September 2000

Musculoskeletal Trauma
of the Wrist
Murat Akalin, Harvard Medical School, Year- IV
Gillian Lieberman, MD
The Wrist
• Most common site of injury in entire
skeleton
• Distal radius and ulna fractures are 10 times
more common than carpal bone fractures
• Mechanism of injury is most often
“Fall On OutStretched Hand”
FOOSH
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 The Wrist
• Complex anatomy makes identification of
abnormalities difficult
• Dislocations are easy to overlook
• Complications are significant so these fractures are
among the “MUST NOT MISS”radiologic
diagnoses

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Anatomy

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 Anatomy

Radiographic Anatomy of the Skeleton Michael L.Richardson, M.D. http://www.scar.rad.washington.edu/RadAnatomy.html

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Anatomy

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Modified from Radiographic Anatomy of the Skeleton Michael L.Richardson, M.D.
http://www.scar.rad.washington.edu/RadAnatomy.html
Anatomy
capitate

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Zone of Vulnerability

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 Standard Imaging Studies for
Suspected wrist trauma or
complications
• Wrist series
– PA, lateral, and oblique plain films
• Special views
– usually of scaphoid
• CT scan
– useful for occult fractures, fragments,
nonunion, osteonecrosis
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Other Imaging Studies
(Less Useful in Evaluation of Acute Injury)
• MRI • Flouroscopy
– Early/occult – Carpal instability with
osteonecrosis reproducible symptoms
– cartilaginous and
ligamentous injuries
– marrow processes
• Arthrogram • Bone scintigraphy
– disruption of – Occult fractures
ligamentous – Osteomyelitis
compartments

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Common Wrist
Fractures

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Case 1: 23 Year Old with FOOSH

Fracture

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 Scaphoid (navicular) Fracture
• Most commonly fractured
carpal
• Difficult to detect
• Frequently occult,
becoming evident only
over time (5-10 days)
• If there is “snuff box”
tenderness, special
scaphoid view(s) should
be requested

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 Scaphoid View
• Ulnar flexion
– Better visualisation of radial
surface of scaphoid, where
fractures often occur
– “Fourth view” often added
to standard wrist series

• Variety of other special

scaphoid views

Image from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995. 14
Multiple Scaphoid Views

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 Osteonecrosis of the Scaphoid
• 5-15% of scaphoid
fractures
• Increased radiodensity
over proximal pole
• Take weeks to appear
• Likelihood depends on
location of fracture line
• Other complications:
nonunion, instabilty, DJD
• Complications increase
with delayed diagnosis
and treatment Electronic Journal of Hand Surgery
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http://www.eatonhand.com/img/IMG00016.htm
Wrist CT

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CT Reconstruction

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Scaphoid Fracture s/p ORIF

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n pearl Scaphoid Fracture
• Common
• Difficult to detect
• Especially prone to complications
• May become radiographically evident only over
time
• Therefore…
If scaphoid views are requested, the patient MUST
be followed-up radiographically, even if initial
studies are negative
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Case 2: 60 Year Old with FOOSH

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 Colles’ Fracture
• Transverse fracture of
distal radius
• Distal fragment
angulated dorsally
• Often comminuted
• Often impacted
• 60% have associated
ulnar styloid fracture

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Case 3:
6 Year Old with
FOOSH

Radiology Cases in Pediatric Emergency Medicine, (1) 18.

http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html 23
 Greenstick Fracture
• Children
• Greater bone elasticity
• Break in 1 cortex
• Usually angulated
• Usually not subtle

Radiology Cases in Pediatric Emergency Medicine, (1) 18.

http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
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Case 4: 6 Year Old with FOOSH

Radiology Cases in Pediatric Emergency Medicine, (1) 18.

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http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
 Torus Fracture
• Children
• Buckling of 1 cortex
• Variant of greenstick
• Little or no angulation
• Often subtle and easily
missed

Radiology Cases in Pediatric Emergency Medicine, (1) 18.

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http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
Case 5: 16 Year Old with FOOSH

Radiology Cases in Pediatric Emergency Medicine, (1) 18. 27

http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html
 Salter-Harris Fracture
• Involves growth plate
• Risk of premature fusion
and deformity
• S-H classification
predicts risk
• May be impossible to
detect radiographically

• Therefore…
tenderness at growth plate Radiology Cases in Pediatric Emergency Medicine, (1) 18.

should be treated as S-H http://www2.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html

fracture, even in absence 28

of radiographic evidence
Salter-Harris Classification

American Family Physician Vol. (46), number 4

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 Common Wrist Fractures
Kids:
•Greenstick Fracture
•Torus Fracture
•Salter-Harris Fracture

Adults:
•Scaphoid Fracture
•Colles Fracture
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Wrist Dislocations

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 Dislocations of Wrist
• Less common than fractures, but still
comprise about 10% of carpal injuries

• Anatomy may be confusing at first,

but a few simple tips will make it easy

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 On the Frontal View…
• Look for Three Arcs
– Clear, smooth, and
continuous Arc 3
– Spaces should be 2mm Arc 2
or less Arc 1
• Disruption in any one
of these arcs signifies
dislocation

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On the Lateral View…
• Look to see that the
radius + lunate and
lunate + capitate
articulate
• Like an apple in a
cup in a saucer
• If the cup is empty,
there is a
dislocation Image from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995.
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 Lunate Dislocation
• Most common dislocation
• Best seen on lateral view

• On frontal view, Arcs 2

and 3 disrupted and “pie
sign” is present

• Treatment is traction and

closed reduction vs ORIF
and ligamentous repair
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Image from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995.
 Perilunate Dislocation
• Best seen on lateral view

• On frontal view, again,

Arcs 2 and 3 are disrupted

• Often associated with

scaphoid fracture

Image from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995.
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 Navicular Subluxation
(Scaphoid Dislocation
AKA Scapholunate
Dissociation)
• Second most frequent
carpal dislocation
• Subluxation, not a full
dislocation
• “David Letterman” sign
(aka “Terry Thomas” sign)
• “Ring” sign
• Arcs 1 2 & 3 disrupted
• Often associated with
Image from Raby, Berman and Lacy. Accident and Emergency Radiology, 1995. radius fracture 37
 Common Wrist Dislocations

•Lunate dislocation : pie sign

•Perilunate dislocation
•Navicular subluxationi:
David Letterman/Terry Thomas Sign
Ring Sign

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 Summary
• Common fractures • Particular vigilance
required for scaphoid
may be predicted from fractures
the age of patient:
• CT is modality of choice
for detecting occult
Child Æ Greenstick fractures
Teen Æ Salter-Harris
Adult Æ Scaphoid • Dislocations may be
detected with knowledge
Older Æ Colles’ of normal carpal relations
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References
Chew F. Skeletal Radiology: The Bare Bones. 1st edition, 1989.

Dee R, Mango E, Hurst L. Principles of Orthopaedic Practice. 1998.

Eisenberg R. Clinical Imaging: An Atlas of Differential Diagnosis. 3rd edition. 1998.

Hodge J, Gilula L. Imaging of the Wrist and Hand www.sma.org/soa/jsoawt96/jsoawt6.htm

Rogers L. Radiology of Skeletal Trauma. 2nd edition, 1992.

Raby N, Berman L, de Lacey G. Accident and Emergency Radiology. 1995.

Brown J., Deluca S. Growth Plate Injuries: Salter Harris Classification American Family
Physician Volume(46), number 4, Figure 2.

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 Acknowledgements

Beverlee Turner
Larry Barbaras

The end.
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