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

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

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

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).

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

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

NO !

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

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

2.GILULA’S ARCS

3. CARPAL HEIGHT & CARPAL TRANSLATION RATIO carpal height ratio = L2/L1 normal = 0.54 +/- 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’’

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

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

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

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

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

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

SPC relationship in LAT projection True Lat

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

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

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 = 0 - 10 (either volar or dorsal lunate angulation) Capitolunate angle = 0 - 15 Radioscaphoid = 120 -150 Scapholunate angle = 30 - 60

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

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

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

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

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

> 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

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

“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

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

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

PA NEUTRAL

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”)

VISI DISI

LAT NEUTRAL

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

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

הערכה רנטגנית של שורש היד וכף היד A1= “radial angulation” 120-125 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

הערכה רנטגנית של שורש היד וכף היד: Rheumatoid arthritis

הערכה רנטגנית של שורש היד וכף היד: Rheumatoid arthritis

Thank you ! CESAREA MARITTIMA

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

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