Wrist Imaging

Upper Extremity Trauma: page 1 of 14 Wrist

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Arm: Radius rotates around ulna 3D Wrist CT Radius: [L] “ray” (radial head) Anatomy Anatomy Wrist: Radius is the foundation upon Radiographs Radiographs 4 Views 4 Views which the carpal bones reside Looking down on Lister’s Tubercle (dorsal) CT/MR CT/MR articular surface Normal anterior (volar) Scaphoid FOOSH FOOSH Fossa Lunate (palmar) tilt of distal radius Colles Colles Fossa Radial Normal Perpen- Torus Torus Styloid 2-20° dicular to Barton Barton volar long axis Scaphoid Scaphoid Anterior Long axis of Frontal Ulna side Frontal Ulna side radius WOW view view WOW view R view R www.schreibman.info www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 1 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 2 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist aka “Navicular of hand” Should have opening up Scaphoid:[Gr]“boat” (confusing Navicular in foot) Lunate:[L] “moon” Like a teacup holding tea Anatomy Scaphoid bridges the proximal and Anatomy Lunate sits ½ over radius (lunate fossa), Radiographs Radiographs 4 Views distal carpal rows 4 Views ½ over Triangular Fibro Cartilage (TFC) Lunate is nearly surrounded by cartilage CT/MR Distal Waist CT/MR Distal Pole Lunate susceptible FOOSH Pole S Waist Distal pole sticks S FOOSH S to AVN (Kienböck) S Colles out anteriorly Colles Torus Proximal Torus L One  Proximal  One L small Barton Scaphoid Pole Barton Scaphoid TFC small Fossa Pole Fossa  artery Scaphoid Scaphoid Lunate artery posterior Fossa anterior Frontal Ulna side Frontal Ulna side WOW view R view R WOW view R view R www.schreibman.info www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 3 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 4 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist [L] “arm”… related to “ell”, “cubit” * Proximal Carpal Row:(S+L+Tq+P) Ulna:[L] “elbow” Unit of length equal to the forearm Anatomy Triquetrum (Tq): [L] “three-cornered” Anatomy Ulna major component of elbow, forearm Radiographs Radiographs 4 Views Pisiform (P): [L] “pea” 4 Views Role at wrist is limited PT Jt Doesn’t even normally touch carpal bones CT/MR Radio- Distal  CT/MR Forms the ½ Radius fxs have FOOSH Carpal Pole FOOSH Ulnar styloid fxs** Joint S P P Distal S P Often remain P Colles Tq Pisiform Tq Colles Radio- Tq ununited Tq Torus L stick out Torus Ulnar L Seldom require Barton  LT Jt L Barton surgery L TFC anterior Joint TFC Ulna Scaphoid SL Jt Scaphoid  (If DRUJ stable) Styloid  Ulna Frontal Ulna side Frontal DRUJ Styloid Ulna side WOW view R view R WOW view R U view U www.schreibman.info www.schreibman.info *www.etymonline.com © 2015 Ken L Schreibman, PhD/MD Slide 5 of 84 © 2015 Ken L Schreibman, PhD/MD **orthopedics.about.com Slide 6 of 84

©Ken L Schreibman, PhD/MD 10/27/15 www.schreibman.info Upper Extremity Trauma: page 2 of 14 Wrist

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Head-shaped round proximal end Hook-shaped process (H) Capitate:[L] “head” sits inside open end of the lunate Hamate:[L] “hook” sticks out anterior Anatomy Anatomy Hook of Hamate Radiographs Radiographs sticks out 4 Views 4 Views H anteriorH C C C CT/MR Capitate CT/MR Distal Pole FOOSH S P Lunate P FOOSH S P P Colles Tq Radius Tq Colles Tq Tq Torus form a Torus Pisiform L L L L Barton TFC straight Barton TFC Scaphoid stack Scaphoid Frontal Ulna side Frontal Ulna side WOW view R U view RU WOW view R U view U www.schreibman.info www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 7 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 8 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Capitate articulates with Long finger MC Metacarpals Hamate articulates with Ring & Small finger Trapezoid:[Gr] “table shaped” 2 parallel sides Anatomy Anatomy Radiographs Radiographs 4 Views 4 Views H H Td H H C C aka “Lesser CT/MR CT/MR Trapezoid Multangular” FOOSH S P P FOOSH articulates S P P Colles Tq Tq Colles Tq Tq Torus Torus with index L L finger MC L L Barton TFC Barton TFC Scaphoid Scaphoid Frontal Ulna side Frontal Ulna side WOW view R U view U WOW view R U view U www.schreibman.info www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 9 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 10 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist no parallel Trapezium:[Gr] “little table” sides Carpal Tunnel Anatomy Anatomy Walls of the carpal tunnel are made of Radiographs Radiographs the carpal bones that stick out anteriorly 4 Views H H 4 Views Tm Td C aka “Greater Tm CT/MR Multangular” CT/MR Tm S H P FOOSH TrapeziUM S P P FOOSH Colles articulates Tq Tq Colles Torus with the Torus L L Barton ThUMb TFC Barton Scaphoid Scaphoid Frontal Ulna side WOW view R U view U WOW www.schreibman.info www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 11 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 12 of 84

©Ken L Schreibman, PhD/MD 10/27/15 www.schreibman.info Upper Extremity Trauma: page 3 of 14 Wrist

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Hand ≠ Wrist Hand ≠ Wrist Anatomy Hand Hand Hand Anatomy Wrist Wrist Wrist Radiographs PA Obl Lat Radiographs PA Obl Lat 4 Views 4 Views Wrist Ul Dev CT/MR CT/MR FOOSH FOOSH Colles Colles Torus All Negative Torus Still Negative… Barton Barton Scaphoid Scaphoid

WOW WOW Bennett Fracture! www.schreibman.info R,A 27yoM, fell off bike www.schreibman.info R,A 27yoM, fell off bike © 2015 Ken L Schreibman, PhD/MD Slide 13 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 14 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Hand ≠ Wrist Hand vs Wrist: X-ray Beam Anatomy PA Hand PA Wrist (next day) Anatomy Hand radiographs: Wrist Radiographs Radiographs  X-ray beam centered radiographs: 4 Views 4 Views @ 3rd MC head  X-ray beam CT/MR CT/MR centered @ FOOSH FOOSH capitate Colles Colles Torus ? Torus Barton Barton Scaphoid ! Scaphoid

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Wrist: PA = Standard View Wrist: PA View Anatomy Elbow @ Anatomy PA: Standard view Carpal Alignment Radiographs shoulder height X-ray beam Radiographs 4 Views Elbow @ 90° PosteriorAnterior 4 Views Proximal Carpal Row = “PA” Joint Alignment C-MC CT/MR  Raise CT/MR Radio-Carpal Joint FOOSH cassette FOOSH R-C Jt Colles Shield Colles Ulna Carpal-Metacarpal Jt Torus X-rays Torus shorter Distal Radio-Ulnar Jt Barton Barton than Low Ulnar Length Scaphoid chair Scaphoid  Radius X-ray beam centered DRUJ Normally, Ulna same length as Radius WOW on Capitate WOW www.schreibman.info www.schreibman.info D,H 21yoF © 2015 Ken L Schreibman, PhD/MD Marty age 15 Slide 17 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 18 of 84

©Ken L Schreibman, PhD/MD 10/27/15 www.schreibman.info Upper Extremity Trauma: page 4 of 14 Wrist

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Ulnar Variance Wrist: Lateral View Anatomy Ulna shorter than Radius Ulna longer than Radius Anatomy Radiographs “Negative Ulnar Variance” “Positive Ulnar Variance” Radiographs 4 Views Risk AVN Lunate (Kienböck) Ulna can punch hole in TFC 4 Views AVN Lunate Ulna can impact upon Lunate CT/MR with collapse “Ulna Abutment Syndrome” CT/MR C C FOOSH FOOSH Colles Colles Torus Torus L L Barton Barton Scaphoid 2Premature y earlier, Treated Scaphoid Anterior R R Ulna is only fusionnormal radius, with ulna Normal continuedunfused shortening slightly shorter ulnagrowth growth Compared to osteotomy 2-20° WOW than Radius Radius shortening plates UV normal side WOW volar www.schreibman.info S,Z 18yoM T,C 14yoM www.schreibman.info C,S 48yoM © 2015 Ken L Schreibman, PhD/MD Slide 19 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 20 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Can see most carpal bones on Lateral Triquetral Fracture Anatomy Can’t see Anatomy Classically presents Radiographs Triquetrum on Radiographs 4 Views lateral view… 4 Views as a tiny avulsion fracture dorsal to CT/MR C SP C CT/MR Fx the mid-carpus FOOSH S Tq FOOSH Colles P Colles There are no normal Torus L L Torus ossicles dorsal to the Barton Barton carpal bones Scaphoid R R Scaphoid If you see a small bone Hard to see Ulna as it U back there, it’s a fracture overlaps Radius on a May be old, as these tiny WOW good lateral view WOW fractures don’t always heal www.schreibman.info C,S 48yoM www.schreibman.info M,G 50yoM © 2015 Ken L Schreibman, PhD/MD Slide 21 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 22 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Wrist: Standard 3 Views Wrist: Oblique View Anatomy PA View Oblique View Lateral View Anatomy Best view of: Radiographs Radiographs 4 Views 4 Views STT joint MC Thumb C-MC joint CT/MR CT/MR Td Common sites for OA FOOSH FOOSH Tm Colles Thumb Colles S Additional view of: Torus Down Thumb Torus Carpals (scaphoid) Barton Thumb Up Barton Metacarpals Scaphoid Halfway Scaphoid Radius (styloid) Between Sometimes a fracture is WOW WOW seen only on this view www.schreibman.info www.schreibman.info K,M 20yoF © 2015 Ken L Schreibman, PhD/MD Slide 23 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 24 of 84

©Ken L Schreibman, PhD/MD 10/27/15 www.schreibman.info Upper Extremity Trauma: page 5 of 14 Wrist

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Scaphoid (Ulnar Deviation) View 4 View Series for Scaphoid Fracture Anatomy Patient holds LateralAnatomy PA View Oblique View Scaphoid Radiographs wrist in ulnar ViewRadiographs View 4 Views deviation 4 Views CT/MR CT/MR FOOSH Yields an FOOSH Colles Colles Dorsal ? Torus elongated Torus swelling Barton view of the Barton Scaphoid scaphoid. Scaphoid Helps when looking for Doesn’t show Negative Negative? Positive! WOW fractures. WOWscaphoid well scaphoid waist fx www.schreibman.info S,B 21yoF www.schreibman.info K,T 32yoF © 2015 Ken L Schreibman, PhD/MD Slide 25 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 26 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Wrist: CT Wrist CT: Positioning Anatomy Good for complex fractures Anatomy Mighty Mouse Radiographs Radiographs Position 4 Views Aid in surgical planning 4 Views Good to assess fracture healing CT/MR Even in the presence of metal CT/MR  FOOSH PA view Scaphoid CT:Coronal CT:Obl Sag Acutrak® CT:Obl Sag FOOSH Colles Colles view Tm screw Torus Td C H Torus Barton Barton Scaphoid Tq Scaphoid We don’t scan patients with We scan patients with their    S Fx! S  Fx? Fx Fx! L Healed! their wrist down at their side wrist over the head R  Excess radiation across torso  No excess radiation to body WOW R WOW  X-ray scatter decreases res.  No x-ray scatter www.schreibman.info E,A 18yoM www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 27 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 28 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Wrist: CT Wrist MR: Positioning Anatomy NOT good for occult fractures Anatomy We scan patients with their Radiographs Radiographs wrist over the head 4 Views Fractures non-displaced on radiographs… 4 Views  In a wrist coil …are non-displaced on CT  Functions best in the center of CT/MR ScaphoidPA view view CT: Coronal MR:MR: T2fs T1 Coronal Coronal Acutrak® screw CT/MR the magnetic field FOOSH FOOSH Colles Colles Torus Torus Marrow Barton edema Barton  Scaphoid Scaphoid  Wrist coil Black fracture WOW No fracture No fracture line WOW www.schreibman.info L,N 21yoF www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 29 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 30 of 84

©Ken L Schreibman, PhD/MD 10/27/15 www.schreibman.info Upper Extremity Trauma: page 6 of 14 Wrist

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Fall On Out-Stretched Hand (FOOSH) The most famous penguin on the Internet Anatomy Most injuries to the wrist are due to one Anatomy Radiographs common mechanism Radiographs 4 Views Perhaps THE most common injury 4 Views CT/MR 1-in-6 ER fractures occur in the distal radius* CT/MR FOOSH Humans are a clumsy species FOOSH Colles We walk upright Colles Torus We’re top heavy Torus Barton When falling, we instinctively protect our head, by Barton Scaphoid Extending our arm Scaphoid Striking the ground with our hand This mechanism of injury is perhaps WOW UNIQUE to humans WOW www.schreibman.info *orthopedics.about.com www.schreibman.info www.youtube.com © 2015 Ken L Schreibman, PhD/MD Slide 31 of 84 © 2015 Ken L Schreibman, PhD/MD www.youtube.com Slide 32 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Fall On Out-Stretched Hand (FOOSH) Fall On Out-Stretched Hand (FOOSH) Anatomy R Anatomy Hyperextension of wrist  Radiographs A U Radiographs 4 Views D L 4 Views Hyperextensive forces on: S I N CT/MR U A CT/MR Radius Hyperextend Hyperextend S Colles fracture FOOSH Wrist Wrist FOOSH Colles Colles Torus fracture (children) Torus Torus Barton S Barton Carpal bones Scaphoid HAND Scaphoid Barton fracture Scaphoid fracture WOW WOW Lunate/perilunate dislocations FOOSH www.schreibman.info www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Marty age 8½ Slide 33 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 34 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Colles Fracture Dorsal Angulation is Bad  Anatomy Transverse Fx distal radius Anatomy Lateral view To measure angle: Radiographs Radiographs Hyperextension forces cause:  Draw line along 2 weeks later… 4 Views S 4 Views distal radius Dorsal angulation From front corner CT/MR ± Dorsal displacement CT/MR To back corner FOOSH Lateral view Lateral view FOOSH Lateral view  Draw line along Colles Colles Fx 5° shaft of radius 20° Torus Torus Dorsal Perpendicular to this Dorsal Barton Barton  Measure this angle Scaphoid Scaphoid The ligaments are Normal is VOLAR not designed to DORSAL ANGULATION 2-20° support carpal bones on a dorsal WOW ALWAYS ABNORMAL! WOW Dorsal = Abnormal sloped radius www.schreibman.info R,C 92yoF O,M 20yoM www.schreibman.info R,C 92yoF © 2015 Ken L Schreibman, PhD/MD Slide 35 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 36 of 84

©Ken L Schreibman, PhD/MD 10/27/15 www.schreibman.info Upper Extremity Trauma: page 7 of 14 Wrist

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Must reduce angle to heal right Colles fractures very common Anatomy Anatomy In children Secretary Judy Wife Lynn Radiographs Radiographs 4 Views 4 Views Fall a lot Torus fracture CT/MR CT/MR FOOSH FOOSH In women Colles Colles Osteopenia Torus Torus 2 women in Barton Barton my life… Scaphoid Scaphoid ER lateral view: Following reduction 6 weeks later: Marked dorsal & casting in ER: Healing, normal In the WOW angulation Volar angulation volar angulation WOW media… www.schreibman.info M,D 59yoF www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 37 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 38 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Colles vs Smith Fracture Smith Fracture = Reverse Colles Anatomy Anatomy Radiographs Radiographs 4 Views 4 Views S CT/MR CT/MR FOOSH FOOSH Colles Anatomically Colles Torus impossible? Torus Barton Barton Scaphoid Scaphoid Smith: Colles: Hyper- Hyper- flexion Lateral view: Reductionextension & cast: VOLAR Too much volar DORSALNormal volar WOW WOW angulation angulation  angulationangulation  www.schreibman.info Season 15, Episode 2 www.schreibman.info S,K 51yoF © 2015 Ken L Schreibman, PhD/MD original air date 9/22/04 Slide 39 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 40 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Mechanisms: Colles vs Smith Mechanisms: Colles vs Smith Anatomy Anatomy Radiographs Radiographs FOOSH  Hyperextension  Colles 4 Views 4 Views whether fall Forwards or Backwards CT/MR CT/MR FOOSH FOOSH Colles Colles Torus Torus Barton Barton Scaphoid Colles: Scaphoid Hyper- FOOSH extension DORSAL WOW angulation WOW www.schreibman.info www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 41 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 42 of 84

©Ken L Schreibman, PhD/MD 10/27/15 www.schreibman.info Upper Extremity Trauma: page 8 of 14 Wrist

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Mechanisms: Colles vs Smith Abraham Colles (1773-1843) Anatomy Fall onto Back of hand Smith fracture Anatomy Radiographs Hyper- Radiographs 4 Views flexion is much less 4 Views Smith Fx common than CT/MR VOLAR Colles CT/MR FOOSH angulation FOOSH Colles Colles “I should consider this as by far the most common Torus Torus injury to which the wrist or carpal extremities of the radius and ulnar are exposed.” Barton Colles: Barton Scaphoid Scaphoid “The injury to which I wish to direct the attention of Hyper- surgeons, had not, as far as I know, been described by extension any author.” DORSAL (81 years before WOW angulation WOW Roentgen) www.schreibman.info www.schreibman.info babel.hathitrust.org © 2015 Ken L Schreibman, PhD/MD Slide 43 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 44 of 84

Upper Extremity Trauma Wrist Robert William Smith (1807-1873) Anatomy Radiographs 4 Views

CT/MR FOOSH Colles Torus Barton Scaphoid (1847?) MDCCCL=1850

©Ken L Schreibman, PhD/MD 10/27/15 www.schreibman.info Upper Extremity Trauma: page 9 of 14 Wrist

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Fractures in Children FOOSH Fractures in Children Anatomy Lateral PowerPoint Model PA view Anatomy Lateral PowerPoint Model Adult bones: Brittle Radiographs AdultChild Lateral Radiographs Child Lateral 4 Views Epiphysis 4 Views Snap under force A physis A Child bones: Soft CT/MR (growth plate) CT/MR Bend under force FOOSH R FOOSH FOOSH  Colles A Metaphysis Colles Torus R Torus R Hyperextension distal Barton DA Barton A radial metaphysis Scaphoid DI Scaphoid D Buckling metaphysis- I Diaphysis I diaphysis junction UU U Buckle Fracture WOW SS WOW S “Torus Fracture” www.schreibman.info K,V 2yoM www.schreibman.info G,A 5yoM © 2015 Ken L Schreibman, PhD/MD Slide 49 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 50 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Torus Fractures: Lateral View Torus Fractures: PA View Anatomy Anatomy Lateral Lateral Cortex buckles IN Axial Cortex buckles Radiographs Radiographs Axial Load 4 Views FOOSH (Colles) 4 Views Load OUTWARD Dorsal cortex PA view CT/MR Fall on back of wrist CT/MR FOOSH (Smith) FOOSH Colles Volar cortex Colles Torus R Torus R Barton A Nature does not make angles… Barton A Scaphoid Cortex D Nature makes smooth curves Scaphoid D of radius I If you see cortex angulation in I & ulna U a child that should be smooth, U overlap WOW S it’s likely a torus fracture! WOW S H,T 8yoF www.schreibman.info S,A 5yoF A,C 6yoM www.schreibman.info FOOSH PowerPoint Model © 2015 Ken L Schreibman, PhD/MD Slide 51 of 84 © 2015 Ken L Schreibman, PhD/MD Child PA View Slide 52 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Torus Fractures: Common… Subtle Torus Fractures: Common… Subtle Anatomy Run eyes PA view PA view Anatomy Run eyes PA view Lat view Lat view Radiographs along cortex Symptomatic side Asymptomatic side Radiographs along cortex Symptomatic side Sympt. Asympt. 4 Views Focus on 4 Views Focus on CT/MR metaphysis CT/MR metaphysis FOOSH PA view FOOSH Lat view Colles Buckles Colles Buckles Torus outward Torus inward Barton Not sure? Barton Not sure? Scaphoid Compare to Scaphoid Compare to normal side normal side Use other Use other WOW views! WOW views! www.schreibman.info A,B 14yoF www.schreibman.info A,B 14yoF © 2015 Ken L Schreibman, PhD/MD Slide 53 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 54 of 84

©Ken L Schreibman, PhD/MD 10/27/15 www.schreibman.info Upper Extremity Trauma: page 10 of 14 Wrist

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist “Torus” Fall On Out-Stretched Hand (FOOSH) Anatomy [L]:“swelling,protuberance,bulge” Capital Anatomy Hyperextension of wrist  Radiographs Radiographs 4 Views [Architecture]: 4 Views Hyperextensive forces on: A large convex molding, S S CT/MR semicircular in cross section, CT/MR Radius FOOSH at base of a classical column. h FOOSH Colles fracture Colles a Colles Torus fracture (children) Torus f Torus Barton Barton Carpal bones Scaphoid t Scaphoid (Proximal carpal row) Torus Barton fracture Plinth WisconsinWOW State Capitol Base WOW www.schreibman.info RadioGraphics 2004; 24:p1025 www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 55 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 56 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Barton Fracture Dorsal Barton Fracture Anatomy Hyperextension of wrist  Anatomy Dorsal Barton Lateral view Lateral view Radiographs Radiographs  Due to FOOSH 4 Views Impaction of carpal bones S 4 Views is much more S on radius dorsal rim  CT/MR CT/MR common than FOOSH Fracture radius rim FOOSH Volar Barton Colles Intra-articular fracture Colles  Due to blow to Torus Potentially more serious than Colles Torus back of wrist Barton (extra-articular fracture) Barton Scaphoid Scaphoid (Just as Colles May require surgical fixation is much more Surgeon may order CT for planning common than WOW WOW Smith fracture) M,M 58yoF S,G 37yoM www.schreibman.info www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 57 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 58 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Volar Barton Fracture John Rhea Barton (1794-1871) Anatomy Lateral view CT: Sagittal Open Anatomy Radiographs Reduction Radiographs 4 Views S Internal 4 Views Fixation CT/MR CT/MR FOOSH FOOSH Colles Colles Torus Torus Barton Barton Scaphoid Scaphoid

It was said that Barton was ambidextrous and that once he had positioned himself WOW WOW for an operation, he did not move about. www.schreibman.info A,D 43yoM www.schreibman.info The Medical Examiner www.kmle.co.kr © 2015 Ken L Schreibman, PhD/MD Slide 59 of 84 © 2015 Ken L Schreibman, PhD/MD Nov 7, 1838; 1, 23; p 365-8 whonamedit.com Slide 60 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Fall On Out-Stretched Hand (FOOSH) Scaphoid Fractures Anatomy Hyperextension of wrist  Anatomy Scaphoid THE Radiographs Radiographs most common 4 Views Hyperextensive forces on: S 4 Views Radius carpal bone to be CT/MR CT/MR fractured. FOOSH Colles fracture FOOSH 71% of all carpal fxs* Colles Torus fracture (children) Colles Scaphoid bridges Torus Carpal bones Torus Barton Barton the carpal rows Scaphoid (Proximal carpal row) Scaphoid Traumatic shear forces Barton fracture between the rows … (Distal carpal row) shearing fracture WOW Scaphoid fracture WOW across the scaphoid www.schreibman.info www.schreibman.info *emedicine.com © 2015 Ken L Schreibman, PhD/MD Slide 61 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 62 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Scaphoid Fractures Locations Scaphoid Fractures Locations Anatomy PA View Wrist Ulnar Deviation View Wrist Anatomy PA View Wrist PA View Wrist Radiographs Radiographs 4 Views 4 Views

CT/MR CT/MR FOOSH FOOSH Colles Colles Torus Torus Barton Barton Scaphoid Scaphoid Waist Scaphoid Proximal Pole Scaphoid Scaphoid Distal Pole Scaphoid Tubercle 70% of scaphoid fractures 20% occur at scaphoid proximal pole 10% occur at distal pole Rare, usually uncomplicated. occur at the waist Increased risk of non-union/AVN These are usually uneventful* If nonunion, usually asympt.* WOW S,A 24yoM B,J 21yoM WOW T,B 20yoM B,T 44yoM www.schreibman.info www.gentili.net www.schreibman.info *emedicine.com © 2015 Ken L Schreibman, PhD/MD Slide 63 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 64 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Scaphoid & Radius Fractures Scaphoid with Radius Fracture Anatomy Same common mechanism (FOOSH) Anatomy PA View Wrist Obl View Wrist PA View Wrist Radiographs Radiographs 4 Views Distal Radius Fracture 4 Views Proximal Pole Screw Scaphoid Fracture fixates CT/MR …BOTH! CT/MR scaphoid FOOSH FOOSH fracture Colles Watch out for “satisfaction of search” Colles Torus Torus Ulna “Aha, I found the fracture… I’d done looking” Styloid Barton Barton Plate Scaphoid Old Radiology Axiom: Scaphoid Colles fixates The hardest fracture to find is the 2nd fracture Colles WOW WOW fracture www.schreibman.info www.schreibman.info W,M 19yoF © 2015 Ken L Schreibman, PhD/MD Slide 65 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 66 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Scaphoid doesn’t heal as well as other bones Scaphoid doesn’t heal as well as other bones Anatomy PA22yo View M Hand 2 months later… Anatomy after 4 months… CT: Coronal CT: FBSagittal Radiographs Healing Radiographs Oblique 4 Views 03:00 4 Views Unbelted passenger CT/MR HighIntubated speed MVC Acetabular CT/MR FOOSH fracture FOOSH Colles T-boned by minivan Colles FB FB Torus Air bags deployed FB Torus OK Barton Took 20 minutes to Barton Scaphoid extract from car Scaphoid Non-union … OK scaphoid OK WOW WOW waist www.schreibman.info V,G 22yoM www.schreibman.info V,G 22yoM © 2015 Ken L Schreibman, PhD/MD Slide 67 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 68 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Scaphoid has a tenuous blood supply Scaphoid Non-Union  AVN Anatomy Radial artery PAObl Anatomy PA View Wrist CT: Coronal CT: Sagittal Radiographs supplies: Hand Radiographs Oblique 4 Views Distal Pole (DP) Heavy arterial calcification 4 Views Pt w/ diabetes, renal failure Non-union of Scaphoid (S) Radial DP CT/MR  Not Proximal Pole (PP) Artery CT/MR scaphoid S waist fx FOOSH The more proximal  FOOSH Colles  PP Colles the fracture, the  Torus greater the risk of Torus Barton non-union. Barton Scaphoid The more distracted S Scaphoid the fracture, the Collapse & greater the risk of fragmentation WOW non-union. L,T 60yoM WOW PP = AVN www.schreibman.info www.schreibman.info Q,B 62yoF © 2015 Ken L Schreibman, PhD/MD Slide 69 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 70 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Proximal Row Carpectomy To avoid non-unionAVN PRC Anatomy PA View Wrist Lateral View Wrist Anatomy All scaphoid fxs require early treatment! Radiographs Radiographs 4 Views 4 Views Probably with a screw if displaced At least with a splint or cast if non-displaced CT/MR CT/MR But non-displaced fractures are hard to see FOOSH FOOSH Colles C Colles because they are non-displaced Torus R Torus So how do we know if a patient has a Barton Barton non-displaced scaphoid fracture? Scaphoid Resection: Scaphoid, Lunate, Triquetrum Scaphoid Radius articulates with Capitate (distal row) SNUFFBOX TENDERNESS = WOW Only treatment for fragmented scaphoid AVN WOW PRESUMED SCAPHOID FRACTURE www.schreibman.info Q,B 62yoF www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 71 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 72 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Anatomical Snuffbox Snuffbox Tenderness Anatomy Anatomy = PRESUMED SCAPHOID FRACTURE Radiographs Radiographs 4 Views 4 Views What if the radiographs are normal? Beautiful! Then it’s a non-displaced fracture CT/MR CT/MR Treat anyway with a cast/splint Extensor Pollicis Longus Tendon Make sure radiologist agrees they’re negative FOOSH  FOOSH Colles Colles Have patient follow-up in 2 weeks Torus Torus Re-examine… if still tender… back into the splint Barton Barton Get repeat radiographs (out of the cast/splint) Scaphoid  Scaphoid We’re taught occult fxs become visible after 1-2 weeks Extensor Pollicis Brevis Tendon from bone resorption at fx margins… I’m not sure it’s true… If you really need to know… WOW WOW MRI (we don’t miss fractures on MRI) www.schreibman.info www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 73 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 74 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Resorbtion of Fracture Margins? Resorbtion of Fracture Margins? Anatomy PA View Scaphoid View Oblique View Anatomy PA View MRI: 19 days after injury Radiographs Radiographs 8 days later Coronal T1 Coronal T2fs 4 Views No scaphoid fx No scaphoid fx No scaphoid fx… 4 Views Still snuffbox tenderness CT/MR CT/MR No Bone marrow edema in Scaphoid FOOSH FOOSH resorbtion   Colles Colles scaphoid Black Torus Torus fracture fx line Barton Barton margins Black Black Scaphoid Scaphoid Still no fx line scaphoid fx fx line Importance of multiple views! Occult scaphoid WOW Radius fractures WOW fracture! Bone marrow edema in Radius www.schreibman.info M,D 55yoM, cutting tree branches, FOOSH 15ft www.schreibman.info M,D 55yoM, cutting tree branches, FOOSH 15ft © 2015 Ken L Schreibman, PhD/MD Slide 75 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 76 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Resorbtion of Fracture Margins? Anatomical Snuffbox? Anatomy PA View Scaphoid View Oblique View Anatomy snuffhouse.org Radiographs after 29 days… Radiographs 4 Views 4 Views Still no CT/MR resorbtion CT/MR scaphoid FOOSH fracture FOOSH Colles margins Colles Torus Torus Barton Negative radiographs do not exclude a scaphoid fracture Barton Scaphoid Snuffbox Tenderness = Presumed Scaphoid Fracture! Scaphoid

Still see lucent WOW radius fractures WOW www.snuffstore.co.uk schmalzlerfranzl.de www.schreibman.info M,D 55yoM, cutting tree branches, FOOSH 15ft www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 77 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 78 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Wrist: What to Order When (WOW) Wrist: What to Order When (WOW) Anatomy Radiographs: MR Anatomy Wrist Radiographs (95%) Radiographs 3% Radiographs 4 Views 4 Views 3-view wrist series Trauma RG PA (not AP) CT/MR Pain 95% CT CT/MR Lateral FOOSH Arthritis (Hand radiographs) 2% FOOSH Oblique Colles CT Colles If snuffbox tenderness, add 4th view Torus Surgical planning known fractures Torus Scaphoid (ulnar deviation) Barton Barton Scaphoid MR Scaphoid If snuffbox tenderness+negative radiographs Occult fractures (scaphoid) TREAT AS PRESUMED SCAPHOID FRACTURE Synovitis (w/Gd) (Usually includes MCPs ± IPs) Cast/splint, follow-up in 2 weeks WOW  …pain? WOW If still has snuffbox tenderness, keep treating www.schreibman.info UW data 2005 & 2014 www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 79 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 80 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Wrist: What to Order When (WOW) Wrist: What to Order When (WOW) Anatomy Wrist CT Anatomy Wrist MR Radiographs Radiographs 4 Views Predominantly used for surgical planning of 4 Views Occult fractures (scaphoid) known radius/carpal bone fractures Persistent symptoms despite negative radiographs CT/MR Ordered by Orthopedics from ER or clinic CT/MR Synovitis (RA) FOOSH Assess healing of known scaphoid fracture FOOSH Needs IV contrast Colles With or without prior screw fixation Colles Normal synovium does not enhance Torus Small screws cause virtually no CT artifacts Torus Vascularized pannus greatly enhances Barton We always reformat in 3 orthogonal planes Barton Ordering provider should specify area of concern Scaphoid Scaphoid Just intercarpal joints For scaphoid, we add oblique sagittal Also Metacarpal-phalangeal joints We have a specialized protocol for DRUJ instability Also Interphalangeal joints WOW All protocols at: www.radiology.wisc.edu WOW  Field of View =  Resolution www.schreibman.info www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 81 of 84 © 2015 Ken L Schreibman, PhD/MD Slide 82 of 84

Upper Extremity Trauma Wrist Upper Extremity Trauma Wrist Wrist: What to Order When (WOW) That’s all we have on wrists… Anatomy Wrist Charges Anatomy Radiographs Radiographs 4 Views Wrist Radiographs 4 Views  3 views = 4 views = $137 CT/MR It costs nothing to add the scaphoid view to a 3 view series CT/MR FOOSH  1 view = 2 views = $128 FOOSH Colles Going from 2 views to 4 views adds only $9 (7%) Colles Torus Wrist CT Torus Barton (without contrast) = $1,460 Barton Scaphoid Wrist MR Scaphoid  (without contrast) = $2,921 WOW  (with contrast) = $3,377 WOW www.schreibman.info UWMF charges 2012 www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Slide 83 of 84 © 2015 Ken L Schreibman, PhD/MD Marty age 7 Slide 84 of 84