PLAIN RADIOGRAPHY OF HAND AND WRIST

Dr.Bhaskaranand KumarProfessor & Head,

Hand & Microvascular Surgery,Department of Orthopaedics,Kasturba Medical College &

HospitalManipal - 576 104.

HISTORYHistory of imaging of hand and wrist is the history of radiology

William Conrad Roentgen (Dec 1895) x- ray of human hand

William Conrad Roentgen(1845-1923)

The first radiograph was of his wife's hand given to her as a Christmas present

William Conrad Roentgen(1845-1923)

What was

20mins

exposure

then, has been reduced to

milliseconds now

HISTORY

Few months later in Feb. 1896 first clinical

application of x-ray in USA to diagnose

Colles’ fracture

A good orthopedist needs to be “his own radiologist”

-Prof. V.

Chacko

A good radiologist must aim at becoming a good orthopaedic radiologist

-Dr. Jaganmohan Reddy

It is a common mistake to ask for wrong or insufficient views

Common mistakes

Exposing two hands in single film

Common mistakes

To include entire hand, wrist

and forearm in a single film

Common mistakes

Breaking the rule of minimum two views

Common mistakes

Breaking the rule of minimum two views

Common mistakes

Writing for AP view in hand and wrist

X ray of hand and wrist in a single film is a

false sense of economy

Standard views of the hand differ from those of the wrist

Similarly when fingers are to be studied properly they need separate X-ray

BASIC VIEWS•Wrist- PA, lateral,•Hand - PA, Lateral, oblique

•Fingers- PA, lateral, oblique

WRIST•PA and Lateral view•Centre point-head of capitate

•Exact positioning is most important

WRIST PA VIEW

Position: (sitting)•Shoulder: 900 abduction•Elbow: 900 flexion•Forearm: pronated•Wrist: neutral •Fingers: extended

WRIST PA VIEW

Long axis of 3rd metacarpal,capitate and radius in a straight line

WRIST PA VIEW

WRIST PA VIEW

What is a good PA view?

• CMC joints must be seen without foreshortening

• If wrist is dorsiflexed these are not seen

WRIST PA VIEW

What is a good PA view?

WRIST PA VIEW

What is a good PA view?• Ulnar styloid arises from ulnar

border of head of ulna• In AP view it arises from the

center of distal end of ulna

WRIST PA VIEW

What is a good PA view?• Fovea is seen just lateral to the

base of ulnar styloid process• Triangular fibro cartilage is

attached here

WRIST PA VIEW

What is a good PA view?• ECU groove is at or radial to the

fovea, at the base of the ulnar styloid.

WRIST PA VIEW

What is a good PA view?

• If ECU groove overlaps ulnar styloid it means that elbow is kept at a lower level than shoulder

• More the groove overlaps, lower the elbow

-Gilula and Yin

WRIST PA VIEW

What is a good PA view?

• Ulna becomes more positive if shoulder abduction is reduced

WRIST PA VIEW

What is a good PA view?

WRIST lateral view

• Patient – sitting • Shoulder - adducted against the

trunk• Elbow – 900 flexion • Forearm – midprone• Wrist – neutral flexion• Fingers - full extension

WRIST lateral view

A good lateral view

• Long axis of the radius, capitate and metacarpal should be in the same line

WRIST lateral view

A good lateral view

• ‘‘ Line of sight ” - SPC• Ideal lat. View – palmar margin

of pisiform should project midway between the palmar margins of distal pole of scaphoid and head of capitate

WRIST lateral view

A good lateral view

SPC

WRIST lateral view

• The more supinated the wrist , the pisiform will project more anterior to the scaphoid

WRIST oblique view

Position-

• Wrist - pronation 450 from the lateral position

Step wedge can be used

WRIST oblique view

Advantages

Evaluation of • Base of the thumb• Scaphotrepezio-trepezoid

joint• Additional view of scaphoid

WRIST ulnar deviation PA

Position- • Like for PA view but wrist in

ulnar deviation

WRIST ulnar deviation PA

Position- • Like for PA view but wrist in

ulnar deviation

• Scaphoid looks elongated

WRIST AP view

Position-

• Forearm in full supination

• Best for evaluation of scapholunate and lunotriquetral interspace

CLENCH FIST VIEW AP

This increases the gap between the carpal bones

PA AP

Scapholuno diastases

Compare the gap with opposite wrist

Normal Compare the width with the

adjacent capitolunate joint

Radial inclination

16-28 (22)

Radial length

11 – 12 mm

Palmar tilt

90 deg

Palmar tilt

0-22 deg (11)

HANDPA, lateral & oblique views

Centre point head of the metacarpal

Exact positioning is important

HAND PA VIEW

Position- sitting

•Hand kept with entire palm touching the cassette

•Fingers and thumb slightly opened up

HAND PA VIEW

HAND PA VIEW

Metacarpals and proximal phalanges are best exposed

Distal phalanges are over exposed

Carpal bones are under exposed

HAND PA VIEW

HAND LATERAL

Position- Sitting•Wrist neutral •Hand kept with its ulnar

border of fingers and hypothenar touching the cassette

•Fingers with MCP flexion at varying degrees of flexion and thumb abducted

HAND LATERAL

There should be no digital overlapping

Centre point:head of 3rd metacarpal

HAND LATERAL

HAND OBLIQUE

Position- Sitting Hand is kept at 450 of pronation

with hypothenar eminence touching the cassette

A step wedge with steps to accommodate the fingers, could be used

HAND OBLIQUE

Good for visualizing metacarpals which tend to overlap in a true lateral view

Fingers PA, lateral and oblique

Center point over the point of interest

( may be PIP or DIP )

Finger PA Position – Sitting

Finger – volar side touching the cassette

All digits abducted from the center

Finger lateral

Index, Middle & Little – respective MCP extended, remaining fingers flexed

Finger lateral Ring – others extended and

ring flexed

Finger oblique

Helpful in the assessment of joint injuries