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Wrist joint an imaging insight

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Imaging of wrist joint

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Wrist joint an imaging insight

  1. 1. SOURAV TALUKDER MBBS
  2. 2. WRIST JOINT INCLUDES DRUJ, RADIOCARPAL, PISOTRIQUETRAL, MIDCARPAL, 1ST CMC, 2ND -5TH CMC AND ASSOCIATED LIGAMENTS AND TENDONS
  3. 3. RADIOGRAPHY USG CT SCAN MRI
  4. 4.  P-A VIEW CENTERING- MIDWAY BETWEEN RADIUS AND ULNAR STYLOID PROCESS
  5. 5.  ULNAR NEUTRAL- ULNA NO MORE THAN 2MM SHORTER THAN RADIUS  ULNAR MINUS- KIENBOCK DISEASE  ULNAR PLUS- ULNOLUNATE IMPACTION SYNDROME AND TFC TEAR
  6. 6. . ARC OF GILULA . GREATER AND LESSER ARCS . VULNERABLE ZONE
  7. 7.  CARPAL HEIGHT-  Distance from 3rd metacarpal base to distal radius articular surface  CARPAL HEIGHT RATIO-  Carpal height/3rd metacarpal shaft length (nl-0.54)  CARPAL HEIGHT INDEX-  Carpal height ratio of dominant hand/ carpal height ratio of non-dominant hand (nl- 1.0 ±0.15)
  8. 8. Width of the lunate/ width of the radial lunate fossa (Nl.- Less than 50% Lunate overhangs the ulnar edge of the radius)
  9. 9.  Bet. One line connecting the radial styloid tip and ulnar aspect of the distal radius and a second line perpendicular through the longitudinal axis of the radius
  10. 10.  Angle formed by tangential lines to proximal scaphoid-lunate and proximal triquetrum-lunate Positive carpal sign-angle is 117◦ or less
  11. 11.  Create a contour reminiscent of an ‘m’
  12. 12. LATERAL VIEW CENTERING- ON STYLOID PROCESS OF RADIUS
  13. 13.  Line drawn tangent to ant and post . radial margins intersects line drawn perpendicular to radial long axis  Nl- 2-20˚, average 11˚
  14. 14.  RADIO-LUNATE- <15˚  SCAPHOLUNATE- 30-60˚  CAPITO-LUNATE- 0-30˚  LUNO-TRIQUETRAL- 14-16˚
  15. 15. OBLIQUE VIEW CENTERING-BETWEEN RADIUS AND ULNAR STYLOID PROCESS
  16. 16.  STAGE 1- SCAPHO-LUNATE DISSOCIATION  STAGE 2- PERILUNATE DISLOCATION  STAGE 3-TRIQUETRO-LUNATE DISSOCIATION  STAGE 4- LUNATE DISLOCATION
  17. 17.  Lunate is centered over distal radius and rest of the carpal bones are tilted dorsally  High energy trauma  Trans-scaphoid perilunate dislocation  Tear of radioscapho-capitate ligament
  18. 18.  CAUSES- # Triquetrum LT ligament injury with associated injury of Radioluno-triquetral and dorsal radio-carpal ligament NEITHER LUNATE OR CAPITATE IS IN ALIGNMENT WITH DISTAL RADIUS
  19. 19.  High energy trauma  A-p view- overlaps capitate, hamate and triquetrum, ▲ shape-” piece of pie” sign  Lat view- tilted volarly- ” spilled tea cup “ appearance  Due to dorsal radio-carpal ligament tear
  20. 20.  VISI Volar rotation of lunate and dorsal rotation of capitate and hamate Due to tear of ulnar sided radio-carpal ligaments and L-T Ligament Capito-lunate angle- >30˚
  21. 21.  DISI  Dorsal tilt of lunate  Capito-lunate angle- >30˚  Causes- Scaphoid # s-l ligament tear
  22. 22. # SCAPHOID BENNET’S #
  23. 23.  Distal metaphysis of radius  Dorsal angulation and displacement  Elderly, osteoporotic patient
  24. 24.  Younger patient  High energy trauma  Volar displacement and angulation
  25. 25. DORSAL TYPE VOLAR TYPE (AKA-REVERSE BARTON’S #)
  26. 26. Depression # of lunate fossa of distal radius May be asso. With proximal subluxation of lunate
  27. 27. A- EXTRA-ARTICULAR # A1- ulna, radius intact A2- radius, simple and impacted A3- radius, multifragmentary
  28. 28. B- PARTIALLY ARTICULAR # B1- radius, sagital B2- radius, frontal, dorsal rim B3- radius, frontal, ventral rim
  29. 29.  C- COMPLETELY ARTICULAR C1- articular, simple, metaphyseal simple C2- articular simple, metaphyseal multi-fragmentary C3- articular multifragmentary
  30. 30. A. BENDING #- ONE CORTEX OF METAPHYSIS FAILS DUE TO TENSILE STRESS AND THE OPPOSITE CORTEX UNDERGOES SOME COMMINUTION B. SHEARING #- FRACTURE OF JOINT SURFACE C. COMPRESSION #- # WITH IMPACTION AND COMMUNITION D. AVULSION #- # OF THE LIGAMENTOUS ATTACHMENTS E. COMBINED #- COMBINATION OF TYPES, HIGH ENERGY FORCES
  31. 31.  Stable- avulsion # of tip of ulnar styloid or stable # of the ulnar neck
  32. 32.  Unstable- avulsion of the base of the ulnar styloid of tear of tfc
  33. 33.  Potentially unstable-intra- articular # of the sigmoid notch or intraarticular # of the ulnar head
  34. 34.  SYNOVIAL A. DIFFUSE AND SYMMETRIC JOINT SPACE NARROWING B. PERI-ARTICULAR OSTEOPENIA C. BONE EROSIN D. SOFT TISSUE SWELLING  CHONDROPATHIC A. ASYMETRIC JOINT SPACE NARROWING B. GEODE FORMATION C. OSTEOPHYTE FORMATION D. SUBCHONDRAL SCLEROSIS
  35. 35. SYNOVIAL CHONDROPATHIC
  36. 36. Causes- untreated chronic scapho-lunate dissociation Scaphoid # cppd deposition ds. Watson’s staging- Grade 1- radial styloid and scaphoid Grade 2-whole radio-scaphoid articulation Grade 3- radio-scaphoid + capito-lunate Grade 4- radio-carpal +other intercarpal ± druj
  37. 37. ISOLATED- TRANSVERSE LUNO-TRIQUETRAL CAPITO-HAMATE SYNDROMIC- PROXIMO-DISTAL TRAUMA, INFECTION, RA
  38. 38.  Lunula- bet. TFC and triquetrum  Os styloideum- on the dorsal surface of the 2nd/ 3rd metacarpal base  Os triangulare- just distal to ulnar fovea  Trapezium secondarium- medial to tubercle of trapezium on volar surface  Os epilunate- dorsal to lunate  Os hamuli proprium-at tip of hamate hook
  39. 39.  PATIENT POSITION  PROBE SELECTION  EXAMINATION PROTOCOL
  40. 40.  SIX GROUPS
  41. 41. SYNOVITIS
  42. 42.  Erosion
  43. 43.  Tenosynovitis
  44. 44.  Stenosing tenosynovitis involving 1st extensor group  Intertendinous septum
  45. 45.  At the intersection of 1st and 2nd tendon sheaths  Approx. 4 cm prox to lister tubercle
  46. 46.  Tenosynovitis of epl when it crosses group 2 tendons
  47. 47. DIAMETER CRITERIA ‘NOTCH SIGN’ ↑ DOPPLER SIGNAL SECONDARY NV. CHANGES-Hypoechoic swollen nv. Loss of fascicular pattern Flattening of the nv. ASSOCIATED FACTORS-Persistent median artery Bifid median nv.
  48. 48.  MAGNET  COIL  POSITION  ORIENTATION  SEQUENCES
  49. 49.  T1WI  T2WI/ PDWI  FS PD FSE/ FS T2 FSE- Fluid sensitive  T2*GRE- Ligament evaluation  3D SPGR TECHNICAL CONSIDERATIONS CONTRAST ADMINISTRATION
  50. 50. DIRECT UNICOMPARTMENTAL MULTICOMPARETMENTAL INDIRECT PROCEDURE- 0.1 ml of gd diluted into 20 ml of solution ( 10 ml of saline + 5 ml iodinated contrast material + 5 ml of lidocaine 1%)
  51. 51.  GENERAL CONSIDERATIONS VOLAR RADIO-CARPAL LIGAMENTS Radio-scapho-capitate Volar radio-luno-triquetral Radio-scapho-lunate (ligament of Testut) Short Radio-lunate
  52. 52. VOLAR ULNO-CARPAL LIGAMENT  Ulno-lunate ligament  Ulno-triquetral ligament  Ulno-capitate ligament  Arcuate ligament (rsc+uc+tc)
  53. 53.  VOLAR MIDCARPAL Scapho-trapezium-trapezoid Scapho-capitate Triquetro-capitate Triquetro-hamate Piso-hamate Deltoid (sc+tc)
  54. 54.  DORSAL RADIO-CARPAL LIGAMENT (radioluno-triquetral ligament)  Modified viegas classification
  55. 55.  DORSAL INTERCARPAL LIGAMENT
  56. 56.  PROXIMAL INTEROSSEUS LIGAMENTS Scapho-lunate Ligament Luno-triquetral Ligament
  57. 57. DISTAL INTEROSSEUS LIGAMENTS  Trapezio-trapezoid  Trapezio-capitate  Capito-hamate
  58. 58. CARPO-METACARPAL LIGAMENTS DISTAL RADIO-ULNAR LIGAMENTS Piso-metacarpal Carpo-metacarpal ligaments of thumb Dorsal carpometacarpal Volar carpometacarpal  Dorsal radio-ulnar  Volar radio-ulnar
  59. 59. S-L LIGAMENT L-T LIGAMENT
  60. 60.  Tfc proper  Meniscus homolouge  Ulnar collateral ligament  Dorsal and volar radio-ulnar ligament  Extensor carpi ulnaris tendon  Ulnocarpal ligament
  61. 61. BLOOD SUPPLY Ulnar artery Ant. Interosseus artery FUNCTIONS Stabilisation of DRUJ and ulnar carpus Load bearing structure Prevention of volar subluxation of ulnar carpus
  62. 62.  PALMER CLASSIFICATION CLASS 1 (TRAUMATIC) A. Central perforation B. Ulnar avulsion with or without distal ulnar fracture C. Distal avulsion D. Radial avulsion with or without sigmoid notch fracture
  63. 63.  PALMER CLASSIFICATION CLASS 2 (DEGENERATIVE) A. TFCC wear B.TFCC wear with lunate and/or ulnar chondromalacia C. TFCC perforation with lunate and/or ulnar chondromalacia D. C plus LT ligament perforation E. D plus ulnocarpal arthritis
  64. 64.  PREDISPOSING FACTORS Congenital positive ulnar variance Essex-Lopresti # Malunited distal radius # Premature physeal closure of radius Surgically excised radial head
  65. 65. ULNAR IMPACTION SYNDROME PATHOLOGIC SPECTRA
  66. 66. PREDISPOSING FACTORS  Abnormally elongated styloid (6 mm) or Ulnar styloid process index > 0.21 ± 0.07  Curved ulnar styloid (parrot beak appearance)  Malunited # Styloid- Type 1 and 2
  67. 67. USPI PATHOLOGIC SPECTRA
  68. 68. PREDISPOSING FACTORS  Congenital negative ulnar variance  Premature physeal closure of ulna  Surgical removal of distal ulna
  69. 69. ULNAR IMPINGEMENT SYNDROME PATHOLOGIC SPECTRA
  70. 70.  Chondromalacia of proximal pole of hamate  Type 2 lunate morphology
  71. 71.  EROSION  EDEMA  SYNOVITIS  TENOSYNOVITIS
  72. 72. MARROW EDEMA SYNOVITIS
  73. 73.  VOLAR CARPAL LIGAMENT  FLEXOR RETINACULUM  EXTENSOR RETINACULUM
  74. 74.  ANATOMICAL SNUFFBOX  CARPAL TUNNEL  GUYON CANAL
  75. 75.  SIGNS Swelling of nv. Flattening/angulation of nv. Bowing of Flexor retinaculum (Bowing Ratio > 15%) ↑ T2 signal intensity of nv.
  76. 76. NORMAL ABNORMAL
  77. 77.  Minnar de villers’ classification Type 1-Proximal pseudo-arthrosis Type 2- Proximal osseus bridge with distal notch Type 3- Complete osseus fusion Type 4- Associated other carpal abnormalities
  78. 78.  GROUP 1- Vessel entering only one surface or large area dependent on single vessel scaphoid, capitate, 8% of lunate  GROUP 2- Absence of internal anastomosis hamate, trapezoid  GROUP 3- Rich internal anastomosis trapezium, triquerum, pisiform, 92% of lunate
  79. 79.  Proximal pole of scaphoid  Lunate  Proximal pole of capitate
  80. 80.  ENCHONDROMA  INTRA-OSSEUS GANGLION CYST
  81. 81. GANGLION CYST COMPOUND PALMAR GANGLION

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