Wrist sep09

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xray wrist carpal instability gilula lines

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Wrist sep09

  1. 1. sep 2009
  2. 2. Was bedeutet der handsurgeonwissen wollen?
  3. 3. Xray Measurements• Carpal height• Ulnar variance• Radial inclination• Radial length• Palmar tilt• Radial shift
  4. 4. Position• Neutral PA• Neutral Lat
  5. 5. Position• Neutral PA• Neutral Lat
  6. 6. Position: PA• Wrist and elbow shoulder height• radius and ulna parallel
  7. 7. Extensor carpi ulnarisgroove• Radial to mid styloid
  8. 8. Extensor carpi ulnarisgroove• Radial to mid styloid
  9. 9. Position: Lateral• Elbow adducted• Shoulder elbow wrist in 1 plane
  10. 10. Lateral CCC• Radius• Lunate• Scaphoid
  11. 11. Lateral CCC• Radius• Lunate• Scaphoid
  12. 12. Lateral CCC• Scaphoid• Pisiform• Capitate
  13. 13. Lateral CCC• Scaphoid• Pisiform• Capitate
  14. 14. CCC OK!
  15. 15. Lunate dislocation
  16. 16. CCC niet OK.
  17. 17. Shape Lunate
  18. 18. Scaphoid shape Ext Uln. deviation
  19. 19. Scaphoid flex / radialdeviation rad deviation flex
  20. 20. Scaphoid axis
  21. 21. Lunate axis
  22. 22. Capitate axis
  23. 23. Obliquetrapezo-trapezoid
  24. 24. Obliquetrapezo-trapezoid
  25. 25. Carpal height• Base MC3• Radiocarpal• Collapse – RA – SL collapse – Lunatomalacie
  26. 26. Carpal height• Ratio – MC3 (0.54) – Capitate (1.57)
  27. 27. Carpal height• Ratio – MC3 (0.54) – Capitate (1.57)
  28. 28. Ulnar variance
  29. 29. Ulnar variance• Load transfer• Growth disorder• Post trauma
  30. 30. Ulnar variance• Association – SL instable – Ulnocarpal impaction – TFCC• Normal + 3 mm Mid
  31. 31. Radial inclination• Fracture: – <5° poor outcome• Madelung steep• Normal 16-28°
  32. 32. Radial inclination• Fracture: – <5° poor outcome• Madelung steep• Normal 16-28° Mid
  33. 33. 1878 O. W. Madelung: Die spontaneSubluxation der Hand nach Vorne.
  34. 34. Radial length• Styloid length• Shortening after #• Compare L-R• Normal 10-18 mm
  35. 35. Radial length• Styloid length• Shortening after #• Compare L-R• Normal 10-18 mm Mid
  36. 36. Palmar tilt• Volar ligaments• Dorsal bony ridge• Residual deformity – 200% load ulnocarpal• Normal 0-22 °
  37. 37. Palmar tilt• Volar ligaments• Dorsal bony ridge• Residual deformity – 200% load ulnocarpal• Normal 0-22 ° Mid
  38. 38. Radial shift• # dislocation• PA• Styloid• Midshaft• Compare L-R – max 1mm
  39. 39. Radial shift• # dislocation• PA Width• Styloid• Midshaft• Compare L-R – max 1mm Mid
  40. 40. Wrist conditions• Carpal instability• Scapholunate Collapse• Ulnar translocation• Ulnocarpal impaction• Radio-Ulnar impingement
  41. 41. Carpal instability• SL - scapholunate• LT - lunotriquete• SLT - Combined• Ligaments intact?
  42. 42. Arc I LT
  43. 43. Arc II SL LT
  44. 44. Arc III CH
  45. 45. DISIDorsal intercalated segment instability
  46. 46. DISI (pathology)Dorsal ... instabilityLunatum kijkt naar posterior A A
  47. 47. VISIVolar intercalated segment instability
  48. 48. VISI (variant)Volar .. instabilityLunatum kijkt naar anterior A A
  49. 49. VISILT Collapse
  50. 50. InstabilityLT CollapseArc 1Short ScaphoidParallel
  51. 51. VISIPalmar tilt Scaphoid Lunate
  52. 52. VISIPalmar tilt Scaphoid Lunate
  53. 53. VISIPalmar tilt Scaphoid Lunate
  54. 54. VISISL angle < 30 °
  55. 55. Scapho lunate advancedcollapse• Progressive• Clinical & Radiological• Narrowing• Sclerosis• Osteophyte SLAC• CPPD deposition• Non union
  56. 56. SLAC•a
  57. 57. Ulnar translocation• Clinical & Radiological• Disruption R-C lig.• Instability• Ulnar displacement – Scaphoid-Styloid – Hamate-Ulna
  58. 58. Ulnar translocation Scaphoid-Styloid
  59. 59. Ulnar translocation Ulna - Hamate
  60. 60. Ulnocarpal impaction• U-L-T Joint degeneration• Compressive forces• Ulna +
  61. 61. Ulnocarpal impaction• U-L-T Joint degeneration• Compressive forces• Ulna + T L U
  62. 62. Radio-Ulnar impingement• ulna -, concave radius, convergence
  63. 63. TFCCIntact #
  64. 64. CasesParallel jointsOverlapCarpal ArcsShapeFracture
  65. 65. Case 1
  66. 66. Case 1• Lunate not parallel• Arc 1 en 2• Triangular lunate• Dislocated!
  67. 67. Case 2
  68. 68. Case 2TL, HL overlapParallel R,L,prox S, prox C Triq,H,dist S, dist H, Trap# H, S
  69. 69. Case 2TL, HL overlapParallel R,L,prox S, prox C Triq,H,dist S, dist H, Trap# H, STrans scaphoid and capitate perinlunate #dislocation
  70. 70. Case 2
  71. 71. Case 2
  72. 72. Case 3
  73. 73. Case 3LT not parallelArc 1, 2 brokenSL tiltedVISI LT dissociation
  74. 74. Case 4
  75. 75. Case 4All parallelSL wideScaphoid tiltLunate tiltArthrosis RS CLSLAC (SL tear)
  76. 76. SLAC (CPPD)
  77. 77. ApproachCCC and CCCParallel jointsOverlapCarpal ArcsShapeFracture
  78. 78. Handletselboek.pdfHandsurgeryDerrick cars

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