1. Radiographic Examination of the Wrist Igo Goldberg M.D, Hand Surgeon
Tel-Aviv, Israel

2. IMAGING INVESTIGATIONS
Routine (screening) radiographic examination
Specialized radiographic projections
Scintigraphic examination
Arthrography CT
MRI
Diagnostic arthroscopy (ARS)

3. Which radiographic views should be obtained in the evaluation of every patient with wrist injury?
“Routine Wrist Radiography”
PA OBLIQUE LAT SUPINATED OBLIQUE

4. הקרן המרכזית של הרנטגן מאונכת לקסטה ומרוכזת על ראש עצם הקפיטטום
How should the standard (PA) radiogram for the examination of the wrist be obtained?
“90-90 position”
כתף באבדוקציה ל-90 מע', מרפק בכיפוף ל-90 מע', כף היד (ולא שורש היד) שטוחה על הקסטה (ללא כיפוף,יישור או הטיות לצדדים).
הקרן המרכזית של הרנטגן מאונכת לקסטה ומרוכזת על ראש עצם הקפיטטום
(קסטה גדולה מספיק בכדי להדגים את מלוא אורכן של עצמות המסרק).

5. קריטריונים לצילום נכון:1
(יש להדגים את כל אורך המטקרפוס השלישי).
המיקום של הסטילואיד האולנרי מראה האם הצילום נעשה בתנוחת PA או AP .
הופעת התעלה של ECU רדיאלית לסטילואיד אולנרי מראה שהמרפק היה בגובה הכתף בזמן הצילום, כפי שאכן צריך להיות.
ציר האורך של עצם המסרק צריך להיות בקו ישר להמשך ציר האורך של הרדיוס, מה שמצביע שלא היו הטיות לצדדים בזמן הצילום.
קווי הפרקים הקרפומטקרפלים 2-5 צריכים להיות מקבילים שאם לא כן שורש היד היה בכיפוף או ביישור.
Scaphoid fat pad 4 5 6 2 3

6. Why is it important to obtain adequate PA view of the wrist?
Ulnar variance measurements should not be made on a PA view of the wrist that does not meet the above criteria because there is a difference in the ulnar length on different position of the forearm and elbow: pronation gives the impression of positive ulnar variance and supination gives the impression of negative ulnar variance; adduction of the elbow towards the patient’s side usually makes the ulna more positive.
PA with forearm pronation and firm grip AP PA
Conventional PA

7. NO !

8. What are we looking for on PA views?
radial inclination
Normal = 16-30
Mean=22
radial length
Normal = 9 mm
Gilula’s arcs
carpal height = L1/L2
normal = 0.54
+/- 0.03
carpal translation = L3/L2
normal = 0.3
+/- 0.03
Modified carpal height ratio= L3/L2 normal = 1.57 (+/- 0.05

9. 1.RADIAL LENGTH & INCLINATION
radial inclination
Normal =16-30
Mean=22 deg.
radial length
Normal = 9 mm

10. 2.GILULA’S ARCS

11. 3. CARPAL HEIGHT & CARPAL TRANSLATION RATIO
carpal height ratio = L2/L1
normal = /- 0.03 L3 L2
ככל שהיחס קטן –
התמט של שורש היד גדל
carpal translation ratio = L3/L1
normal = 0.3 +/- 0.03 L1
L1’
L1’’

12. CARPAL HEIGH RATIO - modified
ככל שהיחס קטן –
התמט של שורש היד גדל
modified carpal height ratio = L2/L3
Normal = 1.57 (+/- 0.05)

13. 4.ULNAR VARIANCE
The relationship between the distal articular surfaces of the radius and ulna as seen on a standardized PA view of the wrist

14. What are the three methods of measuring ulnar variance?
Project-a-line technique
Concentric circle method
Method of perpendiculars

15. 5. IMPACTION SYNDROMES Ulnar styloid impaction syndrome
U.S.P.I =C-B/A=0.21+/-0.07
Ulnar styloid impaction syndrome
Ulnar impaction syndrome
Ulnar impingement syndrome
Ulnocarpal impaction syndrome
2ndary to ulnar styloid nonunion
Hamatolunate impaction syndrome

16. How should the standard lateral view of the wrist be obtained?
Elbow flexed to 90 deg. and adducted against the trunk
No flexion or extension of the wrist
The pronator quadratus fat pad is seen and is straight.
Scaphopisocapitate (SPC) relationship

17. Adequacy of the projection: the scaphopisocapitate (SPC) relationship
the ulna should be
within 3 mm
of the radial cortex
The volar-most edge of the pisiformis is within the boundaries of the scaphoid and volar-most edge of the capitate

18. SPC relationship in LAT projection
True Lat

19. What are we looking for on LAT views?
PALMAR TILT
CARPAL INSTABILITY ANGLES
INTRASCAPHOID ANGLES
RELATIONSHIP BETWEEN THE SCAPHOID & LUNATE IN FLEXION & EXTENSION OF THE WRIST

20. 1.PALMAR TILT 90 deg. – the tilt is zero degrees.
Palmar tilt is identified by (+) sign
Dorsal tilt is identified by (-) sign
Normal = +11 deg

21. 2.CARPAL INSTABILITY ANGLES
Collinear alignment of the radius, lunate and capitate:
Lines are perpendicular to radiolunate and lunocapitate articulations
Intercarpal angles of carpal instability
Radiolunate angle = (either volar or dorsal lunate angulation)
Capitolunate angle =
Radioscaphoid =
Scapholunate angle =

22. Carpal instability angles: radiolunate angle
10 deg. either volar or dorsal lunate angulation
> +10 deg. susp.DISI
< -10 deg. Susp.VISI

23. Carpal instability angles: capitolunate angle
0-15 deg. L C
VISI
DISI

24. Carpal instability angles: radioscaphoid angle
120 – 150 deg. S S’
C pattern
V pattern
(S-L dissociation)

25. Carpal instability angles: scapholunate angle
DISI
Lunate dorsiflexed
Scaphoid palmarflexed
VISI
Lunate volarflexed
Scaphoid palmarflexed

26. Example of combination of PA and LAT views:……
Disrupted Gilula’s arc at L-T joint
volarflexed lunate and scaphoid
Lunotriquetral lig. disruption (VISI)

27. > 45 deg. Increased risk for OA changes
3.INTRASCAPHOID ANGLES
Posteroanterior intrascaphoid angle
Lateral
intrascaphoid angle
Normal angles < 35 deg.
> 45 deg Increased risk for OA changes

28. “Routine wrist radiography”
כף היד צ"ל
שטוחה על הקסטה
OBLIQUE SUPINE PA
LAT
OBLIQUE

29. “Routine wrist radiography” “Wrist motion view series”
Of which radiographic views consists the “wrist instability series” described by Gilula?
“Routine wrist radiography” PA
LAT
Oblique
Supinated Oblique
“Wrist motion view series”
Clenched-fist AP
(Clenched-fist PA with UD)
PA view in: neutral
radial deviation
ulnar deviation
LAT view in: neutral
dorsiflexion
volarflexion

30. CLENCHED- FIST AP
The intercarpal spaces of a normal wrist will not appear different than on a nonstressed AP projection

31. CLENCHED - FIST PA (a matter of personal preference)
The intercarpal spaces of a normal wrist will not appear different than on a nonstressed AP projection

32. PA NEUTRAL

33. PA RADIAL- DEVIATION PA ULNAR-DEVIATION Proximal raw Proximal raw
dorsiflexes
Proximal raw
palmarflexes
SCAPHOID
foreshortened
elongated
LUNATE
quadrangular
triangular
TRIQUETRUM
Proximal
(“high position”)
Distal
(“low position”)

34. VISI
DISI

35. LAT NEUTRAL

36. LAT in EXTENSION LAT in FLEXION
Scaphoid:
35 extension
Scaphoid:
75 flexion
Lunate:
50 flexion
Lunate:
further 30

37. מרכזי צמיחה 2 2 2 2 1 6 7 1 12 1 3 5 4 1 6

38. הערכה רנטגנית של שורש היד וכף היד
A1= “radial angulation”
deg.
A2= ulnar deviation of the fingers
Pathological >25 deg.
L2/L1= “carpal heigh”
0.54+/-0.03
L3/L1= “ulnar translocation”
0.30+/-0.03

39. הערכה רנטגנית של שורש היד וכף היד: Rheumatoid arthritis

40. הערכה רנטגנית של שורש היד וכף היד: Rheumatoid arthritis

41. Thank you !
CESAREA MARITTIMA

42. ARTHROGRAPHY VS. ARTHROSCOPY
Roth & Haddad (1986)
Koman et al (1990)
Kelly & Stanley (1990)
Levinshon et al (1991
Adolfson (1992)
Vanden et al (1994)
Weiss et al (1996)
Only 69% of SL tears and 86% of LT tears were seen on arthrography
A negative arthrogram does not exclude a wrist pathology because in 92% of those patients a lesion can be found on arthroscopy
An arthroscopy is indicated on clinical suspicion, even when the arthrogram is negative

43. MRI vs. ARTHROGRAPHY VS. ARTHROSCOPY
Golimbu (1989)
Zlatkin (1989)
Metz et al (1996)
Linkous & Gilula (1998)
MRI is the gold standard for the diagnosis of osteonecrosis (eg: Kioenbock’s disease)
MRI is shown to be both sensitive and specific in identifying pathology in the TFCC
MRI is more sensitive (86% for SL, 50% for TL) and more specific (100% for SL and TL) than arthrography
MRI may replace arthrography in evaluating the painful wrist as the technique is refined and becomes more cost-effective.
Arthroscopy defines better the nature of ligament (Geissler’s classification) and TFCC lesion (Palmer’s classification) and enables surgery accordingly