wrist sep09
DESCRIPTION
xray wrist carpal instability gilula linesTRANSCRIPT
sep 2009
Was bedeutet der handsurgeon wissen wollen?
Xray Measurements
• Carpal height• Ulnar variance• Radial inclination• Radial length• Palmar tilt• Radial shift
Position
• Neutral PA• Neutral Lat
Position
• Neutral PA• Neutral Lat
Position: PA
• Wrist and elbow shoulder height• radius and ulna parallel
Extensor carpi ulnaris groove
• Radial to mid styloid
Extensor carpi ulnaris groove
• Radial to mid styloid
Position: Lateral
• Elbow adducted• Shoulder elbow wrist in 1 plane
Lateral CCC
• Radius• Lunate• Scaphoid
Lateral CCC
• Radius• Lunate• Scaphoid
Lateral CCC
• Scaphoid• Pisiform• Capitate
Lateral CCC
• Scaphoid• Pisiform• Capitate
CCC OK!
Lunate dislocation
CCC niet OK.
Shape Lunate
Scaphoid shape
Ext Uln. deviation
Scaphoid flex / radial deviation
flexrad deviation
Scaphoid axis
Lunate axis
Capitate axis
Oblique
trapezo-trapezoid
Oblique
trapezo-trapezoid
Carpal height
• Base MC3• Radiocarpal• Collapse
– RA– SL collapse– Lunatomalacie
Carpal height
• Ratio– MC3 (0.54)– Capitate (1.57)
Carpal height
• Ratio– MC3 (0.54)– Capitate (1.57)
Ulnar variance
Ulnar variance
• Load transfer• Growth disorder• Post trauma
Ulnar variance
• Association– SL instable– Ulnocarpal impaction– TFCC
• Normal + 3 mmMid
Radial inclination
• Fracture: – <5° poor outcome
• Madelung steep • Normal 16-28°
Radial inclination
• Fracture: – <5° poor outcome
• Madelung steep • Normal 16-28°
Mid
1878 O. W. Madelung: Die spontane Subluxation der Hand nach Vorne.
Radial length
• Styloid length• Shortening after #• Compare L-R• Normal 10-18 mm
Radial length
• Styloid length• Shortening after #• Compare L-R• Normal 10-18 mm
Mid
Palmar tilt
• Volar ligaments• Dorsal bony ridge• Residual deformity
– 200% load ulnocarpal
• Normal 0-22 °
Palmar tilt
• Volar ligaments• Dorsal bony ridge• Residual deformity
– 200% load ulnocarpal
• Normal 0-22 °
Mid
Radial shift
• # dislocation• PA• Styloid• Midshaft• Compare L-R
– max 1mm
Radial shift
• # dislocation• PA• Styloid• Midshaft• Compare L-R
– max 1mm
Width
Mid
Wrist conditions
• Carpal instability• Scapholunate Collapse• Ulnar translocation• Ulnocarpal impaction• Radio-Ulnar impingement
Carpal instability
• SL - scapholunate• LT - lunotriquete• SLT - Combined• Ligaments intact?
Arc I
LT
Arc II
SL LT
Arc III
CH
DISI
Dorsal intercalated segment instability
DISI (pathology)
Dorsal ... instabilityLunatum kijkt naar posterior
A A
VISI
Volar intercalated segment instability
VISI (variant)
Volar .. instabilityLunatum kijkt naar anterior
A A
VISI
LT Collapse
Instability
LT CollapseArc 1 Short ScaphoidParallel
VISI
Palmar tilt ScaphoidLunate
VISI
Palmar tilt ScaphoidLunate
VISI
Palmar tilt ScaphoidLunate
VISI
SL angle < 30 °
Scapho lunate advanced collapse
• Progressive• Clinical & Radiological• Narrowing• Sclerosis• Osteophyte• CPPD deposition• Non union
SLAC
SLAC
• a
Ulnar translocation
• Clinical & Radiological• Disruption R-C lig.• Instability• Ulnar displacement
– Scaphoid-Styloid– Hamate-Ulna
Ulnar translocation
Scaphoid-Styloid
Ulnar translocation
Ulna - Hamate
Ulnocarpal impaction
• U-L-T Joint degeneration • Compressive forces • Ulna +
Ulnocarpal impaction
• U-L-T Joint degeneration • Compressive forces • Ulna +
U
T L
Radio-Ulnar impingement
• ulna -, concave radius, convergence
TFCC
Intact #
Cases
Parallel joints OverlapCarpal ArcsShape Fracture
Case 1
Case 1
• Lunate not parallel• Arc 1 en 2• Triangular lunate• Dislocated!
Case 2
Case 2
TL, HL overlapParallel
R,L,prox S, prox CTriq,H,dist S, dist H, Trap
# H, S
Case 2
TL, HL overlapParallel
R,L,prox S, prox CTriq,H,dist S, dist H, Trap
# H, STrans scaphoid and capitate perinlunate
#dislocation
Case 2
Case 2
Case 3
Case 3
LT not parallelArc 1, 2 brokenSL tilted
VISI LT dissociation
Case 4
Case 4
All parallelSL wideScaphoid tiltLunate tiltArthrosis RS CL
SLAC (SL tear)
SLAC (CPPD)
Approach
CCC and CCCParallel joints OverlapCarpal ArcsShape Fracture
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