Normal Wrist Research Articles

Measurement of the wrist in posteroanterior radiographs and its clinical significance

Objective To obtain normal values of parameters of the wrist joint by measuring posteroanterior X-rays of normal wrist joints and provide basis of using these parameters for judgment of pathological conditions of the wrist. Methods Standard postereanterior X-rays of 40 normal wrists were taken.The Pacs System software was used to measure 9 parameters in these radiographs, including 7 new parameters:the ulnar styloid length (USL), ulnar head length (UHL), ulnar head diameter (UHD), maximal distal radius width (MDRW), proximal distal radius width ( PDRW), sigmoid notch width (SNW) and sigmoid notch length (SNL). The respective indices were defined by the ratio of these parameters to the length of the third metacarpus. Results The values and indices of USL, UHL, UHD, MDRW and PDRW are (3.01±1.65) mm,(0.05±0.03), (9.11±1.54) mm, (0.15±0.02), (18.56±1.96) mm, (0.30±0.03),(29.60±2.70) mm, (0.48±0.04), (27.60±2.00) mm and (0.45±0.03), respectively. Four types (Ⅰ toⅣ) of sigmoid notch were identified, with types Ⅰ, Ⅱ and Ⅳ present dominantly. The SNW of types Ⅰ, Ⅱ, and Ⅳ are (3.32±1.61) mm, (3.53±1.15) mm and (1.55±1.01) mm, respectively. The SNL of types Ⅰ, Ⅱ,and Ⅳ are ( 10.15±1.61 ) mm, ( 10.96 ± 2.33) mm and ( 10.32 ± 1.57) mm, respectively. Correspondingly,the SNW indexes were (0.05±0.02), (0.06±0.02), and (0.03±0.02); the SNL indexes were (0.16±0.02), (0.18±0.03) and(0.17±0.02). Conclusion The study presents a number of new indices which may be useful in quantifying the changes of wrists in radiograph. The measured normal values provide a basis for evaluation of changes in wrist disorders. Key words: Carpal joints; X-ray film; Parameter

Management of Posttraumatic Arthritis of the Wrist With Radiolunate Fusion Enhanced With a Sliding Autograft

Although in rheumatoid cases radiolunate fusion presents with satisfying results, in cases with posttraumatic carpal distortion, the variability of injury pattern can influence the type of fixation and the rate of bony union. In this case report, we present an alternative technique of radiolunate fusion for the management of posttraumatic arthritis, which combines the traditional procedure with a corticocancellous autograft, created from the dorsal side of the radius that slides over the bones to be fused. That procedure provides the best environment for the bones to heal and an additional stabilizing effect on the radiolunate construct, thus better preserving the normal intercarpal relationships and wrist height. Patient's clinical and radiological outcome was very satisfactory until the last follow-up.

Long-standing Elbow Pain In A Gymnast

HISTORY: An 18-year-old female gymnast and cheerleader presented with right elbow pain for the last 8 months. The pain is constant and is associated with locking and catching in the elbow. Her symptoms are worsened with increased activity. She does not recall any trauma and is unsure how the injury occurred. Previously, she had an MRI done and was diagnosed with lateral epicondylosis by orthopedics. She has had 3 corticosteroid injections and has undergone a course of physical therapy without significant pain relief. PHYSICAL EXAM: Right upper extremity with normal shoulder and wrist exam. The elbow has full range of motion in flexion, extension, pronation, and supination. There is global tenderness to palpation over the lateral epicondyle, medial epicondyle, and olecranon. There is pain with valgus and varus stress of the elbow at 30 degrees without any gapping present. There is pain with the "milking" maneuver. There is no reproduction of catching or clicking. Tinel's over the extensor wad is equivocal. DIFFERENTIAL DIAGNOSIS: Lateral epicondylosis Elbow joint loose body UCL/RCL sprain Posterior interosseous nerve entrapment Elbow instability TEST AND RESULTS: MRI Pseudo-defect of the capitellum reported as normal Minor elbow joint effusion Diagnostic Ultrasound Swelling of posterior interosseous nerve just proximal to the arcade of Frohse Nerve measures 1.1mm in diameter compared with 0.7mm on the asymptomatic left side Nerve tapers abruptly as it enters the supinator muscle FINAL DIAGNOSIS: Posterior interosseous nerve entrapment TREATMENT AND OUTCOMES: 1. Ultrasound guided cortisone injection/fenestration at the arcade of Frohse 2. Temporary symptom relief after cortisone injection 3. Surgical release with decompression of posterior interosseous nerve 4. Returned to normal activities with full elbow range of motion without pain, catching, or locking

HS13P TOTAL WRIST ARTHROPLASTY‐A REVIEW OF PATIENTS WITH DYSFUNCTIONAL WRISTS

Background: The wrist is essential for augmentation of fine motor control of the hand and fingers. The normal wrist motion involves a complex interaction of articulations from the radius, ulna and carpal bones. Hence, when a disease process disrupts any one of these elements, a painful, deformed and dysfunctional wrist arises. Total wrist arthroplasty is considered an alternative surgical option to wrist fusion for the management of advanced wrist arthritic diseases. Though less commonly performed in comparison to lower‐limb arthroplasty, wrist arthroplasty has its role as a salvage procedure to alleviate pain and preserve function in the wrists.Method: Four patients were collected from the Centre of Hand Surgery, Sydney. Medical records of these patients were reviewed. The patient's pre‐and post‐operative functional status via clinical and radiographic assessments were closely followed over an average period of five years to ensure the continuity of progress. A table was formulated to provide an objective survey of both quantitative and qualitative improvement of a patient's wrist function.Result: The four patients received different types of prostheses. This is an indication of a lack of universal acceptance of wrist anatomy and biomechanics. Regardless, all patients in this study had improved functional outcomes. Pain‐relief was the most successful aspect of wrist arthroplasty during post‐operative follow‐ups. The successful outcome of these patients has proven that total wrist arthroplasty can provide pain relief and an improvement in hand function through appropriate patient selections, careful peri‐operative planning, sound operative technique and well‐designed post‐operative hand therapy.

The Radiographic Measurement of Ulnar Translation

Our purpose was to quantify the Gilula score for measurement of lunate uncovering, to compare it with another method of measurement and to examine the reliability of these measurements in posteroanterior (PA) views in radial and ulnar deviation. Seventy-six normal wrist arthrograms were reviewed retrospectively. Carpal height and lunate uncovering measurements were made. Statistical analysis included mixed effects models to evaluate the difference between the mean measurements in each position. Reproducibility was assessed using imprecision estimates. Normal values for the Gilula method were 40% lunate uncovering in neutral, 49% in radial and 20% in ulnar deviation. There was a statistically significant difference between the values in the different views. Ulnar translation of the carpus can be measured reliably on neutral and radially deviated PA views using the Gilula method, but the different normal values for each view should be used. The Schuind method of measurement is comparable to the Gilula method in the neutral PA view.

Scaphoid nonunion and distal fragment resection: analysis with three-dimensional rigid body spring model

Background.Distal fragment resection is one of the salvage procedures for scaphoid nonunion with osteoarthritis. Despite being reported as a simple procedure with favorable midterm outcomes, further arthritic changes remain a concern in the long term. Scaphoid waist fracture is classified into volar or dorsal types according to the displacement pattern, but the indications for distal fragment resection have never been discussed for these fracture types. Method.We reconstructed a normal wrist model from computed tomography images and performed theoretical analysis utilizing a three-dimensional rigid body spring model. Two types of scaphoid fracture nonunion followed by distal fragment resection were simulated. Results.With volar-type nonunion, the force transmission ratio of the radiolunate joint increased, and the pressure concentration was observed in the dorsal part of the scaphoid fossa and volar part of the lunate fossa of the radius; no deterioration was seen in the midcarpal joint. In the distal fragment resection simulation for volar-type nonunion, pressure concentrations of the radiocarpal joint resolved. With dorsaltype nonunion, force transmission ratio in the radiocarpal joint resembled that of the normal joint model. Pressure concentrations were observed in the dorsoulnar part of the scaphoid fossa and radial styloid. The pressure concentration in the dorsoulnar part of the scaphoid fossa disappeared in the resection model, whereas the concentration in the radial styloid remained. In the midcarpal joint, pressure was concentrated around the capitate head in the nonunion model and became aggravated in the resection model. Conclusions.With volar-type scaphoid nonunion, distal fragment resection seems to represent a reasonable treatment option. With dorsal-type nonunion, however, pressure concentration around the capitate head was aggravated with the simulated distal fragment resection, indicating a potential risk of worsening any preexisting lunocapitate arthritis.

In Vivo Length Changes of Selected Carpal Ligaments During Wrist Radioulnar Deviation

To investigate changes in the lengths of selected carpal ligaments during wrist radioulnar deviation in vivo. We studied in vivo changes in the lengths of fibers of 5 palmar and dorsal intracapsular ligaments of the wrist during radioulnar deviation in 6 wrists of healthy volunteers using a noninvasive approach. Using serial computed tomography scans and volume registration techniques, the carpal kinematics were examined at 4 positions, from 40 degrees ulnar deviation to 20 degrees radial deviation, in 20 degrees increments. The 3-dimensional structures of the carpal bones, distal radius and ulna, and metacarpal bones were reconstructed using customized software. We modeled the paths of fibers of 5 palmar and dorsal carpal ligaments: radioscaphocapitate (RSC), long radiolunate (LRL), ulnocapitate (UC), dorsal intercarpal (DIC), and dorsal radiocarpal (DRC) ligaments. We analyzed changes in the lengths of these ligaments during wrist radioulnar deviation. During wrist ulnar deviation, the RSC, LRL, and DIC ligaments lengthened significantly. During radial deviation, the UC and DRC ligaments lengthened significantly. Compared with their lengths at the neutral position of the carpus, the LRL ligament showed the greatest elongation rate at wrist ulnar deviation, and the DRC ligament showed the greatest elongation rate at wrist radial deviation among the 5 ligaments studied. Among ligaments measured, the RSC, LRL, and DIC ligaments are tensed during wrist ulnar deviation. The UC and DRC ligaments are tensed during wrist radial deviation. Results of this in vivo study suggest that radial or ulnar deviation may predispose some carpal ligaments to excessive tensile load. The finding that the ligaments undergo different elongation rates during wrist motion may also indicate their roles in maintaining normal wrist kinematics.

Ultrasonographic Study of Wrist Ligaments: Review and New Perspectives

Imaging strategy for wrist injury usually begins with standard radiographs. When a ligamentous disorder is suspected clinically, the next step is arthrographic computed tomography or arthrographic magnetic resonance imaging. When the diagnosis remains unclear, magnetic resonance imaging (MRI) is the preferred examination. Ultrasonography is usually used to assess structures like tendons and bone surface, but thanks to the performances of high-frequency transducers, it can also enable visualization of the main ligaments of the wrist. Ultrasonography could thus replace MRI because of its lower cost, as recently reported in the literature. However, a good knowledge of normal and pathological wrist anatomy is required to avoid false negatives. Wrist ligaments comprise interosseous and capsular ligaments as well as the triangular fibrocartilaginous complex. All these ligaments may be involved in carpal instability. Clinical examination has a major role to play in helping radiologists orient their procedures. A few studies have reported that ultrasonography of the triangular fibrocartilaginous complex is reliable compared with arthrography or MRI, but most of these studies were limited to the radioulnar ligaments. In this article we propose a more extensive protocol.

Maladie de Kienböck chez un garçon de neuf ans : à propos d’un cas

The authors report a case of Kienböck's disease in a nine-year-old male gymnast, treated conservatively. It resulted in a clinically normal wrist and complete revascularisation of the lunate on MRI. This case suggests that the natural course of Kienböck's disease can be more favourable in children as compared to adults.

INVESTIGATION OF RADIOLUNATE RELATIONS IN NORMAL AND FRACTURED WRISTS

As the distal radius fracture is one of the most commonly encountered upper limb injuries, the aim of this study was to provide a quick and easy method to aid in the assessment of fractured wrists, both pre- and post-fixation, by utilising the relationship of the radial shaft and the lunate. A retrospective analysis on 100 consecutive patients with normal wrist radiographs was performed. The results demonstrated that the variations of radiolunate anatomy followed a normal distribution. The normal anatomical relationship was then described. A second part to the study consisted of reviewing our method of radiocarpal analysis on a cohort of patients who had sustained a distal radius fracture. Carpal alignment pre- and post-fixation was measured, with the results demonstrating that by using this assessment method, it was possible with a quick glance of the radiograph, to determine whether satisfactory correction of the fracture had been achieved.

Distal Radius Morphometry in the Malaysian Population

The goal of treatment in distal radius fracture is to restore the anatomy of the distal radius, however the criteria currently used to evaluate the quality of reduction are based on Western based published figures. This goal of this study was to investigate whether there are variations in the morphology of the distal radius among the multiracial population of Malaysia. Consecutive normal wrist radiographs of patients who presented to the accident and emergency unit in three major hospitals in Malaysia were measured. . The palmar tilt of the distal radius averaged 12.6o ± 3.55o, and the radial inclination averaged 25.1o ± 3.42o. The ulnar variance averaged ‐ 0.1 ± 1.31mm, 38.4% of the patients had neutral ulnar variance, 28.8% have negative ulnar variance and 32.9% have positive ulnar variance. Our results indicate that distal radius morphometric parameters in the Malaysian population are comparable to Western figures.

Madelung’s Deformity: Quantitative Radiographic Comparison with Normal Wrists

Four measurements, ulnar tilt, lunate subsidence, lunate fossa angle and palmar carpal displacement, on wrist radiographs of 26 patients with Madelung's deformity and 48 normal subjects were compared. The range of measurements on wrists with Madelung's deformity was wider than on normal wrists, with severe deformities having very abnormal values. Some Madelung's patients had values that were within the normal range for each of the four measurements. Measurement of the lunate fossa angle demonstrated the least overlap between normal wrists and wrists of patients with Madelung's deformity with only two in the normal range. A lunate fossa angle over 29 degrees may help identify early Madelung's deformity.

Mini-Incision Fixation of Nondisplaced Scaphoid Fracture Nonunions

Scaphoid nonunions are commonly repaired by an open surgical technique involving debridement, bone grafting, and internal fixation. The purpose of our study is to describe a small subset of scaphoid nonunions that are nondisplaced and might be suitable for a more limited, minimally invasive technique that might offer good results while potentially reducing soft tissue injury. Nine patients seen over a 3-year period by a single surgeon were identified as having scaphoid nonunions without radiographic evidence of displacement, angulation, degenerative changes, osteonecrosis, or carpal instability. Two additional patients with well-aligned delayed unions of 4 months' duration were also studied. All had surgery through a tiny dorsal incision with reaming, local cancellous bone grafting, re-reaming, and compression screw fixation. This was performed under fluoroscopy but without arthroscopy. Pain, range of motion, and grip strength as well as radiographic evidence of healing were recorded. Patients treated for nonunions were followed up for an average of 27 months (range 10-45 months), and all 9 fractures healed at a mean time of 3 months. At final follow-up, there were no radiographic signs of nonunion. The mean arc of wrist motion was 124 degrees, or 91% of that of the contralateral, normal wrist. The mean postoperative grip strength was 29 kgf, or 85% of the value in the opposite hand. At final follow-up, all but 1 patient were pain free, and none had evidence of progression of degenerative changes or carpal instability on final radiographs. The 2 delayed union cases healed at 2 and 3 months with similar postoperative functional measurements. There were no complications. Uncomplicated scaphoid nonunions that are nondisplaced and nonangulated are candidates for the minimally invasive bone grafting and compression screw fixation procedure described. Patients who fit the strict inclusion criteria can expect a reliable healing rate and good functional outcome with a more limited procedure. Therapeutic IV.

Wrist Arthroscopy: Current Concepts

Wrist arthroscopy has steadily grown from a mostly diagnostic tool to a valuable adjunctive procedure in the treatment of myriad wrist disorders. The number of conditions that are amenable to arthroscopic treatment continues to grow. A detailed knowledge of the topographical and intracarpal anatomy, however, is essential to minimize complications and maximize the benefits. Although wrist arthroscopy can identify an anatomic abnormality, it cannot be used to differentiate between an asymptomatic degenerative condition versus a pathologic lesion that is the cause of wrist pain. A thorough wrist examination is still integral to any arthroscopic assessment. This article focuses on the methodology behind a normal arthroscopic wrist examination and discusses some of the more standard arthroscopic procedures along with the expected outcomes.

Subchondral bone mineral density patterns representing the loading history of the wrist joint after a proximal row carpectomy

To evaluate force transmission patterns in vivo of patients with complaints of wrist instability requiring a proximal row carpectomy, bone mineral density (BMD) patterns of the wrist were established using computed tomography absorptiometry. Normal wrists show a BMD pattern in which the scaphoid fossa and lunate fossa of the distal radius contain a center of force transmission. Wrists with pathology of the proximal carpal row or distal radius show a shift of BMD towards the dorsal edge and the styloid process of the scaphoid fossa. After a proximal row carpectomy, the BMD of the scaphoid fossa decreases, and a BMD center is formed in the center of the lunate fossa, demonstrating that the force transmission is concentrated in its center.

Une tumeur osseuse rare au radius : hémangiome capillaire

Hemangioma is a rare benign vascular tumor composed of dystrophic capillaries, preferentially located in the spinal region (70 %). Bony localizations are exceptional, less than 1 % of cases in large series of bone tumors. We report the case of a 35-year-old male who complained of pain the right forearm for two months. The pain was of an inflammatory type and was triggered by palpation and mobilization. The plain x-ray revealed a bony defect involving the posterior cortical of the mid-third of the radius. Magnetic resonance imaging revealed a defect of the shaft cortex without involvement of the central part of the bone, the endostium or the soft tissue. Surgical resection was limited to the tumor. Histology reported intraosseous capillary hemangioma. The course was favorable with bone healing and gap filling, with normal elbow and wrist function. The patient resumed occupational activities three months after surgery. This case illustrates a rare localization of this tumor rarely reported in major series.

The Clinical Significance of the Scaphoid Cortical Ring Sign: A Study of Normal Wrist X-Rays

The scaphoid cortical ring sign, identified as a radiological indicator of rotary subluxation of the scaphoid, is frequently seen on normal wrist X-rays. This study examined the clinical significance of this sign in 139 normal wrists in 114 patients, with a mean age of 52 (range 15-81) years. In this study, there were no significant relationships between the appearance of a cortical ring sign and age, gender or hand dominance. Consequently, a cortical ring sign indicates scaphoid flexion, but may be visible in the normal wrist at any age or gender and in either hand and is not necessarily an indicator of pathology in the wrist.

Functional Disability of the Wrist: Direct Correlation With Decreased Wrist Motion

Motion-limiting wrist procedures have demonstrated both efficacy and reproducibility as a treatment for alleviating painful wrist conditions, but the reduction of pain achieved is necessarily accompanied by a marked loss of wrist motion. However, no study demonstrates a functional difference between variable degrees of wrist motion. The hypothesis of this study is that wrist motion is directly correlated with functional ability. Using a prospective, randomized, crossover design, we randomized 42 men and women above 45 years of age with normal wrists to wear both a partially restricted and a highly restricted splint for 24 hours each. Serving as their own controls, objective and subjective outcome measurements were taken at baseline and after each of the 2 splinting periods. The specific measurements included range of motion parameters (flexion/extension, radioulnar deviation, supination/pronation, circumduction), subjective surveys (Disabilities of the Arm, Shoulder, and Hand; Patient Rated Wrist Evaluation; and Modern Activity Subjective Survey), and an objective timed test (Modern Activity Timed Test; MATT). The simulated flexion/extension arc of motion for baseline, partially restricted, and highly restricted conditions were 138 degrees , 58 degrees , and 20 degrees , respectively. Median Disabilities of the Arm, Shoulder, and Hand scores for the 3 conditions significantly increased from 1.8 to 14.4 and 20.8 (p <.01), respectively. In addition, Patient Rated Wrist Evaluation results increased from 2.5 to 16.4 and 27.1, and the Modern Activity Subjective Survey results increased from 0.3 to 9.1 and 14.9 across restricted motion conditions. Modern Activity Timed Test results matched the perceived difficulty reflected by the subjective surveys, demonstrating significant increases in performance time for 6 of the 8 individual MATT items as well as significant differences for the sum of all tasks (MATT score) between the highly and partially restricted conditions. Use of low-profile splinting to restrict wrist motion demonstrates a direct correlation between restriction of wrist motion and functional disability.

Le carpe à double cupule : illustration de la géométrie variable du carpe

The variable frontal geometry of the carpus has been known for many years, however there is no unanimity as to whether to describe the dynamic model of the carpus as comprising row or columnar functional units. The place of the scaphoid is also discussed. This study attempts to understand the organization and the composition of the functional units of the carpus. We took radiographs of 40 normal right wrists in radial and ulnar deviation and measured the displacement in the coronal plane of each carpal bone except the pisiform. We measured the angular movements of each carpal bone compared to a vertical axis passing through the geometric centre of the carpus. This axis is parallel to the radial axis which is defined as the line joining the midpoints of the radius at 2 and 5 cm proximal to the radial articular surface. We studied the movement of each row and each column. Recorded angular movements were the followings: scaphoid 26 degrees, lunate 28 degrees, triquetrum 29 degrees, trapezium 44 degrees, trapezoid 50 degrees, capitate 50 degrees, hamate 56 degrees. Average angular movement within the first row is 27 degrees, within the second row is 50 degrees. Average angular movement within the radial column is 38 degrees, middle column is 39 degrees, ulnar column is 42 degrees. The amplitude of movement are similar for the bones of each row, and different for the bones of each column. The bones of each row tend to move together and can alone account for all movements of the wrist. The movements measured between each column are torsional intrarow movements, allowing congruence between the two rows and the glenoid surface of the radius. The scaphoid movements are superposable with those of lunate and triquetrum. Scaphoid kinematics joins the first row. Radio-ulnar deviation of the wrist is shared equally between the radiocarpal and midcarpal joints. This sharing of wrist movement between the two rows constitutes for us a double cup carpal model.

Abnormal surface EMG during clinically normal wrist movement in cervical dystonia

We investigated whether patients with cervical dystonia (CD) have abnormal muscle activation in non-dystonic body parts. Eight healthy controls and eight CD patients performed a flexion-extension movement of the right wrist. Movement execution was recorded by surface electromyography (EMG) from forearm muscles. Although patients had no complaints concerning wrist movement and had no apparent difficulty in executing the task, they demonstrated lower mean EMG amplitude (flexor: 0.32 mV and extensor: 0.61 mV) than controls (flexor: 0.67 mV; P = 0.021 and extensor: 1.18 mV; P = 0.068; borderline significant). Mean extensor muscle contraction was prolonged in patients (1860 ms) compared with controls (1334 ms; P = 0.026). Variation in mean EMG amplitude over movements tended to be higher in patients (flexor: 43% and extensor: 35%) than controls (flexor: 34%; P = 0.072 and extensor: 26%; P = 0.073). These results suggest that CD patients also have abnormal muscle activation in non-dystonic body parts at a subclinical level. This would support the concept that in dystonia, non-dystonic limbs are in a 'pre-dystonic state'.