Fractures and dislocations Fractures and dislocations of the wristof the wrist

Dr Ihab RassemDr Ihab RassemLecturer of radiology Ain Shams Lecturer of radiology Ain Shams

University University Cairo, EgyptCairo, Egypt

Radiographic viewsRadiographic views

Dorsovolar (PA)Dorsovolar (PA) Lateral Lateral Dorsovolar with ulnar deviation Dorsovolar with ulnar deviation

(scaphoid)(scaphoid) Supinated oblique (pisiform, Supinated oblique (pisiform,

pisotriquetral jointpisotriquetral joint)) Pronated oblique (triquetral)Pronated oblique (triquetral) Carpal tunnel (hook of hamate, pisiform, Carpal tunnel (hook of hamate, pisiform,

volar trapezium)volar trapezium)

Dorsovolar with ulnar Dorsovolar with ulnar deviationdeviation

Supinated obliqueSupinated oblique

Pronated oblique viewPronated oblique view

Carpal Tunnel viewCarpal Tunnel view

Carpal bones fracturesCarpal bones fractures

Scaphoid fractureScaphoid fracture

Most common carpal bone to be Most common carpal bone to be fracturedfractured

Age 15-30Age 15-30 Fall on outstretched armFall on outstretched arm ClassificationClassification

Distal pole and tubercle 5-10%Distal pole and tubercle 5-10% Proximal pole 15-20% (nonunion & AVN)Proximal pole 15-20% (nonunion & AVN) Waist 70-80%Waist 70-80%

Scaphoid fractureScaphoid fracture

PA PA PA with ulnar PA with ulnar deviation deviation

Nonunited scaphoid fractureNonunited scaphoid fracture

Scaphoid fracture seen in Scaphoid fracture seen in MRIMRI

AVN of scaphoidAVN of scaphoid

Fracture of triquetralFracture of triquetral

Usually a subtle fractureUsually a subtle fracture Best seen in the lateral or pronated Best seen in the lateral or pronated

oblique view.oblique view.

Hamate fracturesHamate fractures

Usually arise due to direct blow to the Usually arise due to direct blow to the volar aspect of the wristvolar aspect of the wrist

Two typesTwo types Fracture of the hook (hamulus) of hamate: Fracture of the hook (hamulus) of hamate: Fracture of the body of hamateFracture of the body of hamate

Hook of hamate is seen in dorsovolar view Hook of hamate is seen in dorsovolar view as a cortical ring. Absence, indistinctness, as a cortical ring. Absence, indistinctness, or sclerosis of this ring suggests hamulus or sclerosis of this ring suggests hamulus fracture (eye sign)fracture (eye sign)

Carpal tunnel view is also helpful may may Carpal tunnel view is also helpful may may be difficult due to painbe difficult due to pain

Fracture of pisiform boneFracture of pisiform bone

Rare Rare Results from fall on the outstretched Results from fall on the outstretched

hand or use of the hand as a hammer hand or use of the hand as a hammer to strike an objectto strike an object

May be isolated or co-exist with other May be isolated or co-exist with other bone fractures bone fractures

Best seen in supinated oblique or Best seen in supinated oblique or carpal tunnel viewcarpal tunnel view

Fractrue of the capitateFractrue of the capitate

Results from fall on outstretched Results from fall on outstretched hands or form direct blowhands or form direct blow

Usually associated with other carpal Usually associated with other carpal bone injuries particularly scaphoid bone injuries particularly scaphoid fracture and perilunate dislocationfracture and perilunate dislocation

Waist (neck) of capitate is the most Waist (neck) of capitate is the most common sitecommon site

PA viewPA view Tomogram Tomogram

Fracture of the lunate boneFracture of the lunate bone

Usually result from fall on the Usually result from fall on the dorsiflexed wrist or ecessive push on dorsiflexed wrist or ecessive push on the heal of the handthe heal of the hand

Often associated with perilunate Often associated with perilunate dislocation.dislocation.

More commonly occur as a More commonly occur as a pathologic fracture in the setting of pathologic fracture in the setting of Kienböck diseaseKienböck disease

Kienböck DiseaseKienböck Disease

Avascular necrosis of the lunate bone,Avascular necrosis of the lunate bone, May be related to repeated traumaMay be related to repeated trauma May be related to negative ulnar varianceMay be related to negative ulnar variance ClassificationClassification

Stage I: radiograph normal, transverse linear Stage I: radiograph normal, transverse linear fracture on tomographyfracture on tomography

Stage II: increased density with some flattening Stage II: increased density with some flattening on the radial sideon the radial side

Stage III: marked decrease in height of lunate Stage III: marked decrease in height of lunate with proximal migration of capitatewith proximal migration of capitate

Stage IV:Stage IV:radiocarpal joint osteoarthritisradiocarpal joint osteoarthritis

Stage I Stage I

Stage IIStage II

Stage IIIStage III

Stage IVStage IV

Fracture of the trapeziumFracture of the trapezium

Most commonly loading injury in the Most commonly loading injury in the setting oa adducted thumb where setting oa adducted thumb where the first metacarpal is driven into the first metacarpal is driven into trapeziumtrapezium

Associated with fracture of the 1Associated with fracture of the 1stst metacarpal base and subluxation or metacarpal base and subluxation or dislocation of 1dislocation of 1stst carpometacarpal carpometacarpal jointjoint

Fracture trapezoidFracture trapezoid

Rare fracture.Rare fracture. Associated with dislocation of the 2Associated with dislocation of the 2ndnd

metacarpal bonemetacarpal bone

Carpal bones dislocationsCarpal bones dislocations

Normal anatomical relationsNormal anatomical relations

Lateral view with wrist in neutral Lateral view with wrist in neutral position: radius, lunate, capitate, 3position: radius, lunate, capitate, 3rdrd metacarpal should be in the same metacarpal should be in the same line.line.

Normal anatomical relationsNormal anatomical relations

Dorsovolar view with wrist in neutral Dorsovolar view with wrist in neutral postion: 3 smooth unbroken arcs postion: 3 smooth unbroken arcs should be seen (Gilula arcs)should be seen (Gilula arcs) Arc I: Arc I: proximal articular surfaces of the proximal articular surfaces of the

scaphoid,lunate,& triquetrum scaphoid,lunate,& triquetrum Arc II: distal concavities of scaphoid, Arc II: distal concavities of scaphoid,

lunate, & triquetrum lunate, & triquetrum Arc III: proximal convexities of capitate Arc III: proximal convexities of capitate

& hamate & hamate

Vulnerable zones theoryVulnerable zones theory

Dislocations around the lunate can occur in two Dislocations around the lunate can occur in two patterns.patterns.

Lesser arc injury patternLesser arc injury pattern: consist of pure : consist of pure ligamentous injuries leading to dislocationsligamentous injuries leading to dislocations

Greater arc injury patternGreater arc injury pattern: consist of dislocation : consist of dislocation in addition to fracture of one or more of the bones in addition to fracture of one or more of the bones around the lunate (scaphoid, trapezium, capitate, around the lunate (scaphoid, trapezium, capitate, hamate, triquetrum).hamate, triquetrum).

In cases of greater arc injury you mention the In cases of greater arc injury you mention the prefix prefix trans-trans- followed by the name of the followed by the name of the fractured bone then the dislocation e.g. trans- fractured bone then the dislocation e.g. trans- scaphoid perilunate dislocationscaphoid perilunate dislocation

Greater arc =blueGreater arc =bluelesser arc = redlesser arc = red

Dislocations around the Dislocations around the lunatelunate

Occur in sequential stages according Occur in sequential stages according to the severity of traumato the severity of trauma

Stage I: Scapholunate dissociation; Stage I: Scapholunate dissociation; rotatory subluxation of scaphoidrotatory subluxation of scaphoid

Stage II: perilunate dislocationStage II: perilunate dislocation Stage III: midcarpal dislocationStage III: midcarpal dislocation Stage IV: lunate dislocationStage IV: lunate dislocation

Dislocations around the Dislocations around the lunatelunate

Scapholunate dissociationScapholunate dissociation

Results from injury of the Results from injury of the scapholunate ligamentscapholunate ligament

Radiographicaly diagnosed by Radiographicaly diagnosed by Terry Terry Thomas sign Thomas sign due to widening of the due to widening of the space between the scaphoid and space between the scaphoid and lunate more than 2 mmlunate more than 2 mm

Terry Thomas signTerry Thomas sign

Rotatory subluxation of Rotatory subluxation of scaphoidscaphoid

Related condition to scapholunate Related condition to scapholunate dissocaition where there is in addition dissocaition where there is in addition rotation of the scaphoid along its long axisrotation of the scaphoid along its long axis

Radiographically diagnosed by Radiographically diagnosed by signet ring signet ring signsign: volar tilt of the scaphoid makes it : volar tilt of the scaphoid makes it appear foreshortened with its tuberosity appear foreshortened with its tuberosity seen end on giving a cortical ring.seen end on giving a cortical ring.

Radiographs in dorsovolar view should be Radiographs in dorsovolar view should be in the neutral position or with ulnar tilt for in the neutral position or with ulnar tilt for this sign to be reliable one this sign to be reliable one

Neutral position Neutral position signet ring signsignet ring sign

Radial tiltRadial tiltNormal scaphoid Normal scaphoid

Perilunate dislocationPerilunate dislocation On lateral view: On lateral view:

Dorsal or volar dislocation of the capitate.Dorsal or volar dislocation of the capitate. Lunate remains in articulation with the Lunate remains in articulation with the

radius although there may be some degree radius although there may be some degree of tiltof tilt

On dorsovolar viewOn dorsovolar view Crowdening of the proximal and distal carpal Crowdening of the proximal and distal carpal

rowsrows Break in arcs II and III at the site of the Break in arcs II and III at the site of the

capitate capitate

Lunate dislocationLunate dislocation

On lateral viewOn lateral view Axis of lunate is titled away from the Axis of lunate is titled away from the

articular surface of radius (articular surface of radius (spilled tea cup spilled tea cup signsign))

Capitate remains in normal alignment Capitate remains in normal alignment with radius and 3with radius and 3rdrd metacarpal metacarpal

On dorsovolar viewOn dorsovolar view Disruption of arc II while arc III remains Disruption of arc II while arc III remains

intactintact

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