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Differential Diagnosis/Imaging > Wrist and Hand Imaging and Complaints > Flashcards

Wrist and Hand Imaging and Complaints Flashcards

1
Q

Differential diagnosis of the wrist and hand

A
  • Radiograph: initial study for all hand/wrist Fx and dislocations
  • MRI/MRA: occult or stress Fx (scaphoid, lunate), staging osteonecrosis, post-traumatic arthritis, ligamentous injuries such as TFCC tears
  • CT: complex Fx (hook of hamate, scaphoid), distal radioulnar joint or thumb dislocation, intra-articular Fx
  • Ultrasound: tendon injury, nerve lesion, ganglion cyst, & soft tissue masses
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2
Q

Appropriate imaging for wrist trauma/1st exam

A
  • X-ray including at least a PA, Lateral, & semi-pronated oblique
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3
Q

Appropriate imaging for suspect acute distal radius Fx, radiographs normal, next procedure

A
  • Cast & repeat x-ray first in 10-14 days or MRI wrist without contrast
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4
Q

Appropriate imaging for comminuted, intra-articular distal radius Fx on radiographs, surgical planning

A
  • CT west without contrast
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5
Q

Appropriate imaging for suspect acute scaphoid Fx, 1st exam

A
  • X-ray wrist
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6
Q

Appropriate imaging for suspect acute scaphoid Fx, radiographs normal, next procedure

A
  • Cast & repeat x-ray wrist in 10-14 days or MRI wrist without contrast
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7
Q

Appropriate imaging for suspected occult scaphoid Fx, initial & repeat x-rays after 10-14 days of casting normal, continued clinical suspicion of scaphoid Fx, next prcedure

A
  • MRI wrist without contrast
  • CT wrist without contrast if MRI cannot be performed
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8
Q

Appropriate imaging for suspect distal radioulnar joint subluxation

A
  • X-ray wrist & CT wrist without contrast bilateral
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9
Q

Appropriate imaging for suspect hook of hamate Fx, initial radiographs normal or equivocal

A
  • X-ray wrist include supinated and carpal tunnel views
  • CT wrist without contrast
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10
Q

Appropriate imaging for suspect metacarpal Fx or dislocation

A
  • X-ray hand
  • CT hand without contrast (if strong concern following radiograph)
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11
Q

Appropriate imaging for suspect phalangeal Fx or dislocation

A
  • X-ray hand or finger include a PA, lateral, & externally rotated oblique views
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12
Q

Appropriate imaging for suspect thumb Fx or dislocation

A
  • X-ray thumb include AP or PA, lateral, & rotated oblique
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13
Q

Appropriate imaging for suspect gamekeeper injury (thumb MCP metacarpophalangeal ulnar collateral ligament injury)

A
  • X-ray thumb include PA & lateral view
  • MRI thumb without contrast (if no Fx in x-ray)
  • US thumb (alternative to MRI)
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14
Q

Appropriate imaging for chronic wrist pain with or w/o prior injury, best initial study

A
  • X-ray wrist
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15
Q

Appropriate imaging for routine radiographs normal or non-specific persistent Sx, next study

A
  • MRI wrist without contrast
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16
Q

Appropriate imaging for routine radiographs normal or non-specific suspect inflammatory arthritis, next study

A
  • MRI wrist without & with contrast
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17
Q

Appropriate imaging for radiographs normal or non-specific arthritis, exclude infectious, next study

A
  • Aspiration wrist
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18
Q

Appropriate imaging for ulnar sided pain, normal or non-specific radiographs, next study

A
  • MRI wrist without contrast
  • MR arthrography wrist
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19
Q

Appropriate imaging for radial sided pain, normal or non-specific radiographs, next study

A
  • MRI wrist without contrast
20
Q

Appropriate imaging for x-ray normal, suspect Kienbock’s disease (avascular necrosis of lunate), next study

A
  • MRI wrist without contrast
21
Q

Appropriate imaging for palpable mass or suspected occult ganglion cyst, normal x-ray, next study

A
  • MRI wrist without contrast
  • MRI wrist without & with contrast
  • US wrist (MRI alternative)
22
Q

Appropriate imaging for pain for more than 3 wks, suspect occult Fx or stress Fx, x-ray non diagnostic, next study

A
  • MRI wrist without contrast
  • CT wrist without contrast
23
Q

Appropriate imaging for x-ray shows old scaphoid Fx, evaluate for union, next study

A
  • MRI wrist without contrast
  • CT wrist without contrast
24
Q

Appropriate imaging for suspect carpal tunnel syndrome

A
  • X-ray wrist
25
Q

Routine radiograph views of the wrist & hand

A
  • PA
  • Lateral
  • Oblique
  • Other: ulnar or radial deviated views; fist view; scaphoid view; carpal tunnel view
26
Q

Describe Gilula 3 carpal arcs

A
  • 1) proximal curves of the scaphoid, lunate, triquetrum
  • 2) distal surfaces of the same bones
  • 3) proximal curves of the capitate & hamate
27
Q

Why is there a higher incidence of aseptic necrosis & nonunion noted with fractures on the side of the scaphoid

A
  • because no blood vessels enter the proximal pole of the scaphoid
28
Q

Describe Terry Thomas sign

A
  • gap between the scapholunate
29
Q

Clinical signs of a scaphoid fracture

A
  • Snuff box tenderness
  • Scaphoid tubercle tenderness (volar side of wrist, extend wrist to palpate)
  • Longitudinal compression (handshake with overpressure, radially deviate to compress)
  • All 3 present = 100% SN and 74% SP
30
Q

Describe radial inclination

A
  • Angle between one line drawn perpendicular to the long axis of the radius & another line drawn from the top of the radial styloid to the ulnar border
  • <15º relative indication for distal radius fracture operative management
  • Normal = 21-25º
31
Q

Describe ulnar variance

A
  • Relates to the lengths of the distal articular surfaces of the radius & ulna
  • Positive = play a role in TFCC thinning
  • Negative = suspect Kienbock’s disease
  • Neutral
31
Q

Describe a phalangeal fracture

A
  • Fx of the middle & proximal phalangeal shafts may be classified as stable, unstable, or intra-articular
  • MOI: more than 50% of hand Fx are work related; avulse Fx occur when a distraction stress overcomes the tensile capacity of the ligament to stabilize the joint
  • Imaging: radiographs are sufficient for diagnosis
32
Q

Describe a boxer fracture

A
  • 5th metacarpal fracture
33
Q

Describe thumb metacarpal fracture: Gamekeeper’s thumb and Bennett’s fracture

A
  • Bennett’s = intra-articular Fx/dislocation of the base of the thumb; Gamekeeper’s = common injury at the thumb’s metacarpophalangeal joint whereby a valgus force disrupts the ulnar collateral ligament & may avulse bone
  • MOI: axial loading or direct trauma
  • Imaging: Difficult to diagnosis with standard radiographic projections; additional oblique views, fluoroscopy, or CT may be necessary
34
Q

Describe a Rolando fracture

A
  • A 3 part or comminuted intra-articular fracture/dislocation of the base of the thumb (proximal first metacarpal)
  • Can be thought of as a comminuted Bennett fracture
35
Q

MRI indications for the wrist and hand

A
  • TFCC tears/degeneration
  • Scapholunate or lunotriquetral interosseous ligament tears
  • Dorsal & volar extrinsic wrist ligament abnormalities
  • Fx of distal radius, scaphoid, & other carpal bones
  • Soft tissue injury
  • Complications due to scaphoid Fx
  • Ganglion cyst
  • Osteonecrosis
  • Guyon’s canal syndrome, carpal tunnel, nerve sheath tumors
  • Flexor & extensor tendon abnormalities
  • Osteochondral & articular cartilage abnormalities
36
Q

MRI wirst & hand ABCDS

A
  • Alignment/anatomy: scaphoid most fractured
  • Bone signal: proximal pole of the scaphoid & lunate
  • Cartilage: TFCC best seen on coronal image
  • eDema: confirm that it is edema, seen as an intermediate signal on anatomy defining sequences & a high signal on fluid sensitive sequences
  • Soft tissue
37
Q

Describe extrinsic and intrinsic tendons

A
  • Extrinsic: connect radius & unla to carpals, carpals to metacarpals
  • Intrinsic: connect carpals to carpals
38
Q

Quick tips for tendons, neural structures, & muscles

A
  • Tendons: tendon sheath can fill with fluid & show high signal intensity (white) on T2 weighted images indicating inflammation
  • Neural structures: cross section & axial image view
  • Muscles: intermediate signals
39
Q

Describe osteonecrosis of the lunate: Kienbock’s disease

A
  • Usually affects the dominant wrist in men 20-40 yrs
  • Imaging: MRI is most sensitive to marrow changes consistent with osteonecrosis in the early stages of the disease when radiographs are nondiiagnostic
40
Q

CT imaging indications for the worst & hand

A
  • Trauma
  • Displaced distal radial fractures or carpal fractures
  • Osteochondral lesion if MRI not available
  • Any study an MRI can do if MRI is contraindicated
41
Q

CT order of most radiolucent to most radiopaque

A
  • Air = black
  • Fat = gray/black
  • Water = gray
  • Bone = gray/white
  • Metal = white
42
Q

What could be a potential cause for a hook of hamate fracture

A
  • Usually happen to athletes who grip a bat or club
43
Q

Describe a CT arthrogram for TFCC tear

A
  • Leakage of contrast from the radoiocarpal joint into the distal radioulnar joint indicates a tear of the TFCC
  • Ulnar variance can be assessed with radiograph; Pos. = describes where the distal articular surface of the ulna is more distal when compared to the articular surface of the radius
44
Q

Describe children primary ossification centers in the wrist & hand

A
  • Capitate: 1-3 mo
  • Hamate: 2-4 mo
  • Triquetral: 2-3 yrs
  • Lunate: 2-4 yrs
  • Scaphoid: 4-6 yrs
  • Trapezoid: 4-6 yrs
  • Pisiform: 8-12 yrs
45
Q

Describe children secondary ossification centers in the wrist & hand

A
  • Metacarpal heads fuse at 14-19 yrs
  • Phalangeal bases fuse at 14-19 yrs

Differential Diagnosis/Imaging (20 decks)

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