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Fractures and dislocations of the wrist

Fractures and dislocations of the wrist. Dr Ihab Rassem Lecturer of radiology Ain Shams University Cairo, Egypt. Radiographic views. Dorsovolar (PA) Lateral Dorsovolar with ulnar deviation (scaphoid) Supinated oblique (pisiform, pisotriquetral joint ) Pronated oblique (triquetral)

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Fractures and dislocations of the wrist

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  1. Fractures and dislocations of the wrist Dr Ihab Rassem Lecturer of radiology Ain Shams University Cairo, Egypt

  2. Radiographic views • Dorsovolar (PA) • Lateral • Dorsovolar with ulnar deviation (scaphoid) • Supinated oblique (pisiform, pisotriquetral joint) • Pronated oblique (triquetral) • Carpal tunnel (hook of hamate, pisiform, volar trapezium)

  3. Dorsovolar with ulnar deviation

  4. Supinated oblique

  5. Pronated oblique view

  6. Carpal Tunnel view

  7. Carpal bones fractures

  8. Scaphoid fracture • Most common carpal bone to be fractured • Age 15-30 • Fall on outstretched arm • Classification • Distal pole and tubercle 5-10% • Proximal pole 15-20% (nonunion & AVN) • Waist 70-80%

  9. Scaphoid fracture

  10. PA PA with ulnar deviation

  11. Nonunited scaphoid fracture

  12. Scaphoid fracture seen in MRI

  13. AVN of scaphoid

  14. Fracture of triquetral • Usually a subtle fracture • Best seen in the lateral or pronated oblique view.

  15. Hamate fractures • Usually arise due to direct blow to the volar aspect of the wrist • Two types • Fracture of the hook (hamulus) of hamate: • Fracture of the body of hamate • Hook of hamate is seen in dorsovolar view as a cortical ring. Absence, indistinctness, or sclerosis of this ring suggests hamulus fracture (eye sign) • Carpal tunnel view is also helpful may may be difficult due to pain

  16. Fracture of pisiform bone • Rare • Results from fall on the outstretched hand or use of the hand as a hammer to strike an object • May be isolated or co-exist with other bone fractures • Best seen in supinated oblique or carpal tunnel view

  17. Fractrue of the capitate • Results from fall on outstretched hands or form direct blow • Usually associated with other carpal bone injuries particularly scaphoid fracture and perilunate dislocation • Waist (neck) of capitate is the most common site

  18. PA view Tomogram

  19. Fracture of the lunate bone • Usually result from fall on the dorsiflexed wrist or ecessive push on the heal of the hand • Often associated with perilunate dislocation. • More commonly occur as a pathologic fracture in the setting of Kienböck disease

  20. Kienböck Disease • Avascular necrosis of the lunate bone, • May be related to repeated trauma • May be related to negative ulnar variance • Classification • Stage I: radiograph normal, transverse linear fracture on tomography • Stage II: increased density with some flattening on the radial side • Stage III: marked decrease in height of lunate with proximal migration of capitate • Stage IV:radiocarpal joint osteoarthritis

  21. Stage I

  22. Stage II

  23. Stage III

  24. Stage IV

  25. Fracture of the trapezium • Most commonly loading injury in the setting oa adducted thumb where the first metacarpal is driven into trapezium • Associated with fracture of the 1st metacarpal base and subluxation or dislocation of 1st carpometacarpal joint

  26. Fracture trapezoid • Rare fracture. • Associated with dislocation of the 2nd metacarpal bone

  27. Carpal bones dislocations

  28. Normal anatomical relations • Lateral view with wrist in neutral position: radius, lunate, capitate, 3rd metacarpal should be in the same line.

  29. Normal anatomical relations • Dorsovolar view with wrist in neutral postion: 3 smooth unbroken arcs should be seen (Gilula arcs) • Arc I: proximal articular surfaces of the scaphoid,lunate,& triquetrum • Arc II: distal concavities of scaphoid, lunate, & triquetrum • Arc III: proximal convexities of capitate & hamate

  30. Vulnerable zones theory • Dislocations around the lunate can occur in two patterns. • Lesser arc injury pattern: consist of pure ligamentous injuries leading to dislocations • Greater arc injury pattern: consist of dislocation in addition to fracture of one or more of the bones around the lunate (scaphoid, trapezium, capitate, hamate, triquetrum). • In cases of greater arc injury you mention the prefix trans- followed by the name of the fractured bone then the dislocation e.g. trans- scaphoid perilunate dislocation

  31. Greater arc =bluelesser arc = red

  32. Dislocations around the lunate • Occur in sequential stages according to the severity of trauma • Stage I: Scapholunate dissociation; rotatory subluxation of scaphoid • Stage II: perilunate dislocation • Stage III: midcarpal dislocation • Stage IV: lunate dislocation

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