Wrist PPT 2 Imaging of the Upper Extremity PDF

Imaging of the Upper Extremity: Injuries of the wrist and hand Sarah Maceda OTR/L CHT Normal Wrist Anatomy Radial Inclination • Radial inclination is 22-24 deg. • Palmar tilt 10 -12 degrees. • Post DRFX – goal is to restore radial inclination >15 degrees , palmar tilt between -15 and 20 deg. Rad...

Imaging of the Upper Extremity: Injuries of the wrist and hand Sarah Maceda OTR/L CHT Normal Wrist Anatomy Radial Inclination • Radial inclination is 22-24 deg. • Palmar tilt 10 -12 degrees. • Post DRFX – goal is to restore radial inclination >15 degrees , palmar tilt between -15 and 20 deg. Radial shortening <5 mm. • Failure to do this causes : ROM impairment, dec strength, ulnar wrist pain, cosmetic deficits. Three Wrist arches Gilula three carpal arcs refer to the carpal alignment described on posteroanterior or anteroposterior wrist radiographs and are used to assess normal alignment of the carpus: first arc: is a smooth curve outlining the proximal convexities of the scaphoid, lunate and triquetrum. second arc: traces the distal concave surfaces of the same bones. third arc: follows the main proximal curvatures of the capitate and hamate. Ulna positive Variance Ulnar Impact syndrome • Impingement of ulnar head against the carpus causes synovitis, articular disc perforations, chondromalacia, ligament degeneration. • Cause : Malunion or DRFX, Premature closure of radial physis, Essex-lopresti injury, Madelung’s Deformity • Patient symptoms: pain with ulnar dev, gripping with the forearm in pronation, axial loading (opening jars ). • Surgical treatment of choice: Ulnar shortening osteotomy if plus variance is 2.6 mm. Ulna shortening Osteotomy Immobilize wrist and forearm- Muenster cast 6 weeks then into a short arm splint until 8 weeks 10 days post AROm and PROM begins 8 weeks wean out of splint if healed and begin strengthening Distal Radius FX • Most common in children 6-10 years olds • Adults over 60 , Women > Men • Fixed Angle Volar plate has become standard over last 10 years for intra-articular Fractures and those that lose Radial Height. DRFX Classifications • Colles’ FX extra-articular fracture with dorsal displacement, radial shortening, and dorsal angulation of the distal Radius. • Smith’s FX- Reverse Colles’ fx : Volarly Displaced, angulated fracture of the distal radius • Barton’s FX – Displaced and unstable unstable fracture subluxation of the distal radius with the carpus following the articular fragment. • Chauffer’s FX – Fracture of Radial Styloid Treatment DRFX • Post operative after ORIF -10-12 days the patient has a custom wrist control orthotic fabricated that they can remove for AROM to wrist, digits and forearm.(Some doctors may start AROM in 1st week depending on age of patient and success of fixation) • Week 4 - PROM • Week 6 -Strengthening as tolerates. Begin to wean from orthotic • Week 8- DC orthotic. If bone is healed begin to transition to normal activities/sports. CMC OA Scaphoid Fracture • The scaphoid is the most commonly FX bone in the hand . Wrist hyperextension injury with radial deviation. • Fractures of the waist are most common. May interfere with interosseous Blood Supply • Proximal pole fractures at risk of AVN 100%. Anatomy of Scaphoid MRI Scaphoid FX • 15% of Xrays are false negatives at the time of the time of injury . Xray needs to be repeated 2-3 weeks after injury for proper diagnosis • MRI 100% accurate 72 hours post injury Treatment for Scaphoid Fracture • Stable nondisplaced FX of the waist, distal pole 8-10 weeks in Thumb spica cast. • Fracture of middle portion 6 weeks Long arm thumb spica . • Proximal Fractures 6 weeks Long arm thumb spica . 6 months in a short arm thumb spica. (most doctors would fixate) • Proximal pole need ORIF with compression screws. • Nonunion common- Tx with bone graft 30% effective. cause a Humpback Deformity (flexion deformity of the nonunion site) . This is also referred to as a Scaphoid Nonunion Advanced Collapse (SNAC) . SNAC wrist • Radioscaphoid narrowing • Capitolunate narrowing • Cyst formation • Dorsal intercalated Segment instability • Treatment – Proximal Row Carpectomy (PRC), Wrist fusion Hammate FX Fracture of the hook of the hamate is the most common hamate fx . Cause: Direct trauma or crush injury ,Improper Golf Swing , Tennis players CT scans are helpful in DX Loss of grip strength primary limitation Phalanx Fractures • Distal Phalanx : crush injuries • loss or ROM of DIP • Hypersensitivity of Tip of finger. • More complicated with children if FX into growth plate or open injury can cause osteomyelitis or nail growth deformity Proximal and Middle Phalanx FX • Middle and Proximal Phalanx FX : Most common in 1029 year olds , Sports injuries • Absolute stability with ORIF begin AROM 24-72 hours . (plate, screws). Dynamic splinting 10-14 days .4-6 weeks light PREs. Decrease time in orthotic • Unstable fixation: AROM 3-10 days. PROM when healed (6-8 weeks) • Hand based MP flex /PIP ext orthotic. (Safe Position ) for base or shaft fractures. Gutter orthotic may be ok for distal Fx of base or neck • DC orthotic 6-8 weeks Fixation Middle phalanx Fx with Screws Pilon FX Metacarpal Shaft FX Oblique or Spiral Fractures • Oblique fractures from a torque injury. Only minimal shortening to result in significant rotational Deformity • This can result in scissoring of the digits over each other • Treatment involves Kwire Fixation or screws and plates • Rigid Stabilization can begin ROM 24 to 72 hours after Surgery • Splint in Intrinsic Plus position in between exercises • DC splint 4 weeks • 6 weeks Begin Strengthening • With incomplete stability PROM not started till 3-4 weeks . • Unstable Fractures may not begin AROM till 4 weeks Boxers FX • Metacarpal Neck FX, usually RF and SF • TX with Dorsal forearm based max MP flex (70 deg) wrist in 15 deg ext orthotic 6-8 weeks. • Splinting in extension can result in MP release surgery due to ligament and capsule shortening Carpal Instability • Intact SL & LT ligaments ensures the PCR flexes as a unit with radial Dev / extends with Ulnar dev . • SL ligament is the most common injured ligament of the wrist . • Increased stress on Radioscaphoid and Capitolunate Joints cause a SLAC Wrist • SLAC wrist –degeneration of scaphoid, lunate capitate and radius. TX – PRC or wrist fusion Dorsal Intercalated Segment Instability • Completet Disruption of SL Ligament • Lunate assuming an extended position • Scaphoid assuming a palmar-flexed position • Young to middle aged , fall on an outstretched wrist . • Positive scaphoid shift test , Clenched fist x-ray SL interval > 3mm. DISI and VISI • VISI – LT injury cause lunate flexion . #2 Scaphoid /lunate angle less than 30 • DISI – Pic # 3 Lunate is dorsally rotated into extension . Scaphoid lunate angle greater than 70 • Carpal Instability Dissociative • Early diagnosis before 6 weeks SL repair . SLAC Wrist • Chronic Scapholunate instability • The scaphoid rotates and the capitates pushes in-between the scaphoid and lunate • degeneration 1st at the scaphoid radial styloid joint 2nd at the capitate lunate. Four Bone Arthrodesis • Excise the scaphoid • Fuse lunate, capitate, hamate and triquetrum • Eliminates midcarpal degeneration and further capitate migration • 50-60% of normal wrist ROM and 80% Grip strength. Good Long term results Kienbock Disease • AVN Lunate caused by ulnar-negative variance which causes micro fracture to Lunate . Fractures of lunate not usually due to Trauma. • variations in interosseous vasculature Proximal Row Carpectomy • Disease affecting the Proximal carpal row • AVN of Lunate or scaphoid • Motion of capitate and radius is rotational and translates • 70-80 deg of wrist flex/ext arch . Grip strength 71-79% of normal What is this ?