral
      • loss of colinearity of radius, lunate, and capitate
        • in stage III injury, capitate displaces dorsal to lunate
        • in stage IV injury, lunate displaces volar to radius to form "spilled teacup sign"
      • scapholunate angle > 70°
      • spilled teacup sign
  • Treatment criteria
    • nonoperative treatment NOT acceptable
    • emergent closed reduction/splinting followed by open reduction, ligament repair, fixation, possible carpal tunnel release if acute injury (< 8 weeks)
    • proximal row carpectomy if chronic injury (> 8 weeks)
    • total wrist arthrodesis if chronic injury with degenerative changes
 Triquetrum fracture  
  • Classification
      Triquetrum Fractures
      Dorsal cortical fractures
       • most common (accounts for up to 93%)
       • mechanism includes avulsion, shearing force, or impaction

      Body fractures
       • second most common
       • subtypes: sagittal, medial tuberosity, transverse proximal pole, transverse body, comminuted

      Palmar cortical fractures
       • mechanism includes avulsion or shearing force
       • risk of instability

  • Recommended views
    • PA
    • lateral
      • useful for visuzalizing dorsal cortical fractures
    • IR oblique
      • useful for visuzalizing dorsal cortical fractures
  • Optional views
    • radial deviation
      • may be helpful in identifying palmar cortical fractures
  • Findings
    • "pooping duck" sign
      • represents dorsal cortical fractures
  • Treatment criteria
    • nonoperative treatment acceptable if 
      • dorsal cortical fractures without evidence of instability
      • nondisplaced body fractures
      • palmar cortical fractures without evidence of instability
    • ORIF if
      • dorsal cortical fractures with evidence of instability
      • displaced body fractures
      • palmar cortical fractures with evidence of instability
 Hook of hamate fracture  
  • Classification = Milch
       Milch Classification

      Description Subtypes Image
      Type I  Hook of hamate fx (most common) 
       • I - avulsion
       • II - middle of hook
       • III - base of hook
        
      Type II
       Body of hamate fx
       • IIA - coronal
       • IIB - transverse
       
  • Recommended views
    • PA
    • lateral
    • ER oblique
    • carpal tunnel
      • best view to see hook of hamate fractures
  • Findings
    • PA view
      • absence of eye sign of cortical ring
        • normally produced by intact hook
      • sclerosis in region of the hook
  • Treatment criteria
    • nonoperative treatment acceptable in most cases
    • excision if chronic non-union
 Hamate body fracture  
  • Classification = Milch
       Milch Classification

      Description Subtypes Image
      Type I  Hook of hamate fx (most common) 
       • I - avulsion
       • II - middle of hook
       • III - base of hook
        
      Type II
       Body of hamate fx
       • IIA - coronal
       • IIB - transverse
       
  • Recommended views
    • PA
    • lateral
    • ER oblique
      • best view to see hamate body fractures
    • carpal tunnel
  • Treatment criteria
    • nonoperative treatment acceptable if extra-articular and non-displaced (rare)
    • ORIF if
      • extra-articular and displaced
      • intra-articular
 Pisiform fracture  
  • Recommended views
    • PA
    • lateral
    • ER oblique
    • carpal tunnel
    • best seen with ER oblique or carpal tunnel view
  • Treatment criteria
    • nonoperative treatment acceptable in most cases
    • pisiformectomy if
      • severely displaced and symptomatic fractures
      • painful nonunion
 

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