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Wrist Fractures: What the Clinician Wants to Know¹

¹ From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110 (Y.Y., L.A.G.); the Department of Orthopaedic Surgery, Washington University Medical School, St Louis, Mo (C.A.G., M.I.B.); and Radiology Imaging Associates, Englewood, Colo (A.J.F.). Received March 23, 1999; revision requested May 21; revision received December 28; accepted February 1, 2000. Address correspondence to L.A.G. (e-mail: gilulal@mir.wustl.edu).

View larger version (97K): [in a new window]   Figure 1. Anatomic diagram shows the radiocarpal joint with fossae to articulate with the scaphoid (scaphoid fossa) (arrow), lunate (lunate fossa) (arrowhead), and ulnar side of the carpus. (Modified and reprinted, with permission, from reference 7.)

View larger version (154K): [in a new window]   Figure 2a. (a) Schematic shows dorsal view of the wrist joint. 1 = dorsal intermetacarpal ligament, 2 = dorsal carpometacarpal ligament, 3 = radial collateral ligament, 4 = dorsal intercarpal ligament, 5 = pars radioscaphoid of the dorsal radiocarpal ligament, 6 = pars radiolunate of the dorsal radiocarpal ligament, 7 = pars radiotriquetrum of the dorsal radiocarpal ligament, 8 = TFC, 9 = ulnar collateral ligament, 10 = ulnar collateral ligament, 11 = capitohamate ligament, 12 = trapezoidocapitate ligament, 13 = trapeziotrapezoid ligament. (b) Schematic shows volar view of wrist joint. 14 = volar carpometacarpal ligament, 15 = pisohamate ligament, 16 = ulnar collateral ligament, 17 = ulnotriquetral ligament, 18 = ulnolunate ligament, 19 = triangular fibrocartilage, 20 = capsule of distal radioulnar joint, 21 = volar radioscapholunate ligament, 22 = volar radiolunatotriquetral ligament, 23 = volar radiocapitate (radioscaphocapitate) ligament, 24 = radial collateral ligament, 25 = trapeziotrapezoid ligament, 26 = trapezoidocapitate ligament (intercarpal capsular and interosseous), 27 = scapholunate interosseous ligament, 28 = volar capitotriquetral ligament, 29 = capitohamate ligament, 30 = lunotriquetral interosseous ligament, 31 = scaphotrapeziotrapezoidal intercarpal capsular ligament, 32 = scaphocapitate intercarpal capsular ligament. (Reprinted, with permission, from reference 9.)

View larger version (167K): [in a new window]   Figure 2b. (a) Schematic shows dorsal view of the wrist joint. 1 = dorsal intermetacarpal ligament, 2 = dorsal carpometacarpal ligament, 3 = radial collateral ligament, 4 = dorsal intercarpal ligament, 5 = pars radioscaphoid of the dorsal radiocarpal ligament, 6 = pars radiolunate of the dorsal radiocarpal ligament, 7 = pars radiotriquetrum of the dorsal radiocarpal ligament, 8 = TFC, 9 = ulnar collateral ligament, 10 = ulnar collateral ligament, 11 = capitohamate ligament, 12 = trapezoidocapitate ligament, 13 = trapeziotrapezoid ligament. (b) Schematic shows volar view of wrist joint. 14 = volar carpometacarpal ligament, 15 = pisohamate ligament, 16 = ulnar collateral ligament, 17 = ulnotriquetral ligament, 18 = ulnolunate ligament, 19 = triangular fibrocartilage, 20 = capsule of distal radioulnar joint, 21 = volar radioscapholunate ligament, 22 = volar radiolunatotriquetral ligament, 23 = volar radiocapitate (radioscaphocapitate) ligament, 24 = radial collateral ligament, 25 = trapeziotrapezoid ligament, 26 = trapezoidocapitate ligament (intercarpal capsular and interosseous), 27 = scapholunate interosseous ligament, 28 = volar capitotriquetral ligament, 29 = capitohamate ligament, 30 = lunotriquetral interosseous ligament, 31 = scaphotrapeziotrapezoidal intercarpal capsular ligament, 32 = scaphocapitate intercarpal capsular ligament. (Reprinted, with permission, from reference 9.)

View larger version (40K): [in a new window]   Figure 3. Illustration of the scaphopisocapitate criterion for lateral wrist alignment. The ventral cortex of the pisiform bone (P) should lie between the ventral cortices of the distal pole of the scaphoid (S) and the head of the capitate (C). When the ventral cortex of the pisiform bone is outside of these borders, lateral alignment is unacceptable. The bone with hatch marks is the pisiform bone. L = lunate, R = radius. (Reprinted, with permission, from reference 12.)

View larger version (161K): [in a new window]   Figure 4a. (a) PA radiograph of the left wrist demonstrates a normal appearance. (b) Lateral radiograph of the same wrist demonstrates a chip fracture (arrow) from the dorsal aspect of the triquetrum.

View larger version (149K): [in a new window]   Figure 4b. (a) PA radiograph of the left wrist demonstrates a normal appearance. (b) Lateral radiograph of the same wrist demonstrates a chip fracture (arrow) from the dorsal aspect of the triquetrum.

View larger version (29K): [in a new window]   Figure 5a. (a) Schematic shows method for determination of radial height (radial length) (normal measure, 10-13 mm), which is the measured distance between points D and E, where D represents the distal-most tip of the radial styloid and E is a point on line EC. Line DE is the shortest distance between point D and line EC. Radial inclination angle (arrow) is measured by drawing a perpendicular line (line EC) to the radial axis (AB) through the distal sigmoid notch (the ulnar edge of the lunate fossa) and by drawing another line (line DC) joining the distal tip of the radial styloid and the distal sigmoid notch (ulnar edge of the lunate fossa). These two lines form the radial inclination angle (normal angle, 21°-25°). (b) Schematic shows the palmar (volar) tilt, which is the angle created between the line (Y) joining the most distal points of the dorsal and ventral rims of the distal articular surface of the radius and the line (Z) drawn perpendicular to the long axis (line XBA) of the radius. The average tilt is 11°, with a range of 2°-20°. (Modified and reprinted, with permission, from reference 18.)

View larger version (22K): [in a new window]   Figure 5b. (a) Schematic shows method for determination of radial height (radial length) (normal measure, 10-13 mm), which is the measured distance between points D and E, where D represents the distal-most tip of the radial styloid and E is a point on line EC. Line DE is the shortest distance between point D and line EC. Radial inclination angle (arrow) is measured by drawing a perpendicular line (line EC) to the radial axis (AB) through the distal sigmoid notch (the ulnar edge of the lunate fossa) and by drawing another line (line DC) joining the distal tip of the radial styloid and the distal sigmoid notch (ulnar edge of the lunate fossa). These two lines form the radial inclination angle (normal angle, 21°-25°). (b) Schematic shows the palmar (volar) tilt, which is the angle created between the line (Y) joining the most distal points of the dorsal and ventral rims of the distal articular surface of the radius and the line (Z) drawn perpendicular to the long axis (line XBA) of the radius. The average tilt is 11°, with a range of 2°-20°. (Modified and reprinted, with permission, from reference 18.)

View larger version (153K): [in a new window]   Figure 6a. Colles fracture. (a) PA radiograph of the right wrist demonstrates a comminuted intraarticular fracture of the distal radius with a proximal and ulnar shift of the carpus relative to the radius. (b) Lateral radiograph of the same wrist demonstrates a distal radius fracture with the distal fracture fragments displaced and angled dorsally relative to the proximal fracture fragment.

View larger version (140K): [in a new window]   Figure 6b. Colles fracture. (a) PA radiograph of the right wrist demonstrates a comminuted intraarticular fracture of the distal radius with a proximal and ulnar shift of the carpus relative to the radius. (b) Lateral radiograph of the same wrist demonstrates a distal radius fracture with the distal fracture fragments displaced and angled dorsally relative to the proximal fracture fragment.

View larger version (156K): [in a new window]   Figure 7a. Smith fracture. (a) PA radiograph of the left wrist demonstrates a transverse comminuted fracture of the distal radius. (b) Lateral radiograph of the same wrist demonstrates a comminuted distal radius fracture (between arrows) with the distal fracture fragment displaced and angled in the palmar direction relative to the proximal fracture fragment. The distal articular surface of the radius has an abnormally increased palmar tilt.

View larger version (157K): [in a new window]   Figure 7b. Smith fracture. (a) PA radiograph of the left wrist demonstrates a transverse comminuted fracture of the distal radius. (b) Lateral radiograph of the same wrist demonstrates a comminuted distal radius fracture (between arrows) with the distal fracture fragment displaced and angled in the palmar direction relative to the proximal fracture fragment. The distal articular surface of the radius has an abnormally increased palmar tilt.

View larger version (150K): [in a new window]   Figure 8a. Reverse (volar) Barton fracture. (a) PA radiograph of the right wrist demonstrates a comminuted intraarticular fracture of the distal radius with the distal fracture fragment migrated proximally and radially. (b) Lateral radiograph of the same wrist demonstrates an intraarticular fracture of the distal radius with the volar fragment (arrows) maintaining its relationship with the carpus. The volar fracture fragment and carpus have migrated proximally relative to the dorsal fracture fragment and shaft of the radius.

View larger version (133K): [in a new window]   Figure 8b. Reverse (volar) Barton fracture. (a) PA radiograph of the right wrist demonstrates a comminuted intraarticular fracture of the distal radius with the distal fracture fragment migrated proximally and radially. (b) Lateral radiograph of the same wrist demonstrates an intraarticular fracture of the distal radius with the volar fragment (arrows) maintaining its relationship with the carpus. The volar fracture fragment and carpus have migrated proximally relative to the dorsal fracture fragment and shaft of the radius.

View larger version (45K): [in a new window]   Figure 9. Diagram shows a die-punch fracture, which, in this case, is a depressed fracture (arrows) of the lunate fossa of the articular surface of the distal radius. Here, carpal arcs I and II (see text) are broken between the scaphoid and lunate (arrowheads), but these arcs may be intact. It would be rare to break the normal alignment between the capitate and hamate, as illustrated in this diagram.

View larger version (62K): [in a new window]   Figure 10. Diagram shows the Frykman classification of distal radius fractures with or without involvement of the ulnar styloid: type I, simple metaphyseal area fracture; type II, simple metaphyseal area fracture and ulnar styloid fracture; type III, metaphyseal area fracture with radiocarpal joint extension; type IV, metaphyseal area fracture with radiocarpal joint extension and ulnar styloid fracture; type V, metaphyseal area fracture with DRUJ extension; type VI, metaphyseal area fracture with DRUJ extension and ulnar styloid fracture; type VII, metaphyseal area fracture with DRUJ and radiocarpal extension; type VIII, metaphyseal area fracture with DRUJ and radiocarpal extension and ulnar styloid fracture. (Modified and reprinted, with permission, from reference 7.)

View larger version (84K): [in a new window]   Figure 11. Diagrams show the Melone classification of distal radius fractures. (Reprinted, with permission, from reference 29.)

View larger version (25K): [in a new window]   Figure 12. Diagrams show the five types of distal radius fractures described by Fernandez and Jupiter. (See text for specific information regarding each type.) On the lateral drawings, dorsal is to the reader’s right. * = transverse (end-on) view of distal radius and ulna. Type I is a metaphyseal bending fracture. One cortex fails in tension, and the opposite fails in compression (eg, Smith fracture and Colles fracture). Type II is a shear fracture of the joint surface (Barton fracture). Type III is a compression fracture of the joint surface. Type IV is an avulsion fracture, usually associated with ligamentous injury. Type V is a high-energy injury, usually the result of a combination of mechanisms and forces. (Modified and reprinted, with permission, from reference 30.)

View larger version (204K): [in a new window]   Figure 13. Scaphoid fracture. PA radiograph of the left wrist demonstrates a transverse fracture of the scaphoid waist. The fracture line (arrow) is visible at the capitate articular surface.

View larger version (193K): [in a new window]   Figure 14a. Osteonecrosis of the scaphoid. (a) PA radiograph of the left wrist demonstrates a transverse fracture at the proximal third of the scaphoid (black arrows) and fragmentation of the proximal fracture fragment (white arrow). The distal fragment appears sclerotic, but this is due to foreshortening of the scaphoid, with its distal pole overlapping its waist. (b) PA fluoroscopic spot view of the same wrist with ulnar deviation. The proximal articular surface is irregular, with a mixture of sclerosis and lysis. Part of the proximal subchondral bone cortex has disappeared (arrows). The distal portion of the scaphoid has normal mineralization.

View larger version (190K): [in a new window]   Figure 14b. Osteonecrosis of the scaphoid. (a) PA radiograph of the left wrist demonstrates a transverse fracture at the proximal third of the scaphoid (black arrows) and fragmentation of the proximal fracture fragment (white arrow). The distal fragment appears sclerotic, but this is due to foreshortening of the scaphoid, with its distal pole overlapping its waist. (b) PA fluoroscopic spot view of the same wrist with ulnar deviation. The proximal articular surface is irregular, with a mixture of sclerosis and lysis. Part of the proximal subchondral bone cortex has disappeared (arrows). The distal portion of the scaphoid has normal mineralization.

View larger version (52K): [in a new window]   Figure 15a. (a), Drawings show development of the dorsal humpback deformity of the scaphoid after fracture of the scaphoid waist, with angulation between the proximal and distal scaphoid fracture fragments. At first, there is angulation between fragments; next, the two fragments settle or impact into each other; and finally an exostosis (curved arrow) or bony prominence (the humpback deformity) develops dorsally at the fracture site. (b), Long-axis scaphoid CT image shows a developing dorsal humpback deformity (arrow). This deformity is caused by ventral angulation of the distal scaphoid fracture fragment and late exostosis formation at the fracture site dorsally. Nonunion is evident with cortical margins (arrowheads) along the ventral half of the fracture line. (c), In another patient, who underwent internal fixation, exostosis (arrow) is developing dorsally on the scaphoid (S). R = radius. (Reprinted, with permission, from reference 47.)

View larger version (166K): [in a new window]   Figure 15b. (a), Drawings show development of the dorsal humpback deformity of the scaphoid after fracture of the scaphoid waist, with angulation between the proximal and distal scaphoid fracture fragments. At first, there is angulation between fragments; next, the two fragments settle or impact into each other; and finally an exostosis (curved arrow) or bony prominence (the humpback deformity) develops dorsally at the fracture site. (b), Long-axis scaphoid CT image shows a developing dorsal humpback deformity (arrow). This deformity is caused by ventral angulation of the distal scaphoid fracture fragment and late exostosis formation at the fracture site dorsally. Nonunion is evident with cortical margins (arrowheads) along the ventral half of the fracture line. (c), In another patient, who underwent internal fixation, exostosis (arrow) is developing dorsally on the scaphoid (S). R = radius. (Reprinted, with permission, from reference 47.)

View larger version (157K): [in a new window]   Figure 15c. (a), Drawings show development of the dorsal humpback deformity of the scaphoid after fracture of the scaphoid waist, with angulation between the proximal and distal scaphoid fracture fragments. At first, there is angulation between fragments; next, the two fragments settle or impact into each other; and finally an exostosis (curved arrow) or bony prominence (the humpback deformity) develops dorsally at the fracture site. (b), Long-axis scaphoid CT image shows a developing dorsal humpback deformity (arrow). This deformity is caused by ventral angulation of the distal scaphoid fracture fragment and late exostosis formation at the fracture site dorsally. Nonunion is evident with cortical margins (arrowheads) along the ventral half of the fracture line. (c), In another patient, who underwent internal fixation, exostosis (arrow) is developing dorsally on the scaphoid (S). R = radius. (Reprinted, with permission, from reference 47.)

View larger version (168K): [in a new window]   Figure 16a. Scaphoid fracture. (a) PA radiograph of the right wrist with ulnar deviation demonstrates a questionable fracture fragment (arrow) at the radial side of the scaphoid with otherwise normal appearance. (b) A 45° oblique radiograph of the right wrist with full ulnar deviation and tube angulation toward the elbow clearly demonstrates a transverse fracture line (arrows) at the scaphoid waist.

View larger version (171K): [in a new window]   Figure 16b. Scaphoid fracture. (a) PA radiograph of the right wrist with ulnar deviation demonstrates a questionable fracture fragment (arrow) at the radial side of the scaphoid with otherwise normal appearance. (b) A 45° oblique radiograph of the right wrist with full ulnar deviation and tube angulation toward the elbow clearly demonstrates a transverse fracture line (arrows) at the scaphoid waist.

View larger version (26K): [in a new window]   Figure 17. Diagrams show the Russe classification of scaphoid fractures, which include horizontal oblique (HO),transverse (T), and vertical oblique (VO) fractures. (Reprinted, with permission, from reference 7, p 806.)

View larger version (50K): [in a new window]   Figure 18. Diagrams show the Herbert classification of scaphoid fractures. (Reprinted, with permission, from reference 7, p 805.)

View larger version (134K): [in a new window]   Figure 19a. Kienböck disease. (a) PA radiograph of the right wrist demonstrates increased sclerosis of the lunate with fragmentation. A transverse fracture line (arrows) through the lunate with a sclerotic margin is present, and the distal fracture fragment has migrated toward the ulna. (b) Lateral radiograph of the same wrist further demonstrates sclerotic changes and fragmentation of the lunate. A separate fracture fragment (arrow) is present in a volar location.

View larger version (128K): [in a new window]   Figure 19b. Kienböck disease. (a) PA radiograph of the right wrist demonstrates increased sclerosis of the lunate with fragmentation. A transverse fracture line (arrows) through the lunate with a sclerotic margin is present, and the distal fracture fragment has migrated toward the ulna. (b) Lateral radiograph of the same wrist further demonstrates sclerotic changes and fragmentation of the lunate. A separate fracture fragment (arrow) is present in a volar location.

View larger version (169K): [in a new window]   Figure 20a. Triquetral fracture. (a) PA radiograph of the right wrist demonstrates a vertical fracture line (arrows) located at the radial third of the triquetrum. (b) A 45° oblique radiograph of the right wrist demonstrates the same fracture line (arrows), with 1-mm separation between the fracture fragments.

View larger version (175K): [in a new window]   Figure 20b. Triquetral fracture. (a) PA radiograph of the right wrist demonstrates a vertical fracture line (arrows) located at the radial third of the triquetrum. (b) A 45° oblique radiograph of the right wrist demonstrates the same fracture line (arrows), with 1-mm separation between the fracture fragments.

View larger version (140K): [in a new window]   Figure 21a. Trapezial fracture. (a) PA radiograph of the right wrist demonstrates a transverse fracture line (arrows) through the proximal third of the trapezium, with approximately 2-mm ulnar displacement of the distal fracture fragment. (b) Lateral radiograph of the same wrist demonstrates 2-mm separation (arrow) between the fracture fragments of the trapezium.

View larger version (143K): [in a new window]   Figure 21b. Trapezial fracture. (a) PA radiograph of the right wrist demonstrates a transverse fracture line (arrows) through the proximal third of the trapezium, with approximately 2-mm ulnar displacement of the distal fracture fragment. (b) Lateral radiograph of the same wrist demonstrates 2-mm separation (arrow) between the fracture fragments of the trapezium.

View larger version (171K): [in a new window]   Figure 22a. Hamate fracture. (a) PA radiograph of the right wrist demonstrates an oblique fracture line (arrows) at the distal ulnar third of the hamate, with 0.5-mm separation of the ulnar fracture fragment. (b) A 45° oblique radiograph of the same wrist demonstrates the hamate fracture (arrow), with 2-3 mm of distal and dorsal displacement of the fracture fragment.

View larger version (162K): [in a new window]   Figure 22b. Hamate fracture. (a) PA radiograph of the right wrist demonstrates an oblique fracture line (arrows) at the distal ulnar third of the hamate, with 0.5-mm separation of the ulnar fracture fragment. (b) A 45° oblique radiograph of the same wrist demonstrates the hamate fracture (arrow), with 2-3 mm of distal and dorsal displacement of the fracture fragment.

View larger version (154K): [in a new window]   Figure 23a. Hamate hook fracture. (a) PA radiograph of the right wrist demonstrates a normal-appearing wrist. (b) Lateral radiograph of the same wrist demonstrates no fracture. (c) Carpal tunnel radiograph of the same wrist demonstrates an oblique fracture (arrow) of the hook of the hamate.

View larger version (118K): [in a new window]   Figure 23b. Hamate hook fracture. (a) PA radiograph of the right wrist demonstrates a normal-appearing wrist. (b) Lateral radiograph of the same wrist demonstrates no fracture. (c) Carpal tunnel radiograph of the same wrist demonstrates an oblique fracture (arrow) of the hook of the hamate.

View larger version (68K): [in a new window]   Figure 23c. Hamate hook fracture. (a) PA radiograph of the right wrist demonstrates a normal-appearing wrist. (b) Lateral radiograph of the same wrist demonstrates no fracture. (c) Carpal tunnel radiograph of the same wrist demonstrates an oblique fracture (arrow) of the hook of the hamate.

View larger version (171K): [in a new window]   Figure 24a. Capitate fracture. (a) PA radiograph of the left wrist demonstrates a fracture line (arrows) at the proximal third of the capitate, with a widened gap at its ulnar side. (b) Lateral view of the same wrist demonstrates subtle dorsal tilting of the proximal fracture fragment (arrows), with a step-off at the palmar side of the cortex (top arrow).

View larger version (103K): [in a new window]   Figure 24b. Capitate fracture. (a) PA radiograph of the left wrist demonstrates a fracture line (arrows) at the proximal third of the capitate, with a widened gap at its ulnar side. (b) Lateral view of the same wrist demonstrates subtle dorsal tilting of the proximal fracture fragment (arrows), with a step-off at the palmar side of the cortex (top arrow).

View larger version (120K): [in a new window]   Figure 25a. Trapezoidal fracture. (a) PA radiograph of the right wrist demonstrates proximal migration of the second metacarpal bone with compression fracture (arrow) of the trapezoid. (b) Fluoroscopic spot view of the same wrist further demonstrates the trapezoid fracture (arrow) and proximal migration of the second metacarpal bone.

View larger version (155K): [in a new window]   Figure 25b. Trapezoidal fracture. (a) PA radiograph of the right wrist demonstrates proximal migration of the second metacarpal bone with compression fracture (arrow) of the trapezoid. (b) Fluoroscopic spot view of the same wrist further demonstrates the trapezoid fracture (arrow) and proximal migration of the second metacarpal bone.