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

2. TRAPEZIUM TRAPEZOID CAPITATE HAMATE TRIQUETRUM PISIFORMIS LUNATE SCAPHOID הפיגום הגרמי

3. Radiocarpal joint: Radioscaphoid radiolunate Ulnocarpal joint Distal Radio Ulnar Joint )DRUJ( Micarpal joint Carpometac arpal joints

5. Force transmission across the wrist RS: 50-56% LOAD RL: 29-35% Ul: 10-21%

6. מה הפתולוגיה שניתן להדגים בעזרת צילומי רנטגן? שברים פריקות פגיעה ברצועות מחלות דלקתיות מחלות מולדות

7. Imaging investigations Routine (screening) radiographic examination Specialized radiographic projections Scintigraphic examination Arthrography CT MRI Diagnostic arthroscopy (ARS)

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

9. 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).

10. 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 1 2 3 4 5 6

11. 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

12. NO !

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

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

15. 2.GILULA’S ARCS

16. ככל שהיחס קטן – התמט של שורש היד גדל 3. CARPAL HEIGHT & CARPAL TRANSLATION RATIO carpal height ratio = L2/L1 normal = 0.54 +/- 0.03 carpal translation ratio = L3/L1 normal = 0.3 +/- 0.03 L1 L2 L3 L1 L1’ L1’’

17. 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

18. 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

19. What are the three methods of measuring ulnar variance? Project-a-line techniqueConcentric circle method Method of perpendiculars

20. 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

21. 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

22. 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

23. SPC relationship in LAT projection True Lat

24. 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

25. 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

26. 2.CARPAL INSTABILITY ANGLES 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 Collinear alignment of the radius, lunate and capitate: Lines are perpendicular to radiolunate and lunocapitate articulations

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

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

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

30. Rotatory instability of scaphoid

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

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

33. LUNATE DISLOCATION סימן "ספל תה ההפוך"

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

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

36. 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

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

38. 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

39. PA NEUTRAL

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

41. VISI DISI

42. MONEIM’S VIEW למרווח S-L תקין פתולוגי 1.קרן מאונכת 2.הצד האולנרי של שורש היד מורם ב-20 מע' מהקסטה

44. PA UD AP UD

45. SLAC WRIST

46. LAT NEUTRAL

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

48. הערכה רנטגנית של פרק טרפזיו-מטקרפלי CMC1) ) דורזליפלמרי

49. מה מייחד את כף היד האנושית ? תנועת האופוזיציה של האגודל אופוזיציה: הבאת כרית הגליל הרחיקני של האגודל במגע עם הכריות של האצבעות האחרות במטרה לבצע צביטה

50. אופוזיציה של האגודל מול האצבעות מתאפשרת בעיקר ע"י פרק CMC1 שרירים אינטרינסיים של האגודל MOBILITY FORCE

51. dorsalpalmar “The saddle joint”

52. AP FPL APL APB 1 kg 3 kg 5,4 kg 12 kg Compression forces in the thumb ray Dorsal subluxation force is inherent with each pinch because of weak ligaments on the radial side of the joint and is resisted by AOL

54. Robert’s view

55. Clements-Nakayama Position

56. RADIOLOGICAL STAGING OF THE DISEASE Menon 1997 1987

57. Stage I Painful joint instability after injury or congenital

58. Eaton Stress Thumb Position חובה ללחוץ את האגודלים בכוח אחד כנגד השני !

59. WRONG !! WRIGHT!!

60. Stage II S/P Eaton- Littler operation

61. Stage III

62. Stage IV

63. הערכה רנטגנית של עצמות קרפליות

64. שכיחות השברים בעצמות שורש היד Scaphoid79% Triquetrum 14% Trapezium 2.3% Hamate 1.5% Lunate 1% Capitate 1% Trapezoid 0.2%

65. FRACTURES OF THE SCAPHOID 80% of carpal bones fractures Second to distal radius fractures 43 fractures per 100,000 population (3225 fractures for 7.5 million – Israel…)

66. Fractures of the scaphoid are the most commonly missed fractures of the upper limb; yet, early diagnosis is essential for successful treatment

67. The simplest and most commonly used classification: The fairly benign scaphoid tubercle fractures The scaphoid waist fractures benign but with propensity for carpal collapse with subsequent malunion and arthritis. Proximal pole fractures can result in an avascular proximal segment that will not heal, ultimately causing degenerative arthritis over time if not properly treated. 80% of adults Most frequent in children 70%20%10%

69. What is the role of the scaphoid in the wrist? The scaphoid connects proximally to the lunate (S-L lig) and distally to the capitate and trapezium & trapezoid: S-L dissociation # waist of scaphoid with humpback deformity Stabilizing bridge between PCR and DCR

70. RSC RL Most injuries to the carpus occur in wrist extension. The contact point of the injury determines the type of fracture/dislocation pattern that occurs: Injuries with a contact occurring at the distal radius produce distal radius fractures. Injuries with a contact occurring over the carpus, carpal fracture and dislocations occur. When the contact point is more distal, fractures and dislocations at the CMC joints occur. MECHANISM Scaphoid # to occur: Wrist dorsiflexion>95 deg. Wrist radial deviation>10 deg

71. What is navicular fat stripe sign? Radiolucent line Fracture leads to radial displacement or (usually) obliteration of the fat stripe

72. צילומים לסקפואיד Stecher Position אגרוף קמוץ והטיה אולנרית קלה Scaphoid Position

74. What is an occult scaphoid fracture? 1.Completely undisplaced fracture that may not appear on plain films initially. 2.2-3 weeks needed for resorption to occur at the fracture site 3.Clinical examination positive 4.Casting until definite diagnosis

75. Initial Rx6 m later Occult scaphoid fracture

76. What are the criteria for classifying the scaphoid fracture as displaced? 1 mm of displacement (gapping) on any radiographic view Non-union rates climb 10-20-fold Angular displacement > 10 degrees Fracture comminution

77. Unstable,displaced fracture of scaphoid

78. An angle > 40° suggest scaphoid collapse/malunion and an increased rate of DJD (SNAC WRIST) Scaphoid Collapse (Amadio JHS 1989) PA intra- scaphoid angleLA intra-scaphoid angle

79. Scaphoid Collapse Sagittal CT is best to measure intrascaphoid angle. Angle > 40° suggest collapse

80. SNAC WRIST (Scaphoid Nonunion Advanced Collapse) How do scaphoid fractures contribute to wrist arthritis?

81. TRIQUETRUM 14% of carpal fractures

82. HOOK OF HAMATE Papilion Hook of Hamate Position Carpal Tunnel View

83. Hook Of Hamate Trapezium ridge Pisiformis TrapezoidCapitate 50% of fractures of hook of hamate detected in this position

84. PISIFORMIS Supinated Oblique View

85. CARPAL BRIDGE POSITION גב שורש היד על הקסטה

86. CARPAL BOSS POSITION

87. “EXPLODED VIEWS” מה האבחנה?

88. Lunotriquetral coalition מה האבחנה?

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

90. 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

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

93. Thank You!

94. ARTHROGRAPHY VS. ARTHROSCOPY 1.Roth & Haddad (1986) 2.Koman et al (1990) 3.Kelly & Stanley (1990) 4.Levinshon et al (1991 5.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

95. 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