SCIENCE. Denser = Whiter. X-ray Vision for the Hand Therapist Susan Weiss OTR/L CHT handtherapy.com

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1 X-ray Vision for the Hand Therapist Susan Weiss OTR/L CHT handtherapy.com SCIENCE X-rays are electromagnetic waves that fall between ultraviolet light and gamma rays on the wavelength scale. High energy beam is absorbed by dense body parts, passes thru other less dense areas. The x-ray is created when photons reach the film placed behind the body part and create a chemical reaction. Denser = Whiter X-rays were discovered accidentally in 1895 by the German physicist Wilhelm Roentgen First x-ray ever taken In 1896 the first clinical use of x-rays was when two British doctors used them to find a needle in a woman s hand Baby Rabbit 1

2 Why Request or View X-rays? Recent trauma Atypical lumps and bumps Previous trauma with persistent pain Assess for OA, RA, or degenerative changes Hx of cancer Post-op to check on healing or positioning Post-op check due to lack of progress Confirm or rule out dx after clinical eval What might you find on an X-ray? Too much bone Not enough bone Fractures Malalignment Tumors Congenital anomalies Foreign bodies Arthritis Infection Over 80 views described TYPICAL VIEWS HAND / FOREARM PA (Posterior Anterior) PA with zero rotation Oblique Ulnar deviation Lateral Clenched fist Carpal tunnel 2

3 Elbow typically flexed 90 o Forearm pronated Wrist in neutral Digits extended POSTERIOR ANTERIOR PA with ZERO ROTATION Shoulder abducted to approx 90 o Elbow flexed to approx 90 o Forearm neutral, but appears pronated OBLIQUE Elbow flexed Forearm midway between neutral and pronation Digits fanned 3

4 ULNAR DEVIATION Elbow flexed Forearm pronated Wrist ulnarly deviated Scaphoid view Shoulder neutral Elbow flexed Forearm neutral May or may not fan digits Thumb slightly abducted LATERAL CLENCHED FIST Usually both fists (for comparison) Elbows flexed Forearms supinated Wrists neutral Digits tightly fisted (clenched) Look for S-L gap 4

5 CARPAL TUNNEL Shoulder externally rotated Elbow extended Forearm supinated Wrist extended Difficult for both pt and technician Hook of the hamate or pisiform issues DORSAL HOOD VIEW FRACTURE TERMINOLOGY Open Closed Intra-articular Extra-articular Segmental Comminuted Green-stick Transverse Oblique Spiral Dislocation Subluxation Nonunion Malunion 5

6 DESCRIBING FRACTURES Name the bone State the section of the bone Proximal, distal, mid-shaft State the type of fracture Describe the: Angulation Shortening Rotation Displacement Overview of Fracture Terminology Closed Fracture - no broken skin Open Fracture - bone fracture that breaks through the skin INTRA-ARTICULAR EXTRA-ARTICULAR 6

7 Segmental Comminuted Greenstick Oblique diagonal break across the bone Transverse straight across; most common type; likely to heal Spiral looks like a corkscrew common in twisting injuries NONUNION MALUNION Doesn t heal back together Heals in an abnormal position 7

8 DISPLACEMENT Usually stated as displaced or non-displaced. Sometimes measured in mm. Described in terms of displacement of the distal fragment. Dorsal Displacement Volar Displacement DISLOCATION Displacement of the ends of a bone through a joint SUBLUXATION Incomplete or partial dislocation ANGULATION Dorsal Displacement Described in terms of direction of the apex of the angle formed by the fragments of the fracture. Apex dorsal or apex volar Apex Volar 8

9 Dorsal displacement Volar Displacement Dorsal dislocation PIPJ Volar dislocation Photo courtesy Primal Pictures SHORTENING *A likely cause of decreased AROM *Can also present with a shorter digit 9

10 Malrotation Malrotation is detected by clinical examination of the hand The long axis of all fingers should point to the scaphoid tubercle, or the distal radius, and the fingernails should be parallel to each other Rotation is often more disabling than angulation because of the digit overlap issue As little as 5 degrees of rotation can cause a 1.5 overlap in fingertip flexion X-ray courtesy of Dr. Eaton *Typically seen in the SF after a boxer s fx *Causes loss of ROM and grip strength Osteoarthritis Narrowing of the joint space indicates the loss of cartilage Spur X-rays are not very useful for detecting osteoarthritis in the early stages because they do not show changes in cartilage, which is where the earliest abnormalities occur. 10

11 OTHER TERMS Osteophyte: also known as bone spur, form due to the body's increase of a damaged joint's surface area; most commonly from the onset of arthritis; usually limits joint movement and typically causes pain. OTHER TERMS Osteoporosis a disorder in which the bones become increasingly porus, brittle and subject to fx, due to loss of calcium and other mineral components Osteopenia a general reduction in bone mass (less severe than osteoporosis) caused by the resorption of bone at a rate that exceeds bone synthesis. Bones are darker on x-ray due to less density RSD Periarticular osteoporosis 11

12 OTHER TERMS Sclerosis an abnormal hardening of a tissue or part Edges of bones appear whiter on x-rays as they are denser than they should be. Photo courtesy Primal Pictures OTHER TERMS Heterotopic excessive or out of place formation of bone Facts Radiographic changes can correlate poorly with symptoms. For example, an x-ray may show only a minor change while the person is having severe symptoms, or an x-ray may show numerous changes while the person is having very few, or no symptoms. Therefore never judge by x-ray alone and always perform a detailed clinical exam FIRST! X-rays are used to confirm or deny a diagnosis 12

13 Distal Radius Fracture X-Ray Tips Knowledge of the amount of radial shortening radial inclination dorsal angulation the presence of any articular step-offs DRUJ issues will help you to formulate appropriate treatment goals and plans RADIAL HEIGHT Radial Height = 11 to 12 mm RADIAL INCLINATION Inclination 22 o Radial Inclination = 22 o 13

14 RADIAL/PALMER TILT Radial Tilt = 11 o LATERAL WRIST ULNAR VARIANCE Normal = 1 to 2 mm Positive ulnar variance a/w ulnar impaction syndrome, TFCC tears, ulnar sided wrist pain Negative ulnar variance a/w Kienbock s disease 14

15 CLINICAL IMPLICATIONS Radial shortening (decreased height) Decreased grip strength Can affect pronation Radial shortening as minimal as 2.5 mm can substantially complicate this and markedly increase ulnar loading TFCC problems Loss of radial inclination May cause decreased UD and grip strength with a decrease of 5-10 degrees Wrist may appear radial deviated if inclination is less than 15 degrees CLINICAL IMPLICATIONS Loss of radial/palmer tilt results in Dorsal angulation Ulnar sided wrist pain due to load shift at the TFCC Silverfork deformity Positive Ulnar Variance Increased pain, decreased grip, decreased rotation TFCC damage Distal Radius Fracture Ulnar Plus Variance Dorsal tilt or Angulation Decreased radial height and inclination 15

16 Corrective Osteotomy Before After Ex Fix and Pinning Before After SCAPHOLUNATE ANGLE NORMAL 50 o Scapholunate Angle o 16

17 Normal Alignment Lateral view Capitate Lunate Collinear 45 degrees The normal scapholunate angle is between 30 and 60, Radius VISI and DISI Volar Intercalated Segmental Instability Due to disruption of the lunotriquetral ligament Most are abnormal Lunate looks volarly or toward the palm Scapholunate angle is typically less than 30 o Dorsal Intercalated Segmental Instability Due to disruption of the scapholunate ligament Can be a normal variant Lunate looks dorsally or toward the back Scapholunate angle is typically greater than 60 o DISI (DISI) The scapholunate angle is typically greater than 60 degrees. VISI (VISI) The scapholunate angle is typically less than 30 degrees 17

18 LATERAL VIEW - DISI > 60 o > 60 o NOT NORMAL LATERAL VIEW - VISI < 30 Look at the position Look for the C s Find the lunate Bisect the lunate Bisect the scaphoid Measure the angle looks pretty small probable VISI 18

19 90 o Look for the c s. Find the lunate (which way is it facing?). Draw a line bisecting the lunate. Find the scaphoid (if you can) and draw a line bisecting it. Examine the angle it is > 60 o This is a DISI Lunate vs. perilunate dislocation The key to differentiation between these is what is centered over the radius. If the capitate is centered over the radius and the lunate is tilted out, it is a lunate dislocation. (A) If the lunate centers over the distal radius and the capitate is dorsal, we are dealing with a perilunate dislocation (B) A B Lunate Dislocations capitate is centered over the radius and the lunate is tilted out X-ray courtesy of Dr. Eaton 19

20 Trans scaphoid perilunate dislocation lunate centers over the distal radius and capitate is dorsal Ulnar Deviation PA position Normal Wrist Facts about - Radial Deviation PA Position Normal Wrist Scaphoid flexes in RD signet ring/cortical ring sign 20

21 Case Studies Soft tissue detection and distal phalanx doesn t look quite right but not a clear picture with the AP view The lateral view shows a bony mallet deformity intraarticular X-ray Courtesy of Jim W Roderique MD What type of injury is this? Transverse, displaced open fx of the proximal phalanx Near amputation 21

22 Foreign body Remember Whiter = more density Piece of glass Photo Courtesy of Deborah A. Schwartz OTR/L, CHT 40+ y/o female with pain in finger Look at the darkness of this phalanx Observe how it extends to the very edges of the bone This is an enchondroma 22

23 Joint dislocations due to RA Swanson Finger Joint Implants What s wrong here? Note the brightness or the RF PIPJ It is due to the overlapping of P1 and P2 Volar dislocation of the PIPJ CMCJ LRTI and assessment with a stress view note laxity on unrepaired side 23

24 Scaphoid non-union leads to SLAC Photo Courtesy of Deborah A. Schwartz OTR/L, CHT 4 bone fusion Which bones are here? Which bones aren t here? So what is this? It s a PRC Notice bowers hemiresection and styloid excision Can you name all the things wrong with this pt who was sent to OT for CTS and wrist pain? Dislocated lunate! + ring sign Ulnar neg variance Capitate sitting in the lunate fossa! (SLAC) 24

25 Lateral view of the previous case Immature Carpal Bones (Child) Photo Courtesy of Deborah A. Schwartz OTR/L, CHT Child with Bifed or Duplicate Thumb Photo Courtesy of Deborah A. Schwartz OTR/L, CHT 25

26 Safe Position IPs straight MPs flexed 1 st Web Open Don t assume that a cast is doing the job inside even if it looks good on the outside Hook of Hamate Fracture Carpal Tunnel View Supinated Oblique View Scaphoid fracture in a teenager Photo Courtesy of Deborah A. Schwartz OTR/L, CHT 26

27 LT Coalition Photo Courtesy of Deborah A. Schwartz OTR/L, CHT Avascular necrosis of the lunate- Ulnar minus Photo Courtesy of Deborah A. Schwartz OTR/L, CHT Treatment - radial osteotomy Instructed to perform ROM and strengthening for OA of the hand 27

28 SLAC 3 weeks after ROM and strength program Most likely another incidental finding Interosseus lunate cyst ROM Complex PIP Fracture Photo Courtesy of Paul Bonzani OTR/L CHT After traction splinting 28

29 Proximal interphalangeal joint reconstruction with the Avanta implant arthroplasty. X-ray courtesy of Dr. Eaton AP VIEW X-ray courtesy of Dr. Eaton Transverse Midshaft metacarpal fx can see cast on x-ray cast can ultimately fail as these can be hard to hold in place X-ray Courtesy of Jim W Roderique MD 29

30 ORIF can be used to provide greater stability X-ray Courtesy of Jim W Roderique MD Scaphoid Fracture Treatment: compression screw with radial bone graft Photo Courtesy of Deborah A. Schwartz OTR/L, CHT Scaphoid fracture Acutrac screw placed backed out Gap widens with UD X-ray Courtesy of Jim W Roderique MD 30

31 Treatment Options Tx - 4 bone fusion with scaphoid excision Same procedure with a spider plate X-ray Courtesy of Jim W Roderique MD Distal radius fx significant ulnar pain Ulnar Shortening and Hardware removal Both bone forearm fx. Fixed only one side 31

32 Giant cell tumor treated with a darrach procedure X-ray Courtesy of Jim W Roderique MD Adult bilateral congenital Madelung's deformity with pain X-ray courtesy of Dr. Eaton 32

33 Treated with the Sauve Kapandji X-ray courtesy of Dr. Eaton Lateral View X-ray courtesy of Dr. Eaton There is a comminuted fx of the proximal ulna. There is a superolateral dislocation of the radius (radial head). This is called a Monteggia Fracture. 33

34 The Monteggia Fx Fixed Monteggia Fx Patient complained of wrist pain after this fracture 34

35 Heterotopic ossification of the olecranon process. Left distal humerus supracondylar fracture Photo courtesy: Charleen Stennett, OTR/L, CHT Photo courtesy: Charleen Stennett, OTR/L, CHT 35

36 Humeral fx out of country fell off a bike Treated with Ex-Fix In fracture brace Did not heal Added rod 36

37 Photo courtesy: Charleen Stennett, OTR/L, CHT Photo courtesy: Charleen Stennett, OTR/L, CHT REFERENCES Radiography: A Review for the Rehabilitation Professional Susan Weiss, Deborah A. Schwartz, Stephen C. Anderson Journal of Hand Therapy April 2007 (Vol. 20, Issue 2, Pages ) hand.html

38 REFERENCES assmus.pdf Radiography: A Review for the Rehabilitation Professional: Susan Weiss, Deborah A. Schwartz, Stephen C. Anderson Journal of Hand Therapy, Vol. 20, Issue 2, p Published in issue: April 2007 Yin, Y., Mann, F.A., and Gilula, L.A. Positions and techniques. in: L.A. Gilula, Y. Yuming (Eds.) Imaging of the Wrist and Hand. WB Saunders CO, Philadelphia, PA; 1996: Gilbert, T.J. Imaging of acute injuries to the wrist and hand. Radiol Clin North Am May; 35: Harvey, C.J., Allen, S.D., and O'Regan, D. Interpretation of wrist and hand radiographs. Br J Hosp Med (Lond). 2006; 67: M48 M52 Stein, F. Radiographic examination of the hand and wrist. Emerg Med Clin North Am. 1985; 3: Irwin, J.P., Joule, W.W., Peterson, G.H., Liebman, C.E., and Aaron, J.O. How the radiologist can help to evaluate injuries and diseases of the upper extremity. in: M.L. Kasdan (Ed.) Occupational Hand and Upper Extremity Injuries and Diseases. Hanley and Belfus, Inc, Philadelphia, PA; 1991: Thank you! 38