Lecture 2

Upper Extremities
Outlines

Anatomy of Upper Extremities HAND & WRIST.

The normal adult wrist
Lunate dislocation.
Fractures of Wrist.
The Elbow -Normal anatomy.
Ossification centres.
HAND , WRIST& ELBOW

1. styloid process (radius). 8. trapezoid.

2. styloid process (ulna). 9. capitate.
3. Scaphoid. 10. hamate.
4. lunate. 11. hook of hamate.
5. triquetrum. 12. metacarpals.
6. pisiform. 13. phalanges. PA hand
7. trapezium.

PA oblique hand
 MRI: Axial wrist

. Flexorretinaculum
. Carpal tunnel
MRI: Coronal wrist

1. Ulna.
2. Radius.
3. Scaphoid.
4. Lunate.
5. Triquetrum.
6. Trapezium.
7. Trapezoid.
8. Capitate.
9. Hamate.
10. Flexor Tendons.
The normal adult wrist

Three carpal arcs should be traced:

1. Along the proximal row of carpal bones;
proximal aspect.
2. Along the proximal row of carpal bones;
distal aspect.
3. Along the capitate and hamate proximally.
Phalanges
At the head or base of the phalanges and head of the
adjacent metacarpal.
More subtle, and yet clinically significant, are
fractures to the base of the 4th or 5th metacarpal.
Finger - Crush fracture
Finger fractures are often multiple. Here
there is a comminuted fracture of the
little finger distal phalanx due to a crush
injury - and a transverse fracture of the
.ring finger middle phalanx

Finger - Salter-Harris fracture

This child's X-ray shows loss of bone alignment at the
growth plate of the proximal phalanx.
Thumb
A common fracture at the base of the 1st metacarpal is an oblique intra-articular
fracture, usually with dorsal Subluxation of the shaft. This is the Bennett’s
fracture-dislocation.
Similar to the Bennett’s fracture-dislocation, but comminuted, is the Rolando’s
fracture-dislocation. Both are unstable injuries.
 Scaphoid fracture - Scaphoid series
The Scaphoid fracture is only visible on 2 of the 4 standard
images in this case.
If a Scaphoid fracture is suspected clinically then the
patient should be treated as such even if the standard series
of X-rays shows no fracture. The wrist is immobilized and
the patient is reassessed clinically, typically at 10 days.

Scaphoid fracture - Occult on X-ray - MRI

If a Scaphoid injury is suspected then the patient should be
treated as such even if the X-rays shows no fracture.
Occasionally repeat X-rays do not show a fracture and MRI is
needed.
Here is the normal X-ray with the MRI which clearly shows the
fracture.
Lunate dislocation

Lunate loses its articulation with both the capitate and the radius and
is displaced volarly with up to 90 degrees rotation. The capitate
remains aligned with the radius but sinks proximally.
Perilunate dislocation
 The Lunate maintains its normal articulation with the radius.

 The capitates articular surface is dislocated from the Lunate, normally dorsally.

Clinical features:

 Patients will often complain

of pain and swelling.


Movement at the wrist will be

limited.

 Localized tenderness especially

in the scapholunate region.

Midcarpal dislocation

The lunate tilts volarly but is not dislocated from the radius. The
capitate is dislocated from the lunate but not as dorsally as seen in a
perilunate dislocation:
Metacarpals
Fractures to the shaft, neck or head, particularly of the 4th or 5th metacarpal are common.
Most often caused by punching injuries. and are rarely missed as they are usually displaced.

More subtle, and yet clinically significant, are fractures to the base of the 4th or 5th
metacarpal:
Boxer's fracture
A boxer's fracture typically involves the neck of the 5th metacarpal bone.
In addition to any deformity seen from the angulation of the fracture.
The Wrist - Colles / Smiths fracture

•Fractures of the distal radius are classified depending on

which direction the distal fragment is displaced. If displaced
posteriorly, it is refered to as a Colles fracture. The term
“Colles” was originally used to describe a very specific injury,
but the term is now used more generally.
•If the distal fragment is displaced anteriorly, the fracture is
classified as a Smith's fracture.
Galeazzi fracture-dislocation

Refers to a displaced fracture of the distal radial shaft accompanied by a dislocation

to the distal radio-ulnar joint:
Radial Styloid Fracture

•Fractures are common due to blunt trauma directly to the radial

styloid process. Fractures are oblique, intra-articular and are
usually minimally displaced.

•Greenstick fractures of the radial and ulna shaft are demonstrated by a break in one cortex only
(incomplete), with displacement/angulation. An increase in the force will result in a complete
fracture.
Carpal Dislocations

•Lunate dislocation - Lunate loses its

articulation with both the capitate and
the radius and is displaced anteriorly
with up to 90 degrees rotation.
•The capitate remains aligned with the
radius but sinks proximal.
The Elbow -Normal anatomy

• Capitellum articulates with the radial head (lateral).

•Trochlea articulates with the olecranon (medial).
•The articulating surfaces of the distal humerus are offset anteriorly to
the humeral shaft (as viewed on the lateral film).
Ossification centres
•At birth, the distal humerus and proximal radius and ulna consist of
cartilage, which contain no ossification centres. Six centres of ossification
progressively appear in a consistent order until the age of 12 years.
• The ossification centres enlarge, and fuse between the ages of 14 and 16
years (except the medial epicondyle, which fuses last at 18 to 19 years).
•These ossification centres, and the sequence with which they appear
can be remembered by the mnemonic CRITOL:
C = CAPITELLUM
R = RADIAL HEAD
I = INTERNAL EPICONDYLE (MEDIAL)
T = TROCHLEA
O = OLECRANON
L = LATERAL EPICONDYLE
Anterior humeral line

•On a lateral projection, when a line is drawn along the anterior surface of the
humeral cortex and extended, it should pass through the middle third of the
Capitellum (as the articulating surfaces of the distal humerus are offset anteriorly):
•This is especially useful for demonstrating subtle supracondylar fractures, as
the line will pass through the anterior third of the capitellum with the
characteristic posterior displacement of the distal humeral fragment.
 Supracondylar fracture

Complications such as vascular or nerve damage arise from widely displaced

fractures, as the brachial artery and median nerve both run anteriorly.
Monteggia fracture-dislocation
As the radius and ulna are a ring structure, if one displaced fracture is seen, another should be
sought. The second injury may be a dislocation.
The Monteggia fracture-dislocation refers to a fracture of the proximal ulna shaft with an
associated dislocation of the radial head. This can be identified by drawing the radiocapitellar
line.