Wrist

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=100 BGCOLOR="#000000" TEXT="#F7F7FF" bgproperties="fixed" background="03f00640dvldtc.gif"> <div> <FONT SIZE="5" COLOR="#FFCC66" FACE="Arial" ><B>Radiographers Reporting</B></FONT><B>     |     </B><A HREF="index.htm" TARGET="_top" TITLE="Radiographers Reporting"><U><B>home</B></U></A></div> <div> <A HREF="id37.htm" TARGET="_top" TITLE="The Report"><U>The Report</U></A>   |   <A HREF="id19.htm" TARGET="_top" TITLE="Shoulder"><U>Shoulder</U></A>   |   <A HREF="id20.htm" TARGET="_top" TITLE="Elbow"><U>Elbow</U></A>   |   <B>Wrist</B>   |   <A HREF="id22.htm" TARGET="_top" TITLE="Hand"><U>Hand</U></A>   |   <A HREF="id23.htm" TARGET="_top" TITLE="Pelvis/Hip"><U>Pelvis/Hip</U></A>   |   <A HREF="id24.htm" TARGET="_top" TITLE="Knee"><U>Knee</U></A>   |   <A HREF="id25.htm" TARGET="_top" TITLE="Ankle"><U>Ankle</U></A>   |   <A HREF="id26.htm" 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<B><IMG SRC="114b50e0.jpg" border=0 width="181" height="270" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>4.</B></div> <div> <B><IMG SRC="33db40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>5.</B></div> <div> <B><IMG SRC="117b9140.jpg" border=0 width="185" height="276" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>6.</B></div> <div> <B><IMG SRC="147b6c80.jpg" border=0 width="182" height="200" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>7.</B></div> <div> <B><IMG SRC="25cb40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>8.</B></div> <div> <B><IMG SRC="328b4b50.jpg" border=0 width="180" height="181" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>9.</B></div> <div> <B><IMG SRC="434b40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>10.</B></div> <div> <B><IMG SRC="436b40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>11.</B></div> <div> <B><IMG SRC="438b40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>12.</B></div> <div> <B><IMG SRC="119b7110.jpg" border=0 width="183" height="273" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>13.</B></div> <div> <B><IMG SRC="1f3b40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>14.</B></div> <div> <B><IMG SRC="1f5b40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>15.</B></div> <div> <B><IMG SRC="3f6b40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>16.</B><B> <A NAME="pisiform__"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B></div> <div> <B><IMG SRC="360b40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>17.</B></div> <div> <B><IMG SRC="44cb40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>18.</B></div> <div> <A HREF="#lunate__" TITLE="Wrist"><U><B><IMG SRC="472b8130.jpg" border=0 width="184" height="275" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <div> <B>18.</B></div> <div> <B> <A NAME="lunate__"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B><IMG SRC="474b8130.jpg" border=0 width="184" height="275" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>19.</B></div> <div> <B><IMG SRC="149b7110.jpg" border=0 width="183" height="273" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>20.</B></div> <div> <B><IMG SRC="11bb9150.jpg" border=0 width="185" height="277" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>21.</B></div> <div> <B><IMG SRC="11db7110.jpg" border=0 width="183" height="273" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>22.</B></div> <div> <B><IMG SRC="14bb3780.jpg" border=0 width="179" height="120" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>23.</B></div> <div> <B><IMG SRC="339b40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>24.</B></div> <div> <B><IMG SRC="37cb4f10.jpg" border=0 width="180" height="241" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>25.</B></div> <div> <B><IMG SRC="3b0b4790.jpg" border=0 width="180" height="121" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>26.</B></div> <div> <B><IMG SRC="37fb49d0.jpg" border=0 width="180" height="157" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>27.</B></div> <div> <B><IMG SRC="14db20a0.jpg" border=0 width="178" height="266" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>28.</B></div> <div> <B><IMG SRC="189b77b0.jpg" border=0 width="183" height="123" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>29.</B></div> <DIV ALIGN="LEFT"></DIV> <div> <IMG SRC="10eb30c0.jpg" border=0 width="179" height="268" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>30.</B></div> <div> <B><IMG SRC="2e7b40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>31.</B></div> <div> <B><IMG SRC="25cb40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>32.</B></div> <div> <B><IMG SRC="1f3b40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>33.</B></div> <div> <B><IMG SRC="29cb40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>34.</B></div> <div> <B><IMG SRC="387b40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>35.</B></div> <div> <B><IMG SRC="40fb40d0.jpg" border=0 width="180" height="269" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>36.</B></div> <div> <B><IMG SRC="46ab87b0.jpg" border=0 width="184" height="123" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>37.</B></div> <div> <B><IMG SRC="496b8d10.jpg" border=0 width="184" height="209" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>38.</B></div> <div> <B><IMG SRC="498b8dc0.jpg" border=0 width="184" height="220" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> </td> <td valign="top" height=380 BGCOLOR="#000000" TEXT="#F7F7FF"> <div> Wrist</div> <div> The most common injury to the wrist are the fractures of the distal radius and ulna. A little harder to diagnose for the less experienced are the carpal fractures and dislocations.</div> <bR> <div> <B><U>THE COLLES FRACTURE.</U></B></div> <bR> <div> The Colles fracture is a fracture of the distal radius and ulna with posterior displacement of the distal portions and the carpal bones. See <B>images 1 and 2</B>. Most, if not all, medical and paramedical staff will know what a Colles fracture is if asked, but again, it is suggested that the reporting radiographer describes the appearances of the fracture in their report rather than just saying "there is a Colles fracture". </div> <bR> <div> <B><U>THE SMITH'S FRACTURE.</U></B></div> <bR> <div> The Smith's fracture is also a fracture of the distal radius and ulna but this time the distal portion and carpals are displaced anteriorly. See<B> image 3</B>.</div> <bR> <div> Of course it is not always as easy to diagnose a fracture when there is little or no displacement, or as in <B>image 4</B> some impaction. Look closely at <B>image 4</B> and you should see a sclerotic (lighter) band obliquely across the distal radius. It arises from the ulna aspect and is visible across the radius to a step in the articular surface. This is an impacted fracture. The sclerotic band is caused by the overlapping or impaction of the bone fibres.</div> <bR> <div> <B><U>THE SCAPHOID FRACTURE.</U></B></div> <bR> <div> It is very important to be able to diagnose the scaphoid fracture correctly, see <B>image 5</B>, as it's blood supply tends to be from the distal part. Therefore any fracture across the waist of the scaphoid may result in avascular necrosis of the proximal portion, delayed union or even non-union. Scaphoid fractures tend to be either across the waist or the distal pole as in <B>image 6</B>. Take care with distal pole fragments as there is a normal growth variant at this site, see <B>image 7</B>. Any suspicion of bony trauma should be highlighted in the report and a suggestion for "further radiographs in a week to ten days if clinically indicated" should be included.</div> <bR> <div> <B><U>THE FRACTURED TRIQUETRIUM.</U></B></div> <bR> <div> It is relatively rare to see a fracture through the body of the triquetrium. <B>Image 8</B> is an example of an undisplaced fracture which was only visible on this one projection.<B> Images 9, 10 and 11</B> are further examples of a fracture through the body of the triquetrium, but on this occasion it was visible on all the projections, although missable on all but the lateral view. It is more common to see an avulsion fracture from the posterior aspect which is almost never seen on any view except the lateral, see <B>image 12</B>. The fracture appears as a small fragment of bone lying posteriorly to the carpal bones and is the avulsion of the radiotriquetral and ulnotriquetral components of the radiocarpal ligament. As <A HREF="#perilunatum_1" TITLE="Wrist"><U>accessory ossicles</U></A><A HREF="#perilunatum_1" TITLE="Wrist"><U> </U></A>are very rare in this area, any small fragment seen after trauma, which does not appear corticated, is almost certainly an avulsion fracture from the  triquetrium.</div> <bR> <div> <B><U>THE FRACTURED HAMATE.</U></B></div> <bR> <div> A  fracture of the hamate is quite a rare injury. It can be difficult to diagnose due to the overlapping of the carpal bones.<B> Images 13 and 14</B> show a hamate fracture. Notice also the accessory ossicle adjacent to the ulna styloid, this is a normal variant. <B>Image 15</B> also shows a hamate fracture.</div> <bR> <div> <B><U>THE FRACTURED PISIFORM.</U></B></div> <bR> <div> <B>Image 16 </B>shows the very rare appearance of the fractured pisiform. This particular image is cropped from a very badly injured wrist with a comminuted distal radius and fractured scaphoid. It would be very unusual to see a fractured pisiform with no other injury, although they can occur in isolation. The other thing to remember is that the pisiform can have <A HREF="id33_pisiform_ossify.htm" TARGET="_top" TITLE="Paediatric arm."><U>multiple ossification centers</U></A> which could resemble a fracture, although these tend not to persist into adulthood. </div> <bR> <div> <B><U>THE FRACTURED TRAPEZIUM.</U></B></div> <bR> <div> <B>Image 17</B> shows a fracture through the trapezium.</div> <bR> <div> <B><U>THE FRACTURED LUNATE.</U></B></div> <bR> <div> It is very rare to see a fractured lunate. <B>Image 18</B> shows an example. In this case however the fracture was probably due to the fact that the lunate is very flattened and therefore weakened possibly due to a necrotic process such as Keinbock's disease. Click on the image to highlight the lunate and the fractures.</div> <bR> <div> <B><U>CARPAL DISLOCATIONS.</U></B></div> <bR> <div> Carpal dislocations are quite rare and when seen are usually the lunate or peri-lunate dislocations. These can be a little difficult for the less experienced but this is an area where the reporting radiographer needs to know the normal radiographic anatomy. Take a look at <B>image 19</B>. The author has highlighted the capitate, lunate and distal radius. It can be seen that the capitate sits in the lunate which in turn sits in the distal radius. This is often referred to as the "apple in the cup in the saucer".</div> <bR> <div> In the case of the lunate dislocation, the lunate is forced anteriorly whilst the capitate and radius stay in line. See <B>image 20</B>. <B>Image 21</B> shows the P.A. appearance which should be obvious but could be missed by those who are unsure of the normal anatomical appearance of the carpal bones as highlighted in<B> image 22</B>. There should be a rough "S" shaped joint line between the proximal and distal rows of carpal bones.</div> <bR> <div> Don't be fooled by the appearance in <B>image 23</B> which is the pisiform not fully ossified resembling a dislocated lunate, the lunate is still in place.</div> <bR> <div> <B>Image 24</B>, courtesy of <A HREF="http://www.x-ray2000.co.uk" TARGET="_top" TITLE="http://www.x-ray2000.co.uk"><U>Nick Oldnall at x-ray2000</U></A> shows the peri-lunate dislocation where the capitate, along with the rest of the carpus, is forced posteriorly out from the lunate articulation but the lunate remains in place articulating with the distal radius.</div> <bR> <div> Also quite rare are carpal subluxations. The most common of these is the scapho-lunate subluxation as in <B>image 25, </B>and<B> image 26</B>, an MRI image courtesy of <A HREF="http://www.x-ray2000.co.uk" TARGET="_top" TITLE="http://www.x-ray2000.co.uk"><U>Nick Oldnall at x-ray2000</U></A>. This presents as a widening of the joint space between the scaphoid and lunate seen on the P.A. view. To those of the older generation, this is known as the "Terry Thomas sign" after the recently dead actor who had a prominent gap between his top front teeth. The joint spaces between the carpal bones in the adult wrist should be of a uniform width, any widening of one should raise suspicion. Care should be taken with the early paediatric and the elderly wrists. In the paediatric wrist the joint spaces are not as uniform as in the adult skeleton due to the carpal bones ossifying at different ages, see <B>image 27</B>. In the elderly wrist there can be loss of joint space around individual carpal bones due to degeneration and general wear and tear, see<B> image 28</B>.</div> <bR> <bR> <div> <B><U>TECHNIQUE NOTE.</U></B></div> <bR> <div> When radiographing the wrist, the P.A. view should be done with the elbow in the lateral position, and the lateral view of the wrist should be done with the elbow in the A.P. position. If the elbow is not turned from one view of the wrist to the other, then two views of the ulna will not be achieved. It has to be remembered that the olecranon process of the elbow is the proximal end of the ulna, and if the elbow is not turned then how can the distal ulna be turned, all that would happen is that the distal radius is rotated over the distal ulna.</div> <bR> <bR> <div> <B><U>THE FOREARM.</U></B></div> <bR> <div> Fractures of the shafts of the long bones are often quite straight forward and not hard to see but <B>image 29</B>, is an interesting injury which it was thought would be good to highlight. A fracture of both radius and ulna when the fracture sites are alongside each other may cause problems during healing in that a "callus bridge" may form joining the two bones which would prevent pronation and supination.</div> <bR> <div> <B>Image 30</B> shows an unusual injury. This is an undisplaced fracture of the distal ulna caused by the wrist being hit by the wing mirror of a passing car. Being undisplaced it is a little difficult to see, but the viewer should be able to see a crescent of disrupted trabeculae on the radial aspect, from the distal surface to a point just proximal to the radio-ulna joint.</div> <bR> <div> <B><U>NORMAL VARIANTS OF THE WRIST.</U></B></div> <bR> <div> Care should be taken to check for cortication with fragments at the distal pole of the scaphoid as there is a normal variant of an un-united secondary ossification centre at this site, see<B> image 31</B>.</div> <bR> <div> See also <B>image 32</B> which demonstrates an accessory ossicle adjacent to the ulna styloid.</div> <bR> <div> <B>Image 33</B> shows an un-united ulna styloid. This may be due to earlier trauma but is more likely to be a normal growth variant.</div> <bR> <div>  <A NAME="perilunatum_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>As stated above, accessory ossicles posterior to the carpus are very rare but <B>image 34 </B>shows the appearance of os perilunatum. (There is also a fracture of the distal radius). <B>Image 35 </B>shows a small os styloideum.</div> <bR> <div> <B>Image 36</B> shows a capitate which is almost entirely bone cyst. This is almost certainly benign and of little concern apart from the fact that the bone is weakened and prone to fracture. This would be a coincidental finding and not the cause of the patient's presentation. A second opinion by a radiologist would be wise to exclude other pathology.</div> <bR> <div> <B>Images 37 and 38</B> are a P.A. and oblique view of the same wrist with some congenital anomalies. Firstly there is a fragment of bone adjacent to the first metacarpal. This is a remnant of a second thumb which was removed shortly after birth. Secondly on <B>image 37</B> it can be seen that the scaphoid is an odd shape and in two pieces, this is not due to trauma in this case. Lastly on <B>image 38</B> it can be seen that there are two trapezium bones, one for each thumb as was. In addition the distal radius is also abnormal in shape.</div> </td> </tr></table></body>