1. Wrist and Hand

2. Wrist X-ray Basic views: PA & lateral Carpal bones mnemonic
Some Lovers Try Positions That They Can’t Handle
Trapezium = Thumb
Scaphoid fracture: delayed imaging
Carpal tunnel view

4. Some Lovers Try Positions That They Can’t Handle

6. Wrist X-ray

7. Normal Wrist

8. Normal Wrist
Ulnar Deviation

9. Demonstration Wrist X-rays 4 views PA PA Oblique Lateral
PA with Ulnar Deviation

10. Case 1 21 y.o. female DDx? What would be the most common injury?
snowboarding & lost her balance
falling backwards she reached out her right hand to catch herself
acute onset of wrist pain
DDx? What would be the most common injury?

11. Scaphoid Fracture M/C carpal bone fracture M/C mechanism: FOOSH
Pain on radial wrist & TTP in snuff box (ulnar deviation)
X-ray: PA, lateral, scaphoid view (ulnar dev)
Management pearls
clinical suspicion, neg x-rays
thumb spica splint/cast
re-image in days

12. Scaphoid Fracture

13. Scaphoid Fracture

14. Scaphoid Fracture
Scaphoid view

15. Case 2 & 3 48 y.o. LH new golfer 29 y.o. LH golfer
hard swing & unknowingly hits a tree root
pain on ulnar aspect of R palm
29 y.o. LH golfer
pain on ulnar aspect of R palm for
a few months

16. Hook of the Hamate Fx
Usually seen in individuals who participate in sports involving a racquet, bat, or club
Rare but relative common fx in “swingers”
Acute or overuse type injury
Imaging
carpal tunnel view but notoriously missed on x-ray
CT scan
Swingers vs Throwers

17. Hook of the Hamate Fx

18. Hook of the Hamate Imaging

19. Hook of the Hamate Imaging

20. Colle’s Fracture Mechanism: FOOSH Victims
young w/ high energy trauma
older w/ osteoporotic bones & low energy trauma
Fracture of distal radius w/ dorsal
angulation of the distal
fracture fragments

21. Colle’s Fracture
Due to the dorsal angulation of the distal fragment, Colle’s fractures are often said to have a "dinner fork" appearance

22. Dinner Fork Deformity

23. Colle’s Fracture X-rays
Dorsal angulation of distal segment

24. Colle’s Fracture Management Complications
nondisplaced, minimal angulation: sugar-tong splint
displaced: refer for reduction
Complications
median nerve injury, compartment syndrome & vascular compromise
Be aware of associated injuries (ulnar styloid, scaphoid, etc)

27. Normal Hand

28. Normal Hand

29. Normal Oblique Hand

30. Demonstration
Hand 3 Projections PA
PA Oblique
Lateral

31. Metacarpal (Boxer’s) Fracture
Most common of all metacarpal fractures
Associated with martial arts/boxing
MXN:
direct axial force caused by punching another person or object
Direct impact to hand

32. Boxer’s fracture

33. Boxer’s fracture

34. Metacarpal fractures

35. Mallet Finger
MXN:
Blow to tip of finger, jamming it and avulsing the extensor tendon from its insertion at the distal phalanx
Can cause an avulsion fraction as well

36. Mallet finger

37. Mallet finger

38. Mallet finger

39. Mallet finger-stack splint

40. Stack splint

41. Jersey Finger MXN: Forced extension/hyperextension of DIP joint
Grabbing on to a jersey
Rupture of flexor digitorum profundus tendon and or avulsion fracture

42. Jersey finger

43. Boutonniere Deformity
MXN:
DIP joint forced into extension and PIP joint forced into flexion
Rupture of extensor tendon mechanism at the PIP joint

44. Boutonniere deformity

45. Boutonniere deformity

46. Boutonniere deformity

47. Gamekeeper’s Thumb MXN:
Forced abduction and hyperextension of the proximal phalange of thumb
Falling on the thumb
Sprains UCL of 1st MP joint

48. Gamekeepers thumb

49. Gamekeepers thumb

50. Interphalangeal Dislocation
Can affect PIP or DIP joint
Axial force to the tip of the finger
Blow to tip of finger
Falling directly on extended finger
May rupture tendon, avulse bone, pinch volar plate

51. Dislocation

52. Dislocation

53. Dislocation

54. Dislocation

55. Dislocation

56. PIP dislocation

57. TX:
Physician referral for reduction & x-ray
Splint (about 3 weeks)
Ice

58. Finger fracture MXN: Stepped on (direct force)
Hit on the tip of finger
Twisting/torsion

59. Fracture

60. Fracture

61. Finger Sprain
MXN:
Axial force to the tip of the finger, “jamming” it

62. sprain

63. Sprain

64. Subungual Hematoma MXN: direct blow to the fingernail
S/S: throbbing pain due to accumulation of blood under the nail
TX: ice (water) to numb, release pressure under nail by drilling/burning a hole it the nail

65. Ring injury MXN: getting ring/jewelry caught on something
S/S: deformity, bleeding, pain, loss of body part
Tx: find body part, control bleeding, cover open wound, treat for shock, send to ER

66. Ring injury

67. Arthritis of the Hand Normal Osteoarthitis Rheumatoid arthritis
CPPD crystal deposition
Gout
Psoriatic arthritis

68. Normal Hand X-ray

69. Osteoarthritis (DJD) Gradual degeneration of articular cartilage
Joint pain relieved with rest
Morning stiffness resolves within 30 minutes
Traditionally affects DIPs, 1st IP
No systemic symptoms
Painless nodules
Heberden’s at DIPs
Bouchard’s at PIPs

70. OA – Radiographic findings
Joint space narrowing
Osteophyte formation (white arrow)
Subchondral sclerosis (black arrows)

71. Joint space narrowing distally
Marginal osteophytes
Relatively unchanged proximal structures

72. Another example of OA Oblique and AP views
1st carpal metacarpal shows decreased joint space and subchondral sclerosis
2nd and 3rd DIP shows osteophytes and subchondral sclerosis (Heberden’s nodes)

73. Rheumatoid Arthritis Systemic inflammatory disease
Affects synovial membranes
Pannus (granulation tissue) develop in joint spaces and erode into the articular cartilage and bone
Prolonged morning stiffness (>1 hr)
PIPs, MCPs, and wrist commonly involved
Symmetric joint involvement

74. RA radiography - early
Earliest signs include soft tissue swelling due to effusion, tenosynovitis, and edema
Periarticular osteopenia
Marginal erosions often first seen at 2nd and 3rd MCPs and 3rd PIP articulations

75. Severe erosive changes at radio-ulnar joints carpal bones at the metacarpal heads
Bilaterally symmetric

76. Advanced RA Boutonniere (top) Swan neck Labs:
+RF in 80%: IgM against Fc of IgG
Elevated ESR
Anemia of chronic disease

77. RA - Late Complete MCP involvement
Large marginal erosions have nearly destroyed the joints
Bones are lucent due to osteopenia
Ulnar deviation

78. RA Bone Scan Technetium-99 bone scan
Uptake shown in subclinical inflammation of joints
Symmetrical
Polyarticular

79. Calcium pyrophosphate dihydrate crystals (CPPD)
“Pseudogout”
Associated with metabolic diseases such as hyperparathroidism, hemochromatosis, hypothyroidism
Compared to gout:
Large joints affected (2nd to 5th MCPs, radio-carpal)
Rhomboid crystals
Positive birefringence
Calcification of articular cartilage
No cortical erosions

80. CPPD Chondrocalcinosis Distal radius and MCPs (2nd and 3rd)
Cartilage destruction similar to OA – differentiate by location
Location similar to RA – differentiate by absense of erosions
Calcium deposition at triangular fibrocartilage of the wrist (picture)

81. CPPD
Diffuse condrocalcinosis at the radiocarpal joint, the MCP joints and the PIP
Joint space narrowing, sclerosis, and subchondral cysts within the carpals

82. Brief summary so far

83. Gout
Disorder of purine metabolism – overproduction versus underexcreation
Deposition of urate crystals in joint spaces
Middle-aged men
Acute onset of extreme pain in small joints with redness and swelling
Needle shaped crystals with negative bifringence
Asymmetric, monoarticular

84. Gout

85. Gout Radiography
All joints of hand and wrist possible (2nd-5th PIP most common)
Soft tissue swelling
Well demarcated osseous erosions with sclerotic rims and overhanging edges
No decrease in bone density
Tophi not calcified
Relative sparing of joint space until late in the disease
Long latent period between onset of symptoms and radiographic changes

86. More gout

87. Psoriatic Arthritis HLA-B27 positive, RF negative Inflammatory
Seronegative spondyloarthropathy
Asymmetric and bilateral
Primarily distal involvement associated with nail changes
No periarticular osteoporosis
Five different patterns
Usually accompanies skin disease

88. Psoriatic Arthritis – Rad findings
Asymmetric proliferative erosions with ill-defined margins
Periosteal reaction
Soft tissue swelling
“Pencil-in-cup” deformity
Resorption of distal phalangeal tufts
Subluxation

89. Psoriatic arthritis