A fracture is a discontinuity in a bone resulting from mechanical forces exceeding the bone's strength. Common fractures of the distal forearm include Colles' fractures, Barton's fractures, Smith's fractures, Galeazzi fractures, and Piedmont fractures. Fractures of the wrist bones like the scaphoid, triquetral, and hamate can also occur. Delayed treatment of scaphoid fractures can lead to nonunion or osteonecrosis. Ulnar impingement syndrome and ulnar impaction syndrome can cause ulnar-sided wrist pain.

3. Fracture
A fracture is a discontinuity in a bone (or cartilage) resulting from
mechanical forces which exceed the bone's ability to withstand
them

5. I] Injury to the Distal Forearm
1]Fractures of the Distal Radius
a] Colles Fracture

6. a] Colles Fracture
European literature as the Pouteau fracture,
• Fracture line is extra-articular,
• distal fragment is radially and dorsally displaced and shows
dorsal angulation
Mechanism of injury : Fall on the
outstretched hand with the forearm
pronated in dorsiflexion
Complications
1]At the time of fracture, concomitant injury to the median
and ulnar nerves may occur

8. Smith Fracture/ Reverse Colles fracture

9. posteroanterior and lateral projections are
sufficient to demonstrate Colles fracture.
detector size
24 cm x 30 cm
exposure
50-60 kVp
3-5 mAs
Lateralposteroanterior

10. C]Reverse Barton
fracture: volar
margin of radius
into radio carpal
joint
b]Barton Fractures
dorsal margin of distal
radius into radio
carpel joint

11. Hutchinson fracture/chauffeur's fracture
Radial margin of the radial styloide process into
Radio carpal articulation

12. dorsi-palmar oblique
non-opaque pad.
detector size
18 cm x 24 cm
exposure
50-60 kVp
1-5 mAs

13. Galeazzi Fracture
Fall on the outstretched hand combined with marked pronation of the forearm
Fracture of distal 1/3rd of radius distal fragment is dorsally displaced with
distal radio ulnar dislocation

14. Two types of Galeazzi injury have been identified.
Type I: The fracture of the radius is extra-articular in the distal third of the bone
Type II: the radius fracture is usually comminuted and extends into the radiocarpal
joint
Type I:
Type II

15. I] Injury to the Distal Forearm
1]Fractures of the Distal Radius
a] Colles Fracture
b] Barton and Hutchinson Fractures
c] Smith Fracture/ Reverse Colles fracture
d] Galeazzi Fracture

17. Ulnar Impingement Syndrome
Ulnar impingement syndrome is caused by a short distal ulna that impinges on the
distal radius

18. A short ulna may represent a congenital anomaly,
1]such as negative ulnar variance,
A]result of premature fusion of the distal ulnar growth
plate secondary to previous trauma.
B] surgical procedures that involve resection of the
distal ulna secondary to trauma, rheumatoid arthritis,
clinical symptoms of the ulnar impingement syndrome
consist of
1]ulnar-sided wrist pain
2] limitation of motion in the radio-carpal joint.
3]discomfort during pronation and supination of the
forearm.

19. On radiography,
short ulna and scalloping of the medial aspect of the distal radius in
cases of negative ulnar variance or premature fusion of the distal ulnar
growth plate,
radial scalloping and radio-ulnar convergence in cases of distal ulnar
resection.
Before these findings become obvious on conventional radiologic studies,
MRI may be helpful in early recognition of this condition

20. ulnar variance or Hulten variance: radial styloid process
exceeds the length of the articular end of the ulna by 9 to 12 mm
Articular surfaces of the radius and the ulna are on the same level,
yielding neutral ulnar variance
ulna projects more proximally—negative ulnar variance
ulna projects distally—positive ulnar variance

21. posteroanterior view

22. Ulnar Impaction Syndrome/ulnolunate
abutment syndrome,
Chronic impaction between the ulnar head and the Triangular Fibro Cartilage
complex and ulnar carpus results in
1]positive ulnar variance
2]Degenerative tear of the Triangular Fibro Cartilage complex
3]chondromalacia of the lunate bone, triquetral bone, and distal ulnar head
4]instability or tear of the luno-triquetral ligament
5]osteoarthritis of the ulnocarpal and distal radioulnar join
Clinically: ulnar wrist pain, swelling, and
limitation of motion related to excessive
load bearing across the ulnar aspect of the
wrist.
Treatment of this condition includes TFCC
debridement and ulnar shortening

23. MR imaging reveals bone marrow edema of the distal ulna
and lunate, subchondral sclerosis and cyst formation, and
destruction of the cartilage. Associated abnormalities, such
as tears of the triangular fibrocartilage and lunotriquetral
ligament,

25. I] Injury to the Distal Forearm
1]Fractures of the Distal Radius
a] Colles Fracture
b] Barton and Hutchinson Fractures
c] Smith Fracture/ Reverse Colles fracture
d] Galeazzi Fracture
e] Piedmont Fracture
f] Ulnar Impingement Syndrome
g] Ulnar Impaction Syndrome/ulnolunate abutment syndrome,
Smith Fracture

26. 2]Injury to the Wrist

27. Scaphoid Bone

28. A] Fracture of the Scaphoid Bone
Mechanism: falls on the outstretched palm of the hand
Scaphoid fractures can be classified according to direction of the
fracture line : Russe classification of scaphoid fractures

29. rarely cause any significant clinical
problems
good healing
nonunion and osteonecrosis

30. fracture of the scaphoid is suspected,
Postero-anterior in ulnar deviation,
Anterior oblique – ulnar deviation
Postero-anterior in ulnar deviation,
1]The patient is seated alongside the table with the affected
side nearest the table.
2] The arm is extended across the table with the elbow flexed
and the forearm pronated.
• The wrist is positioned over one-quarter of the cassette and
the hand is adducted (ulnar deviation).
• Ensure that the radial and ulnar styloid processes are equidistant
from the cassette.
Direction and centring of the X-ray beam
• The vertical central ray is centred midway between the radial
and ulnar styloid processes

31. Anterior oblique – ulnar deviation
Position of patient and cassette
• From the postero-anterior position, the hand and wrist are
rotated 45 degrees externally and placed over an unexposed
quarter of the cassette. The hand should remain adducted in
ulnar deviation.
Direction and centring of the X-ray beam
• The vertical central ray is centred midway between the radial
and ulnar styloid processes

32. Thin-section trispiral tomography

34. Humpback deformity of the scaphoid after
a fracture
distal fragment undergoes palmar flexion
proximal fragment dorsiflexes

35. proximal fragment dorsiflexes
distal fragment undergoes palmar flexion Humpback deformity

36. Complications
Delayed diagnosis /delayed treatment of scaphoid fracture may lead
1]nonunion
2]osteonecrosis
[ first two of which are the most commonly seen.]
3]posttraumatic arthritis,

37. osteonecrosis usually affects the
proximal fragment
rarely the distal pole- good supply of
blood

38. Osteonecrosis most frequently becomes apparent 3 to 6 months after the injury
when the affected fragment shows evidence of increased density on
conventional radiography
Times fail to demonstrate this feature: CT or trispiral tomographic examination
is recommended as a valuable aid
Tehranzadeh and colleagues introduced
lateral flexion–extension complex motion tomography to evaluate the healing
process after scaphoid fractures
The examination includes acquisition of
1] Neutral lateral tomographic views followed by
2] lateral tomograms, first with full flexion
3] lateral tomograms full extension of the wrist
detection of motion between the fracture
fragments of unstable scaphoid fractures

39. MRI is very effective in demonstrating a
fracture line that is not apparent on
conventional radiographs

41. Injury to the Wrist
1] Fracture of the Scaphoid Bone
2]Fracture of the Triquetral Bone

42. Triquetral Bone

43. Fracture of the Triquetral Bone
1] Fractures of the triquetrum usually occur from forced hyperflexion or
as an avulsion injury
2] Frequently seen as dorsal chip fractures on the lateral projection since
the pisiform usually overlies the triquetrum on the frontal projection of
the wrist

44. Lateral view
The hand and wrist are placed such that medialaspect of the wrist is in
contact with the cassette.
The hand is adjusted to ensure that the radial and ulnar styloid
processes are superimposed.
Direction and centring of the X-ray beam
The vertical central ray is centred over the radial styloid
process.

45. Injury to the Wrist
1] Fracture of the Scaphoid Bone
2]Fracture of the Triquetral Bone
3]Fracture of the Hamate Bone

46. Hamate Bone

47. Fracture of the Hamate Bone
Mechanism of fracture : Direct blow to the volar aspect of the wrist.
Most hamulus fractures occur in sports activities requiring the use of a
racket, club, bat, that may cause direct injury to the palmar aspect of the
wrist

51. Hamate hook /hamulus fracture standard -dorsovolar view of the wrist,
Norman and colleagues have identified the eye sign.
The sign derives its name from the dense, oval, cortical ring shadow that is
normally seen over the hamate on the dorsovolar projection.
This ―eye of the hamate is actually the hook of the hamate seen on end.
absence or indistinct outline of the cortical shadow or the presence of
sclerosis suggests the diagnosis of hamulus fracture,

54. Confirmation of the diagnosis : carpal–tunnel view
This view effective when the suspected fracture is distal to the
base of the hook as the eye of the hamate may still be visible
The carpal–tunnel view

55. carpal–tunnel view
Axial – method 1
• The patient stand with their back towards the table.
• The cassette is placed level with the edge of the tabletop.
• The palm of the hand is pressed on to the cassette, with the
wrist joint dorsiflexed to approximately 135 degrees.
Direction and centring of the X-ray beam
• The vertical central ray is centred between the pisiform and
the hook of the hamate medially and the tubercle of the
scaphoid and the ridge of the trapezium laterally.

56. Axial – method 2
• The patient is seated alongside the table.
• The cassette is placed on top of a plastic block approximately
8 cm high.
• The lower end of the forearm rests against the edge of the
block, with the wrist adducted and dorsiflexed to 135 degrees.
• This position is assisted using a traction bandage held by the
patient’s other hand.
Direction and centring of the X-ray beam
• The vertical central ray is centred between the pisiform and
the hook of the hamate medially and the tubercle of the
scaphoid and the ridge of the trapezium laterally.

58. Injury to the Wrist
1] Fracture of the Scaphoid Bone
2]Fracture of the Triquetral Bone
3]Fracture of the Hamate Bone
4]Fracture of the Pisiform Bone

60. 4]Fracture of the Pisiform Bone
It usually results from direct injury to the wrist as, for example,
1]from a fall on the outstretched hand
2]use of the hand as a hammer to strike an object.
It may be an isolated injury or may coexist with fractures of other bones

62. Radiographs in the supinated oblique

63. Injury to the Wrist
1] Fracture of the Scaphoid Bone
2]Fracture of the Triquetral Bone
3]Fracture of the Hamate Bone
4]Fracture of the Pisiform Bone
5]Fracture of the Capitate Bone

64. Capitate Bone

65. 5]Fracture of the Capitate Bone
1]Mechanism of fracture : fall on the outstretched hand, with
hyperdorsiflexion of the hand causing impingement of the bone
against the distal radius
2]The waist (or neck) of the capitate is the most common site of
fracture.

66. The dorsovolar view of the wrist usually demonstrates the abnormality

68. Fracture of the Lunate Bone
Mechanism of Injury
1]Fall onto an outstretched hand
2]Direct blow on wrist
dorsovolar and lateral projections, are usually sufficient to demonstrate
this fracture

69. Kienbock Disease
Single or repeated trauma to the lunate or dislocation of the bone may impair its
blood supply and cause it to become necrotic.
Negative ulnar variance in individuals whose
ulna projects more proximally.
because of compression of the lunate against the irregular articular surface
created by the discrepancy in radial and ulnar lengths.
Repeated trauma to the lunate
They may be predisposed to Kienbock disease

70. Single or repeated trauma to the lunate or dislocation of the bone may impair its blood
supply and cause it to become necrotic.
Once lunate necrosis begins,
progression is marked by lunate flattening and elongation,
proximal migration of the capitate, scapholunate dissociation
osteoarthritis of the radiocarpal joint.

75. radiologist to demonstrate the integrity of the bone. Impotents because
At an early stage of the disease, in the absence of fracture or fragmentation,
revascularization procedure aimed at restoring circulation to the lunate may
prevent further progression of the necrotic process prevnted

76. Dislocations of the Carpal Bones
1] Scapholunate Dissociation

77. Injury to the scapholunate ligament
result in intercarpal ligament instability
rotary subluxation of the scaphoid,
On the dorsovolar view of the wrist,
two signs can be seen that indicate its presence.
1] Terry-Thomas sign,
2] signet-ring sign,

78. Terry-Thomas sign,
widening of the space between the scaphoid and the lunate,
[normally measures less than 2 mm ]

79. signet-ring sign,
cortical ring shadow that is normally not seen on the scaphoid on the
dorsovolar projection with the wrist in the neutral position
In Scapholunate Dissociation
volar tilt and rotation of the scaphoid cause it to appear foreshortened and the
bone's tuberosity to be seen on end, producing the characteristic ring shadow

80. Gilula three carpal arcs refer to the carpal alignment described on
posteroanterior or anteroposterior wrist radiographs and are used to
assess normal alignment of the Carpals
1]first arc: is a smooth curve outlining the proximal convexities of
the scaphoid , Lunate and Triquetrum
2]second arc: traces the distal concave surfaces of scaphoid
, Lunate and Triquetrum
3] third arc:
follows the main proximal curvatures of the
capitate and hamate

82. Lunate and Perilunate Dislocations
Mechanism of injury : Fall on outstretched hand causing high velocity
forced hyperextension and ulnar deviation of the wrist
On lateral view clearly demonstrates, the normal alignment of the
longitudinal axes of the lunate, the capitate, and the third metacarpal over
the distal radial surface
a break at any point in this line is pathognomonic of subluxation or
dislocation.

83. spilled teacup sign

84. disruption of arc II
triangular appearance of the lunate

86. Trans -scaphoid Perilunate Dislocation
the prefix trans indicates which bone is fractured.
[trans scaphoide –scaphoide fractured ] with perilunate dislocation.

87. 1]isolated dislocation scaphoide - distal carpal row is normal
Treated with closed reduction.

88. 2]dislocation of scaphoide in conjunction with axial carpal disruption. -
disruption of the distal carpal row and proximal migration of the radial half of
the carpus

89. Scaphoid axis
The true axis of the scaphoid is the line through the midpoints of its
proximal and distal poles.
Since the midpoint of the proximal pole is often difficult to appreciate, an
almost parallel line that is traced along the most ventral points of the
proximal and distal poles of the bone

90. Lunate axis
The axis of the lunate runs through the midpoints of the convex proximal
and concave distal joint surfaces
best be drawn by finding the perpendicular to a line joining the distal
palmar and dorsal borders of the bone as demonstrated on the left.
Scapholunate angle
Normal: 30 - 60?
Questionably abnormal: 60 - 80?[instability]
Abnormal: > 80-This indicates instability of the wrist.

91. Capitate axis
The capitate axis joins the midportion of the proximal convexity of the
third metacarpal and that of the proximal surface of the capitate.
Capitolunate angle
Abnormal: > 30-This indicates instability of the wrist.

92. DISI [Dorsal intercalated segmental instability ]or dorsiflexion instability
The intercalated segment is the proximal carpal row identified by the lunate.
Intercalated segment' refers to it being the part in between the
1]proximal segment of the wrist consisting of the radius and the ulna
2]Distal segment, represented by the distal carpal row and the metacarpals.
DISI or dorsiflexion instability the lunate is angulated dorsally.
scapholunate angle -30-60 -normal
60-80 ? Instable
>80 –instable
capitolunate angle > 30 Insteble

93. VISI or volarflexion instability
Volar intercalated segmental instability or palmar flexion instability is when the
lunate is tilted palmarly too much.
1] scapholunate angle less than 30°
2]capitolunate angle measures more than 30°
many cases VISI is a normal variant, especially if the wrist is very lax.

94. Injury to the Hand
A] Fractures of the Metacarpal Bones
1] Bennett Fracture
2] Rolando Fracture
Bennett and Rolando fractures are intraarticularfractures
that occur at the base of the first metacarpal bone.

95. Bennett fracture
1]Fracture of the proximal end of the first metacarpal that extends
into the first carpo-metacarpal joint.
2] a small fragment on the volar aspect of the base of the first
metacarpal remains in articulation with the trapezium bone,
3]Rest of the first metacarpal is dorsally and radially dislocated as
the result of pull of the abductor pollicis longus

96. The Rolando fracture
A comminuted Bennett fracture
the fracture line may have a Y, V, or T configuration.

98. Boxer's Fracture
1] Fracture of the metacarpal neck
2] Palmar angulation of the distal fragment.
occur in any of the metacarpal bones but is most commonly seen in
the fifth metacarpal.

99. Gamekeeper's Thumb
Gamekeeper's thumb
1] disruption of the ulnar collateral ligament of the first metacarpo-
phalangeal joint,
2] often accompanied by fracture of the base of the proximal
phalanx.
gamekeeper's thumb because it was originally seen affecting
Scottish game wardens who injured the ulnar collateral ligament
because of the method they used to kill rabbits.
more frequently seen in skiing accidents, the term ―skier's thumb
used

100. When ruptured, the torn end of the ulnar collateral ligament can become
displaced superficially to the adductor pollicis aponeurosis. This is known
as the Stener lesion.
,