lab/ecg/x-ray rounds grant kennedy ccfp-em resident

LAB/ECG/X-Ray LAB/ECG/X-Ray RoundsRounds

Grant KennedyGrant Kennedy

CCFP-EM residentCCFP-EM resident

WRIST INJURIESWRIST INJURIES

Wrist InjuriesWrist Injuries

OBJECTIVES:OBJECTIVES:

*Brief review of anatomy*Brief review of anatomy

*Review of common *Review of common fractures/dislocations seen in the EDfractures/dislocations seen in the ED

*Discuss appropriate ED treatment*Discuss appropriate ED treatment

X-Ray Assesment (PA)X-Ray Assesment (PA)

ADEQUACY:ADEQUACY:

Distal Radius and Ulna should not Distal Radius and Ulna should not overlapoverlap

Axis of 3Axis of 3rdrd metacarpal should parallel metacarpal should parallel that of the radius.that of the radius.

Lunate should articulate with both Lunate should articulate with both radius and ulna in 50:50 manner.radius and ulna in 50:50 manner.

X-Ray Assessment (PA)X-Ray Assessment (PA)

ALIGNMENT:ALIGNMENT: Joint spaces are uniform in width; 1-2 Joint spaces are uniform in width; 1-2

mm.mm. Adjacent bones have parallel surfacesAdjacent bones have parallel surfaces Excessive widening or narrowing Excessive widening or narrowing

suggestssuggests ligament disruption, carpal ligament disruption, carpal instability, or fracture/dislocations of at instability, or fracture/dislocations of at least one of the adjacent carpal bones. least one of the adjacent carpal bones.


ALIGNMENT:ALIGNMENT: 3 smooth arcs outline the articular 3 smooth arcs outline the articular

surfaces at the radiocarpal and surfaces at the radiocarpal and midcarpal jointsmidcarpal joints

2 of these arcs formed by proximal 2 of these arcs formed by proximal and distal surfaces of the scaphoid, and distal surfaces of the scaphoid, lunate, and triquetrumlunate, and triquetrum

1 formed by proximal articular surface 1 formed by proximal articular surface of capitate and hamate in the of capitate and hamate in the midcarpal jointmidcarpal joint


Radial styloid extends 9 to 12 mm beyond Radial styloid extends 9 to 12 mm beyond articular surface of distal ulnaarticular surface of distal ulna

Ulnar slant of distal radius : 15 to 25 degreesUlnar slant of distal radius : 15 to 25 degrees

X-Ray Assessment (Lateral)X-Ray Assessment (Lateral)

ADEQUACY:ADEQUACY: Radius and Ulna should completely Radius and Ulna should completely

overlapoverlap Radial styloid should be centered Radial styloid should be centered

over the distal radial articular surfaceover the distal radial articular surface


ALIGNMENT:ALIGNMENT: Axis of radius, lunate, capitate is Axis of radius, lunate, capitate is

collinearcollinear ““Apple (capitate) in a cup (lunate) Apple (capitate) in a cup (lunate)

sitting on a saucer (radius)”sitting on a saucer (radius)” ““3 C’s”3 C’s”

X-Ray Assessment X-Ray Assessment (Lateral)(Lateral)

Distal radius has Distal radius has a normal volar tilt a normal volar tilt of 10 to 25 of 10 to 25 degrees degrees


3 C’s3 C’s provide a provide a gross assessmentgross assessment of carpal alignmentof carpal alignment

Measurement of Measurement of capitolunate andcapitolunate and scapholunate anglesscapholunate angles is a more is a more preciseprecise assessment of carpal assessment of carpal alignment.alignment.


Axis of Axis of Lunate and CapitateLunate and Capitate should should nearly overlap and form an angle nearly overlap and form an angle <20 <20 degreesdegrees

Axis of Axis of Lunate and ScaphoidLunate and Scaphoid should should form an angle between form an angle between 30 and 60 30 and 60 degreesdegrees..

Deviation from these angles suggests Deviation from these angles suggests ligament disruption and carpal instability.ligament disruption and carpal instability.

Scapholunate Ligament Scapholunate Ligament Instability/RuptureInstability/Rupture

3 X-ray Findings:3 X-ray Findings: 1.1. (PA): widening of >3mm of (PA): widening of >3mm of

scapholunate joint. scapholunate joint. “Terry Thomas”“Terry Thomas” 2.2. (PA) scaphoid has tilted towards the (PA) scaphoid has tilted towards the

observer and is viewed more on its end. observer and is viewed more on its end. Circular cortex of bone becomes more Circular cortex of bone becomes more prominent and appears as a ring. prominent and appears as a ring. “Cortical Ring Sign”“Cortical Ring Sign”

3.3. (Lateral): (Lateral): Dorsal Intercalated Dorsal Intercalated Segment Instability Segment Instability

X-ray Assessment (Lateral)X-ray Assessment (Lateral)

Dorsal Intercalated Segment Dorsal Intercalated Segment Instability (DISI):Instability (DISI):

Lunate tilts dorsal Lunate tilts dorsal Axis of Axis of Lunate and Capitate >20 Lunate and Capitate >20

degreesdegrees Scaphoid tilts palmarScaphoid tilts palmar Axis of Axis of Lunate and Scaphoid >60 Lunate and Scaphoid >60

degreesdegrees

Scapholunate Ligament Scapholunate Ligament Instability/RuptureInstability/Rupture

Treatment:Treatment:

Radial gutter splintRadial gutter splint Surgical referralSurgical referral

Triquetrolunate InstabilityTriquetrolunate Instability

Triquetrolunate Ligament Triquetrolunate Ligament InstabilityInstability

3 X-ray Findings:3 X-ray Findings: 1. 1. (PA): widening of triquetrolunate (PA): widening of triquetrolunate

joint space joint space 2.2. (PA): obliteration of capitolunate (PA): obliteration of capitolunate

joint space because of volar tilt of joint space because of volar tilt of the lunate.the lunate.

3. 3. (Lateral): (Lateral): Volar Intercalated Volar Intercalated Segment InstabilitySegment Instability


Volar Intercalated Segment Volar Intercalated Segment Instability (VISI):Instability (VISI):

Lunate tilts volarLunate tilts volar Axis of Axis of Lunate and Capitate >20 Lunate and Capitate >20

degreesdegrees Axis of Axis of Lunate and ScaphoidLunate and Scaphoid

remains remains normal at 30-60 degreesnormal at 30-60 degrees


Treatment:Treatment: Ulnar gutter splint in ERUlnar gutter splint in ER Surgical referralSurgical referral

Perilunate DislocationPerilunate Dislocation

Mechanism: FOOSH with Forceful Mechanism: FOOSH with Forceful Dorsiflexion Dorsiflexion

Tearing of scapholunate, radiocapitate, Tearing of scapholunate, radiocapitate, lunatotriquetral ligamentslunatotriquetral ligaments

Opening of space of PoirierOpening of space of Poirier

Capitate displaced posteriorlyCapitate displaced posteriorly Lunate retains contact with radiusLunate retains contact with radius


X-Ray Findings:X-Ray Findings: 1. 1. (Lateral). Linear arrangement of 3 C’s (Lateral). Linear arrangement of 3 C’s

disrupted, with capitate (3disrupted, with capitate (3rdrd C) displaced C) displaced posterior. posterior. Lunate maintains contact Lunate maintains contact with radius.with radius.

2. 2. (PA). 3 smooth arcs are disrupted, (PA). 3 smooth arcs are disrupted, capitolunate joint space is obliterated as capitolunate joint space is obliterated as bones overlap one another. bones overlap one another. “crowded “crowded carpals”carpals”


Watch for associated fractures.Watch for associated fractures. Scaphoid and capitate most Scaphoid and capitate most

common.common.

Treatment:Treatment: Reduce in ERReduce in ER Long arm splint Long arm splint Surgical referalSurgical referal

Lunate DislocationLunate Dislocation

Mechanism:Mechanism: Similar to perilunate (disruption of Similar to perilunate (disruption of

many ligaments) plus…many ligaments) plus… After being displaced posteriorly, After being displaced posteriorly,

capitate rebounds with sufficient capitate rebounds with sufficient force to push the lunate off the force to push the lunate off the radius and into the palm.radius and into the palm.


X-Ray Findings:X-Ray Findings: 1. 1. (PA). Lunate has a triangular shape (PA). Lunate has a triangular shape

“piece-of-pie”“piece-of-pie” sign. Pathognomonic. sign. Pathognomonic.

2. 2. (Lateral). Disruption of 3 C’s. (Lateral). Disruption of 3 C’s. Lunate (middle C) has been pushed off Lunate (middle C) has been pushed off the radius into the palm. the radius into the palm. “Spilled “Spilled Tea-Cup”Tea-Cup”..


Treatment:Treatment: Closed ReductionClosed Reduction Long arm SplintLong arm Splint Surgical ReferralSurgical Referral

Scaphoid FractureScaphoid Fracture X-Rays:X-Rays: Scaphoid views should be Scaphoid views should be

obtained.obtained. X-Ray negative, but clinically suspicious = X-Ray negative, but clinically suspicious =

cast and re x-ray 10-14 dayscast and re x-ray 10-14 days Treatment: Treatment: Proximal/mid = Proximal/mid = long-arm thumb-spica x 4-long-arm thumb-spica x 4-

6 wks6 wks Distal =Distal = short arm thumb spica. short arm thumb spica. REFERREFER: displaced > 1mm, comminuted, : displaced > 1mm, comminuted,

carpal instability pattern notedcarpal instability pattern noted Risk Factors for AVN: Risk Factors for AVN: proximal, oblique, proximal, oblique,

or displacedor displaced

Triquetrum FractureTriquetrum Fracture

X-Ray:X-Ray: Avulsion # best seen as tiny flake of Avulsion # best seen as tiny flake of

bone on dorsum of triquetrum on lateral bone on dorsum of triquetrum on lateral x-rayx-ray

Treatment:Treatment: Avulsion: Avulsion: wrist splint x 1-2 weekswrist splint x 1-2 weeks Body (non-displaced): Body (non-displaced): short arm cast short arm cast

x 6 weeksx 6 weeks Body (displaced >1mm): Body (displaced >1mm): referrefer

Lunate FractureLunate Fracture

X-ray:X-ray: clinical suspicion should dictate clinical suspicion should dictate acute treatment, as # may be missedacute treatment, as # may be missed

Risk of AVN due to distal to Risk of AVN due to distal to proximal blood supply.proximal blood supply.

Keinbock disease = AVN, can lead Keinbock disease = AVN, can lead to lunate collapse, OA, chronic pain, to lunate collapse, OA, chronic pain, weak gripweak grip

Treatment:Treatment: thumb spica and refer all thumb spica and refer all

Trapezium FractureTrapezium Fracture

Treatment: Treatment: Non-displaced = thumb-spica x 6 wksNon-displaced = thumb-spica x 6 wks Displaced > 1mm = ReferDisplaced > 1mm = Refer

Pisiform FracturePisiform Fracture

Pisiform FracturePisiform Fracture

Sesamoid bone within the flexor carpi Sesamoid bone within the flexor carpi ulnaris tendonulnaris tendon

Exam:Exam: Pisiform and hook of Hamate Pisiform and hook of Hamate form walls of Guyon’s canal. Rule out form walls of Guyon’s canal. Rule out injury to ulnar nerve and artery.injury to ulnar nerve and artery.

Treatment: Treatment: splint in 30 degrees splint in 30 degrees flexion, ulnar deviation to relax flexion, ulnar deviation to relax tension from FCU, tension from FCU, vsvs. short arm cast x . short arm cast x 4-6 weeks.4-6 weeks.

Hamate FractureHamate Fracture

Exam:Exam: R/O injury to ulnar R/O injury to ulnar nerve/arterynerve/artery

Treatment:Treatment: Non-displaced body/ Hook # = short Non-displaced body/ Hook # = short

arm cast including 4arm cast including 4thth/5/5thth MCPs x 4-6 MCPs x 4-6 weeks w/ f/uweeks w/ f/u

Displaced = volar splint + referDisplaced = volar splint + refer

Less Common FracturesLess Common Fractures

Capitate Fracture:Capitate Fracture: Potential for AVN (like lunate, scaphoid)Potential for AVN (like lunate, scaphoid) Treat with short arm splint (if swollen) Treat with short arm splint (if swollen)

vs. short arm cast + refervs. short arm cast + refer Displaced = splint + referDisplaced = splint + refer

Trapezoid Fracture:Trapezoid Fracture: x-rays often negative. Tx with thumb x-rays often negative. Tx with thumb

spicaspica

lab/ecg/x-ray rounds grant kennedy ccfp-em resident

Documents

xray assessment paalignment

cup lunate

degreesaxis of lunate

axis of radius

carpal instability

scapholunate joint

pa scaphoid

ligament disruption