Scribd
Upload
8 views28 pages

Weiss 2007 Radiography

The article reviews the significance of radiography in hand therapy, emphasizing its role in assessing traumatic and degenerative conditions of the distal upper extremity. It discusses various x-ray views and their specific purposes in diagnosing injuries, including common fractures and carpal instability patterns. Additionally, it highlights the importance of understanding radiographic terminology and findings related to conditions such as osteoarthritis and rheumatoid arthritis.

Uploaded by

dagamo2632
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
8 views28 pages

Weiss 2007 Radiography

The article reviews the significance of radiography in hand therapy, emphasizing its role in assessing traumatic and degenerative conditions of the distal upper extremity. It discusses various x-ray views and their specific purposes in diagnosing injuries, including common fractures and carpal instability patterns. Additionally, it highlights the importance of understanding radiographic terminology and findings related to conditions such as osteoarthritis and rheumatoid arthritis.

Uploaded by

dagamo2632
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
Scienmiric/CLINICAL ARTICLE JHT Reap For Crevit #057 Radiography: A Review for the Rehabilitation Professional Susan Weiss, OTR/L, CHT Exploring Hand Therapy, Saint Petersburg, Florida Deborah A. Schwartz, OTR/L, CHT bilitation Center of New Jersey, Stephen C. Anderson, MD Gateway Radiology Consultants, P.A, Saint Petersburg, Florida Obtaining xrays or radiology reports allows a rehabilitation specialist the opportunity to obtain valuable information about the patient, which can then be used to improve the clinical treatment plan, and lead to a better outcome. There are many specific anatomic abnormalities that can be reviewed with the radiologist or other physician and implications for care discussed. Examples of these are to observe the bony cortex for irregularities, the joint spaces to detect normal spacing or narrowing of joint spaces, sclerotic changes near joint surfaces suggestive of abnormal force transmission, and bone density changes in the specific area of patient complaint Typically, more than one view of the injured body part is taken and occasionally the opposite extremity is studied as well for comparison purposes. LIMITATIONS The case studies in this article will be limited to primarily traumatic and degenerative conditions of the distal upper extremity. Radiographs of course Correspondence and reprint requests to Susan Weiss, OTR/L, CHT, CEO of Exploring Hand Therapy Inc, 7991 9th Ave South, ‘[Link], FL.33707; e-mail: . (0894-1130/$ — see front matter © 2007 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved <4oi:10.1197 /jht.2007.03,001 152 JOURNAL OF HAND THERAPY play an important role in many other medical condi- tions such as congenital disorders. POSITIONS AND VIEWS The position of the hand on the plain film deter- mines what bones are revealed. The terms posteri- anterior (PA) and anterioposterior (AP) refer specifically to the direction of the radiographic beam as it enters the hand and exits it.! Common po- sitions for the hand and wrist include oblique or semipronated views, lateral views, ulnar and radial stress views, and clenched fist views.” Each x-ray view has a specific purpose and highlights explicit pathology. The PA (posterior to anterior) view is com- monly used to assess the hand and wrist (Figure 1A and B).’ PA refers to the x-ray beam entering the sur- face of the hand from the posterior or dorsal surface and exiting from the anterior or palmar surface. The AP view refers to an x-ray beam entering the surface of the hand from the anterior or palmar side and ex- iting from the posterior of dorsal side.* A basic radiographic survey of the wrist will include a simple PA view, lateral view, oblique view, and a PA view with the wrist in ulnar devia- tion.” A true wrist PA view (sometimes referred to as “0 of rotation” view*) is performed with the shoul- der abducted to 907, the elbow flexed to 90°, and the forearm pronated (Figure 2). This position ensures that there is no rotation between the radius and the FIGURE 1. (A and B) Posterior to anterior view (wrist). ulna, Italso allow’s fora standardized way to evaluate relationships between bones and bone length.” The oblique position is a good view to assess the carpal in- terspaces as these joints are highlighted in this posi- tion (Figure 3A and B). A true lateral of the wrist is also critical when assessing wrist pathology and pos- sible intercarpal ligament instability. The lateral view is taken with the shoulder adducted, the elbow flexed to 90, and the forearm in the neutral position (Figure 4A and B).? Additionally, when the wrist is x-rayed in the ulnar deviated position, the scaphoid FIGURE 2, Zero degree of rotation is elongated and this allows for easier detection of subtle fractures (Figure 5A and B)..* Typical x-rays of the hand include the oblique lateral, and PA views.* AP and PA views are used in basic hand examinations similar to wrist examina tions. The oblique view gives a basic hand survey and highlights metacarpal pathology.! In this posi tion, the hand is semipronated and often rests on a step wedge sponge to separate the fingers (Figure 6A and B).* The splayed lateral view of the hand demonstrates palmar and dorsal abnormalities and is especially helpful at diagnosing volar-plate avulsions and angulations of phalangeal fractures (Figure 7A and B).! One of the specialty views of the wrist is known as the clenched fist view, which can be completed via AP or PA (Figure 8).’ This view is used when a scapholunate (SL) diastasis is suspected. When a SL tear is present, the gap noted between the scaphoid and the lunate is widened (Figure 9) as compared to when no clenching is performed Another special view is the carpal tunnel view, which is useful for detecting carpal bone fractures (Figure 10A and B)'° This view shows the palmar aspects of the carpal bones, but especially high- lights the hook of the hamate, the triquetrum, the entire pisiform, and the palmar soft-tissue area Radial and ulnar deviation views (Figure 11A and B) are part of the wrist instability series and these views are used to compare the distal carpal row with the proximal carpal row and the radius. These views help to determine normal versus ab normal intercarpal and radiocarpal motion.’ The scaphoid is normally elongated with ulnar devia- tion’ (Figure 5B) and appears flexed with radial de- viation. When the scaphoid is flexed, it appears as a round bone rather than the “peanut shape” more commonly seen. This is referred to as a cortical ring sign (Figure 12).""° This cortical ring sign is normal in a radial deviated wrist position, April-June 2007 153 FIGURE 3. (A and B) Oblique view (wrist) however; this same sign detected on an x-ray with the wrist in a neutral position (Figure 13) may indi cate SL dissociation. TERMINOLOGY There are many basic terms used to describe radiographic findings. Intra-articular refers to in: juries within the joint capsule (Figure 14) and extra- articular refers to those outside of the joint (Figure 15). A comminuted fracture (Figure 14) de- scribes a fracture broken into more than two parts, 154 JOURNAL OF HAND THERAPY FIGURE 4. (A and B) Lateral ew (wrist), while a segmental fracture (Figure 16) refers to multi- ple fractures within the same bone.'! An incomplete fracture (Figure 17) is simply a frac- ture line that does not go all the way through a bone and is very often stable. Fractures are often described as stable or unstable to plan for the best treatment Stable fractures often do well with immobilization, but unstable fractures require some form of surgical intervention FIGURE 5. (A and B) Ulnar deviation (wrist) Other types of fractures include oblique fractures (diagonal fracture across a bone) (Figure 18), trans- verse fractures (a break straight across a bone) (Figure 19), and spiral fractures (corkscrew diagonal fracture common in twisting injuries) (Figure 20). Ligamentous disruption of joint surfaces is called subluxation if only partial, and a dislocation if complete.! ANGULATION/DISPLACEMENT/ INCLINATION Bone structure and pathology are described and defined by describing ratios and angles. The direction of angulation or displacement is typically described by the direction of displacement of the distal fragment in relation to the proximal fragment.'’ If the distal fragmentis dorsal, the fracture is classified as dorsally displaced (Figure 21). Likewise, ifthe distal fragment FIGURE 6, (A and B) Oblique view (hand) is volar, the fracture is volarly displaced (F Another way to describe the displacement is to look at the apex of angulation: which is either volar or dor- sal. This refers to the angle formed by the fracture fragments (Figure 23).!° This apex of angulation ter- minology is often used along with the displacement terminology but can be used independently FIGURE 7. (A and B) Splayed lateral (hand) April-June 2007. 155 Bone shortening occurs when a fractured section slips down and settles in a shortened position (Figure 24). Ultimately, bone shortening affects range of motion due to tendon length discrepancies and causes decreased grip strength and decreased hand function." Malrotation is more easily detected in a clinical exam and is often difficult to assess radiographi- cally.'° The therapist can evaluate this in the clinic by having the patient flex one finger at a time down to the palm. The long access of each finger should point to the scaphoid tubercle, or the distal radius, and the fingernails should be parallel to each other as demon- strated in Figure 25 (note white lines lining up with scaphoid tubercle).'° Slight rotational deformities of the metacarpals will appear more significant with full finger flexion because of digital overlap (scissc ing). As little as 5 of rotation can cause a 1.5 cm ove lap in fingertip flexion (Figure 25).” Distal radius fractures have their own set of unique radiographic terminology and clinical implications. FIGURE 9. Gap between scaphoid and the lunate. 156 JOURNAL OF HAND THERAPY FIGURE 10. (A and B) Carpal tunnel view. The amount of radial shortening, radial inclination, dorsal angulation, presence of articular step-offs, or distal radial ulnar joint issues will impact outcome, and knowledge of such will assist the therapist in formulating appropriate and realistic treatment plans and goals. Figure 26 demonstrates the normal radial height (11 mm) and radial inclination (22°) depicted along with a neutral ulnar variance (normal). Figure 27 displays the normal palmer tilt of 11°.” ‘A decreased radial height (Figure 28) may result in decreased grip, limited pronation, and triangular fi- bro cartilage complex (TFCC) issues.’ This loss of height commonly results in radial shortening (as minimal loss as 25mm) and can substantially in- crease ulnar loading and lead to ulnar-sided wrist problems.* The loss of normal alignment of the artic ular surface following a distal radius fracture may lead to distal radio-ulnar joint problems, including ulnar-sided wrist pain, TFCC degeneration, and ul- nocarpal abutment syndrome.° This can develop into arthritis of the ulnar wrist, decreased wrist FIGURE 12, Wrist radial deviation depicting cortical ring sign FIGURE 13. Cortical ring sign with wrist at neutral. ion views, ted fracture FIGURE 14. Intra-articular comn motion, and decreased grip strength.” Variance refers to the relative length of the radius in relationship to the ulna."* When the two bones are positioned at equal levels, the variance is considered neutral ). If the ulna extends distally, toward the variance (Figure carpus, it is labeled a positive ulnar (Figure 29); whereas if the ulna is shifted proximally the ulnar variance is termed ulnar negative variance (Figure 30). Figure 31 demonstrates a typical PA view after a wrist fracture. Figure 32 demonstrates external fixa tion and pinning to recreate the “normal’’ anatomy as closely as possible. FIGURE 15. Extra-articular fracture April—June 2007 157 FIG) IRE 16. Si COMMON CARPAL INSTABILITY PATTERNS Trauma to the wrist can also cause carpal instabil- ity. The two common instability patterns that occur are Dorsal Intercalated Segment Instability (DISI) or Volar Intercalated Segment Instability (VISD.”"” The DISI is a more common instability pattern,'° while the VISI can be a normal variant in a lax wrist.!® FIGURE 17. Incomplete fracture 158 JOURNAL OF HAND THERAPY FIGURE 18. Oblique fracture. The best way to detect either a VISI or DISI is by studying the lateral wrist view. Normal alignment laterally is collinear, with the lunate sitting in the con- cavity of the distal radius and the capitate sitting in the concavity of the lunate (Figure 33).’ Figure 34 il- lustrates a normal angle of 45° (normal SL angles be- tween 30 and 60)).'” The SL angle is determined by drawing one line parallel to the scaphoid (A) (Figure 34) and another line perpendicular through the lunate (B) (Figure 34). When a DISI exists this an- gle is typically greater than 60 (Figure 35) and the lu- nate rotates dorsally.” When a VISI is present, the angle is usually less than 30° (Figure 36) and the lu- nate rotates volarly (lunate is depicted in yellow and the scaphoid in blue). In summary, intercalated segmental instability refers to the direction in which FIGURE 19. Transverse fracture. FIGURE 20. Spiral fracture. the lunate is displaced. If the lunate is dorsally dis- placed, then DISI exists, and if the lunate volarly dis- places, a VISI exists. Two well-described carpal dislocations are the lunate and peri-lunate dislocations, differentiated by which bone remains centered over the radius." When the capitate is centered over the radius and the lunate is tilted out, this is known as a lunate dis- location (Figure 37). Whereas, when the lunate re- mains centered over the distal radius and the capitate is displaced dorsally, the correct terminology is a peri-lunate dislocation (Figure 38). OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS Radiography is a helpful examination to detect arthritic conditions. Osteoarthritis (OA) is suspected when narrowing of the joint space and sclerotic changes are noted on an x-ray, particularly on the radial side of the hand and wrist.'” Another sign of FIGURE 21. Dorsal displacement. FIGURE 22. Volar displacement. OA is an osteophyte, or spur, which is a bony growth that can limit range of motion (ROM) or cause pain (Figure 39). x-rays may not be of great value in the early stages of OA as they will not show initial degen eration in the cartilage, which is where early changes occur and x-rays can correlate poorly with symp: toms. Figure 40 demonstrates radiographic findings following an elective procedure know as ligament re- tendon interposition arthroplasty which is performed in cases of severe thumb carpo- metacarpal joint OA. The trapezium has been resected and the flexor carpi radialis tendon is used to reconstruct the construction Dee sole FIGURE 23. Voter apex of angulation. April-June 2007 159 FIGURE 27. Normal palmer tilt. FIGURE 24, Bone shortenin, palmar oblique ligament as well as maintain the ce for the excised carpal bone. Figure 41 demon- strates the findings prior to surgery Rheumatoid arthritis also has significant findings on x-rays and typically affects the wrist, thumb and finger joints. It can cause severe deformities, contrac: tures, and joint subluxation.'? A typical x-ray of this diagnosis shows ulnar deviation of all the digits at the metacarpal—phalangeal joints. The joint spaces FIGURE 25. Digit fracture, Neutral Variance MIRED a Decreae carn i cig) ationandneutral FIGURE 28. Decreased radial height and ulnocarpal FIGURE 26. Normal radial height, inclination and» URE variance. 160 JOURNAL OF HAND THERAPY FIGURE 29. Positive ulnar variance are also narrowed and often subluxation is evident The thumb metacarpophalangeal (MP) joint may also display ulnar subluxation, or at times complete subluxation and loss of joint conformity, Other changes noted on x-rays include cartilage loss and joint effusions. Figure 42 demonstrates a case of theumatoid arthritis in which the joints show signif- icant destruction, warranting surgical reconstruction Figure 43 depicts the joints after surgery, including reconstruction with Swanson joint implants and FIGURE 30. fegative ulnar variance FIGURE 31. Typical PA view after wrist fractur grommets (Wright Medical) and fusion of the first car pometacarpal (CMC) joint FINGER CASE REVIEWS The discussion of the interpretation of the patient's x-rays with the radiologist or other physician is only April—June 2007 161 FIGURE 33. Collinear aligny part of the overall consideration by the therapist in treatment planning. Historical information must also be considered. Figure 44 shows a_ translucency around the digit, but on lose examination of the AP view (Figure 44) the distal phalanx appears ab = a normal. Figure 45 shows the lateral view in which FIGURE 35. DISI (scapho-lunate angle is greater degrees). an intra-articular mallet deformity is clearly exposed, The treatment of this injury is seen in Figure 46, with FIGURE 34. Normal scapho-lunate angle (A) parallel line FIGURE 36. VISI (scapho-lunate angle less than 30 to the scaphoid (B) perpendicular line through the lunate. degrees). 162 JOURNAL OF HAND THERAPY FIGURE 37. Lunate dislocation. a k-wire pin applied to stabilize the fracture frag ments. Figure 47 shows a pinning that missed! Figure 48 displays luminousness around the distal phalanx indicative of a cyst, called an epidermoid oc- clusion cyst. An epidermoid occlusion cyst occurs as 4 result of implantation of epidermal elements in the dermis" These cysts grow slowly and usually do not cause symptoms, but they may become inflamed or secondarily infected, resulting in pain and tender. ness. This epidermoid occlusion cyst was treated with a distal radius bone graft (Figure 49). Injuries involving the Proximal Interphalangeal Joint (PIPJ) can be fracture dislocations can lead to significant stiffness and impaired function. Figure 50 demonstrates a PIP} that is virtually nonexistent. The treatment op- tions for PIP] injuries include extension-block splint: ing, percutaneous pinning, traction, external fixation, open reduction and internal fixation, and volar-plate arthroplasty." This case was treated using dynamic very serious. Dislocations and FIGURE 38, Peri-lunate dislocation. traction (Figure 51) to facilitate ligamentotaxis and al low for early range of motion. This patient did excep: tionally well with the treatment approach as evidenced by Figures 52 and 53. Figures 54 and 55 show another method of re constructing a PIP) using an Avanta implant arthroplasty FOREIGN BODIES Figure 56 demonstrates that glass is a radiopaque and does appear on x-rays.” Other foreign bodies FIGURE 39, Osteophyte (spur) April—June 2007 163 FIGURE 40, Status pos interposition ligament reconstruction tendon that w When looking for foreign bodies, a metallic marker uuld be visible on x-rays are metallic objects. nd to is often placed next to the injury site on the ha pinpoint the specific point of entry.* METACARPAL CASES Most metacarpal fractures occur in the active and working population; adolescents and yc Metacarpal fractures account for 30—40% of all hand fractures.’ Metacarpal fractures can occur in the shaft, or base. These injuries are amenable adults, head, neck, FIGURE 41. Carpometacarpal joint osteo-arthritis, 164 JOURNAL OF HAND THERAPY FIGURE 42. Rheumatoid arthritis. to either immobilization, closed or open reduction, which may or may not require fixation." Figure 57 displays a metacarpal shaft fracture and Figure 58 shows stabilization using plate and screws. The benefit of this type of fixation is the patient can very often begin very early range of motion. FIGURE 43. Swanson Joint Implants and grommets (Wright Medical), FIGURE 44. AP view with abnormal appearance of distal phalanx Figure 59 depicts another mid-shaft fracture that has been stabilized in a cast enough stability to hold this fracture in place. Casts are sometimes removed and treatment converted to nning or plate and screws. Figure 60 depicts a suspicious view, indicating the need for additional views. The PA view (Figure 61) and the oblique view (Figure 62) reveal a spiral ob- lique fracture of the index and middle fingers at the metacarpal level. Surgery was performed with plate and screw fixation (Figure 63). The cast may not give FIGURE 45, Lateral view depicting intra-articular mallet deformity. FIGURE 46. K-Wire pinn A crush injury can also result in multiple metacar- pal fractures. Here, the patient's se were treated with multiple k-wires (Figure 64A and B), This patient broke the pins, and an additional pro. cedure involving plate and screws was performed to add stability (Figure 65). Eventually, the patient also broke these (Figure 66). Surprisingly, the patient demonstrates functional grasp and is very pleased with the outcome, despite lack of radiographic aligr ment (Figure 67A and B) e crush injuries CARPAL BONE CASES A patient reporting severe palmar pain may have a hamate fracture, which can be seen in a carpal tunnel FIGURE 47, Missed pinning April—June 2007 165 FIGURE 48. Fpid sic x-ray view (F re 68).° The supinated oblique view also depicts this fracture (Figure 69). The x-ray exhibited in Fi ire 70 shows som normal features in the lunate. The patient reported pain in his wrist. The diag: nosis turned out to be an intraosseous cyst in the lunate and was treated with a distal radial bone graft (Figure 71). A disease associa Kienbock’s dis (Figure 72), d with the lunate is known as vascular necrosis of the lunate Patients with this diagnosis present FIGURE 49. Cyst treated with a distal radius bone graft. 166 JOURNAL OF HAND THERAPY FIGURE 50. Significantly damaged proxim sal joint. nterpha: pha th wrist pain, swelling, decreased motion, and de creased grip strength. They also demonstrate sclero- sis of the lunate on x-ray.“* Often they present with gative ulnar variance (Figure 72). Progression of this disease leads to bone death over time. This pa- tient was treated with a radial (Figure 73), which is one of many surgical interven- tion options, This surgical intervention significantly improves the ulnar negative variance, as evidenced in Figure 73. osteotomy An interesting, presentation of carpal bones ap- pears in Figure 74. The lunate and triquetrum are used into one bone. This is known as a lunotriquetral (LT) coalition.» A carpal coalition is a common ab- normality that can occur either as an isolated phe- nomenon or as part of a generalized malformation FIGURE 1. Dynamic traction splint SURE 52. Ra nge after traction, application. FIGURE 56. Glass fragment FIGURE 53. Radiograph after traction splinting FIGURE 54. Injured proximal interphalangeal joint. FIGURE 57. Metacarpal shaft fracture Scaphoid fractures are the most common carpal fractures. Fractures of the scaphoid occur in people of all ages, including children.” The injury often hap- pens during sports activities or as a result of a motor FIGURE 55, Avanta implant arthroplasty vehicle accident. Figure 75 displays a small chip in a teenager's scaphoid that responded well to cast im- mobilization. The next scaphoid fracture (Figure 76) was treated with a compression screw with a radial ). Figure 78 depicts an acute syndrome. Isolated fusions occur in the same carpal row, while fusions between carpal rows are generally part of a syndrome. The most common coalition is the LT coalition and it is usually asymptomatic LT coalitions are particularly common among West Africans.” bone graft (Figure 7 scaphoid fracture. A screw (Figure 79) was inserted for fixation but unfortunately started to back out and leave the fracture unsupported. If nonunion of April-June 2007 167 FIGURE 58. St vith plate and ser scaphoid fracture occurs, a salvage procedure for the unstable wrist is frequently necessary. ~ One ex ample of a salvage procedure is the four-corner fu sion (Figure 80) This next case is highlighted as a clinical lesson. This x-ray (Figure 81) was not seen by the therapist when the patient was sent for “wrist pain’ with or ders stating “stren thening to involved wrist.” The patient did not progress with her strengthening pro- gram and actually reported increased pain with all activities. The patient followed up with the physician 168 JOURNAL OF HAND THERAPY FIGURE 60, Suspicious view a few weeks later, complaining of increased pain. The seneral physician then referred the patient to a hand surgeon and new films were taken (Figure 82). The hand surgeon shared the x-rays with the therapist, showing how a static SL dissociation had progressed FIGURE 61. PA view FIGURE 62. Oblique view reveals spi FIGURE 63. Plate and screw fixation. al fracture. FIGURE 64. (A and B) Crash injury treated with multiple K-wires significantly (as evidence by the follow-up x-ray; Figure 82) and they discussed how a strength pro: gram assisted in the deterioration and collapse Ultimately, a salvage surgical intervention was planned to treat this case. The salvage procedure can include a four-corner fusion (Figure 80), a proxi mal row carpectomy (Figure 83) or complete wrist fu- sion in some cases (Figure 84).”” A situation such as this can be avoided by obtaining films before treating, the patient. DISTAL RADIUS/FOREARM Figure 85 reveals a distal radius fracture. This frac- ture has been reconstructed with volar plating April—june 2007 169 FIGURE 65. FIGURE 66. Los: screws, fixation with broken plate and FIGURE 67, (A and B) Less than perfect radiographic outcome FIGURE 68. Carpal tunnel view depicting hamate FIGURE 69. Supinated oblique view indicating hamate fracture. fracture 170 JOURNAL OF HAND THERAPY FIGURE 70. Intraosseous cyst in the lunate, (Figure 86). The film in Figure 87 is a patient's wrist status postplating of distal radius fracture. The pa tient reported significant ulnar pain and from the knowledge obtained by read see why! Note the significant ulnar plus variance. Correction included an ulnar shortening and hard ware removal (Figure 88). Note the holes in the ng this article one can Uinar Neg FIGURE 72. Avasc ative variance. lar necrosis of innate with ulnar neg bone left after hardware removal and significant im- provement of ulnar plus variance. This next case (Figure 89) is a both bone forearm fracture where the physician opted to stabilize only the fracture of the radius (Figure 90). This patient attempted rotating the forearm, but experienced extreme pain on the ulnar side of the wrist. After x-rays were obtained, it was clearly seen that with motion of the forearm the nonstabilized fracture rotation and other wrist motions. was mobile durin; FIGURE 71. Intraosseous cyst treated, with radial bone graft. FIGURE 73. Radial osteote April—June 2007 171 FIGURE 74, Lunotriquetral coalition FIGURE 77. Treatment with compression screw and ra- dial bone graft. FIGURE 76. Scaphoid fracture in an adult. FIGURE 78. Acute scaphoid fracture. 172 JOURNAL OF HAND THERAPY FIGURE 81. Seay unate diathesis Surgery on the nonstabilized fracture was performed to eliminate the problem. In the next case the patient presented in the office with a report of a fall on the outstretched hand and a Colles fracture was detected. The patient reported no previous injuries to the hand /arm. However, the x FIGURE 79. Screw backing out of scaphoid fracture rays (Figures 91 and 92) showed evidence of malun: ion from an old fracture FIGURE 82. Advanced deterioration and collapse FIGURE 80. Four corner fusion. Aprit—june 2007 173 FIGURE 83. Proximal row car ure 93 has a distal radius fracture stabilized with plate and screws. Yet the lateral view FIGURE 85. Distal radius fracture (Figure 94) clearly reveals that the plate ¢ quately support the fracture and in fact was broken Not enough points of fixation were used to provide The patient in F FIGURE 84. Complete wrist fusion. FIGURE 86. Volar plating 174 JOURNAL OF HAND THERAPY FIGURE 87. Positive ulnar variance FIGURE 88. Ulnar shortening and hardcoare removal. FIGURE 89. Fractures of bot ulna and radius. FIGURE 90, Fixation of radius. stability. It is recommended to have three points of fixation on either side of the fracture to provide sta bility.!” Figure 95 shows the revision that was per formed which is now providing sufficient support The patient in Figure 96 complained of severe wrist pain after his radial head fracture. His films dis- played an Essex—Lopresti lesion. This refers to a dis- ruption of the distal radio-ulnar joint associated with a displaced radial head fracture and proximal migra: tion of the radius (Figure 97).° Essex—Lopresti in- juries sometimes require the use of a temporary radial head implant. Late surgical options include ul nar shortening osteotomy or the technique of liga- ment reconstruction with a tendon graft April-June 2007 175 FIGURE 93. Fixation, with each x-ray. The terminology described will help the therapist understand and contribute to discussions rding patient care with physicians, case man- agers, and the patients themselves. This article is FIGURE 91. Malunion of previous fi SUMMARY Understand to examine the knowledge of the specific anatomy highlighted in he basic positions and views used rist and hand will lead to increased indicates inadequate fixation. FIGURE 92. Malunion of previous fractur FIGURE 94. Lateral vie 176 JOURNAL OF HAND THERAPY FIGURE 95. Revision of fixation intended to serve as an introduction to the study and, examination of x-rays. Through descriptive cases and, selected diagnoses the therapist will acquire a deeper understanding of the mechanics of what lies beneath the skin. This material was written to enrich ones, knowledge of radiographic anatomy and bony pa thology. Understanding the bony basics will serve as, a foundation for further study. FIGURE 96, Displaced radial head fracture FIGURE 97. Essex-Lopresti injury (pro: of radius results in ulnar plus variance) migration Acknowledgments The authors thank the following doctors for x-ray film contributions: Dr. Charles Eaton (Jupiter, FL), Dr. James Roderique (Atlanta, GA), Dr. Dale Bramlet (St. Petersburg, FL) and Dr. Jorge Rodriquez (St. Petersburg, FL) and the Hand Surgery and Rehabilitation Center of New Jersey. REFERENCES 1. Yin Y, Mann FA, Gilula LA. Positions and techniques. In: Gilula LA, Yuming Y (eds). Imaging of the Wrist and Hand. Philadel phia, PA: WB Saunders CO, 1996, pp 93-158. 2. Gilbert T). Imaging. the wrist and hand. Ra diol Clin North Am, 1997 May;35:701-2 3. Tubiana R, Thomine JM, Mackin E. Examination of the Hand Wrist, London: Martin Dunitz, LTD, 1998. 225~260. tion of wrist and 4. Harvey Cj, Allen SD, O'Regan D. Interpret hand radiographs. Br J Hosp Med (Lond). 2006;67:M48-52. 5. Goldfarb CA, Yin Y, Gilula LA, Fisher AJ, Boyer MI, etal. Wrist fractures: what the clinician wants to know. Radiology. 2001; 219:11-28 6. Bowers W. The distal radioulnar joint. In: Green DP (ed). Oper ative Hand Surgery. 3rd ed. New York: Churchill Livingstone 1993, pp 971-1020 7. Lewis CM, Yang Z, Gilula LA. Validation of the extensor carpi ub nari groove asa predictor forthe recognition of standard postero- anterior radiographs of the wrist. Hand Surg, 2002:27A:252-7 Radiographic examination of the hand and wrist 8. Stein Emerg Med Clin North Am. 1985;3:221-35, 9. Lawand A, Foulkes GD. The clenched pencil view: a modified clenched fist scapholunate stress view. J Hand Surg. 2003;28A: 4148. 10. Meyer S. Radiographic evaluation of wrist trauma, Semin Roentgenol. 1991,26:300-17, Krop PN. Fractures: general principles of surgical manage ‘ment. In: Macken EJ, Callahan AD, Skirven TM, et al (eds). Re habilitation of the Hand and Upper Extremity. 5th ed. St. Louis: Mosby, 2002, pp 371-80. 12. Boles CA, Daniel WW, Adams BD, Rubin MD. Hand and wrist Radiol Clin North Am, 1995;33(2)319-54 April—June 2007 177 13, Falconer DP, Donahue PJ, Barton ML, Maconald C], Sonkow sky SR. Occupational hand fractures and dislocations. In: Kas- dan ML (ed). Occupational Hand and Upper. Extremity Injuries and Diseases, Occupational Hand and Upper Extrem ity Injuries and Diseases. Philadelphia, PA: Hanley and Belfus, Inc, 1991, pp 1812-13, 14. Meunier MJ, Hentzen E, Ryan M, Shin AY, Lieber RL. Predicted effects of metacarpal shortening on interosseous muscle func tion. J Hand Surg. 2004,29:689-93, 15. Ali A, Hamman J, Mass DP. The biot fof angulated boxer’s fractures. JH: 835-84 16. Purdy BA, Wilson RL. Management of non-articular fractures of the hand. Inv Macken EJ, Callahan AD, Skirven TM, et al Rehabilitation of the Hand and Upper Extremity, 5th Louis: Mosby, 2002, pp 382-95. 17. Freeland AR, Jabaley ME, Hughes JL. Stable Fixation of the Hand and Wrist. New York: Springer-Verlag, 1986. 18, Taras JS, Schweitzer ME, Diagnostic imaging of the upper ex In: Macken EJ, Callahan AD, Skirven TM, et al (eds). thanical_ effects Surg, 1999;24 2002, pp 143-60. sen CF. Wrist and hand measurements and clas sification schemes. In: Gilula LA, Yuming Y (eds). Imaging of the Wrist and Hand. Philadelphia, PA: WB Saunders CO, 1996, pp 225-59, 19. 178 JOURNAL OF HAND THERAPY 20. Yin Y, Mann FA, Hodge JC, Gilula LA. Roentgenographic inter- pretation of ligamentous instabilities of the wrist. In: Gilula TA, Yuming Y (eds). Imaging of the Wrist and Hand. Philadel phia, PA: WB Saunders CO, 1996, pp 203-24 Freyschmidt], VenzkeS. Normal variants. In: Gilula LA, Yum- ing Y (eds), Imaging of the Wrist and Hand, Philadelphia, PA: WB Saunders CO, 1996, pp 261-91. Irwin JP, Joule WW, Peterson GH, Liebman CE, Aaron JO, How the radiologist can help to evaluate injuries and diseases ‘of the upper extremity. In: Kasdan ML (ed). Occupational Hand and Upper Extremity Injuries and Diseases. Philadel- phia, PA: Hanley and Belfus, Inc, 1991, pp 89-114 Wagner JP, Chung KC. A historical report on Robert Kienbock (1871-1953) and Kienbock’s disease. J Hand Surg. 2005;30A; 117-21 ‘Thomas AA, Rogriguez E, Segalman K. Kienbock’s disease in ‘an elderly patient treated with proximal row carpectomy, J Hand Surg, 2004;29A:685-8, gh P, Tuli A, Choudhry R, Mangal A. Intercarpal fusion—a, review. | Anat Soc India. 2003;52:183-8 Marco JPE, Maas M, Bos KE. Minnaar type 1 symptomatic Iu- notriquetral coalition: a report of nine patients. J Hand Surg, 2001;26A:261-70. Green DP. Carpal dislocations and instabilities. In: Green DP (ed), Operative Hand Surgery. 3rd ed. New York: Churchill Livingstone, 1993, pp 861-928 JHT Read for Credit Quiz: Article #057 Record your answers on the Return Answer Form found on the tear-out coupon at the back of this sue. There is only one best answer for each question. #1, The terms anterioposterior (AP) and posterioan- terior (PA) refer to a. the position of the hand on the X-ray plate/ table a b. the direction the X-ray beam enters the hand and exits the hand c. X-rays of the wrist only d. X-rays of the elbow only #2. Osteoarthritis often has the following X-ray findings a. bony sclerosis b. narrowing of the joint space . spurs or osteophytes d. all of the above #3. Angulation of a displaced bony part (eg. in fracture or dislocation) is typically described in terms of a. the larger part relative to the smaller part b, the smaller part relative to the larger part . the position of the distal fragment relative to the proximal part d. the position of the proximal fragment relative to the distal part #4, Mal rotation of a digit secondary to a metacarpal or phalangeal fracture is generally more easily detected by a. X-ray than physical examination b. physical examination than ) c. MRI than X-ray d. US than MRI #5, A lateral view of the wrist is especially helpful in evaluating, a. carpal instabilities b. scaphoid fractures c. degenerative changes associated with SLAC wrist d. lunate integrity in Kienbochs disease When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit April—June 2007 179

You might also like