Emergency and Trauma of Hand and Wrist

Seminars in Musculoskeletal Radiology

Emergency and Trauma of the Hand and Wrist --Manuscript Draft--

Manuscript Number: Full Title:

Emergency and Trauma of the Hand and Wrist

Article Type:

Review

Keywords:

Trauma, Hand, Wrist, Fingers, Musculoskeletal Radiology

Corresponding Author:

M. Maas AMC Amsterdam, NETHERLANDS

Corresponding Author Secondary Information: Corresponding Author's Institution:

AMC

Corresponding Author's Secondary Institution: First Author:

Rik B Kraan, MD

First Author Secondary Information: Order of Authors:

Rik B Kraan, MD Frances E Walstra, MD Teun Teunis, MD, PhD Frank F Smithuis, MD Cornelis F van Dijke, MD, PhD Mario Maas, MD, PhD

Order of Authors Secondary Information: Abstract:

Traumatic injuries of the hand and wrist are common in daily practice. A number of challenges arise in the process of diagnosis and guiding the clinician. Knowledge of the complex finger, hand and wrist anatomy is essential to understand the broad array of traumatic injuries extending from (stress)fractures to ligament-, tendon and neurovascular injuries. This paper provides an overview of the different imaging techniques used in the evaluation of the hand and wrist. Emphasis is placed on the most common traumatic injuries of the hand, wrist and fingers and the imaging modality of choice in evaluating these injuries.

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TITLE PAGE

Emergency and Trauma of Hand and Wrist In: Seminars in Musculoskeletal radiology, special issue on Emergency and Trauma in MSK Radiology

Corresponding author Mario Maas, MD Professor of Radiology, Department of Radiology, G1-211 Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands [email protected] 020-5661666

Co-authors Rik B. Kraan, MD

Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands

Frances E. Walstra, MD

Department of radiology, Noordwestziekenhuisgroep Alkmaar, The Netherlands

Teun Teunis, MD, PhD

Department of Plastic, Reconstructive and Hand Surgery, University Medical Center Utrecht, The Netherlands

Frank Smithuis, MD


Cornelis F. Van Dijke, MD, PhD

Department of Radiology, Noordwestziekenhuisgroep Alkmaar, The Netherlands

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TITLE PAGE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

Emergency and Trauma of Hand and Wrist In: Seminars in Musculoskeletal radiology, special issue on Emergency and Trauma in MSK Radiology

Corresponding author Mario Maas, MD Professor of Radiology, Department of Radiology, G1-211 Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands [email protected] 020-5661666

Co-authors Rik B. Kraan, MD


Frances E. Walstra, MD

Department of radiology, Noordwestziekenhuisgroep Alkmaar, The Netherlands

Teun Teunis, MD, PhD

Department of Plastic, Reconstructive and Hand Surgery, University Medical Center Utrecht, The Netherlands

Frank F. Smithuis, MD


Cornelis F. Van Dijke, MD, PhD Department of Radiology, Noordwestziekenhuisgroep Alkmaar, The Netherlands

Emergency and Trauma of Hand and Wrist -

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ABSTRACT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

Traumatic injuries of the hand and wrist are common in daily practice. A number of challenges arise in the process of diagnosis and guiding the clinician. Knowledge of the complex finger, hand and wrist anatomy is essential to understand the broad array of traumatic injuries extending from (stress)fractures to ligament-, tendon and neurovascular injuries. This paper provides an overview of the different imaging techniques used in the evaluation of the hand and wrist. Emphasis is placed on the most common traumatic injuries of the hand, wrist and fingers and the imaging modality of choice in evaluating these injuries.

Key words: Trauma, Hand, Wrist, Fingers, Musculoskeletal Radiology Page count (excluding title page, abstract and references): 23 Figure count: 18 Table count: 1 Reference count: 144


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CONTENTS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

1

Introduction........................................................................................................................ 4

2

Imaging ............................................................................................................................... 4 2.1

2.1.1

Conventional Imaging........................................................................................... 4

2.1.2

Computed Tomography ....................................................................................... 5

2.1.3

Magnetic Resonance Imaging .............................................................................. 6

2.2

Wrist ............................................................................................................................ 6

2.2.1

Conventional imaging........................................................................................... 6

2.2.2


2.2.3

Magnetic Resonance Imaging .............................................................................. 8

2.2.4

Arthrography ........................................................................................................ 8

2.3

3

Distal radius ................................................................................................................. 4

Hand and finger ........................................................................................................... 9

2.3.1

Conventional Imaging........................................................................................... 9

2.3.2


2.3.3

Magnetic Resonance Imaging ............................................................................ 10

2.3.4

Ultrasound .......................................................................................................... 10

Injuries .............................................................................................................................. 11 3.1

Wrist .......................................................................................................................... 11

3.1.1

Distal Radius Fractures ....................................................................................... 11

3.1.2

Carpal fractures .................................................................................................. 13

3.1.3

Soft tissue injuries .............................................................................................. 15

3.2

Hand and finger injuries ............................................................................................ 17

3.2.1

fractures ............................................................................................................. 17

3.2.2

Joint injuries ....................................................................................................... 20

3.2.3

Thumb injuries.................................................................................................... 23

3.3

Nerve injuries............................................................................................................. 24

3.4

Vascular injuries......................................................................................................... 24

4

Acknowledgements .......................................................................................................... 25

5

References ........................................................................................................................ 26

6

Figure captions ................................................................................................................. 33

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Tables ............................................................................................................................... 36

Emergency and Trauma of Hand and Wrist 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

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INTRODUCTION Traumatic hand and wrist injuries occur frequently [1, 2]. For instance, distal radius

fractures are among the most common fractures in daily practice [3, 4]. Carpal injuries are rarer [3, 5], although scaphoid fractures are the second most common wrist fracture [3]. Most distal radius or wrist injuries happen in active and young individuals or osteoporotic elderly, and trauma mechanism often includes a fall on an outstretched hand [5]. Traumatic hand- and finger injuries include both osseous and soft-tissue injuries and often befall during work or sports-participation [6]. The traumatic injuries range from obvious to very subtle, however even subtle injuries can alter hand function significantly and affect performance [7, 8]. Early detection will help prevent long-term complications and allows the patient to get appropriate and timely treatment and quick return to play or work [8, 9]. When dealing with acute hand and wrist trauma as an MSK radiologist, a number of challenges arise in the process of diagnosis and guiding the clinician [10, 11]. Knowledge of anatomy, different imaging techniques and the spectrum of injuries is essential for best practice. This requires an integral approach of all adjacent structures, as presented in this paper. 2 2.1

IMAGING Distal radius

2.1.1 Conventional Imaging Standard imaging of distal radius fractures includes posteroanterior (PA) and lateral radiographs [12]. For both views the patient should be positioned with the shoulder in 90⁰ abduction and the elbow in 90⁰ flexion [13]. This is the solitary position providing parallel positioning of radius and ulna [14]. The groove of the extensor carpi ulnaris should lie radial


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to, or at the level of, the ulnar styloid on the PA view. In addition, processus styloideus ulna 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

has to be located on the most ulnar border of the ulna [13, 14]. A lateral view in relative supination or pronation shows the ulna superimposed on the radius, but with an oblique view of the articular surface. To gauge the quality of a lateral radiograph, the relative position of the pisiform to the distal pole of the scaphoid can be used. On a true lateral image, the pisiform overlies the distal pole of the scaphoid (figure 1) [12]. In relative pronation the pisiform projects dorsal of the distal scaphoid pole, supination cause volar projection of the pisiform compared to the scaphoid [15]. Additional modified lateral projection - in which the beam is angled 10-20° proximally - enhances visualization of the important ulnar two-thirds of the distal radius articular surface [15-17]. Alternatively, the forearm can be raised 10-20° towards the beam [15]. Recently a decision making tool has been developed to enhance selection of adult [18] and pediatric [19] patients with acute wrist trauma for imaging at the emergency department. Both models require external validation but seem to reduce unnecessary radiographs after wrist injury. 2.1.2 Computed Tomography CT imaging has gained tremendous popularity in many fields, as well as in distal radius fractures. CT images enhance injury characterization compared to standard radiographs [12, 17]. Therefore, additional CT-scans often alter treatment plans [20]. In particular, articular comminution and fractures affecting the sigmoid notch can be visualized [17, 21]. Some evidence states that CT scanning leads to higher surgery-rate, without evidence of improved outcome [22]. CT imaging allows for three-dimensional rendering. These three-dimensional models in turn enhance the identification of specific fracture characteristics when compared to two-


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dimensional CT imaging [23]. Measurements on three-dimensional fracture models have 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

been coined quantitative three-dimensional CT (Q3DCT) analyses. Using these techniques three-dimensional displacement of single fragments, fragment articular surface area, and surface area of the articular gap can be accurately measured [24]. Main indications for CT-imaging in distal radius fractures in our institution include preoperative planning of intra-articular fractures. Especially extent of the fracture in the scaphoid and lunate fossa and sigmoid notch of the distal radio-ulnar joint have to be mentioned in the report. 2.1.3 Magnetic Resonance Imaging MRI is not routinely used for the initial evaluation of distal radius fractures [16]. MRI can identify additional soft tissue disruption and occult bony injuries [17]. Correctly visualizing the wrist ligaments and recognizing injuries requires specific MR sequencing and can be complicated by artifacts mimicking defects [25]. MR-imaging can be improved by using specialized coils [26], however correct interpretation requires experience and expertise. 2.2

Wrist

2.2.1 Conventional imaging Similar to conventional imaging of the distal radius, PA and lateral radiographs are the first step for evaluating carpal fractures [13, 27]. Neutral wrist position is important on both views. Therefore, patient positioning and techniques for both views are similar to radiographs of the distal radius. [13, 14]. The pisiform has to be aligned between the palmar cortices of the scaphoid and capitate on adequate lateral views of the wrist (figure 1) [28]. In addition, radius, lunate and capitate should be aligned in extension of each other [3, 28]. The lateral view is important in


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the assessment of ligamentous instability between carpal bones [13] as angle measurements 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

on lateral view can determine correct position of scaphoid, lunate and capitate (figure 2). Since most carpal fractures are difficult to evaluate on conventional imaging, additional views may be beneficial. An overview of different views is provided in figure 3. To enhance visibility of scaphoid fractures three extra views are valuable; an ulnar deviated PA view, an ulnar deviated PA view after raising the distal radius 20⁰ and an ulnar deviated view in a 30-45⁰ oblique angle [13, 29]. To enhance visibility of hamate hook or pisiform fractures carpal tunnel view may be beneficial [3]. Clenched fist view is helpful for assessing scapholunate dissociations [13]. However, with the advantage of imaging techniques this additional views are often replaced by CT or MRI. Plain radiographs for carpal fractures are sufficient in the following two scenarios; when radiographs are normal and clinical suspicion is low, or when a fracture is visible and no concomitant injuries are suspected. If no fracture is shown on plain radiographs but clinical suspicion remains high, additional imaging is indicated. 2.2.2 Computed Tomography CT images provide detailed information about fracture parts, dislocation and alignment of the different fracture parts [3, 12] and should be performed when suspecting carpal injury and radiographs are normal [30]. Discongruity of the joint surface on both sides of the fracture can be adequately analyzed using CT. CT can also be used to assess fracture stability and evaluate presence of concomitant fractures [31]. Therefore, CT is essential for pre-operative planning and prevention of future osteoarthritis [32]. CT has superior accuracy compared to conventional radiographs for evaluating scaphoid fractures. Accuracy is similar compared to MRI if CT-images are reconstructed in planes defined by the long axis of the scaphoid [31, 33].


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2.2.3 Magnetic Resonance Imaging 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

MR imaging for evaluation of carpal injuries should include sagittal, axial and coronal planes with fluid sensitive PD- and T2-weighted (fat saturated) sequences for visualizing pathological (fluid) changes. Especially bone marrow edema indicating a fracture can be adequately visualized using fluid sensitive sequences. As mentioned before, MRI has similar accuracy compared to CT in assessing scaphoid fractures [34, 35]. If initial radiographs are negative in suspected scaphoid fracture advanced imaging is advised [36]. A cost-effectiveness analyses showed that this strategy decreases net expenses compared to traditional approach (cast immobilization with subsequent follow-up radiographs after 2 weeks) [37]. MRI can provide additional information about concomitant fractures, osseous contusions, osteonecrosis and soft tissue injuries, including intrinsic and extrinsic ligamentous pathology [38]. When evaluating carpal injury in children MRI is inevitable due to the visualization of incomplete ossified carpal bones in the immature skeletal system of children [39]. MRI protocols are more sensitive and cost effective for evaluating carpal injuries. However, CT is more easily available than MRI in daily practice [30]. 2.2.4 Arthrography Both CT- and MR-arthrography may be used to enhance visibility of cartilage abnormalities, intrinsic and extrinsic ligaments and the triangular fibrocartilage complex [40, 41]. In wrist arthrography, mainly a three-compartment method is used with contrast administration in the midcarpal joint, distal radioulnar joint and at the radial aspect of the ulnar head under fluoroscopic guidance [41, 42]. The techniques provides enhanced accuracy compared to conventional MRI, however invasiveness is a major disadvantage [43].


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Higher spatial resolution of CT-arthrography provides superior accuracy for diagnosing 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

TFCC tears, cartilage abnormalities and partial scapholunate- or lunotriquetral ligament tears compared to MR-arthrography. However, MR-arthrography is valuable for simultaneous assessing soft tissue- and bone marrow abnormalities [40]. 2.3

Hand and finger

2.3.1 Conventional Imaging Radiography is the first and most important imaging modality in hand- and finger injuries [9, 36]. Radiographs are inexpensive and provide rapid and accurate assessment of fractures, dislocations or presence of a radiopaque foreign body. Most osseous phalanx and thumb-injuries can be identified using PA, true lateral and oblique views [8]. Additional views are beneficial for detecting small avulsion fractures of the head of the middle- or proximal phalanges [9, 11, 36]. In assessing metacarpal fractures or dislocations, three views are recommended; PA, lateral and semi-pronated oblique [9, 36]. Stress views were once recommended to diagnose ulnar collateral ligament injury in the thumb. However, the maneuver may worsen the injury [7, 36, 44]. As stress fractures may not become apparent until several days after injury, additional imaging should be performed in the following days. 2.3.2 Computed Tomography In most cases, CT is abundant for diagnosing hand- and finger injuries. However, CT images may be valuable to determine the extent of the fractures and severity of dislocation or rotation and for guiding surgical planning [7, 36]. In addition, CT may be helpful to identify small fragments and in evaluating mal-, non- or delayed union [45, 46]. Metacarpal and phalanx fractures can be complicated by rotational dislocation. Torsion angle can be measured on CT-images [47]. Torsion angle exceeding 3⁰ is indicative


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for malrotation. These measurements help to plan derotational osteotomy and evaluate 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

therapy results [47] 2.3.3 Magnetic Resonance Imaging MRI is extremely valuable in evaluating traumatic soft tissue injuries of the hand and fingers [48] and is able to accurately diagnose the extent of tendon-, ligament- and other soft tissue injury [46] Tendons, ligaments and volar plates have a homogeneous low signal on T1-,T2weighted- and proton density (PD) sequences [11]. Torn tendons have intermediate to low signal intensity on T1-weighted images. However, post-traumatic bleeding may increase signal intensity [48]. Similar to MRI of the wrist, fluid sensitive sequences (T2- or PDweighted fat-saturated or Short Tau Inversion recovery (STIR) images) are superior to detect pathological fluid changes and edema. Complete tendon-tears will show a gap and retraction [49]. Fraying and laxity of the tendon may also indicate a complete tear [50]. Focal bone marrow edema and cortical irregularity at the origin-site suggest avulsion fracture [48]. Differentiation between partial tear or tendon-contusion is challenging. Focal thickening and high signal may be seen on PD- and T2- weighted sequences [49]. Partial discontinuity of the tendon or bright fluid signal within the tendon implies a partial tear [50]. 2.3.4 Ultrasound Ultrasound (US) is a quick and inexpensive technique beneficial for evaluating soft tissue injuries. In addition, US has the advantage of dynamic examination. Technical advances enhance diagnostic accuracy and visibility of internal architecture of tendons and ligaments due to higher frequency transducers [51]. Excellent knowledge of anatomy in the fingers and hand is necessary for accurate evaluation of pathology.


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Ligament tears are seen as hypoechoic or anechoic gaps, sometimes with fluid and 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

widening of the joint [52]. US is especially helpful if MRI is contra-indicated or unavailable [51]. Tendons are suitable for US evaluation with high resolution probes due to their superficial position. Normal tendons retain a hyperechoic fibrillary pattern [51]. Echogenicity is dependent on orientation and direction of the probe; this anisotropy provides falsely hypoechoic tendons if ultrasound beam does not interrogate the tendons at a 90⁰ angle [53]. Dynamic assessment with flexion of the fingers can confirm flexor pully injuries. In addition, occult fractures can also be detected using US [53]. 3

INJURIES Knowledge of anatomy and injury mechanism is essential to identify different injury

types and their extent. The radiologist should be aware of the spectrum of injuries (ranging from fractures, tendon rupture to soft tissue injuries) to help guide the clinician. Diagnostic imaging of hand and wrist injuries in athletes should include evaluation of stress related injuries due to repetitive straining. Overuse injuries of the upper extremity are uncommon, however are being increasingly recognized as a cause of hand and wrist pain in athletes [6, 54]. Examples of stress related fractures include distal radius and scaphoid stress fractures in gymnasts [55], hamate hook fractures in tennis, golf or baseball players [56] and metacarpal stress fractures in tennis players [57]. 3.1

Wrist

3.1.1 Distal Radius Fractures Prevalence of distal radius fractures has a bimodal distribution by age: a younger, predominantly male, population sustaining sport injuries and high-energy trauma; and an elderly, mainly female, population injured in simple falls from a standing height [58].


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About half of all distal radius fractures are intra-articular [59]. Melone’s concept of 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

the basic components involved in a typical intra-articular distal radius fracture helps understand principal fracture configuration [60]. This can be combined with the threecolumn theory, identifying forces transmitted through the wrist [61] (figure 4). Distal radius fractures nearly always heal, but regularly with deformity and loss of function [62]. Especially elderly often prefer little deformity rather than operative treatment [63]. For stable, minimally or non-displaced fractures, treatment with a removable splint and optional follow-up can be offered [64, 65]. Substantially displaced fractures are usually treated with manipulative reduction combined with splint or cast immobilization. When the reduction does not achieve adequate alignment or the alignment achieved with reduction is not maintained, re-manipulation is ineffective. Instable fractures need surgical stabilization with percutaneous pins, external fixation, or internal fixation [16, 17]. Additional indications for surgical management include radial shortening >3mm, dorsal tilt >10⁰ and intra-articular step of >2mm [66], these measurements should be measured in the report. Surgically repairing ulnar styloid fractures does not improve outcome after distal radius fractures [67, 68]. Several eponyms describe different distal radius fractures. Colles fractures represent dorsal angulation of the metaphysis; conversely Smith fractures are volarly angulated. In Barton fractures the dorsal part of the articular surface is separated from the metaphysis, often with translation of the carpus. In a volar (or reversed) Barton fracture the same happened to the opposite, volar side [12]. A Chauffeur (or Hutchinson) fracture indicates an isolated radial styloid fracture. This fracture is classically caused by the old automobile crank starters directly impacting the radial styloid [12]. In a die-punch fracture – typically at the lunate fossa – a central articular


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fragment is depressed due to direct axial loading [27]. Sometimes this fragment rotates 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

180°, making closed reduction ineffective [69]. Rotated fragments are difficult to identify on plain radiographs, but may be seen as subchondral bone of the articular surface within the metaphyseal bone. 3.1.2 Carpal fractures Carpal fractures are less common than distal radius fractures and are often associated with concomitant fractures of adjacent carpal bones and the distal radius [3]. The most common carpal fractures are scaphoid fracture (50-80%) and triquetral fractures (18%) [10, 70, 71]. As hamate hook stressfractures are common seen in athletes [72] (table 1). Accurate diagnosis of carpal injuries is vital because delayed treatment of carpal fractures may lead to significant long-term complications [34, 38]. In assessing osseous carpal injury the three arcs of Gilula are important. These arcs are drawn along (1) the proximal side of the proximal carpal row, (2) the distal side of the proximal row and (3) the proximal side of the distal row [29] (figure 5). If these arcs are not smoothly visible dislocation of carpal bones is suspected. These complex injuries are mostly located around the lunate [73]. Lateral views can help identify carpal dislocations [13]. However, additional imaging is always warranted. 3.1.2.1 Scaphoid fractures Scaphoid fractures occur after a fall on an outstretched arm due to hyperextension and radial compression [8]. Non-treated scaphoid fractures frequently result in nonunion, so additional scaphoid views or imaging techniques are warranted when suspicion of scaphoid fracture is high [73]. Scaphoid waist and proximal fractures are prone for avascular osteonecrosis of the proximal scaphoid pole due to the distal-proximal orientation of the blood supply [10, 74].


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Soft tissue swelling is a poor, but possibly useful indicator for the presence of a 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

scaphoid fracture. A hematoma can displace the scaphoid fat pad (linear fat collection between radial collateral ligament and synovial tendon sheaths of the extensor pollicis brevis and abductor pollicis longus) to the radial side of the wrist, which is visible on radiographs [13, 75]. Soft tissue swelling should be used to lower diagnostic threshold, but is not a strong indication of an occult fracture. Conservative treatment with cast immobilization is the treatment of choice in stable scaphoid fractures. However, stable proximal pole fracture and unstable fractures often need surgical management due to the high union rate [76, 77]. 3.1.2.2 Triquetrum fractures Fractures can be divided in impaction fractures of the triquetral body and avulsion fractures of the dorsal rim. Body fractures happen after a fall on the extended and ulnar deviated wrist [78]. Avulsion of the dorsal rim occur more frequently and trauma mechanism includes a fall with the wrist in extreme flexion [79]. The avulsion is caused due to torsion of the dorsal radiocarpal or dorsal intrinsic ligaments [5, 79].

Although fractures may be seen on plain posteroanterior (PA), lateral, and 45⁰ pronated radiographs, computed tomographic images (CT) or MRI may be required to further evaluate the extent of the fracture and any associated injuries [5, 8] (figure 6). Additional imaging also helps determine further management. For instance, fracture displacement and presence of associated injuries will determine operative versus nonsurgical treatment [5]. Immobilization for treatment is sufficient for avulsion fractures of the dorsal rim and nondisplaced body fractures [27] and long term consequences are rare [80]. Carpal instability, adjacent injury or nonunion indicate surgical management [79].


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3.1.2.3 Hook of hamate stress-fractures 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

Hook of hamate stress-fractures often are the result of direct impact or repetitive straining often from a baseball bat or tennis racket [72, 79]. Standard radiographs often fail to diagnose hamate fractures [27, 72]. Therefore, additional carpal tunnel view or CT can be used to evaluate suspected injury [27] (figure 7). Ulnar nerve damage may be present as the hook of the hamate is one border of Guyon’s canal [72]. Most fractures heal after immobilization However, exceeding the fractured hook is indicated in patients with symptomatic nonunion [27]. 3.1.2.4 Perilunate dislocation Perilunate dislocations are severe injuries, however uncommon [81]. The injury is regularly caused by high-energy trauma (falling from great height with extended wrist or high-velocity accidents) [27, 81] .The lunate remains in the normal position with the carpus and hand displacing dorsally. The carpus may subsequently dislocate volarly [81]. The dislocation is easily diagnosed on lateral radiographs. Closed reduction may be successful within one week after the injury, however surgical management is recommended [82]. To relieve nerve stretch, reduction should always be attempted [27]. 3.1.3 Soft tissue injuries Wrist ligaments are responsible for the stability of the joints. The ligaments can be categorized into intrinsic (attachment between carpal bones) and extrinsic (extend beyond the carpal bones) [83]. Evaluation of ligament pathology is challenging on all imaging techniques. Ligamentous injury of the wrist is often accompanied with other injuries and is the main cause for painful wrist instability [27].


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3.1.3.1 Intrinsic ligaments 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

Most important intrinsic ligaments include the scapholunate- and lunotriquetralligament. These ligaments provide stability of the lunate and disruption of the ligaments may cause a relatively dorsal or ventral pull on the lunate, providing dorsal intercalated segment instability (DISI) or volar intercalated segment instability (VISI) [84, 85]. Most common injury of the intrinsic ligaments is a scapholunate (SL)-ligament tear. SLligament injury cause SL-dissociation and occur after wrist extension, ulnar deviation and intercarpal supination, for example falling on a pronated hand [73, 86]. Normal radiographs do not rule out disease and often fail to show abnormalities, indicating additional imaging [87, 88]. However, in SL-dissociation the scaphoid may tend to palmar flexion, while the lunate may tend to dorsiflexion. If the angle between the scaphoid and lunate exceeds 60⁰ on lateral radiographs, DISI is suspected. DISI may also occur after extrinsic dorsal intercarpal ligament injury. PA radiograph and CT may show a widened interval (>3mm) between scaphoid and lunate (Terry-Thomas sign) [87-89]. Lunotriquetral (LT) ligament disruption is rare and usually the result of a sudden axial load with wrist extension, radial deviation and intercarpal pronation (for example falling backwards on an outstretched hand) [27, 90]. LT-ligament tears can be accompanied by carpal dislocation [73]. VISI (scapholunate angle less than 30⁰) is associated with LT- and extrinsic dorsal radiocarpal ligament tears [87]. LT-instability is often dynamic and absent in static position due to the presence of secondary ligamentous stabilizers, especially the extrinsic ulnar and volar carpal ligaments [73]. Therefore, imaging techniques frequently fail to detect LT-injury. CT or MRarthrography is valuable for evaluating pathology and MRI may be beneficial to exclude other injuries mimicking complaints (like TFCC tears) [27].


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Increasing numbers of ligament injuries on MRI and arthroscopy are being discovered, 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

but the clinical implications of these findings are unclear [91, 92]. 3.1.3.2 Distal radial-ulnar joint (DRUJ) instability DRUJ injuries mainly accompany distal radius fractures, but may be present solitary [93]. AP radiographs show widening of the space between de distal radius and the ulna. Lateral views are suspected for DRUJ instability when radioulnar distance (most dorsal cortices) exceeds 6mm. If further evaluation is indicated (radioulnar distance of 4 to 5 mm on lateral views) CT is valuable [94, 95]. 3.1.3.3 Triangular fibrocartilage complex tear The triangular fibrocartilage complex (TFCC) is a complex structure situated at the ulnar side of the wrist. The ligament complex between the ulna and the carpals is important for stabilizing the DRUJ and contains a fibrocartilage disk for shock absorption [96]. Radiographs cannot visualize TFCC tears, however can be valuable in excluding associated conditions. MRI or MRA can be used to identify tears [97]. Correlation between images and symptoms is important, because TFCC abnormalities are common in asymptomatic wrists and TFCC-defect prevalence increases with age [98]. 3.2

Hand and finger injuries

For evaluating and understanding traumatic injuries of the hand and fingers knowledge of the complex anatomy of tendons and ligaments is essential. Figure 8 and 9 provide a schematic overview of the anatomy. 3.2.1

fractures For determining optimal treatment it is vital to describe fracture-type (single or

comminuted), location of the fracture (tuft, shaft, base, condylar, subcapital), fractureorientation, joint-relation and presence of displacement, angulation or rotation. Oblique


18

spiral fractures displace easily and may result in malunion [99]. Intra-articular fractures may 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

cause early degenerative changes. In addition, rotation or angulation can result in problematic hand function due to finger shortening, tendon malalignment or overlapping of the fingers when gripping [99, 100]. 3.2.1.1 Metacarpals The fifth and fourth metacarpals are most frequently injured. A subcapital fracture with volar angulation or “boxer fracture” (mainly subsequent to an incorrectly placed punch) is the most common metacarpal fracture [99, 101] (figure 10). Surgical intervention is indicated once metacarpal shortening exceeds 5mm [102]. Requirement of surgical intervention is further dependent on degree of angulation in metacarpal neck and shaft fractures [103]. For metacarpal neck-fractures 10° (index), 15° (long), 30° (ring) and 40° (small finger) is tolerated and for shaft-fractures 0° (index), 0° (long), 20° (ring) and 30° (small finger) [99]. Metacarpal base fractures are mainly caused by forced wrist flexion while the arm is extended [7]. A base-fracture of the fifth metacarpal is susceptible for avulsion and proximal-ulnar fragment displacement due to the pulling forces of the extensor carpi ulnaris [9, 104]. PA radiographs provide poor visibility of carpometacarpal (CMC)-joints. Therefore, supinated oblique view and CT is indicated when suspecting CMC-injuries [7, 9]. 3.2.1.2 Phalanges Fractures of the proximal phalanges often result of a direct blow, hyperextension or a rotatory force [9]. Superimposing osseous structures make evaluation of these fractures challenging [105]. Angulation of phalanx fractures is dependent on fracture location due to tension of tendons [27, 106].


19

Due to their location and the predominance of cortical bone, middle phalanx 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

fractures are less common [9]. Trauma mechanism often include a direct blow or crushing force. Similar to proximal phalanx fractures, location will determine apex angulation (dorsal or volar) due to the insertion of the flexor digitorum superficialis tendon at the middle-third of the phalanx [9, 27]. Pilon fracture are comminuted fractures of the middle-phalanx base with discongruity in the PIP-joint due to central depression and fragment displacement and indicates surgical management [7, 107] (figure 11). The distal phalanx is most often fractured part of the hand [7, 99] and mainly caused by a direct blow, crushing injury or amputation [27]. Due to the trauma mechanism distal phalanx fractures are associated with significant soft tissue damage and nailbed injury, which has to be treated [8, 27, 106]. Fracture types are diverse. Most fractures are stable due to the stabilizing nailplate dorsally and the pulpa with fibrous septa volarly and rarely need surgical management [108]. A Seymour fracture is a metaphyseal fracture 1 to 2 mm distal to the epiphyseal plate in children[7, 109]. Lateral radiographs will show physeal widening or significant displacement [109]. The nailbed may interpose in the fracture [9]. Surgical management is necessary to prevent nailplate deformity and physeal arrest [7, 109]. 3.2.1.3 Thumb Osseous thumb injuries are common in athletes. Metacarpal thumb are a result of axial loading with a flexed metacarpophalangeal-1-joint [110]. Metacarpal thumb fractures can be divided in extra-articular, comminuted, intra-articular two-part (Bennett fracture) and intra-articular comminuted (Rolando fracture) fractures [110] (figure 12). The extra-articular type can displace due to the tension of the abductor pollicus longus tendon and may need surgery [9]. The Bennett fracture has an oblique or vertical


20

fracture line through the base [110]. A small triangular bone fragment at the ulnar side 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

remains attached to the trapezium because of the volar beak ligament [27]. The metacarpus is dorsally and radially displaced due to the pull of the extensor pollicus longus and brevis and the abductor pollicus longus tendons [111]. The Rolando fracture occurs less frequently and fracture lines are orientated in Y- or T-shaped [111]. In proximal phalangeal fractures of the thumb surgical management is only indicated if angular deformities exceed 20⁰ in the frontal plane and 30⁰ in the lateral plane [111]. 3.2.2 Joint injuries 3.2.2.1 Metacarpophalangeal (MCP)-joint A direct blow with clenched fist (for example in boxers) can result in injury of the MCP-joints. Injury of the sagittal bands of the extensor hood is called boxer knuckle and results in ulnar or radial subluxation of the extensor tendon during flexion of the knuckle [112, 113]. MRI is able to visualize disruption of the sagittal bands and extensor subluxation at the MCP-joint [114]. However, US is the imaging modality of choice due to the ability of a dynamic assessment [112]. Dislocation of the MCP-joint is less common than interphalangeal dislocation [115]. Dorsal dislocation occur more frequently compared to volar dislocations. Dorsal dislocation is the result of volar plate avulsion injury due to hyperextension of the joint. Interposition of the volar plate or sesamoid bones in the joint may cause an irreducible dislocation [116]. Radiographs show a widening of the joint space in complex dislocations and lateral radiographs will show dorsal displacement of the proximal phalanx [115]. 3.2.2.2 Proximal interphalangeal (PIP)- joint PIP-joint injury is a very common sports related injury and mostly the ring and middle finger are affected. The injury often occurs after forced hyperextension and axial loading


21

(e.g. a ball hitting the top of the finger) resulting in volar plate injury [7, 117, 118]. A swan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

neck deformity (hyperextension in PIP joint and flexion in DIP joint) may be present. Avulsion fractures can befall at the base of the middle phalanx and rarely at the proximal site [11]. Axial compression can result in additional impaction fracture [119]. Coach’s fingers is a dorsal PIP- joint dislocation due to disruption of the volar plate, extensor system and collateral ligament after forced extension with axial loading [7, 9]. Lateral radiographs are essential, as a ‘V-sign’ can be seen [7, 11] (figure 13). Untreated dislocation may result in a pseudo-boutonnière deformity (inability to extend the PIP joint) [9]. Forceful flexion of the PIP-joint in extension may cause rupture of the central slip, with or without avulsion fracture [7, 9] (figure 14). Untreated central slip injury will result in a boutonnière deformity; flexion at the PIP-joint and hyperextension at the DIP-joint. Volar dislocation of the PIP-joint can also rarely cause a central slip rupture. Radiographs may show associated avulsion fractures and MR imaging is valuable in evaluating extended injury [7]. Collateral ligaments are mainly injured at the proximal insertion at the PIP joint [120]. Trauma mechanism include radial or ulnar deviation in the extended finger. PA radiographs will show ulnar or radial angulation with extended PIP-joint accompanied by tissue swelling. Most collateral ligament injuries do not require surgical management, except for complete tears of the RCL in the index finger [7] 3.2.2.3 Distal Interphalangeal (DIP)-joint A forced hyperextension of a flexed DIP-joint may result in rupture of the flexor digitorum profundus (FDP) [121]. The injury is often called Jersey finger and is typical in ring fingers in football or rugby players [9, 11]. Osseous avulsion at the volar base of the distal


22

phalanx may be present, but mainly the FDP tendon is ruptured. Sometimes retraction of the 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

tendon occurs. Leddy and Packer have classified retraction injuries in type I (retraction into the palm), type II (retraction at level of the PIP-joint) and type III ( small retraction due to a blocking of a large avulsion fragment distal to the A4 pulley) [122]. US or MRI is valuable, especially when no avulsion fragment is present [6]. Avulsion of the FDP needs surgical management and prognosis is worse if treated after 7-10 days [27, 121]. Forced flexion of an extended DIP-joint causes a disruption of the terminal extensor tendon resulting in inability to flex the DIP joint [123]. The injury is often sports related (especially in baseball) [7] and may be called “mallet finger” [11, 123]. Avulsion of the dorsal base of the distal phalanx may occur (osseous Mallet or Mallet fracture) (figure 15). Untreated mallet finger can result in as swan-neck deformity (flexed DIP- and hyperextended PIP-joint). Treatment is mainly conservatively with an uninterrupted splint [123]. However, surgical management can be considered if osseous avulsion exceeds 30-50% of the articular surface or fragment displacement more than 2 mm [7, 11]. Pulley injuries occur during powerful finger flexion with a lot of tension on the pulleys and are most frequently seen in rock climbers [124, 125]. A2 and A3 pulley-injuries are most usual [126]. Pulley tear can lead to bowstringing [125]. US and MRI show increased distance between flexor tendon and bone in combination with pathological fluid increase [124]. Ultrasound provides the advantage of showing increased tendon-bone distance during active flexion (figure 16) [124, 125]. All tendons, ligaments and other soft tissue elements can be injured at any point due to laceration. Extensors are most vulnerable due to their superficial location [127]. MRI is the best imaging modality in the acute setting. US can be helpful when wounds are closed or small or healing. Radiographs may exclude osseous involvement.


23

3.2.3 Thumb injuries 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

The ulnar collateral ligament (UCL) is most often affected in injuries of the thumb. The radial collateral ligament is much less affected, but can occur simultaneously [9, 111]. Trauma mechanism mainly includes abduction and radial directed forces, mainly in skiers and other sports participants (therefore often referred to as gamekeepers- or skiers thumb) [111, 128]. Diagnosis is challenging and assessment should include evaluation of associated avulsion fractures of the ulnar side of the base of the proximal phalanx. Radial deviation or slight subluxation is also associated with UCL injury. MRI is the best modality for evaluating UCL injuries [128]. US might be difficult because posttraumatic swelling and fluid. The synovial recessus at the dorsal side of the proximal phalanx-base may mimic an avulsion. Complete UCL rupture with retraction in combination with dorsal displacement and interposition of the adductor pollicis aponeurosis is called a Stener lesion [129]. The superficial displacement of the ruptured UCL relative to the adductor aponeurosis prevents the lesion from healing with conservative treatment [130]. MRI and US can evaluate the extent of the injury and the location of the UCL. Stener lesions show the “yo-yo on a string”sign where the rolled op UCL is the yo-yo and the adductor aponeurosis the string [131]. A chronic Stener lesion will show a thickened and hyperintense ligament on MRI. MR arthrography can be valuable to diagnose a torn collateral ligament. Contrast will extent from the joint into the torn ligament [132]. Partial thickness tears can be seen as thickening of the ligament with abnormal signal intensity often with focal defects in the ligament [49]. A mallet thumb is rare injury and the result of the disruption of the extensor pollicis longus tendon [9].

Emergency and Trauma of Hand and Wrist 3.3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

24

Nerve injuries Traumatic hand and wrist injuries are uncommon, but may be associated with all three

nerves supplying the hand and wrist; the median, ulnar and radial nerve [133]. Traumatic injuries of the median nerve include injury due to dislocation of the lunate into the carpal tunnel or after distal radius fracture [134, 135]. Radial nerve injury can occur due to repetitive trauma in volleyball players. Injury of the ulnar digital branch of the radial nerve is called bowler’s thumb, due to the trauma mechanism of repetitive compression of the nerve in bowler’s [136]. Ulnar nerve dysfunction can be cause by traumatic hook of hamate or pisiform fracture, due to repetitive vibratory trauma or prolonged pressure as in cycling and weightlifting [137]. Imaging of the nerves in the hand remains a challenging task and usually electrography is used for evaluation [133]. However, US or MRI may provide the clinician with important additional information. Ultrasound can exclude compression of the nerve by surrounding structures and visualize discontinuity [133]. In addition, MRI is able to monitor reinnervation by comparing muscle signal intensity on STIR images over-time [138] (figure 17). 3.4

Vascular injuries Direct vascular injuries of the major vessels may result in emergency situations as

ischemia occurs when blood-flow is impaired. Painful, cold, pale, pulseless and anesthetic limb with paralysis and loss of capillary refill indicate direct surgical management [27]. Loss of radial or ulnar artery does not threaten survival of the limb, however minor ischemic symptoms may occur. Therefore, surgical repair is desirable [27]. Trauma of the hypothenar region can lead to thrombosis of the distal ulnar artery and ischemia of the digits [139] (figure 18). The hypothenar hammer syndrome is an uncommon vascular overuse syndrome caused by blunt repetitive trauma of the palmar


25

portion of the ulnar artery against the Hamulus (often attributed to an overuse sport activity 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

like biking) [140]. Arterial embolism from an injured posterior circumflex humeral artery (PCHA) is another cause of ischemia of the hand. The injury occurs due to repetitive positional compression of the axillary artery, for example during violent overhead motion in volleyball and baseball players [141, 142]. The diagnosis can be made using ultrasound [143]. However, contrast-enhanced MRI or CT are superior, especially in subtle lesions [142]. Radiographs and conventional MRI are only valuable to rule out other causes of arterial embolism due to PCHA occlusion (for example hypertrophy of teres minor or subscapularis muscles or bony anomalies [142]. 4

ACKNOWLEDGEMENTS

We would like to thank S. Walstra for her help processing the images.


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FIGURE CAPTIONS

Figure 1. Lateral view: palmar cortex pisiforme (dashed line P) in between palmar cortex capitate (dashed line 1) and distal scaphoïdpole (dashed line 2) Figure 2. Angle measurements on adequate lateral view to determine correct position of scaphoid, lunate and capitate. Figure 3: Different wrist views: PA (A), lateral (B), oblique with elevated radius (C), PA ulnar deviation (D), PA ulnar deviation 30-45* oblique angle (E), carpal tunnel (F) Figure 4. Basic components involved in a typical intra-articular distal radius fracture and the three columns Figure 5. Gilula's arcs: proximal (1) and distal (2) borders proximal carpal row (scaphoïd, lunate and triquetrum) and proximal border capitate and hamate (3) Figure 6. Dorsal triquetrum fractures seen on lateral view Figure 7. Hamate fracture not seen on plain radiographs (A). The fracture is easily seen on CT, coronal (B), sagittal (C) and transversal (D) reconstructions. Figure 8 and 9. Schematic overview of tendon and ligament anatomy of the fingers. (A) Lateral view of flexors and collateral ligaments and (B) dorsal view of extensors. ACC: Accessory collateral ligament. PCC: Proper collateral ligament. CS: Central slip. CT: Conjoint tendon. TT: Terminal tendon. FDP: Flexor digitorum profundus. VP: Volar plate. FDS: Flexor digitorum superficialis IT: Interosseous tendon. EH: Extensor hood. SB: Sagittal band. EDP: Extensor digitorum profundus. MCP: Metacarpophalangeal joint. PIP: Proximal interphalangeal joint. DIP: Distal interphalangeal joint. Figures 8 and 9 are © by K.F. de Geus and used with permission. Figure 10. Boxer’s fracture due to misplaced punch into wall or object causing a subcapital fracture with volar angulation.


34

Figure 11. A mid-phalanx pilon fracture is a comminuted fracture of the base with 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

discongruity in the PIP-joint due to central depression and displacement of fragments Figure 12. (A) Bennet fracture: Intra-articular two part fracture of thumb-base with dorsal and radial displacement. A small triangular bone fragment remains attached at the ulnar side. (B) Rolando fracture: intra-articular comminuted with Y- or T-shaped fracture lines. Figure 13. PIP luxation and volar plate injury. Look for the classic “V”-sign, where the middle phalanx has migrated proximally and dorsally in regards to the caput of the proximal phalanx (white lines). Figure 14. A volar dislocation of the PIP-joint with multiple fractures causes a central slip rupture. Note the instability in the joint and the proximal and volar displacement of the mid phalanx. Figure 15. Mallet fracture is caused by forced flexion of the DIP joint while in extension resulting in a disruption at the osseous insertion at the dorsal base of the distal phalanx. Figure 16. Climber’s finger with partial rupture of A2 pulley on ultrasound in resting position (A) and during flexion (B) with increased distance between flexor tendon and bone (white lines, bowstringing). Hypoechoic fluid signal between tendon (arrows) and bone is present. Bone-tendon distance increases upon flexion. (C) Bowstringing of the flexor tendon seen on MRI. The black asterix indicates soft-tissue swelling and posttraumatic fluid on the dorsal side of the finger. Figure 17. MR-images (STIR sequence) of the hand after a complete traumatic ulnar nerve transection, at 1, 3, 6, 9 and 12 months after surgical nerve repair. Denervated hypothenar, adductor pollicis, and interosseous muscles show high signal intensity 3 months after trauma. Signal intensity normalizes from the ulnar side towards the radial side, visualizing the re-innervation process.


35

Figure 18. (A) MR angiography revealed an acute stop of the ulnar artery (black circle) and 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

filling defects in the digital arteries (black arrow) in a bicyclist with ischemic symptoms due to repetitive trauma of the hypothenar region leading to hypothenar hammer syndrome. (B) MR angiography of the same hand after treatment with Tolazuline the arterial flow was restored in the ring and small finger (black arrow).


TABLES

Carpal bone

Frequency

Mechanism of injury

Scaphoïd

50-80%

FOOSH, combination of hyperextension and radial compression

Triquetrum

18%

Hyperextension and ulnair deviation will lead to an impression fracture due to the processus styloideus ulnae; hyperflexion will result in an avulsion fracture

Lunate

3.9%

Direct axial compression

Trapezium

3-5%

Axial loading MC1 on trapezium (often combined injury with MC1 or scaphoid); Direct trauma on volair side or avulsion (trapezial ridge)

Capitate

1.9%

High energy compression

Hamate

1.7%

Axial loading on clenched fist in fighting sports (corpus hamatum, often combined in combination with dislocation of CMC4-5); direct compression or repetitive straining on hamate hook (golfers fracture or handle of a tennis racket)

Pisiforme

1.3%

Avulsion fracture of carpal ligament after FOOSH

Trapezoïdeum

0.4%

Axial loading MC2

(Peri)lunar dislocation

7%

High energy compression / hyperextension - fall from height or motor vehicle accident

Tabel 1. Frequency of carpal fractures and mechanism of injury

36

Figure 1

Click here to download Figure [FIGURE 1] Lateral radiograph.tif

Figure 2

Click here to download Figure [FIGURE 2] Angle measurement.tif

Figure 3

Click here to download Figure [FIGURE 3] Distal Radius Columns.tif

Figure 4

Click here to download Figure [FIGURE 4] Radiographic views of the wrist.tif

Figure 5

Click here to download Figure [FIGURE 5] Gilula lines.tif

Figure 6

Click here to download Figure [FIGURE 6] Triquetrum fracture with arrow.tif

Figure 7

Click here to download Figure [FIGURE 7] Hamate fracture.tif

Figure 8 - © by K.F. de Geus, used with permission

Click here to download Figure [FIGURE 8] Flexor lateral anatomy.tif

Figure 9 - © by K.F. de Geus, used with permission

Click here to download Figure [FIGURE 9] Extensor dorsal anatomy.tif

Figure 10

Click here to download Figure [FIGURE 10] MC boxers fracture dig 5.tif

Figure 11

Click here to download Figure [FIGURE 11] Middle phalanx Pilon fracture.tif

Figure 12

Click here to download Figure [FIGURE 12] Thumb Bennet and Rolando fracture.tif

Figure 13

Click here to download Figure [FIGURE 13] PIP luxation and volar plate injury (V-sign).tif

Figure 14

Click here to download Figure [FIGURE 14] PIP central slip injury.tif

Figure 15

Click here to download Figure [FIGURE 15] DIP mallet fracture.tif

Figure 16

Click here to download Figure [FIGURE 16] Climbers finger ultrasound and MRI.tif

Figure 17

Click here to download Figure [FIGURE 17] Re-innervation proces.tif

Figure 18

Click here to download Figure [FIGURE 18] Hand embolism before and after treatment.tif

Table 1

Click here to download Table Tables.doc

TABLES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

Carpal bone

Frequency

Mechanism of injury

Scaphoïd

50-80%

FOOSH, combination of hyperextension and radial compression

Triquetrum

18%

Hyperextension and ulnair deviation will lead to an impression fracture due to the processus styloideus ulnae; hyperflexion will result in an avulsion fracture

Lunate

3.9%

Direct axial compression

Trapezium

3-5%

Axial loading MC1 on trapezium (often combined injury with MC1 or scaphoid); Direct trauma on volair side or avulsion (trapezial ridge)

Capitate

1.9%

High energy compression

Hamate

1.7%

Axial loading on clenched fist in fighting sports (corpus hamatum, often combined in combination with dislocation of CMC4-5); direct compression or repetitive straining on hamate hook (golfers fracture or handle of a tennis racket)

Pisiforme

1.3%

Avulsion fracture of carpal ligament after FOOSH

Trapezoïdeum

0.4%

Axial loading MC2

(Peri)lunar dislocation

7%

High energy compression / hyperextension - fall from height or motor vehicle accident

Tabel 1. Frequency of carpal fractures and mechanism of injury