Hand Bone

Hand and wrist radiograph interpretation

Plain film views of hand and wrist: normal anatomy, fracture and dislocation recognition.

33 questions 5 source pages

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Q1Which classifications are used for radial head dislocation and distal radius fracture on this section?▸

Radial head dislocation — Mason classification
Distal radius fracture — Melone, Frykman, AO and Fernandez classifications
Lafontaine criteria applied to distal radius fracture instability

Q2Which eponymous classifications apply to tendon injuries of the hand?▸

Jersey finger — Leddy & Parker classification
Mallet finger — Doyle classification

Q3Which eponymous classifications apply to finger joint fracture-dislocations?▸

PIPJ fracture dislocation — Eaton, Hasting
MCPJ fracture dislocation — simple/complex (Kaplan)

Q4Which eponymous classifications apply to carpal and wrist conditions?▸

Scaphoid fracture — Herbert, Russe
Perilunate/lunate dislocation — Mayfield, Tavernier
SNAC/SLAC — Geissler, Watson
Kienbock disease — Litchman, Natress/McMurty/Starhl

Q5What classification is used for CMCJ arthritis and which other hand conditions are listed on this section?▸

CMCJ arthritis — Eaton classification
Skier's thumb — Stener
Bennett fracture and reversed Bennett fracture
Enchondroma

Q6Describe the X-ray findings of this hand lesion.▸

Solitary, central, diaphyseal, osteolytic lesion at the 4th metacarpal
Matrix +/- rings and arcs suggestive of calcification
Narrow transitional zone and sclerotic border; mild cortical expansion, no periosteal reaction, cortical breakage
Overall suggestive of a benign tumour

Q7What is the differential diagnosis of a lytic bone lesion?▸

Fluid
Fat
Fibrous
Chondral

Q8How do you assess and manage a suspected enchondroma?▸

Aim: establish diagnosis, rule out complications
PMHx renal disease, trauma/infection, pain, overlying skin change, joint ROM
X-ray very suggestive of enchondroma; may not need biopsy (+/- MRI)
Ddx: enchondroma (if multiple -> Ollier/Maffucci), infection, brown’s tumour, chondrosarcoma
No pathological fracture: observation or curettage with bone graft; pathological fracture: allow healing then curettage

Q9What is the epidemiology and pathogenesis of enchondroma?▸

M:F 1:1; most common 20-50 years; diaphysis/metaphysis
Most common bone tumour in the hand
Benign chondrogenic tumour of hyaline cartilage from abnormal chondroblast function in the physis
Escaped chondrobloast from physis displaced to metaphyseal region and proliferate
Rubin: physeal hyperplasia

Q10How do you distinguish enchondroma from chondrosarcoma?▸

Chondrosarcoma: cortical thickening and destruction, endosteal erosion/scalloping >50% of cortical width, larger >5cm
Histology enchondroma: bland mature hyaline cartilage (blue balls) separated by normal marrow
Histology chondrosarcoma: hypercellularity, plump nuclei, binucleate cells, giant cells with chromatin clumps
Solitary malignant transformation 1%

Q11What injury is demonstrated and what associated injuries must be excluded?▸

Comminuted radial head and neck fracture, Mason type 3
No elbow dislocation or coronoid fracture
Take X-ray one joint above and below, especially to rule out DRUJ instability (Essex-Lopresti injury)

Q12What is an Essex-Lopresti injury?▸

Radial head fracture + dislocation of the distal radioulnar joint + interosseous membrane disruption
Incidence ~1-8%

Q13What is the management of a radial head fracture with longitudinal radioulnar instability?▸

Soft tissue: compartment syndrome, PIN palsy
Bony: restore radial alignment to prevent proximal migration and limited rotational range
Radial head + neck fixation or replacement depending on comminution

Q14What does the JBJS 2022 review (Sheth) advise?▸

Leads to longitudinal radioulnar instability
Acute: restore radial length and temporary DRUJ immobilisation; indication for acute IOM repair/reconstruction unclear
Chronic: restore radial length, wrist levelling +/- treatment of degenerative changes at RCJ or DRUJ
Central band reconstruction debated but can restore forearm load transfer

Q15Describe the X-ray findings in this bony mallet finger.▸

Intra-articular fracture at the dorsal base of the distal phalanx with displacement
Size ~50% of the articular surface, no comminution
No subluxation of the DIPJ

Q16Classify mallet finger injuries using the Doyle classification.▸

Type 1: Close soft tissue mallet
Type 2: laceration
Type 3: deep laceration with tendon loss
Type 4: fracture
Type 4 subtypes: physeal injury, 20-50% art surface, >50% art surface of the articular surface

Q17What are the indications and regime for conservative treatment with a mallet splint?▸

Soft tissue mallet OR small dorsal fragment with no joint subluxation, injury <12 weeks
Immobilise the DIPJ in extension for 6-8 weeks (2 weeks long mallet, 4 weeks short mallet splint)
Warn of residual extension lag that will not affect function, and possible later swan neck deformity

Q18What are the indications for operation in mallet finger and what techniques are used?▸

Incongruent DIPJ, >25% fracture, >2mm displacement, open injury
Screw fixation for a sizable fragment (>50%)
Extension blocking K wire (Ishiguro technique): dorsal block wire plus a second volar wire holding the DIPJ in extension
Pull out wire

Q19What reconstruction options exist for chronic mallet finger?▸

Terminal extensor tendon shortening
Fowler central slip tenotomy
Tenodermodesis (elliptical wound)
Spiral oblique retinacular ligament reconstruction (PL graft from dorsal DP base, radial MP, volar PIPJ, ulnar PP)
Salvage surgery: DIPJ fusion

Q20What are the complications of mallet finger and how is swan neck deformity treated?▸

Stiffness
Swan neck deformity from secondary attenuation of the PIPJ volar plate and transverse retinacular ligament
Mild: correct the mallet finger
Severe: lateral band tenodesis / FDS tenodesis

Q21What history is important in mallet finger?▸

Mechanism of injury - hyperflexion, reducing by extension and vice versa
Hand dominance, smoker, occupation
Chronicity

Q22What examination findings are important in mallet finger?▸

Wounds
Confirm no active DIPJ extension
PROM in chronic cases

Q23What management considerations guide mallet finger treatment?▸

Open or closed
Bony or soft tissue
Size of the bony fragment
Subluxation of the joint
Timing of injury

Q24Describe the X-ray findings of a perilunate dislocation.▸

AP: displaced scaphoid waist fracture, disrupted Gilula line at the proximal and distal curvatures
Piece of pie sign - overlap of capitate and lunate
+/- scaphoid cortical ring sign, +/- radial styloid fracture
Lateral: loss of colinearity of radius, lunate and capitate = trans-scaphoid perilunate dislocation

Q25Outline the acute management of a perilunate dislocation.▸

ATLS, AMPLE history; assess median nerve, wounds, compartments
Closed reduction under sedation; back slab; closely monitor neurovascular status
CT scan
If closed reduction fails: OR with volar approach

Q26Describe Tavernier's manoeuvre.▸

Prolonged traction with wrist extension
Stabilise the lunate volarly
Reduce the capitate onto the lunate with wrist flexion

Q27Describe the Mayfield circle of perilunate instability.▸

I: SLL / scaphoid fracture
II: capitolunate
III: LT
IV: dorsal radiocarpal ligament, lunate dislocation (unopposed SRL pull)
Intrinsic weakest point: space of Poirier, between lunate and capitate

Q28What is the definitive operative management of a perilunate dislocation?▸

Refer hand specialist
Aim: anatomical restoration of carpal alignment and stable fixation for ligaments to heal
Fix scaphoid/styloid, repair ligaments with suture anchors, transfix unstable carpal bones
Pinning: 1. lunate to radius (prevent DISI), 2. transfix SL and LT, 3. CL if capitolunate unstable (CIND)
Pin for 8 weeks, cast for 12 weeks; encourage early finger mobilisation
Dorsal approach: Berger flap (repair intrinsic SL ligament and extrinsic radiotriquetral); volar approach: release carpal tunnel, repair LT and radiocarpal ligaments

Q29What is the prognosis after perilunate dislocation?▸

36% posttraumatic arthritis
Residual scapholunate instability
Stiffness - 50% of movement lost
CRPS

Q30What are the boundaries of the space of Poirier?▸

Intrinsic weakest point of the space of Poirier without ligament b/w lunate & capitate
Bound by volar deltoid ligament (intrinsic) superiorly, RSC radially
RLT (long radiolunate) inferiorly, UC ligament ulnarly

Q31Describe the pathoanatomy of perilunate instability.▸

Disruption follows Mayfield's classification (radial to ulnar)
Greater versus lesser arc injuries
Classical greater arc: radial styloid -> scaphoid fracture -> capitate fracture -> ulnar styloid fracture

Q32Describe the volar extrinsic wrist ligaments.▸

Long volar arch = RSC + UCL; short volar arch = RL + UL
RSC is strongest to prevent ulnar translocation
Long RL / short RL (ligament of Testut, located between SRL/LRL)
UT / UL / UC blend with the TFCC

Q33Describe the intrinsic and dorsal wrist ligaments.▸

Intrinsic: LT, SL (volar and dorsal)
Dorsal extrinsic: DIC (scaphoid to triquetrum), DRC (radius to triquetrum)
Dorsal intrinsic: SL, LT

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Hand and wrist radiograph interpretation