Radiologic examination of the hand

Question 1

Who performed the first radiograph of the hand?

Answer 1

Wilhelm Conrad Roentgen, the discoverer of x-rays, performed the first radiograph of the hand in 1895. Roentgen, then
Professor at the University of Würzburg in Germany, subsequently was awarded the first Nobel Prize for Physics in
recognition of his great discovery. He obtained an image of his wife’s hand using a photographic plate. This radiograph
is widely accepted as the first radiograph of a huma

Question 2

Name some of the most common causes of diagnostic errors in interpreting
radiographs of the hand after trauma.

Answer 2

** Inadequate clinical history and physical examination
** Acceptance of poor-quality radiographs
** Failure to recognize an abnormality that is actually present
** Failure to obtain or insist on an adequate number of proper radiographic projections
** Missing a second significant finding, such as another fracture, dislocation, or foreign body

Question 3

What is Brewerton’s view?

Answer 3

A radiographic projection described by D.A. Brewerton in 1967 for demonstrating involvement of the metacarpal heads
in rheumatoid arthritis. This projection aims at profiling the second through fifth metacarpophalangeal (MCP) joints with
no overlapping of adjacent cortical surfaces. It is sensitive for revealing early erosions due to synovial arthritis and occult
fractures of the metacarpal heads that may not be seen on routine views.

Question 4

Why is Rolando’s fracture considered a significant injury?

Answer 4

Rolando’s fracture is a Y-shaped or comminuted fracture of the metacarpal base of the thumb that involves the
carpometacarpal (CMC) joint and usually requires surgical stabilization (Fig. 116-2). Proper alignment may otherwise be
difficult to maintain because of the opposing pulls of multiple tendons acting on the thumb.

Question 5

5. How are intraarticular fractures of the base of the phalanges classified?

Answer 5

Steele’s classification consists of three categories. Type I is a nondisplaced marginal fracture. Type II is a comminuted,
impaction fracture. Type III is a displaced intraarticular fracture with subluxation of the fracture fragments.

Question 6

List the radiographic hallmarks of rheumatoid arthritis

Answer 6

Periarticular osteoporosis
** Periarticular soft tissue
swelling
** Marginal erosions
** Joint space narrowing
** Proximal and bilateral symmetrical disease
distribution

Question 7

How can the ulnar deviation deformity of rheumatoid arthritis be explained?

Answer 7

The pathogenesis is not fully understood. It appears to be initiated by inflammatory arthritis of the MCP joint with a rise
in intraarticular pressure. Destruction of the ligamentous and capsular tissues results in instability of the joint. Another
possible contributory factor is instability and ulnar displacement of extensor tendons. Ligamentous laxity of the fourth
and fifth CMC joints, resulting in phalangeal volar descent, also may play a role.

Question 8

What is the pattern of involvement of primary osteoarthritis?

Answer 8

Primary osteoarthritis affects the proximal and distal interphalangeal joints of the digits and the CMC joint of the thumbs
in a bilateral symmetric fashion. It is found predominantly in the hands of middle-aged and older women. Its major
features include bone production and osteophytes around narrowed joints.

Question 9

Which is the most common benign bone tumor of the hand?

Answer 9

Enchondroma. In fact, approximately 50% of enchondromas are found in the hand. Radiographically, the tumor
is seen as a well-defined lucent lesion in the diaphysis or metadiaphysis and may have a well-defined sclerotic
rim. It is often expansile with a preserved cortex. The endosteal cortex typically is scalloped or has multiple small
concavities. The presence of internal chondroid-type calcifications is considered characteristic (Fig. 116-4).

Question 10

Why is the finding of multiple enchondromas significant?

Answer 10

The condition of multiple enchondromas is known as Ollier’s disease. When found in combination with soft tissue
hemangiomas, the entity is known as Maffucci’s syndrome. Radiographically, phleboliths and soft tissue masses may be
seen at the sites of hemangiomas. Malignant degeneration of an enchondroma to a chondrosarcoma may occur in up
to 25% of patients with Ollier’s disease by the age of 40 years. Maffucci’s syndrome is associated with an even higher
frequency of malignant transformation of enchondromas.

Question 11

Which is the most common malignant bone tumor of the hand?

Answer 11

Metastases. Metastases and myeloma should be considered whenever a lytic lesion is detected in anyone over the age
of 40 years, especially if the lesion has ill-defined margins and/or cortical breakthrough. Bronchogenic carcinoma is the
most common origin for metastases to the bones of the hand

Question 12

Besides metastases and enchondromas, what is included in the differential diagnosis
of multiple lytic bone lesions in the hand and wrist?

Answer 12

Fibrous dysplasia, eosinophilic granuloma, myeloma, hyperparathyroidism (brown tumor), and infection.

Question 13

What disorder typically produces well-defined erosions with overhanging margins?

Answer 13

Gout. In chronic advanced gout, tophaceous deposits are associated with intraarticular or periarticular erosions.
These erosions are well defined, have overhanging edges (that is, the periosteal bone margins extend outside the
normal cortical margins), and may have sclerotic margins. Tophi calcification is unusual and may reflect a coexisting
abnormality of calcium metabolism.

Question 14

Which disease is characterized by the combination of periarticular soft tissue
calcification and subperiosteal bone resorption?

Answer 14

Hyperparathyroidism secondary to renal failure. Subperiosteal resorption is most frequently seen at the radial aspects
of the middle phalanges of the hand and is considered a classic finding for hyperparathyroidism. In severe disease,
terminal phalangeal resorption also may be present. When the serum calcium–phosphorus ion product is elevated,
metastatic calcification may occur within normal tissues, particularly around joints. Chronic renal failure with secondary
hyperparathyroidism is the most common cause of metastatic calcification and usually is seen in patients on long-term
dialysis. The calcification may decrease or disappear with correction of the metabolic abnormality.

Question 15

List the major causes of a short fourth metacarpal.

Answer 15

Trauma, infarction (e.g., sickle cell anemia), Turner’s syndrome, pseudohypoparathyroidism,
pseudopseudohypoparathyroidism, idiopathic shortening, and multiple exostoses.

Question 16

What is the best way to image complex regional pain syndrome?

Answer 16

Three-phase bone scintigraphy. All phases should have abnormal increased uptake. The 3-hour delayed images of
bone scintiscans have 96% sensitivity and 97% specificity for the diagnosis of complex regional pain syndrome (CRPS;
formerly referred to as reflex sympathetic dystrophy [RSD]). There is diffuse increased isotope uptake around the
radiocarpal, intercarpal, CMC, MCP, and interphalangeal joints (Fig. 116-6). Radiographically, CRPS may manifest as
severe osteoporosis and soft tissue swelling.

Question 17

Does ultrasound have a role in imaging tendons?

Answer 17

Most definitely. By using a high-frequency linear transducer with a stand-off pad, high-resolution images of the
tendons can be obtained (Fig. 116-7). The tendons have a general hypoechoic appearance with multiple longitudinal
internal fibers. Flexing and extending the finger allow identification and dynamic evaluation of the individual
tendons. Indications include tenosynovitis, localized tendinitis, tendon rupture, and functional assessment of
repaired tendons.

Question 18

Is magnetic resonance imaging useful in staging soft tissue tumors?

Answer 18

Yes. In fact, magnetic resonance imaging (MRI) currently is the modality of choice for tumor staging because it provides
exact information about the location and extent of the tumor and its relationship to the surrounding tissues, particularly
the neurovascular structures. This information is important for treatment planning.

Question 19

Can MRI provide a specific tissue diagnosis of soft tissue tumors?

Answer 19

Most soft tissue tumors in the hands are benign. From the combination of signal characteristics on different pulse
sequences and morphologic appearances, certain benign tumors can be diagnosed with confidence on MRI, including
lipoma, giant cell tumor of the tendon sheath, hemangioma, arteriovenous malformation, and ganglion cyst (Fig. 116-8).
For benign tumors with atypical appearances or lesions that do not fit into the list given, malignancy cannot be excluded.
Plain radiographs should always be evaluated in conjunction with MR images because calcifications, ossification, and
cortical abnormalities may be missed on MRI.

Question 20

Does MRI have a role in monitoring the treatment response of inflammatory
arthropathies?

Answer 20

Potentially. The role of MRI is evolving. Inflamed synovium can be demonstrated on T2-weighted images. Subtle changes
in the synovium, articular cartilage, and bone can be detected before they are apparent radiographically. Use of dynamic
gadolinium-DTPA enhancement to identify active pannus appears to be a promising technique. MRI may help in early
diagnosis, identify poor prognostic factors, and aid in the monitoring of response to therapy.