upper extremity trauma page 1 of 12 the hand · upper extremity trauma page 1 of 12 the hand...

©Ken L Schreibman, PhD/MD 10/20/15 www.schreibman.info

page 1 of 12Upper Extremity TraumaThe Hand

HistoryIndicationsTerminology

Hand/WristRadial/UlnarFingers

RadiographsFractures

MalletBoxer’sGamekeeperBennett

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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info

Upper Extremity Trauma Hand & Fingers

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The Hand is “Handy”Hand is very accessibleOne place on the body it is

socially acceptable to touch

Begin-Carter-Sadat

Shaking hands... Holding hands...

Bush-Abdullah





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Slide 2 of 72

The Hand is “Handy”Hand Imaging: Since Day 11st radiograph:Röntgen’s wife’s hand December 22, 1895

Röntgen: “X-rays”

Exposure time: 15 minutes

Exposure time today’s hand radiographs:5 milliseconds(5/1,000th of a second)

www.wikipedia.commedcyclopaedia.com





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Slide 3 of 72

Hand Imaging: Since Day 1

www.uihealthcare.commrmackenzie.co.uk

Albert von Kölliker

1st DemonstrationWürzburg Physical Medical Society January 23, 1896

von Kolliker proposed these newrays be called “Roentgen Rays”





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Slide 4 of 72

1st Clinical Use of X-rays

AJR 1995;164:241-243

Eddie McCarthy,14 years old,Fell ice skating

Prof. Edwin FrostPhysics & AstronomyDartmouth College

Prof. Gilman FrostDartmouth Medical School

Feb 3rd, 1896Hanover, NH

Photograph by Howard LangillRead about Roentgen in newspaperCalled Dartmouth Physics Dept.Supplied the photographic plates

Nurse Frost

20 minuteexposure

Ulnafracture





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1898: What the “in” crowd didTsar Nicholas & AlexandraWinter PalaceSt. Petersburg

Invited Dr. H.H. Horne to make

these “photographs”of their hands

X-ray apparatus overloaded the palace’s

electrical system

www.countway.harvard.eduwww.wired.com





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Slide 6 of 72

Edison brings X-rays to Public1896 National Electrical Exposition, NY

image.eastmanhouse.org1896 Edison’s Lab

ThomasEdison

Edison’s Assistant,Clarence Dally

X-ray tubein box

NYT 1904

Edison looking

at bones of Dally’s

hand

http://www.schreibman.info/


http://en.wikipedia.org/wiki/File:Roentgen_first_medical_xray.jpg

http://www.medcyclopaedia.com/library/radiology/chapter01.aspx


http://www.uihealthcare.com/depts/medmuseum/galleryexhibits/collectingfrompast/xray/xray.html

http://mrmackenzie.co.uk/2010/11/14/x-rays/


http://www.ajronline.org/content/164/1/241.full.pdf+html?sid=865dd5f1-c205-4609-9303-2a54038d2e11


https://www.countway.harvard.edu/chm/rarebooks/exhibits/stones/stones4.html

http://www.wired.com/wiredscience/2008/11/xrays/


http://image.eastmanhouse.org/files/GEH_1960_09_01.pdf

http://article.archive.nytimes.com/1904/10/04/101240949.pdf?AWSAccessKeyId=AKIAJBTN455PTTBQQNRQ&Expires=1320287855&Signature=8ihBoOyLjvuvgaXXOGQGAMIu7qU=







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Slide 7 of 72

Indications: Hand Imaging

“Fight Bite”

meds.queensu.ca chron.com

TraumaFalls (wrist)Bites…

InfectionHumansAnimalsCats (Tooth chip)





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Indications: Hand ImagingTraumaFalls (wrist)Bites…

InfectionHumansAnimalsCats (Tooth chip)Dogs

S,C 60yoF, dog bite to thumb 3 weeks ago

Fx not healing

Lucency around puncture site

Concern for osteomyelitis





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Slide 9 of 72

Indications: Hand Imaging

R,B 37yoM

Thumb vsNail gun

Thumb vsKitchen knife

R,D 21yoM

TraumaFalls (wrist)Bites…

InfectionHumansAnimals

Foreign bodiesLacerations





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Slide 10 of 72



Foreign bodiesLacerationsAmputations

M,L 48yoF

Hand vsTable saw

www.SawStop.com

C,J 56yoM





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Slide 11 of 72



Foreign bodiesLacerationsAmputationsSnow blowers

L,M 55yoM

Hand vsSnow blower

www.cpsc.gov

US Consumer Product Safety Commission, each year snow throwers cause:6,000 ER visits600 finger amps

NO!





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Indications: Hand ImagingArthritisCertainly image whichever joint is painful… … but also image the hands

The most common characteristics:Distribution Erosions Osteophytes

for the most common arthropathies:OA RA EOA Gout CPPD PA

are well reflected in the hands


http://meds.queensu.ca/courses/assets/modules/clerk_acutehand/pathophysiology_and_diagnosis3.html

http://blog.chron.com/animalqa/2010/02/can-i-stop-the-cat-attacks/




http://www.sawstop.com/


http://www.cpsc.gov/cpscpub/pubs/5117.html








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Arthritis in HandsOsteoarthritisJoint narrowingDIPs & PIPsThumb BaseCMC & STT

Sparing MCPs & rest of wrist

Bone productionSub-cortical

sclerosisOSTEOPHYTES!

S,H 73yoF

DIP DIP

PIP PIP

L R





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Arthritis in HandsErosive OANarrowing IP JointsJust like OA

SparingCarpusJust like OA

Gullwing deformity

DIPsSymmetricOlder ♀

S,J 59yoF

L R





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Arthritis in HandsRheumatoidArthritisNarrowingMCPs Inter-carpalsUnlike OA

Sparing IP JointsUnlike OA

SubluxationMCPs ulnar

deviationSymmetry

I,I 60yoF

L R





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Slide 16 of 72

Arthritis in HandsGout(Less common in hands than toes)DistributionRandomNot all IPsNot all MCPs

ErosionSharp

marginsOverhanging

edges

A,J 66yoM

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Erosion





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Arthritis in HandsCPPDNarrowed MCPsUnlike OA, more like RA

ChondrocalcinosisTFCLunate-

TriquetralJoint

M,Y 76yoF

R

Calcium Pyro Phosphate Dihydrate deposition disease





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Arthritis in HandsPsoriaticArthritisDistributionRandom

ErosionsPencil-

in-cup

H,J 73yoM

L RH,J 73yoM













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Slide 19 of 72

Indications: Hand ImagingMassUsually

evaluated with MRI…or US

But should start with radiographsMass sizeHelps to

plan scanC,J 35yoM

SagT2

Schwannoma(Nerve sheath

tumor)





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Indications: Hand ImagingPain?Carpal tunnel syndromeWe expect radiographs to be negativeLooking for unexpected surprises

T,P 57yoF

PA view Lateral view

8 years earlier

Calcificationin Carpal Tunnel





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Slide 21 of 72

Indications: Hand ImagingBone AgeAt birth many bones unossifiedCarpal bonesEpiphyses (ends of bones)Radius/Ulna, MCs, Phalanges

With aging, these bones ossifyAt specific ages

Hand radiographs to compare patient’s skeletal (bone) age to their chronological age.Left hand

Images courtesy of Bradley Maxfield, MD

Gruelich & Pyle1st Edition: 19502nd Edition: 1959

Since then:not republished

not repeated

Middle-class white kids in

Cleveland, 1930sWe still use it!





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Slide 22 of 72

TerminologyHand images include:Distal Radius & UlnaAll 8 carpal bonesAll 5 metacarpalsAll 14 phalangesJointsDistal Radio-Ulna Joint (DRUJ)Radio-Carpal JointMid-Carpal JointCarpal-Metacarpal JointsMetacarpal-Phalangeal JointsInter-Phalangeal (IP, PIPs, DIPs)

Radius

Ulna

Carpal

Bones

Meta-carpals

Phalanges

DRUJ

RCJ

MCJ CMC

MCPMCP

IP

“Hand” vs “Wrist”





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Slide 23 of 72

“Hand” vs “Wrist”Wrist images include:Distal Radius & UlnaAll 8 carpal bonesJust metacarpal bases

JointsDistal Radio-Ulna Joint (DRUJ)Radio-Carpal JointMid-Carpal JointCarpal-Metacarpal Joints

Radius

Ulna

Carpal

Bones

DRUJ

RCJ

MCJ CMC

This allows us to focus: our attention the x-ray beam

on the area of interest





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Slide 24 of 72

Hand vs Wrist: X-ray BeamHand radiographs:X-ray beam centered

@ 3rd MC head

Wrist radiographs:X-ray beam

centered @ capitate













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Slide 25 of 72

Hand vs Wrist: X-ray Beam

S,G 37yoM

PA Hand Lateral Hand

PA Wrist

Lat Wrist

Can’t see this fracture on the Lateral Hand, because it’s not centered over the wrist





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Slide 26 of 72

AP

Medial vs Lateral?For most body parts, we use the terms “medial” and “lateral”

Medial: Towards the middle

Lateral: Towards the side

But for the hands/wrists, these terms are ambiguous

MEDIAL

LATERAL

Tibia





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Slide 27 of 72

Is the thumb medial or lateral?Tomb of Horemheb(1319-1292 BC)

Pharaoh afterTutankhamen before Ramesses

www.eriding.net/media/

ThumbMedial

ThumbLateral





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Is the thumb medial or lateral?Ramesses III(1186-1155 BC)

It depends on how you hold your handsSupinated

(palm up)

Pronated(palm down)

www.eriding.net/media/

ThumbMedial

ThumbLateral





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Slide 29 of 72

Is the thumb medial or lateral?Muffler

MenCreated in 1960s by International Fiberglass Co.,

Venice CA

23 feet tall

www.weirdca.comSan Jose, CAEscondido, CA Rocky Mount, NC





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Slide 30 of 72

Is the thumb medial or lateral?

www.weirdca.comHayward, CA

When hand ispalm up

“supinated”(holding soup)thumb is lateral

When hand ispalm down“pronated”

thumb is medial




http://www.eriding.net/media/ancient_egypt.shtml


http://www.eriding.net/media/ancient_egypt.shtml


http://www.weirdca.com/location.php?location=195


http://www.weirdca.com/location.php?location=195







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Slide 31 of 72

Not medial/lateral…

Radialside

Ulnarside

radial/ulnar instead

www.assh.orgISBN: 0781735858





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Slide 32 of 72

Which Finger Hurts? Nice when tech. puts

an arrow on site of pain.

Nice when we’re given a history of which finger

hurts…but should

indicate that finger not

by number, but by NAME.

B,D 54yoM

Too many arrows is

not helpful





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Slide 33 of 72

Which is the 1st Finger?Index Finger? Thumb?

LongFinger?





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Slide 34 of 72P,A 42yoM

Finger Numbering = ConfusionConfusing forPeople ordering

radiographs…People taking

radiographs…

Example:2 fingers…Same patientSame daySame tech!

Thumb Index finger





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Slide 35 of 72

Radialside

Ulnarside

Finger Numbering = Confusion

M,B 49yoF

Fingers have names(not numbers)

“Thumb” “Index” “Long”

(“Middle”)

“Ring”“Small”

Th

um

b

Index

Long

Ring

Small





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Slide 36 of 72

Radiographs: Need 3 Views

PIP

H,K 23yoM

PIP PIP

PAview

Oblview

Latview


http://www.assh.org/Public/HandAnatomy/Pages/default.aspx

http://www.amazon.com/Essentials-Hand-Surgery-Seiler/dp/0781735858/












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Slide 37 of 72

PA ≠ APChest:PA is

standard

Marty age 13

X-raytube

PosteriorAnterior= “PA”

Portable Chest = AP

X-raytube

AnteriorPosterior = “AP”





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Slide 38 of 72

Hand: PA = Standard View

Marty age 15

Elbow @ shoulder height

Elbow @ 90°

Lowchair

Raise cassette

ShieldX-rays

X-ray beamPosteriorAnterior

= “PA”

X-ray beam centered on 3rd MC head





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Slide 39 of 72

Hand: Fan Finger Lateral

coneinstruments.comS,P 24yoF

Outside radiographFingers not fanned

UW radiographFingers well fanned





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Slide 40 of 72

Hand: Fan Finger LateralGood 2nd

view of: PhalangesDIPs/PIPs

Metacarpals overlap…not a good 2nd view of the MCs

E,B 21yoM

Latview

PAview

Tech’s arrow

Swelling





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Slide 41 of 72

Hand: Oblique View

Latview

PAview

Oblview

E,B 21yoM





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Slide 42 of 72

Step Wedge for Oblique View

coneinstruments.com




http://www.coneinstruments.com/product.asp?pn=203301




http://www.coneinstruments.com/product.asp?pn=203300







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Slide 43 of 72

Hand: Oblique ViewImportant 2nd view of the metacarpals

Yields additionalviews of:PhalangesCarpals bones

Oblview

Q,J 26yoM





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Slide 44 of 72

Why not get all 3 views?Do < 3 hand views save radiation?Not reallyChest PA & Lateral radiographs ≈ 0.06 mSv

≈ 1 week of background radiation3-view Hand radiographs < 0.01 mSv

< 1 day of background radiation

Do < 3 hand views save money?Not much1-view hand = 2-view hand = $113*There is NO reason to order 1-view rather than 2-views!

3-view hand = $142 (only $29 more than 2-views)*UWMF Technical +

Professional charges





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Slide 45 of 72

Radiographs: FingerIf interested in only one finger, should order radiographs of just that finger.Costs less than hand1-view finger =2-view finger =3-view finger = $106*($36 less than 3-v hand)Bend other fingers

out of the wayCenter x-ray beam

over that finger

*UWMF Technical + Professional charges

Can use non-radiopaque object

(tongue blade) to extended

the finger





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Slide 46 of 72

Finger Model (Lateral View)

MCHeadMC

HeadMC

Head

FlexorDigitorum

ExtensorDigitorum

B,S 22yoM

Sag T1





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Slide 47 of 72

MCHead

Mallet Finger

MCHead

aka “Baseball Finger”Tear extensor tendonAvulsion fracture dorsal

base distal phalanx

emedicinehealth.com

Inability to actively

extend DIP





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Slide 48 of 72

Mallet Finger

T,T 19yoM3 weeksin splint 8 weeks

Treated withsplint to hold DIP straight






http://www.emedicinehealth.com/mallet_finger/page15_em.htm








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Slide 49 of 72

“Mallet Finger”Mallet?Google “Mallet”…

Pry bar

“Pry barfinger”?





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Slide 50 of 72

Finger Model (Lateral View)

MCHead

FlexorDigitorumProfundus

(deep) DIP

FlexorDigitorum

Super-ficialis

(“surface”) PIP

MCHead

Ext. Dig. disruption DIP DIP flexion (Mallet)

FDP slips around PIP PIP hyper-extension

MCHead

MCHead





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Slide 51 of 72

Swan Neck Deformity

MCHead

B,M 16yoMaccessmedicine.net

Due to RA(most common)

Due to Trauma

Flexed distally

Extendedproximally

DIP flexion + PIP hyper-extension

DIP flexion

PIP hyper-

extension





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Slide 52 of 72

Boutonnière DeformityPIP flexion +

DIP hyper-extension= Boutonnière

MCHead

DIP flexion + PIP hyper-extension

= SwanNeck

P,C 21yoM

MCHead

Boutonnieresmall finger

Swan neckring finger

Due to RADue to Trauma

Boutonnière [Fr]:“buttonhole”

images.rheumatology.org

DIPhyper-

extension

PIPflexion





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Slide 53 of 72

Boutonnière Deformity

S,P 24yoF

PA views:Negative

Lateral views:Bilateral Boutonnière





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Slide 54 of 72

Boutonnière DeformityThe Three Graces (1638)

Paul Rubens (1577-1640)Model: Hèléne Fourment,

wife, 23yo

RA?* In Hèléne? In Rubens

himself?

public-domain-photos.org

PIP flexion DIP hyper-extension

*Rheumatology 2005;44:681




http://accessmedicine.net/loadBinary.aspx?name=knoo3&filename=knoo3_c011f042t.jpg


http://images.rheumatology.org/image_dir/album75692/md_99-05-0021.tif.jpg



http://images.rheumatology.org/image_dir/album75692/md_99-05-0021.tif.jpg

http://rheumatology.oxfordjournals.org/content/44/5/681.full.pdf







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Slide 55 of 72

“Boxer’s Fracture”Combination of:College Student + Alcohol +Fracture 5th MC neck

a wall…

W,B 30yoM





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Slide 56 of 72

“Boxer’s Fracture”

PAviewhand

Latviewhand

Best view to see MC fractures

Oblviewhand

BoxerFx

Old 4th

MC Fx

Best view to measure angulation

“Trauma is not evenly distributed in the population”

W,B 30yoM





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Slide 57 of 72

“Boxer’s Fracture”

PAviewhand

Latviewhand

Best view to measure angulation

wheelessonline.com

Latview

casted

Casting small & ring MCP jts. 90° flexion

W,B 30yoM





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Slide 58 of 72JBJS 1955;37-B(1):148-9

Examined 24 gamekeepers20 (83%) laxity of the thumbMetacarpo-phalangeal jointUlnar side

maps.google.com

GAMEKEEPER’S THUMBC.S. Campbell, Bridge of Earn, Scotland

The Journal of Bone and Joint Surgery, vol. 37 B, no.1, February 1955





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Slide 59 of 72

Thumb Model (PA View)

Metacarp

Dist

Prox

Dist

Prox

Metacarp

UlnarCollat

Lig

RadialCollatLig

F,D 61yoM

STRESS

Fell a year earlierDecreased pinch strength

TornUCL





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Slide 60 of 72

Injure Thumb MCP UCLAcute trauma/fall“Skier’s Thumb”Falling while holding the

ski pole

Tear UCLAvulsion fracture ulnar

side of the base of the thumb proximal phalanx

Dist

Prox

Metacarp

www.webmd.com




http://www.wheelessonline.com/image6/box22.jpg


http://web.jbjs.org.uk/cgi/reprint/37-B/1/148

http://maps.google.com/



http://www.webmd.com/a-to-z-guides/skiers-thumb?page=4







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Slide 61 of 72

Gamekeeper’s (Skier’s) Fracture

K,J 19yoM

PAviewhand

Latviewhand

Dist

Prox

Metacarp

PAview

thumb

Oblview

thumb

Fx

Sesamoid





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Slide 62 of 72

Injure Thumb MCP UCLRepetitive stress on

the UCLScottish GamekeeperGet rid of pests…

... rabbits…humanely/quickly

“Chinning”

JBJS 1955;37-B(1):148-9





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Slide 63 of 72

Thumb Model (Oblique View)

Fx ulnar base thumb prox. phal.= Gamekeepers

V,M 14yoF F,E 52yoM

Fx ulnar base thumb metacarpal= Bennett fracture

Tm





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Slide 64 of 72

“So trivial an injury does this appear to be… so little deformity… I might fairly be asked what importance attached to the correct diagnosis. Seeing the value of the movements of the thumb, no injury of it is to be lightly regarded, and this fracture, though it unites readily with almost inappreciable deformity, renders the thumb lame and useless. The hand fails to grasp or lift with certainty any body requiring a wide gape of the thumb –for instance, to lift a tumbler full of water from the table…”

Edward Hallaren Bennett (1837-1907)

Described in 1881*Based upon skeletons14 years before x-rays3 years before George Eastman

created photographic film

*Dublin J Med Sci 1882;73:72

Bennett Fracture

www.jbjs.org

Tm Woodcut from

Bennett’s article





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Slide 65 of 72

Bennett FractureAbductor Pollicis Longus TendonPollex: [L] ThumbAbduct: To draw away…

from midline of the body

Tm

medical-dictionary.thefreedictionary.com

Bennett Fx: Intra-articularThumb MCUlnar base

APL is unopposedSubluxation of

Thumb C-MC

APL:AbductsThumb





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Slide 66 of 72

Bennett Fracture18yoM

Fell off his scooter,onto thumb

H,C 18yoM

PAview

Fx

Ulnar deviationview

CMCSublux

Tm

CTCoronalReformat

Fx

CMCSublux Fixation with

K-wires in anatomic alignment

Healedanatomic alignment

3m later



http://web.jbjs.org.uk/cgi/reprint/37-B/1/148



http://www.archive.org/details/dublinjournalme70unkngoog

http://www.jbjs.org/pdfaccess.ashx?ResourceID=58493&PDFSource=0


http://medical-dictionary.thefreedictionary.com/abduction








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Slide 67 of 72

What to Order When (WOW)Always start with radiographs!

Hand 3-views (PA, Lateral, Oblique)When need to see all of the bones and jointsArthritis

For metacarpal fracturesBoxer Fracture

FingerWhen interested in just one fingerMallet, Swan Neck, BoutonniereGamekeeper’s fracture





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Slide 68 of 72

What to Order When (WOW)

S,J 19yoMR,V 17yoM

Tip of ballpoint pen in hand

Foreign bodies (FB)?Radiographs: radiopaque FB

Metal

GlassAll glass is

radiopaque

Glass in hand





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Slide 69 of 72

What to Order When (WOW)Non-Radiopaque foreign bodies?Wood splintersSea urchin spines

Can’t be seen with radiographs or CTMay be able to see with MRALL can be seen with Ultrasound!





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Slide 70 of 72

Non-Radiopaque Foreign Body

M,E 11yoF

PAviewhand

Negative

T1fs+IV ContrastCoronal

T1fs+IVSag

USSag

Focal area of enhancement

Marker

WoodSplinter





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Slide 71 of 72

What to Order When (WOW)Masses, Infections, SynovitisALWAYS START WITH RADIOGRAPHS!MR is the next imaging study of choiceUsually with IV contrastContrast is particularly helpful for synovitis (RA)Normal synovium does not enhanceVascularized pannus greatly enhances

These MR studies should be ordered by the specialist who will be treating the conditionRheumatologistHand Surgeon





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Slide 72 of 72

Questions?Raise your

hand…

P,R 43yoM







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