Updated: 5/23/2021

Wrist Trauma Radiographic Evaluation

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  • Ossification
    • order of ossification (clockwise in a right hand starting at capitate): capitate, hamate, triquetrum, lunate, scaphoid, trapezium, trapezoid, pisiform
    • Order of ossification of the carpal bones
      Carpal bone
      Age at ossification (years)
      Age at fusion
      Capitate
      14-16
      Hamate
      2
      14-16
      Triquetrum
      3
      14-16
      Lunate
      4
      14-16
      Scaphoid
      5
      14-16
      Trapezium
      5-6
      14-16
      Trapezoid
      6-7
      14-16
      Pisiform
      9-10
      14-16
  • 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
      • Carpal bridge/tunnel view positioning
        Method
        Patient position
        Beam position
        Original carpal bridge
        Elbow extended + forearm pronated + wrist extended
        4cm proximal to bend of wrist
        45° caudad

        Modified carpal bridge
        Elbow flexed + wrist extended
        4cm proximal to bend of wrist
        45° caudad
        Carpal tunnel
        Elbow flexed + forearm pronated + wrist extended
        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 radiographic FINDINGS
    • Normal radiographic appearance
    • Normal radiographic appearance
      Bone
      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
        • indications for ORIF
          • 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)
      • 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
      • 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
      • 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
      • 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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