RADIOLOGIC

EVALUATION OF
WRIST and HAND
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 WRIST and HAND
- among the most often radiographed areas of the skeleton in any age
group

Common conditions:
- traumatic fractures
- painful degenerative conditions from repetitive microtrauma or
arthritic deformities
ANATOMY •27 bones
REVIEW Bones in each hand and wrist:
•14 phalanges
•5 metacarpals
•8 carpals
 JOINT MOBILITY
Interphalangeal joints - hinge joints
- permits full extension or hyperextension
- flexion –90 to 110 degrees or more

Metacarpophalangeal joints of the fingers - condyloid

- allows multiplanar motion
- Flexion - 90 degrees
 JOINT MOBILITY
First metacarpophalangeal joint at the thumb- saddle joint
- allows full extension or hyperextension
- flexion- 90 degrees
Carpometacarpal joints - gliding joints
- permits enough flexion and extension
- allows cupping of the palm
First carpometacarpal joint of the thumb - saddle joint
- allows a wide range of motion through a conical space-
opposition to the fingers
 Growth and Development

• hand and wrist - often used as indicators of skeletal age in

children

• 8 weeks of fetal life - ossification of the shafts of the

metacarpals and phalanges (fairly well formed at birth)
Growth and Development

• Carpals – cartilaginous at birth

• 6 months – ossification centers for capitate and hamate are the first to
appear on radiograph
• 2 years old- ossification center for triquetrum appears followed by
lunate, trapezium, trapezoid and scaphoid up to age 6
• 11 years old- pisiform begins ossification
• 14—16 years old – complete ossification at the carpals
Growth and Development

Metacarpals
– secondary ossification centers appear in the distal epiphyses at age 2
- Complete fusion by 16-18 years old
Phalanges
– secondary ossification centers appear in the proximal epiphyses at age 2
and their development parallels that of the metacarpals.
The radial and ulnar shafts begin ossification in the
8th week of fetal life and are well formed at birth.
Practice Guidelines for Extremity Radiography
in Children and Adults

• GOALS: The goal of hand or wrist radiographic examination is to

identify or exclude anatomic abnormalities or disease processes.
• Indications
- trauma; suspected physical abuse in young children; osseous
changes secondary to metabolic disease, systemic disease, or
nutritional deficiencies; neoplasms; infections; arthropathy; pre-
operative, post- operative, and follow-up studies; congenital
syndromes and developmental disorders; vascular lesions;
evaluation of soft tissue (as for a suspected foreign body); pain; and
correlation of abnormal skeletal findings on other imaging studies.
Basic Projections and Radiologic Observations

• The hand and wrist have separate radiographic examinations.

• If an individual finger or the thumb (digit) is the area of
interest, a separate radiographic examination of the digit is
performed.
• RECOMMENDED PROJECTIONS:
- Posteroanterior (PA)
- Lateral
- Oblique
Routine Radiologic Evaluation of the
Hand

• ●Posteroanterior (PA)
- demonstrates the hand, wrist, and
distal forearm.
- structures best shown are the
phalanges, metacarpals, carpals, and
all joints of the hand.
 Routine Radiologic Evaluation of the Hand

OBLIQUE
-demonstrates the phalanges, metacarpals,
carpals, and all joints of the hand in an oblique
view
This position is used more often if t phalanges are the area of interest.
The phalanges and metacarpals are demonstrated with out superimposition.
 Routine Radiologic Evaluation of the Hand

Lateral
- demonstrates the hand and wrist from a
lateral perspective
- Thumb is seen in a true PA projection
- various sesamoid bones may be
demonstrated on this view
Routine Radiologic Evaluation of the Wrist

Posteroanterior
- demonstrates the middle and proximal
portions of the metacarpals, the carpals,
the distal radius and ulna, and all related
joints
Routine Radiologic Evaluation of the Wrist

Oblique
-demonstrates the middle and proximal
metacarpals, the carpals, and the distal radius
and ulna in an oblique view

-structures best shown are the trapezium,

the scaphoid, and the first carpometacarpal
joint of the thumb
Routine Radiologic Evaluation of the Wrist

Lateral
- demonstrates superimposed
proximal metacarpals, carpals,
distal radius, and ulna as seen
from a lateral perspective
The stacked arrangement of the normal
radius–lunate–capitate relationship remains true in any degree of wrist flexion or extension.
The radial articular surface will always contain the lunate, and the lunate will always cup
the capitate in normal conditions.
Optional Wrist Views
● Ulnar deviation PA view
- hand positioned in ulnar deviation to
view
the scaphoid and adjacent opened
radial intercarpal spaces
 Optional Wrist Views

● Radial deviation PA view

-made with the hand positioned in radial
deviation to view the ulnar side carpals and
adjacent opened ulnar intercarpal spaces
Optional Projections

● Carpal tunnel view

- tangential inferosuperior view of
the wrist that allows visualization
of the carpal sulcus
ADVANCED IMAGING EVALUATION
• Radiographs will continue to be the first imaging test
performed for most suspected bone and soft tissue
abnormalities of the wrist and will often suffice to either
diagnose the problem or initiate treatment or exclude an
abnormality and direct further imaging .
• Radiographs may establish a specific diagnosis in patients
with complication of injury, arthritis, infection, some bone
or soft tissue tumors and occasionally wrist instability.
ADVANCED IMAGING EVALUATION
• CT Scan - used particularly in the follow-up of complex
fractures and distal radioulnar subluxations
• CT arthrography - reported to be equivalent to MRI in
diagnosing tears of the interosseous ligaments and the
triangular fibrocartilag complex.

Advantages of CT in wrist imaging:

- widespread availability, rapidity, and relatively lower cost
compared to MRI.
 ADVANCED IMAGING EVALUATION

MRI
- useful in detecting occult fractures, ulnocarpal impaction syndromes,
avascular necrosis, tears of the triangular fibrocartilage complex, and
tears of the extrinsic and intrinsic ligaments

MR arthrography - is recommended for diagnosing scapholunate

ligament tears and peripheral tears of the triangular fibrocartilage
complex
ADVANCED IMAGING EVALUATION
Ultrasound (US)
-is used to evaluate wrist ganglia, tenosynovitis, and tendon rupture and
to guide intra- articular injections of the wrist.
- maybe used for diagnosis of carpal tunnel syndrome, measurement of
triangular fibrocartilage complex thickness, and detection of
scapholunate and lunotriquetreal tears.
- Enlarged median nerve in proximal carpal tunnel
- Thickening of flexor retinaculum
- Edema around flexor tendons in cross sectional images
Introduction to Interpreting Wrist Sectional
Anatomy
Imaging planes for CT and MR of the wrist:
• (1) axial
• (2) sagittal
• (3) coronal
- based on an axial scout view obtained through the proximal
carpal row

Patient positioning for the wrist has the same considerations as

for the elbow
A preferred position for the exam is to have the patient positioned prone
(or supine) with the arm overhead in a “Superman” position.

The forearm is positioned parallel to the sides of the scanners.

 Practice Guidelines for CT of the Wrist

CT examinations should be performed only for a valid medical reason

Example:
radiographs were insufficient to dire surgical treatment or for follow-up
assessment of fracture healing) and with the minimum exposure that
provides the image quality necessary for adequate diagnostic
information
 Practice Guidelines for CT of the Wrist

Indications
• Severe trauma
• Assessment of displacement of distal radial fractures or carpal
fractures
• Evaluation of osteochondral lesions, if MRI is unavailable or
contraindicated
• Evaluation of any condition typically seen by MRI if MRI is
contraindicated.
• Including the use of intra- articular contrast for a CT arthrogram, if
MR arthro- gram is contraindicated.
Basic CT Protocol

• A CT exam of the wrist extends from the distal radial and ulnar
metaphyses to the metacarpal bases.
• The scanning plane and reference slices can be seen on the
preliminary scout view.
• Most current CT scanners obtain very thin (less than 1 mm) slices in
the axial plane.
 Variations in CT Imaging of the Wrist

Scaphoid imaging protocol- performed by placing the hand in ulnar deviation

and aligning the long axis of the scaphoid to the gantry.
An evaluation of distal radioulnar joint stability is achieved by placing both
forearms in the scanner and imaging the wrists while the forearms are
positioned in pronation, neutral, and supination.

Stability is assessed by a bilateral comparison of how the ulna articulates to

the radial sigmoid notch, or if the ulna subluxes from the radial notch, during
each forearm position.
 CT Image Interpretation of the Wrist

• Typically, radiologists review axial slices first, then sagittal and

coronal.
• Each slice is assessed for any abnormalities summarized in the ABCS:
● Alignment of anatomy
● Bone density
● Cartilage/joint spaces
● Soft tissues
 OBSERVATIONS
In each plane, check for abnormalities in the ABCS:
● Alignment: Is the anatomy intact with proper articular relationships
between the radius, ulna, and carpal bones?
● Bone density: Is cortical bone definitive on margins and shafts?
Are trabeculae in organized patterns? Are osseous cysts, cortical
hypertrophy, sclerosis, or destruction present?
● Cartilage: Assess the triangular fibrocartilage complex. Are any
defects present in the cartilage or subchondral bone? Is there any
degeneration of the cartilage due to impingement or impaction at the
radiocarpal joint or intercarpal joints?
● Soft tissues: Are any ganglion cysts present? Are any masses present?
Is there atrophy in the muscular compartments?
AXIAL PLANE

Check:
● Any structures compressing
the median nerve in the carpal
tunnel?

● Any structures compressing

the ulnar nerve in Guyon’s
tunnel?
Sagittal Plane
Coronal Plane
Coronal Plane

fractures at the radial styloid and articular surface

Three-Dimensional Reformat
Practice Guidelines for Magnetic Resonance
Imaging of the Wrist

Indications
• Diagnosis, exclusion, and grading of suspected: Abnormalities of
the triangular fibrocartilage complete (TFCC): partial and
complete tears, and degeneration
• Abnormalities of the scapholunate and lunotriquetral
interosseous ligaments: sprains, partial tears, and complete
tears
• Abnormalities of the dorsal and volar extrinsic wrist ligaments
• Ulnocarpal impaction syndrome
 MRI Indications

(cont.)
• Fractures of the distal radius, scaphoid, and other carpal bones with normal or
equivocal radiographs
• Soft tissue injuries associated with distal radius fractures
• Complications of scaphoid fractures: displacement, nonunion, malunion, and
osteonecrosis
• Osteonecrosis of the carpal bones
• Ganglion cysts
• Abnormalities affecting the peripheral nerves: primary secondary, and
recurrent carpal tunnel syndrome; Guyon’s canal syndrome; entrapment;
hematomas; and nerve sheath tumors
 MRI Indications

• Flexor and extensor tendon disorders: partial and complete tears,

tendonitis, tendonopathy, and tenosynovitis
• Osteochondral and articular cartilage abnormalities
• Vascular abnormalities: arterial aneurysms and pseudoaneurysms,
venous varicies, and arteriovenous malformations
• Congenital and developmental conditions: dysplasia, symptomatic
and asymptomatic normal variants
 MRI Indications
• to further clarify and stage conditions diagnosed clinically and/or suggested by
other imaging modalities, including, but not limited to:
● Neoplasms of bone, joint, or soft tissue
● Infections of bone, joint, or soft tissue
● Rheumatoid arthritis and related diseases
 MRI Indications

MRI of the wrist may be useful to evaluate specific clinical scenarios, including,
but not limited to:
● Acute and chronic wrist instability
● Dorsal or ulnar-sided wrist pain
● Wrist symptoms in adolescent gymnasts
● Unexplained chronic wrist pain, acute wrist trauma, wrist malalignment
● Limited or painful range of motion, unexplained wrist swelling, mass, or
atrophy
● Patients for whom diagnostic or therapeutic arthroscopy is planned
● Patients with recurrent, residual, or new symptoms following wrist surgery
MRI Contraindications
• presence of cardiac pacemakers
• ferromagnetic intracranial aneurysm clips
• certain neurostimulators
• certain cochlear implants, and certain other ferromagnetic
foreign bodies, electronic devices, extensive tattoos, or
nonremovable body piercings
 Basic MRI Protocol

• Define the anatomy

• Detect abnormal fluid

• All protocols will be a combination of anatomy-defining

sequences and fluid-sensitive sequences, divided among the
three imaging planes.
MR Arthrography

• Used primarily for the evaluation of the TFCC, scapholunate, and

lunotriquetral tears.

• Improved resolution of these small structures due to

advancements in coil design and increase in magnet field strength
are expected to decrease the need for arthrography in the future.
 MR Image Interpretation of the Wrist

● Alignment of anatomy
● Bone signal
● Cartilage
● eDema

• Look for edema due to the inflammatory process or injury in all tissues,
both bony and soft, and confirm that it is edema on the fluid-sensitive
sequences.
 MR Image Interpretation of the Wrist

Soft tissue and synovial tissue:

• Ligaments seen as low signal intensity on all MR sequences; they may
appear as striated bands. Interosseous ligaments are short and thick.
• Tendon sheaths are specialized tubular bursae with a potential space
that contains small blood vessels and a minimal amount of fluid. This
space will fill with fluid circumferentially when inflamed and show high
signal intensity on T2-weighted images.
MR Image Interpretation of the Wrist
Soft tissue and synovial tissue:
• Neural structures:
The median, ulnar, and radial nerves are best seen in cross
section on axial plane images. Neural signal intensity is
typically intermediate and is isointense to muscle (same as
muscle) on all sequences.
• Muscles:
Muscles that originate at the wrist are at the thenar group
and at the hypothenar group.
MRI of the WRIST
AXIAL PLANE Structures seen best:
● Neurovascular structures: median, ulnar, and radial nerves
● Distal radioulnar joint
● Tendons in cross section
● Pisotriquetral joint
● Carpal tunnel, including the flexor retinaculum
 Structures seen best:

● Osseous alignment
● Ligaments in cross section
● Tendons in long axes
● Pisotriquetral joint
● Sagittal T1 evaluates the
tendons, bone marrow, and
relationships between the osseous
structures.

Sagittal Plane
 Structures seen best:
● Extrinsic and intrinsic ligaments
●Triangular fibrocartilage complex
● Osseous structures and carpal
alignment
● Scapholunate articulation
● Inversion Recovery is sensitive to
pathological fluid, as may be seen in
an occult scaphoid fracture.

Coronal Plane
Additional Sequences
MR Arthrography

MR arthography is used most often to identify tears of the collateral ligaments,

interosseus ligaments, triangular fibrocartilage, and cartilaginous defects.
TRAUMA AT THE HAND AND
WRIST
• Fractures of the hand - 10% of all fractures
• Distal phalanges- account for more than half of all hand fractures in
adults
• Over 50% of hand fractures - work-related
• Distal radius is the most commonly injured bone at the wrist, followed
by the scaphoid
TRAUMA AT THE HAND AND WRIST
• The true incidence of fracture at the wrist is unknown, because carpal
injuries are often not recognized in the presence of more obvious
associated injuries (such as forearm or metacarpal fractures)

• These fractures at the wrist are often dismissed as sprains.

 TRAUMA AT THE HAND AND WRIST
• The mechanism of the majority of wrist fractures is a fall on an
outstretched hand.
• In children, the most frequently fractured bone anywhere in the
skeleton is the distal radius.
• In adults, the incidence of distal radial fractures in the elderly
correlates with osteopenia and rises in incidence with age, nearly in
parallel with the increased incidence of hip fractures.
Diagnostic Imaging for Trauma
of the Hand and Wrist

• routine radiographic evaluation is recommended as the

first imaging study to perform
• advanced imaging is recommended next only if initial
radiographs are normal or nondiagnostic
• For follow-up of known fractures, radiographic intervals
are generally 7 to 10 days after immobilization to check
the position of fragments and confirm initiation of healing
processes.
Diagnostic Imaging for Trauma
of the Hand and Wrist

• Unless a fracture is at high risk for development of

complications or if the patient presents with persistent pain,
radiographs are usually not necessary until near the end of the
healing time frame.

Radiographs at this point serve to:

● Confirm radiographic evidence of union
● Justify removal of external fixation
● Permit rehabilitation to proceed
FRACTURES of the HAND

• Possible fracture lines: transverse, spiral, and oblique

• Stable fractures – undisplaced
• Unstable fractures - displaced and may exhibit rotational or
angular deformities
• Special features - avulsion and comminution
FRACTURES of the HAND

• If radiographs are normal, recommendations are to cast and

repeat radiographs in 10 to 14 days.
• If immediate confirmation or exclusion of a radial or scaphoid
fracture is required, MRI is recommended.
• Computed tomography (CT) is used if MRI cannot be
performed.
 General Treatment Principles

● Reduction as close to anatomic alignment as possible

● Elevation of the extremity to limit edema
● Immobilization in the intrinsic or protected position
with metacarpophalangeal joints at an angle greater than 70 degrees
● Mobilization of the injured finger as soon as possible after cast removal in
order to minimize joint stiffness
Methods of Immobilization
Stable fractures - “buddy taping” one finger to the other or by
splinting

Unstable fractures – initially immobilized with a cast or rigid gutter

splint or anteroposterior splint

Percutaneous pinning may be used to prevent displacement and

permit earlier mobilization

Unstable fractures that cannot be satisfactorily reduced to near

anatomic alignment are treated with open reduction and internal
fixation.

Methods of fixation include intraosseous wire fixation, tension

band techniques, interfragmentar screws, and plate-and-screw
combinations.
Clinical Considerations and Pitfalls

• Factors that may influence the type of treatment : patient’s age,

hand dominance, occupation, associated soft-tissue injury, patient
motivation and reliability, and comorbid conditions.
• Pitfalls in adequate diagnosis and treatment of hand fractures are
noted in the literature: 27% of finger fractures are treated
inappropriately in the emergency department; inaccurate reduction
and unsatisfactory splinting are the most common errors.
Thumb Metacarpal Fractures

- majority of thumb metacarpal fractures

occur at or near the base and are divided
into intra-articular and extra-articular
types.
Fractures of the Distal Radius

• Incidence
• Postmenopausal women - 60% to 70% of all distal radial fractures as a
result of a fall on an outstretched hand
• Younger adults - 10% to 15% occur in younger adults as a result of violent
injuries, as in fistfights, that drive the lunate or scaphoid in the radius,
breaking the cortex of the radius like sheet metal being stamped; hence a
term for these injuries is die-punch fractures.
In children, distal radial fractures are
the most common of all fractures and
heal without difficulty in most cases

Distal third of the radius, or

metaphysis, is involved most of the
time in young children owing to the
decreased bone density at this region
of newly formed bone
Eponyms for Distal Radial Fractures
• Colles’ fracture – distal radial fracture
• Smith fracture- reverse Colle’s
• Barton fracture - fracture dislocation injury
Fracture Complication – Radial Shortening
SOFT TISSUE DISORDERS

Pathology of the Triangular

Fibrocartilage
Complex
Carpal Tunnel Syndrome

• a compressive neuropathy of the median nerve at the wrist

• the most common neuropathy of the upper extremity

Possible causes of increased intratunnel pressure:

● Anatomic compression (with fracture–dislocations at the wrist)
● Inflammatory conditions such as diabetes, alcoholism, or thyroid disorder
● Mechanical forces such as joint position, tendon load, or vibration
● Fluid shifts, as in pregnancy and menopause.
 Carpal Tunnel Syndrome
Clinical Presentation

• pain and paresthesias in the median nerve distribution of

the hand
• often these symptoms are worse a night or with repetitive
hand motions, especially gripping
• patients frequently report clumsiness and weakness of the
affected hand
Carpal Tunnel Syndrome
Diagnostic Modalities
• Electrodiagnostic testing/ Electromyography - definitive
modality for confirming carpal tunnel syndrome
• -reveals positive waves or fibrillations in the thenar
musculature, indicates the severity and chronicity of nerve
injury
• Conventional radiographs are useful in ruling out osseous
abnormalities or fracture–dislocations at the wrist.
• MRI
• MSK-UTZ
Carpal Tunnel Syndrome
Treatment
• Conservative management in mild cases: splinting, non- steroidal anti-
inflammatory drugs, corticosteroid injection ultrasound, iontophoresis, and
activity modification

• Conservative management of moderate to severe carpal tunnel syndrome is

not usually an option, especially in patients with muscle atrophy or
significant sensory impairment
 Degenerative Joint Disease

Degenerative joint disease (DJD) or osteoarthritis is commonly seen in

the small joints of the adult hand after the fifth decade.

The proximal and distal interphalangeal joints of th fingers and the

carpometacarpal joint of the thumb are particularly affected.

• Heberden’s nodes are DJD deformities in the distal inter- phalangeal

joints.
• Bouchard’s nodes are DJD deformities in the proximal interphalangeal
joints.
• Basal joint arthritis is DJD at the first carpometacarpal joint.
 Radiologic Characteristics
Radiographic evidence of DJD in the hand, as in other larger joints, is
hallmarked by the following:

• 1. Decrease in the radiographic joint space

2. Sclerosis of subchondral bone
3. Osteophyte formation at joint margins
Osteoarthritis
Basal Joint Arthritis
Basal Joint Arthritis
Treatment
Rehabilitation plays a significant role.

Early stages are often treated with pain management, splinting

to prevent or reduce deformity, therapeutic exercise to
maintain motion, and joint protection education.

Later stages may require joint fusion or joint replacement to

preserve a pain-free, functional hand.
Rheumatoid Arthritis

- characteristically seen in the small joints of the wrist, the

metacarpophalangeal joints, and the proximal
interphalangeal joints.
Rheumatoid Arthritis
• Treatment similar to DJD
Rheumatoid arthritis
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