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Slide 2 X-Ray Rounds Wrist Mark Scott Nov. 8, 2007 Wrist Mark Scott Nov. 8, 2007 Slide 3 Systematic Approach Fracture Identification, Look for: Mal-alignment Discontinuity Radio-lucency / radio-opacity Fat pads Fracture Identification, Look for: Mal-alignment Discontinuity Radio-lucency / radio-opacity Fat pads Slide 4 11-22-11 Rule Radius tilted ~11 0 volar on Lat. Radius tilted ~22 0 ulnar on AP Radial Styloid ~11mm distal to ulna Radius tilted ~11 0 volar on Lat. Radius tilted ~22 0 ulnar on AP Radial Styloid ~11mm distal to ulna Slide 5 22 11mm Slide 6 22 11 Slide 7 3 Cs Rule Distal Radius Lunate Capitate appears as 3 Cs on lateral Slide 8 22 Slide 9 Slide 10 Distal Radial # Apply 11-22-11 rule Ortho referral for open, comminuted, unstable or failure to reduce, DRUJ, and NV compromise 3 Generally, Smith # (volar angl.) more unstable than Colles # Research study 4 Apply 11-22-11 rule Ortho referral for open, comminuted, unstable or failure to reduce, DRUJ, and NV compromise 3 Generally, Smith # (volar angl.) more unstable than Colles # Research study 4 Slide 11 22 Slide 12 Dorsal Bartons Fracture Slide 13 Bartons Fracture Intra-articular Shearing injury of dorsal (or volar) radial lip. Require ortho referral due to high- degree of instability (insertion of Brachioradialis tendon) Intra-articular Shearing injury of dorsal (or volar) radial lip. Require ortho referral due to high- degree of instability (insertion of Brachioradialis tendon) Slide 14 Scaphoid # Most commonly # carpal bone (60-70%) Axial loading 70-100% sensitive (better than snuff box tenderness) Evidence suggests below elbow cast with neutral wrist & thumb free is adequate 3 Refer if >1mm displaced or comminuted Follow up within 1 week is crucial. Most commonly # carpal bone (60-70%) Axial loading 70-100% sensitive (better than snuff box tenderness) Evidence suggests below elbow cast with neutral wrist & thumb free is adequate 3 Refer if >1mm displaced or comminuted Follow up within 1 week is crucial. Slide 15 22 Slide 16 Slide 17 CT vs MRI vs Bone Scan for Scaphoid # Radiographs miss 10-20% of scaphoid # CT more sensitive and readily available 3 MRI more info re: ligamentous injury but ties up MRI time. Bone scan very sensitive (72hrs - 2 weeks) but non-specific 3 High resolution US may be imaging modality of choice in future (Sn100%, Sp98%) Radiographs miss 10-20% of scaphoid # CT more sensitive and readily available 3 MRI more info re: ligamentous injury but ties up MRI time. Bone scan very sensitive (72hrs - 2 weeks) but non-specific 3 High resolution US may be imaging modality of choice in future (Sn100%, Sp98%) Slide 18 Slide 19 Scapho-lunate Dissociation Forceful hyper-ext of the wrist Tenderness immediately distal to Listers tubercle Terry Thomas Sign or signet ring sign Ortho referral and look for Lunate/Perilunate dislocation Forceful hyper-ext of the wrist Tenderness immediately distal to Listers tubercle Terry Thomas Sign or signet ring sign Ortho referral and look for Lunate/Perilunate dislocation Slide 20 22 Slide 21 Slide 22 Slide 23 Slide 24 Slide 25 Slide 26 Slide 27 Slide 28 Summary Clinical Scaphoid CT if cant immobilize or cast & f/u bone scan in 3-5 days. 4 Gross reduction of Colles # is adequate to prevent negative sequelae. 1 Stability: Colles > Smiths > Bartons Obtain multiple views and use 11-22-11 and 3 Cs rules. Clinical Scaphoid CT if cant immobilize or cast & f/u bone scan in 3-5 days. 4 Gross reduction of Colles # is adequate to prevent negative sequelae. 1 Stability: Colles > Smiths > Bartons Obtain multiple views and use 11-22-11 and 3 Cs rules. Slide 29 References 1.Jaremko JL et Al. Do radiographic indices of distal radius fracture reduction predict outcomes in older adults receiving conservative treatment?Clinical Radiology. 62(1):65-72, 2007 Jan. 2.McRae, R. Pocketbook of orthopaedics and fractures [2nd ed.]. Churchill Livingstone Elsevier, 2006. 3.Ritchie JV. Emergency Emerg Med Clin North Am - 01-NOV-1999; 17(4): 823-42 4.Seitz et al. Fractures and dislocations of the wrist. Rockwell and Green s Fractures in Adults [5 ed]. Lippincott, Williams & Wilkins, 2002. 5.Tintnelli, JE. Emergency medicine: a comprehensive study guide [6th ed]. American College of Emergency Physicians / McGraw-Hill, New York, 2004. Pp. 1674-84. 1.Jaremko JL et Al. Do radiographic indices of distal radius fracture reduction predict outcomes in older adults receiving conservative treatment?Clinical Radiology. 62(1):65-72, 2007 Jan. 2.McRae, R. Pocketbook of orthopaedics and fractures [2nd ed.]. Churchill Livingstone Elsevier, 2006. 3.Ritchie JV. Emergency Emerg Med Clin North Am - 01-NOV-1999; 17(4): 823-42 4.Seitz et al. Fractures and dislocations of the wrist. Rockwell and Green s Fractures in Adults [5 ed]. Lippincott, Williams & Wilkins, 2002. 5.Tintnelli, JE. Emergency medicine: a comprehensive study guide [6th ed]. American College of Emergency Physicians / McGraw-Hill, New York, 2004. Pp. 1674-84. Slide 30 22 Thank You