Indian J Plast Surg. 2011 May-Aug; 44(2): 186–196. Imaging techniques play an important role in evaluating the complex anatomy of bone and soft tissues of the wrist. The standard wrist radiographs and specialized views still form a very important imaging modality to unravel the wrist pathology in their simplest forms. This
article discusses the routine radiography of the wrist followed by ancillary views and dynamic studies for each of the routine view described that helps reveal both static and dynamic pathologies. The literature search was carried out using the search strings or key words, and the databases were searched using the time frame of 1990 to 2011 that included Scopus, MD consult, Web of Knowledge, Pub Med, Ovid Medline and Cochrane Library. The print journals and books available at Manipal University
library were hand searched and secondary search was done for the relevant articles included in the references of primary articles. Full articles as well as abstracts were used for the review. Keywords: Imaging, plain radiography, wrist When Wilhelm Conrad Rontgen created the radiograph of his wife Anna Bertha's hand in December 1895, the history of radiography and that of the hand and
wrist imaging took its birth.[1] Its first clinical application was also to detect a pathology of the wrist, that is, Colles’ fracture a year later.[2] From a 20-min exposure needed at that time for a radiograph to milliseconds exposure now, and from a plain radiograph to
advanced imaging techniques available today, the understanding of hand and wrist imaging has leaped many folds. Despite these advancements, the humble radiograph still remains the single most important imaging modality for hand and wrist.[3,4] This conventional technique produces a
two-dimensional representation of a three-dimensional anatomical data on a photographic film but, using two views projected perpendicular to one another, three-dimensional perspective can be achieved.[4,5] Standard projections for the wrist are Postero anterior and lateral views.
Some authors also consider oblique view as part of the standard views.[6] The following section of this article describes the standard radiographic views first and proceeds to describe any ancillary views of the same and finally dynamic studies using these projections. The compartmentalization and intricate anatomy of structures in the wrist makes
interpretation of wrist pathology a daunting task at times. Hence, an appropriate combination of these views will help the clinician to better analyse the underlying pathology in the preliminary stages of investigations using these conventional radiographs, which should always be preceded by accurate clinical examination. Advanced imaging techniques later become more focused and useful if the initial interpretation of conventional imaging was methodical. The literature search was
carried out using the following search strings or key words: radiography, plain film, roentgenography, wrist, imaging techniques and wrist pain. To identify published research, the following databases were searched using the time frame of 1990 to 2011. The databases included Scopus, MD consult, Web of Knowledge, Pub Med, Ovid Medline and Cochrane Library. The print journals and books available at Manipal University library were hand searched and secondary search was done for the
relevant articles included in the references of primary articles. Full articles as well as abstracts were used for review. The posteroanterior (PA) projection is obtained with the shoulder abducted 90° from the trunk and the elbow flexed at 90° with the ulna perpendicular to the humerus and forearm in pronated position
[Figure 1]. The wrist should be in neutral position with no flexion, extension or deviation. The hand should be palm down on the cassette with fingers extended.[1] This position ensures that there is no rotation
between the radius and the ulna and permits a standard method of visualizing intercarpal relationships and bone length.[7] Postero anterior view. The central beam is aligned vertical over radial styloid 100 cm from the film In this view, the ulnar styloid is seen arising from the ulnar-most border of the ulna. With the wrist in the neutral position, one-half or more of the lunate should contact the distal radial articular surface.[8] The following features are also noted in the PA view.
Ancillary PA viewsRadiocarpal joint viewThis is obtained by angulating the beam by 25° to 30° towards the elbow centred just distal to Lister's tubercle for better visualization of radiocarpal articulation [Figure 2]. This view will elongate the scaphoid and shorten the capitate and demonstrate minimum bony overlap with parallelism at the radiocarpal joint and provide more details of scaphoid abnormalities.[14] Radiocarpal joint view. The central beam is angled 25° to 30° towards elbow, centred just distal to Lister's tubercle Dorsal tilt viewIt is a PA projection with the central beam angled 25° to 30° towards the fingers, centred on Capitate [Figure 3]. This is useful when there is a suspicion of capitate waist fracture, as here, the capitate is elongated and scaphoid is foreshortened.[14] Dorsal tilt view. The central beam is angled 25° to 30° towards fingers, centred on the capitate Dynamic PA viewsRadiographs obtained with radial and ulnar deviation of the wrist are useful for visualizing the carpal bones, particularly the scaphoid, and for assessing carpal mobility and instability. The distances between the carpal bones are normally equal throughout and are unchanged by radial or ulnar deviation.[16] PA in ulnar deviationAs the wrist is placed in ulnar deviation, the scaphoid rotates its distal pole dorsally and ulnarly and appears elongated. This elongated position of scaphoid allows for easier detection of scaphoid fractures.[8] The scaphoid can also be brought out to length much more by extending the wrist by 20° or by angling the beam towards the wrist by 20° [Figure 4]. PA ulnar deviation. The central beam is angled 20° longitudinal with the forearm, centred at the midcarpal region PA in radial deviationPalmar flexion of the proximal carpal row occurs and the distal pole of the scaphoid rotates into the palm as the wrist is radially deviated. This causes the normal scaphoid to appear foreshortened and exhibit a ring-like appearance of its distal pole as the distal aspect of the scaphoid is seen end on. However, if the same ‘cortical ring sign’ is seen on a PA view in neutral rotation, it may indicate scapholunate dissociation [Figure 5].[16] PA radial deviation. The central beam is angled 20° longitudinal with the forearm, centred at the midcarpal region This view is basically used to visualize the ulnar sided carpal interspaces. If the same view is taken with wrist and hand resting on ulnar surface by tilting 30° oblique and wrist in maximum radial deviation, it becomes a PA radial flexion oblique view. This is an additional view for occult scaphoid fractures.[17] LATERAL VIEWThe lateral view [Figure 6] is critical in assessing intercarpal ligament instability and is obtained with elbow flexed to 90° and adducted against the trunk.[18] The forearm should be midprone and wrist should be in the neutral position such that, in the resulting radiograph, a straight line can be drawn through the axes of radius, lunate, capitate and third metacarpal or they should be coaxial within 10°. Lateral view. The central beam is aligned vertical over radial styloid 100 cm from the film However, the range of capitolunate angle is given to be 0° to 30°.[8] The following features are to be noted in this view.
Ancillary lateral viewsCarpal boss view or off-lateral view [Figure 7]: this lateral view is taken with the ulnar side of the wrist resting on the cassette, in minimal ulnar deviation and 30° supination. The central beam passes tangent to the dorsal prominence. Carpal boss view. The central beam passes through or tangent to the dorsal prominence This view shows the dorsal carpal boss on a tangent and enables distinction of (1) a separate os styloideum; (2) a bony prominence attached to the second or third metacarpal base or apposing surface of the trapezoid or capitate bones; (3) degenerative osteophytes; and (4) a fracture of the dorsal prominence of the second or third metacarpal.[14] Lateral scaphoid view [Figure 8]: this is same as the standard lateral view except that the wrist is kept in 30° extension and the beam is centred on the waist of the scaphoid.[18] Lateral scaphoid view. The central beam is directed perpendicular to the film and centred on the waist of the scaphoid Dynamic lateral views
OBLIQUE VIEWThe oblique views [Figure 11] uniquely reveal abnormalities and changes interpretation by increasing the confidence of the final radiographic diagnosis.[6] This view is classically obtained by pronating the wrist by 45° from the lateral position and can be made easy for the patient by using a step wedge to steady the wrist and hand. The oblique view is particularly useful in evaluating the radial corner of the wrist including the base of the thumb and the scaphotrapeziotrapezoidal joint. It also provides an additional view for scaphoid tuberosity and waist when ulnar deviation is added to same view. It also shows dorsal triquetral margin fractures.[14] Ancillary oblique views
ANTERO POSTERIOR VIEWThe antero posterior or AP view or supinated view [Figure 14] has its specific applications in evaluating wrist pathology. It profiles the scapholunate and lunotriquetral carpal interspaces best and hence used to evaluating them.[1,17] It is also used when the patient cannot pronate and fingers cannot be fully extended.[18] The dorsum of wrist and hand are flat against the film and beam is centred over the capitate head. In the AP view, the ulnar styloid projects from the centre of ulnar head in contrast with PA view where it is at the ulnar border.[5,23] Dynamic AP view (clenched fist view)The AP view can be used dynamically [Figure 15] by asking the patient to clench his fist actively when the film is taken. This will demonstrate any Scapholunate diastasis effectively. The clenched fist creates enough forces of the contracting muscles to drive the capitate towards the scapholunate joint and bring out the diastasis in a dynamic mode.[1] Antero posterior clenched fist view. The central beam is directed perpendicularly at the level of the midcarpal region The following points are to be kept in mind before making the diagnosis of scapholunate instability on clenched fist view (carpal compression or power grip view). The clinical correlation of pain and tenderness at the scapholunate joint should guide the radiographic evidence as even wrists with lax ligaments can show the widening on routine radiographs.
Ancillary AP viewFirst carpometacarpal joint view: [Figure 16] this view is taken with the thumb placed in horizontal position and hand hyper extended. The beam is angled 45° towards the elbow. This is a dedicated anteroposterior projection with beam angulation for changes in first CMC joint in arthritis or traumatic conditions like Bennett's fracture.[5] First carpometacarpal joint view OTHER VIEWS
The beam is angled to profile the carpal tunnel by directing it along the volar aspect to a point 2.5 cm distal to base of fourth metacarpal at an angle of 25° to 30° to the long axis.[16] This view shows the palmar soft tissues and the palmar aspects of the trapezium, scaphoid tuberosity, capitate, hook of the hamate, triquetrum and the entire pisiform.[5,14]
This view helps in evaluating dorsal surface fractures of the scaphoid and dorsal fractures of other carpal bones, lunate dislocation and also demonstrates calcifications and foreign bodies in the dorsal soft tissues.[16] SUMMARYThe radiographic projections described earlier require careful attention to positioning, radiographic exposure and collimation of the beam to provide accurate information. A film that is too widely or narrowly collimated, under or over exposed, or inadequately positioned may be misleading.[24] Using a single film to evaluate adjacent anatomical regions like hand and wrist or digits is a false sense of economy because a dedicated set of images of the region of interest is more diagnostic.[1] Of late, the complex interactions of the carpal bones and the intricate carpal ligamentous network have been better explored by new imaging techniques.[21] Apart from the conventional radiography, the static pathologies are better delineated now with digitally acquired radiography that is superior in image quality. The digital data can also be manipulated to alter the character of the image and can be stored on magnetic media instead of a photographic film. The digital radiographs also depict the soft tissues in a greater detail.[25] Advanced imaging and identification of dynamic pathological conditions of the wrist are increasingly being done now with fluoroscopy, ultrasonography, scintigraphy, conventional and computed tomography, arthrography and magnetic resonance imaging.[21] However, it cannot be over emphasized that to use these tools effectively, a close co-operation between the clinician and the radiologist is essential which will result in tailoring an appropriate imaging protocol best suited for the patient. FootnotesSource of Support: Nil Conflict of Interest: None declared. REFERENCES1. Schreibman KL, Freeland A, Gilula LA, Yin Y. Imaging of the Hand and Wrist. OrthopClinNorth Am. 1997;28:537–82. [PubMed] [Google Scholar] 2. Eisenberg RL. Radiology: An illustrated History. St Louis: Mosby Yearbook; 1992. Early Radiology; p. 63. [Google Scholar] 3. Distouet JM, Gilula LA, Reinus WR. 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Which projection of the wrist best demonstrates the scaphoid carpal bone and its related articulation?Cards
What is the position of the wrist for the PA oblique projection with lateral rotation?For a lateral rotation oblique, from a prone position, rotate the wrist laterally approximately 45 degrees. For a medial oblique, medially rotate the wrist 45 degrees.
Which special projection of the wrist will open up the interspaces on the ulnar side of the wrist?Chapter 5. |