Wrist and Hand

Wrist X-ray Basic views: PA & lateral Carpal bones mnemonic Some Lovers Try Positions That They Can’t Handle Trapezium = Thumb Scaphoid fracture: delayed imaging Carpal tunnel view

Some Lovers Try Positions That They Can’t Handle

Wrist X-ray

Normal Wrist

Normal Wrist Ulnar Deviation

Demonstration Wrist X-rays 4 views PA PA Oblique Lateral PA with Ulnar Deviation

Case 1 21 y.o. female DDx? What would be the most common injury? snowboarding & lost her balance falling backwards she reached out her right hand to catch herself acute onset of wrist pain DDx? What would be the most common injury?

Scaphoid Fracture M/C carpal bone fracture M/C mechanism: FOOSH Pain on radial wrist & TTP in snuff box (ulnar deviation) X-ray: PA, lateral, scaphoid view (ulnar dev) Management pearls clinical suspicion, neg x-rays thumb spica splint/cast re-image in 10-14 days

Scaphoid Fracture

Scaphoid Fracture

Scaphoid Fracture Scaphoid view

Case 2 & 3 48 y.o. LH new golfer 29 y.o. LH golfer hard swing & unknowingly hits a tree root pain on ulnar aspect of R palm 29 y.o. LH golfer pain on ulnar aspect of R palm for a few months

Hook of the Hamate Fx Usually seen in individuals who participate in sports involving a racquet, bat, or club Rare but relative common fx in “swingers” Acute or overuse type injury Imaging carpal tunnel view but notoriously missed on x-ray CT scan Swingers vs Throwers

Hook of the Hamate Fx

Hook of the Hamate Imaging

Hook of the Hamate Imaging

Colle’s Fracture Mechanism: FOOSH Victims young w/ high energy trauma older w/ osteoporotic bones & low energy trauma Fracture of distal radius w/ dorsal angulation of the distal fracture fragments

Colle’s Fracture Due to the dorsal angulation of the distal fragment, Colle’s fractures are often said to have a "dinner fork" appearance

Dinner Fork Deformity

Colle’s Fracture X-rays Dorsal angulation of distal segment

Colle’s Fracture Management Complications nondisplaced, minimal angulation: sugar-tong splint displaced: refer for reduction Complications median nerve injury, compartment syndrome & vascular compromise Be aware of associated injuries (ulnar styloid, scaphoid, etc)

Normal Hand

Normal Hand

Normal Oblique Hand

Demonstration Hand 3 Projections PA PA Oblique Lateral

Metacarpal (Boxer’s) Fracture Most common of all metacarpal fractures Associated with martial arts/boxing MXN: direct axial force caused by punching another person or object Direct impact to hand

Boxer’s fracture

Boxer’s fracture

Metacarpal fractures

Mallet Finger MXN: Blow to tip of finger, jamming it and avulsing the extensor tendon from its insertion at the distal phalanx Can cause an avulsion fraction as well

Mallet finger

Mallet finger

Mallet finger

Mallet finger-stack splint

Stack splint

Jersey Finger MXN: Forced extension/hyperextension of DIP joint Grabbing on to a jersey Rupture of flexor digitorum profundus tendon and or avulsion fracture

Jersey finger

Boutonniere Deformity MXN: DIP joint forced into extension and PIP joint forced into flexion Rupture of extensor tendon mechanism at the PIP joint

Boutonniere deformity

Boutonniere deformity

Boutonniere deformity

Gamekeeper’s Thumb MXN: Forced abduction and hyperextension of the proximal phalange of thumb Falling on the thumb Sprains UCL of 1st MP joint

Gamekeepers thumb

Gamekeepers thumb

Interphalangeal Dislocation Can affect PIP or DIP joint Axial force to the tip of the finger Blow to tip of finger Falling directly on extended finger May rupture tendon, avulse bone, pinch volar plate

Dislocation

Dislocation

Dislocation

Dislocation

Dislocation

PIP dislocation

TX: Physician referral for reduction & x-ray Splint (about 3 weeks) Ice

Finger fracture MXN: Stepped on (direct force) Hit on the tip of finger Twisting/torsion

Fracture

Fracture

Finger Sprain MXN: Axial force to the tip of the finger, “jamming” it

sprain

Sprain

Subungual Hematoma MXN: direct blow to the fingernail S/S: throbbing pain due to accumulation of blood under the nail TX: ice (water) to numb, release pressure under nail by drilling/burning a hole it the nail

Ring injury MXN: getting ring/jewelry caught on something S/S: deformity, bleeding, pain, loss of body part Tx: find body part, control bleeding, cover open wound, treat for shock, send to ER

Ring injury

Arthritis of the Hand Normal Osteoarthitis Rheumatoid arthritis CPPD crystal deposition Gout Psoriatic arthritis

Normal Hand X-ray

Osteoarthritis (DJD) Gradual degeneration of articular cartilage Joint pain relieved with rest Morning stiffness resolves within 30 minutes Traditionally affects DIPs, 1st IP No systemic symptoms Painless nodules Heberden’s at DIPs Bouchard’s at PIPs

OA – Radiographic findings Joint space narrowing Osteophyte formation (white arrow) Subchondral sclerosis (black arrows)

Joint space narrowing distally Marginal osteophytes Relatively unchanged proximal structures

Another example of OA Oblique and AP views 1st carpal metacarpal shows decreased joint space and subchondral sclerosis 2nd and 3rd DIP shows osteophytes and subchondral sclerosis (Heberden’s nodes)

Rheumatoid Arthritis Systemic inflammatory disease Affects synovial membranes Pannus (granulation tissue) develop in joint spaces and erode into the articular cartilage and bone Prolonged morning stiffness (>1 hr) PIPs, MCPs, and wrist commonly involved Symmetric joint involvement

RA radiography - early Earliest signs include soft tissue swelling due to effusion, tenosynovitis, and edema Periarticular osteopenia Marginal erosions often first seen at 2nd and 3rd MCPs and 3rd PIP articulations

Severe erosive changes at radio-ulnar joints carpal bones at the metacarpal heads Bilaterally symmetric

Advanced RA Boutonniere (top) Swan neck Labs: +RF in 80%: IgM against Fc of IgG Elevated ESR Anemia of chronic disease

RA - Late Complete MCP involvement Large marginal erosions have nearly destroyed the joints Bones are lucent due to osteopenia Ulnar deviation

RA Bone Scan Technetium-99 bone scan Uptake shown in subclinical inflammation of joints Symmetrical Polyarticular

Calcium pyrophosphate dihydrate crystals (CPPD) “Pseudogout” Associated with metabolic diseases such as hyperparathroidism, hemochromatosis, hypothyroidism Compared to gout: Large joints affected (2nd to 5th MCPs, radio-carpal) Rhomboid crystals Positive birefringence Calcification of articular cartilage No cortical erosions

CPPD Chondrocalcinosis Distal radius and MCPs (2nd and 3rd) Cartilage destruction similar to OA – differentiate by location Location similar to RA – differentiate by absense of erosions Calcium deposition at triangular fibrocartilage of the wrist (picture)

CPPD Diffuse condrocalcinosis at the radiocarpal joint, the MCP joints and the PIP Joint space narrowing, sclerosis, and subchondral cysts within the carpals

Brief summary so far

Gout Disorder of purine metabolism – overproduction versus underexcreation Deposition of urate crystals in joint spaces Middle-aged men Acute onset of extreme pain in small joints with redness and swelling Needle shaped crystals with negative bifringence Asymmetric, monoarticular

Gout

Gout Radiography All joints of hand and wrist possible (2nd-5th PIP most common) Soft tissue swelling Well demarcated osseous erosions with sclerotic rims and overhanging edges No decrease in bone density Tophi not calcified Relative sparing of joint space until late in the disease Long latent period between onset of symptoms and radiographic changes

More gout

Psoriatic Arthritis HLA-B27 positive, RF negative Inflammatory Seronegative spondyloarthropathy Asymmetric and bilateral Primarily distal involvement associated with nail changes No periarticular osteoporosis Five different patterns Usually accompanies skin disease

Psoriatic Arthritis – Rad findings Asymmetric proliferative erosions with ill-defined margins Periosteal reaction Soft tissue swelling “Pencil-in-cup” deformity Resorption of distal phalangeal tufts Subluxation

Psoriatic arthritis