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Lunate dislocation…

September 30, 2014

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This patient presented with wrist pain after a fall:

 

Lunate 1Lunate edits

This is an example of a lunate dislocation.  The lunate can be seen on the lateral view (blue arrow).  It is dislocated quite a far distance.  Also note that the lunate is not in its usual location on the AP view.

The above radiographs are not subtle.  Keep in mind that lunate dislocation is sometimes not so obvious.  We visited lunate and perilunate dislocation on a prior post (lunate).  Stay tuned in the future for tips on reading wrist radiographs to avoid missing any subtle injuries.

Author:  Russell Jones, MD

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WWWTP #17 Answer…

June 30, 2014

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This is a pediatric radiograph of a patient with wrist pain after a fall:

SHII fx distal radius II SHII fx distal radius

 

There is a subtle linear lucency on the distal radius, best seen on the lateral view.

This is a Salter-Harris Type II Distal Radius fracture.  For a refresher on Salter-Harris classification see:

Salter-Harris

Author:  Russell Jones

References

1.  Salter-Harris Fracture.  http://en.wikipedia.org/wiki/Salter–Harris_fracture

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What’s Wrong With This Picture #17 (WWWTP?)

June 23, 2014

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This is a pediatric radiograph of a patient with wrist pain after a fall:

SHII fx distal radius II SHII fx distal radius

What’s Wrong With This Picture?

Answer to follow.

Author:  Russell Jones

 

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Distal Radius…

October 2, 2013

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Distal Radius 1 Distal Radius 2

This is an example of a distal radius fracture that needs closed reduction.  This fracture shows dorsal and radial angulation with translational displacement of the fracture fragment roughly 50% of the bone width.  The classic eponym for this type of fracture is a Colles’ Fracture. 

Acceptable angulation on reduction is a controversial topic.  It is obviously best to get these fractures as close as anatomic as possible with less than 10-15 degrees of angulation.  Remember to get a post-reduction X-ray so that when it falls off prior to the follow up ortho visit then you can’t be blamed!

Author:  Russell Jones, MD

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Worst distal radius ever…

June 30, 2013

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Not much to talk about other than this is one of the worst distal radius fractures I’ve ever seen:

Worst DR fx everWorst DR fx ever 2

Needless to say, this ended up in the operating room.  Yes, it was open.  You can also see dislocation of the carpus away from the radius and ulna as well as multiple carpal bone fractures. This was very close to a full hand amputation at the wrist!

Author:  Russell Jones, MD

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Another reason not to punch things…

June 22, 2013

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A patient came in the other day after punching a wall.  He had an injury pattern I had never seen before:

mcp DISLOCATIONMCP disloc

These PA and Lateral images of the hand show dorsal dislocation of the index and middle metacarpals at the carpometacarpal joint.  You can see the proximal ends of the index and middle metacarpals posterior to the trapezium, trapezoid, and capitate bones (in order from the base of the thumb toward the ulnar side of the wrist).  This is a very rare injury and may need operative fixation (1).

Image Contributor:  Aaron Bair, MD

Author:  Russell Jones, MD

References

1.  Carpometacarpal fracture dislocation.  Wheeless’ Textbook of Orthopaedics.  http://www.wheelessonline.com/ortho/carpometacarpal_fracture_dislocation.  Accessed 6/12/13.

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Lunate dislocation

March 28, 2013

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This is an image provided by one of our UC Davis resident physicians:

Lunate dislocation

Great example of a lunate dislocation!

The key portion of the film above is the half-moon shaped bone (Lunate) which is dislocated in the palmar direction and has a “spilled teacup” appearance (it is rotated from its normal position with the concave portion of the bone facing the distal fingers).

Lunate dislocation

The AP view on this patient is also interesting.  It shows a “Piece of pie” sign, also frequently found with lunate dislocation.  This is an abnormal triangular hyperdensity seen in the lunate on the AP projection (can also be seen in perilunate dislocation).

Lunate dislocation 2

The distinguishing feature of this radiograph to differentiate between perilunate and lunate dislocation is the alignment on the lateral projection.  The capitate and distal radius are still aligned, the lunate is dislocated.  In a perilunate dislocation the lunate will not have a “spilled teacup” rotation and the capitate will be dorsally displaced off the alignment of the distal radius.  An example of a perilunate dislocation:

PL Dislocation 2

Tip:  on lateral wrist xrays, always draw a line through the distal radius, lunate, and capitate.  It should look like an apple sitting in a teacup on a saucer.

Author:  Russell Jones, M.D.

Image Contributor:  Dane Stevenson, M.D.

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FOOSH!

November 12, 2012

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Another eponym fracture, courtesy of John Neuffer, MD at WVU.  Dr. Neuffer saw a patient with a fall on an outstretched hand (FOOSH) and this was the result:

This is an example of a Colles Fracture.  Colles fracture is a distal radius fracture with dorsal displacement of the distal fracture fragment and wrist.  FOOSH is a popular mechanism of this injury as well as any other mechanism that causes an axial load on the distal wrist with extension of the hand.

There are two other interesting parts of this image:  1.  There is an ulnar styloid fracture  2.  The pisiform is dislocated.

Ulnar styloid fractures are very common with FOOSH mechanism and in conjunction with distal radius fractures.  Common xray findings with a Colles fracture include (1):

  • Transverse radius fracture
  • Dorsal displacement and angulation
  • Radial angulation of the wrist
  • Location 1 inch proximal to the radiocarpal joint
  • Radial shortening
  • Ulnar styloid fracture
  • Salter-Harris fractures in children

Pisiform dislocation is rare.  On the lateral view above you can see the pisiform is displaced off the triquetral bone (its only articulation).

This is what it should look like:

Pnormalpisform.png

(Above is a link to Wikipedia.  James Heilman, MD has a post about the pisiform with a great lateral radiograph demonstrating a normal positioned pisiform.  Go check it out!)

Author:  Russell Jones, MD

Image Contributor:  John Neuffer, MD

Thanks to Dr. Neuffer at WVU for the image as well as pointing out a good EM blog for me to follow:  EMchatter.com.  Keep up the good work and send me more good images!

References

1.  Broder JS.  “Imaging the Extremities.” In: Broder JS.  Diagnostic Imaging for the Emergency Physician.  Elsevier Saunders, 2011.

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