Chapter 4 : Wrist Flashcards by Melissa Unknown

is the thumb on the lateral or medial aspect

Lateral

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what is at the extreme lateral and medial edges of the radius and ulna

Radial and ulnar styloids are at the extreme lateral and medial edges

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what articulation should be open in a pa wrist

Radioulnar articulation is open

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what is rotation controlled by for a pa wrist

hand, elbow, and humerus

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for a pa wrist where is limited superimposition

Superimposition of the MC bases is limited

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criteria for pa wrist:

Radial and ulnar styloids are at the extreme lateral and medial edges
*Radioulnar articulation is open
*Superimposition of the MC bases is limited
*Rotation is controlled by the position of the hand, elbow, and humerus
*Carpal bones in center, ¼ of distal ulna and radius plus ½ of the proximal MC are included in the field

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what better demonstrates the ulna in a pa wrist

when the humerus, elbow, and forearm are in the same plane 90degrees

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what type of fracture is the styloid process likely to get

an avulsion fracture

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what type of fracture happens when there is hyperextension or hyperflexion of a joint

avulsion

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What should be visible on all PA wrist images

Scaphoid fat stripe

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what is adequate to demonstrate the schaphoid fat stripe

contrast and density

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It is convex and located lateral to the scaphoid in an uninjured wrist

scaphoid fat stripe

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A change in the covexity may indicate the presence of a…

joint effusion
radial side fracture of the scaphoid radial styloid process
or proximal first metacarpal

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how should the scaphoid fat pad be?

Convexed

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how are the hand and wrist rotated in this oblique position?:
the MC bases and carpal bones on the medial aspect of the wrist are superimposed( whereas laterally they are not)

Hand and wrist rotated externally into an oblique position

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causes the laterally located carpal bones and MC bases to be superimposed and increases visibility of the pisiform and hamate hoo

Internal rotation of the hand and wrist

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what determines the positioning of the placement of the ulnar styloid

humerus and elbow

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what happens if the humerus remains in a vertical position

If humerus remain in a vertical position the ulna and radius cross over and the ulnar styloid is no longer in profile

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what type of rotation is it when the pisiform is out by itself

internal rotation

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what MC should you be looking at if you are concerned if there is rotation

the third MC- it should be straight

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what brings the ulnar styloid in profile

Abduction the humerus to position the elbow in the lateral position and humeral epicondyles aligned perpendicular to IR

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what is concave and slants 11 degrees from posterior to anterior

Distal radial carpal articular surface

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how many degrees does the distal radial carpal surface concave and slant from posterior to anterior

11 degrees

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if posterior radial margin is distal to the anterior margin , how was the proximal forearm

the proximal forearm was elevated higher than the distal forearm ( elbow was raised)

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if anterior radial margin is distal to the posterior margin how was the proximal forearm positioned

if anterior radial margin is distal to the posterior margin the proximal forearm was positioned lower than distal forearm (elbow lowered)

what would you do to superimpose the distal radial margins and demonstrate the radioscaphoid and radiolunate joints as open spaces

the proximal aspect of the forearm should be positioned slightly lower than the distal forearm(5 to 6 degrees) (so half of the 11 degrees)

what should you do when you have a thick or muscular forearm

A patient with a thick or muscular proximal forearm it may be necessary to extend the arm off the IR or table in order to position it parallel with the IR

how to put the wrist in a neutral position

To put the wrist in a neutral position, flex the patient’s fingers, flexing the until the MC are angled to 10-15 degrees with the IR

results in obscured 3rd -5thCM joint spaces and severely foreshortened scaphoid (signet ring configuration) and triangular lunate

Flexion -fingers are straight out

when there is foreshortening of the schaphoid what is visible

visible signet ring (white circle)

results in foreshortened MC and closed 2nd-3rd CM joint spaces , decreased scaphoid foreshortening, and triangular lunat

Extension (hand extended up) -pullinh distal part of scaphoid up elongating it

Excessive foreshortening and signet ring configuration of scaphoid*Lunate is triangular*3rd -5th CM places are obscured

wrist flexion

what can you do to fix the wrist flexion

The hand needs to be extended*Curl the patient’s finger

Foreshortened MC*Closed 2nd-3rd CM joint spaces*Decreased scaphoid foreshortening*Triangular lunate

wrist extension

distal scaphoid to shift anteriorly (towards palmar surface) and increase foreshortening as if forms the signet ring configuratio

radial deviation

how will the lunate shift in a radial deviation

Lunate will shift medially toward the ulna

distal scaphoid tilts posteriorly (dorsally) and demonstrate decrease foreshortening

Ulnar deviation

how will the lunate shift in ulnar deviation

Lunate will shift laterally towards the radius

why is ulnar deviation or radial deviation typically done

for wrist joint mobility

what is ulnar deviation used for

to demonstrate the scaphoid better - elongates it

criteria for pa oblique projection of the wrist

Contrast and density to demonstrate scaphoid fat stripe *45 degree external oblique *Trapezoid and trapezium are demonstrated without superposition *Trapeziotrapezoidal joint space is open *Scaphoid tuberosity and waist are demonstrated in profile *Small degree of trapezoid and capitate superposition is present

if under-rotated for an oblique wrist how is the trapezoid and trapezium

If under rotated the trapezoid and trapezium are superimposed

how is trapeziotrapezoida joint space when the wrist is under rotated for an oblique

The trapeziotrapezoidal joint space is obscured

The long axis of the 3rdmetacarpal and midforearm are aligned long axis of the collimation field, what position is the wrist in

the wrist is in a neutral position.

does radial or unlar deviation increase the foreshortening of the scaphoid

radial deviation

Preventing visualization of the scaphoid tuberosity and waist and positions the scaphoid directly next to the radius

radial deviation

decreases scaphoid foreshortening, the scaphoid will be elongated

ulnar deviation

in a oblique wrist *If the image demonstrates the posterior radial margin too far distal to the anterior margin , how was the proximal forearm

the proximal forearm was elevated higher than the distal forearm

in an oblique wrist , If the anterior radial margin is demonstrated distal to the posterior margin, how is the proximal forearm

the proximal forearm was positioned lower than the distal forearm

Parallel to the anteriorsurface of the distal radiusNormally convexBowing or obliteration mayIndicate subtle radial fracture

pronator fat stripe

criteria for a lateral wrist

Contrast and density to adequately demonstrate the pronator fat stripe and posterior soft tissue*Elbow flexed 90°and abduct humerus until it is parallel with the IR*Distal scaphoid and pisiform are aligned*Long axis of the 1st MC is aligned parallel with the forearm*¼ distal ulna and radius and ½ proximal MC

how to check for rotation of a lateral wrist

To detect rotation check the relationship between the distal aspect of the scaphoid and the pisiform

how should the the distal aspect of the scaphoid and the pisiform be in a lateral wrist

They should superimpose and demonstrate anterior to the capitate and lunate

criteria for lateral wrist to make sure that is no rotation

-all mc should all be superimposed -radius and ulna superimposed -distal scaphoid and pisiform anterior to capatate and lunate

what is the rotation if the radius is going to the lateral

external rotation

how is the pisiform when the wrist is externally rotated

bringing pisiform forward

how should the pisiform in a true lateral wrist be

scaphoid and pisiform should be superimposed -scaphoid can be slightly anterior but pisiform superimposed over it

how is the scaphoid when the wrist is rotated externally for a lateral wrist

*If wrist is rotated externally (supinated) the distal scaphoid is visible posterior to the pisiform

is this internally or externally rotated *If wrist is rotated externally (supinated) the distal scaphoid is visible posterior to the pisiform*If the distal scaphoid and pisiform are not superimposed and the ulna is positioned anterior to the radius

it is externally rotated

the pisiform , 5th digit and ulna will be anterior when there is internal or external rotation?

external rotation

if this happens is this internal or external rotation for a lateral wrist ? the distal scaphoid is visible anterior to the pisiform

wrist is rotated internally( hand pronated)

If distal scaphoid and pisiform are not superimposed and the ulna is positioned posterior to the radius was the wrist internally or externally rotated for a lateral wrist

the wrist was internally rotated

if the radius, scaphoid, and 2nd digit is going anterior then is this internal or external rotation of a lateral wrist

internal rotation

when the proximal forearm is higher in a lateral wrist is this radial flexion or extension

radial flexion

- align the long axis of the 3rd MC with the midforearm parallel with the IR

neutral lateral wrist

what view forces the distal scaphoid anteriorly and the pisiform is distal to the scaphoid

Radial deviation of wrist

what deviation shifts the distal scaphoid posteriorly

ulnar deviation

The pisiform is proximal to the scaphoid The proximal forearm may not be level ,but lower what does this cause

ulnar deviation

is this wrist flexion or extension? the lunate and distal scaphoid tilt anteriorly

wrist flexion

wrist extension or flexion? the lunate and distal scaphoid tilt posteriorly

wrist extension

is the elbow is higher, is it radial or ulnar deviation

radial deviation

if the elbow is lower, is it radial or ulnar deviation

ulnar deviation

is this radial deviation or ulnar? foreshortened scaphoid will go down anterior pushing pisiform distally

radial deviation

*if the first MC is not lowered it will be foreshortened and its proximal aspect is superimposed over what carpal bone?

trapezium

*Demonstrate scaphoid fat stripe *Scaphotrapezium and scaphotrapezoidal joint spaces are open *These joints are aligned at a 15° angle to the IR when the hand is fully extended *Ulnar deviation approx. 25° *Align 1st MC with the radius

Ulnar Deviation PA Axial Projection

the distal scaphoid tilts anteriorly approx. 20° and results in foreshortening of the scaphoid Why does this happen

wrist is non flexed

if patient is unable to achieve max ulnar deviation what angle should you use

20 degrees

what is the most. common fractured carpal bone?

scaphoid

what area on the scaphoid is the most common spot to be fractured

the waist of the scaphoid

what angle best demonstrates the proximal scaphoid

5 to 10 degress

what degree best demonstrates the waist of the scaphoid

15 degrees

what degree best demonstrates the distal scaphoid

25 degrees

where is most of the stress on when the hand is hyperexteneded

waist of the scaphoid

what degree do you need when the fracture is more distal on the scaphoid

less degree

If the scaphocapitate joint space is closed and the capitate and hamate are demonstrated without superimposition how was the degree of obliquity

insufficient

If the scapholunate joint space is closed and the capitate and hamate demonstrate some degree of superimposition how was the degree of obliquity

rotated more than needed

Pisiform is demonstrated without superimposition *Hamulus of the hamate and carpal canal is clearly demonstrated *Carpal canal is center of collimated field *Trapezium ,distal scaphoid, pisiform and hamulus of the hamate are all included within the field *Hyperextending (dorsiflex) of wrist until long axis of MC are close to vertical *Central ray 25 to 30 degrees, rotate hand to the radial side approx. 10 degrees, 5th MC vertical

criteria for gaynor hart

-tube angled inferior to superior -tangential view skimming base of 3rd MC -want to see arch -good view of hamate - hyperextend wrist til long axia of MC are close to vertical -25-30 degree angulation -rotate hand so 5th MC is perp to IR

Gaynor Hart

why does this happen in a gaynor hart: the carpal canal will not be fully demonstrated and the carpal bones will be foreshortened

angle between the CR and MC is too great

why does this happen in a gaynor hart : the bases of the hamulus process, pisiform and scaphoid are obscured by the MC bases

angle is too small