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

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Presentation on theme: "Igo Goldberg M.D, Hand Surgeon Tel-Aviv, Israel Radiographic Examination of the Wrist."— Presentation transcript:

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

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

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

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

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. Conventional PA PA with forearm pronation and firm grip PA AP

7 NO !

8 What are we looking for on PA views? radial inclination Normal = Mean=22 radial length Normal = 9 mm carpal height = L1/L2 normal = / carpal translation = L3/L2 normal = 0.3 +/ Gilula’s arcs L2 L1 L3 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 ככל שהיחס קטן – התמט של שורש היד גדל 3. CARPAL HEIGHT & CARPAL TRANSLATION RATIO carpal height ratio = L2/L1 normal = / carpal translation ratio = L3/L1 normal = 0.3 +/ L1 L2 L3 L1 L1’ L1’’

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

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 techniqueConcentric circle method Method of perpendiculars

15 5. IMPACTION SYNDROMES U.S.P.I =C-B/A=0.21+/-0.07 Ulnar impaction syndrome Ulnar impingement syndromeUlnocarpal impaction syndrome 2ndary to ulnar styloid nonunion Hamatolunate impaction syndrome Ulnar styloid 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 volar-most edge of the pisiformis is within the boundaries of the scaphoid and volar-most edge of the capitate the ulna should be within 3 mm of the radial cortex

18 SPC relationship in LAT projection True Lat

19 What are we looking for on LAT views? 1.PALMAR TILT 2.CARPAL INSTABILITY ANGLES 3.INTRASCAPHOID ANGLES 4.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 Intercarpal angles of carpal instability Radiolunate angle= (either volar or dorsal lunate angulation) Capitolunate angle= Radioscaphoid= Scapholunate angle= Collinear alignment of the radius, lunate and capitate: Lines are perpendicular to radiolunate and lunocapitate articulations

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

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

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

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

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

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

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

29 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 quadrangular Distal (“low position”) Proximal (“high position ”) LUNATE TRIQUETRUM PA ULNAR-DEVIATION Proximal raw palmarflexes Proximal raw dorsiflexes SCAPHOID triangular foreshortenedelongated PA RADIAL- DEVIATION

34 VISI DISI

35 LAT NEUTRAL

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

37 מרכזי צמיחה

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

41 CESAREA MARITTIMA Thank you !

42 ARTHROGRAPHY VS. ARTHROSCOPY 1.Roth & Haddad (1986) 2.Koman et al (1990) 3.Kelly & Stanley (1990) 4.Levinshon et al ( Adolfson (1992) 6.Vanden et al (1994) 7.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 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 1.Golimbu (1989) 2.Zlatkin (1989) 3.Metz et al (1996) 4.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


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