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Radiographic features of hand and wrist surgery excluding arthroplasties
European Journal of Radiology, 10 (1990) 85-91 Elsevier
EURRAD
85
00011
Pictorial essay
Radiographic features of hand and wrist surgery excluding arthroplasties Douglas K. Smith’, Karen S Baker’, Louis A. Gilula’, Bruce A. Kraemer2, Paul R. Manske3, William B. Strecker3, Paul M. Weeks2 and V. Leroy Young2 ‘MallinckrodtInstituteof Radiology, ‘Division of Plastic Surgery, ‘Divbion of Orthopedic Surgery, Department of Surgery and 4Washington UniversitySchool of Medicine, St. Louk, MO. U.S.A. (Accepted
4 August 1989)
Key words: Wrist, surgery; Wrist, radiography
Introduction
examples of some complications procedures.
Advances in hand surgical techniques have improved the management of hand and wrist disorders. In order to render more meaningful interpretations, radiologists must be familiar with an increasing number of hand and wrist surgical procedures. This article is designed to present a spectrum of common and unusual hand and wrist procedures (excluding prostheses), as well as
associated
with these
Digit replantation Most replantations involve several digits, since the replantation of a single digit (except the thumb) is not commonly performed (Fig. 1). Surgical hemoclips within the soft tissues at the base of a digit suggest a previous replantation.
Fig. 1. (a) Vascular hemoclips (black arrowheads) index through ring fingers. Bony stabilization: K-wire fixation (A), tension band wire fixation (B), and crossed K-wires with dorsal compression wiring(C). Swanson-type silastic PIP joint prosthesis (arrow). Jergen’s ball (white arrowhead) protects sharp end of protruding K-wire. (b) Replantation through the base of the proximal phalanx. Bony stabilization: crossed K-wires and right-angled intraosseous wiring. Fig. 2. (a) Soft tissues disproportionately
of second toe ‘wrapped around’ the degloved bony stump of injured the thumb. Transplanted soft tissues are smaller than the remainder of the thumb. (b) Second toe soft tissues ‘wrapped’ around curved iliac bone graft.
Address for reprints: Louis A. Gilula, M.D., Mallinckrodt U.S.A.
Institute of Radiology, 510 South Kingshighway
0720-048X/90/%03.50 0 1990 Elsevier Science Publishers
B.V. (Biomedical
Division)
Boulevard,
St. Louis, MO 63110,
Fig. 3. (a) Great toe impaled on the bony stump of an amputated thumb (arrow). Transplanted toe soft tissues are bulkier than a toe ‘wrap around’ graft or normal thumb. (b) Great toe transplantation with relatively sclerotic (hypovascular) metatarsal head. Clues to toe transfer: hemoclips in the thenar eminence, absence of sesamoid bones (retained in foot) and disproportionate size of the bones in thumb.
Thumb resu$acing or ‘wrap-around’ reconstruction After traumatic avulsion of the skin and neurovascular bundles of a digit (‘degloving injury’), the soft tissues of the great or second toe may be ‘wrapped around’ the remaining bony stump of the thumb (Fig. 2a). For a total thumb reconstruction, the soft tissues of the great toe are ‘wrapped around’ a reconstructed bony post
Fig. 4. Index finger to thumb transplantation on a vascular pedicle (no hemoclips). Disproportionately small ‘metacarpal head’ (arrow) from the index finger.
(Fig. 2b). This ‘wrap-around’ procedure combines a solid bony core with a relatively cosmetic soft tissue appearance. Toe to thumb transfer This procedure is performed for thumb amputation at the perimetacarpophalangeal joint level (Fig. 3). The
Fig. 5. Index finger MCP joint (arrow) and adjacent growth plates (arrowheads) replacing thumb MCP head and proximal phalanx.
87
Fig. 7. Lauenstein procedure: segmental resection of the distal ulna and radioulnar arthrodesis. Courtesy of Dr. Julio Taleisnik, Orange, California.
soft tissues and bone of the great or second toe are transferred to the thumb amputation site using microvascular techniques. Index finger to thumb pollicization Fig. 6. Full thickness groin flap with subcutaneous fat (arrows) applied to a severely burned hand. Longitudinal K-wires to prevent flexion contractures.
This reconstruction technique is utilized for amputations at the base of the thumb. A ‘thumb’ is reconstructed by transferring the closest remaining digit
b Fig. 8. (a) Hemi-resection
of the distal ulna: concave defect in the radial aspect of the distal ulna. (b) Line drawing: tendon ‘anchovie’ within the bony defect.
Skin coverage Skin grafts, pedicle flaps or free flaps are utilized to provide skin coverage for hand wounds with deep soft tissue loss, exposed tendons or exposed neurovascular structures. Pedicle or free flaps include skin and subcutaneous fat and are recognized radiographically by their bulky appearance and by the presence of subcutaneous fat (Fig. 6).
Fig. 9. Resection of proximal carpal row with intentionally retained carpal fragments attached to carpal ligaments (arrow).
(often the index finger) with its intact neurovascular pedicle (Fig. 4). Since there is no microvascular anastomosis, vascular hemoclips may be absent. The ‘metacarpal head’ of the reconstructed thumb is smaller than normal, since it actually represents a phalangeal head. Free joint transfer A relatively normal joint in an expendible or nonsalvageable ray may be utilized to replace a severely injured joint in a different ray (Fig. 5).
Lauenstein procedure A Lauenstein or Sauve-Kapandji procedure consists of a distal radiouhmr arthrodesis with a segmental resection of the distal ulna (Fig. 7). Pronation and supination is produced by motion through the ulnar pseudarthrosis. This procedure is most commonly performed to restore pronation and supination following distal radioulnar ankylosis, malunited Colles fractures, or malunited fractures of the radial shaft. Hemi-resection distal ulna A hemi-resection inter-positional arthroplasty of the distal ulna is performed for painful impingement of the carpal bones on a prominent distal ulna or a painful distal radioulnar articulation. The radial aspect of the distal ulna is resected leaving the triangular fibrocartilage complex and the ulnar styloid intact (Fig. 8). There may be sclerosis of the lunate or triquetrum from previous inpingement with the ulnar head, or osteophytes about the distal radius from previous distal radioulnar osteoarthritis. A soft tissue spacer or
Fig. 10. (a) Triscaphe fusion performed for a scaphohmate dissociation. (b) SIT fusion to prevent further proximal migration of the capitate following lunate resection. Retained bony fragments to volar carpal ligaments (arrow).
89
Fig. 11. SLC arthrodesis
performed
after unsuccessful
Fig. 12. Triquetrolunate Fig. 13. Corticocancellous
Herbert screw fusion (arrow) of a scaphoid nonunion. Bone graft donor site of distal radius (arrowhead). with single cancellous
screw fixation.
onlay graft (arrow) fixed by three screws. Previous unsuccessful
arthrodesis
triquetrolunate
arthrodesis
with fourth screw.
Fig. 14. (a) Ulnar lengthening with interposed bone graft, sideplate, and screws. Positive ulnar variance (arrow): distal surface of the ulnar head is distal to the lunate fossa (white arrowhead). Distal radial bone graft donor site (black arrowhead) and Kienbock’s disease of the lunate (open arrow). (b) A sliding ‘step-cut’ osteotomy of distal ulna (arrow). Fig. 15. Ulna minus variance (black arrow) with plate fixation of the ulnar osteotomy
(white arrow).
90
Fig. 16. (a,b) Silastic rod along the course of the flexor profundus
‘anchovie’ may be inserted into the bony defect to prevent radial migration of the ulnar head. Proximal row carpectomy
This procedure is utilized as a salvage procedure and involves resection of the scaphoid, lunate and triquetrum (Fig. 9). The capitate head articulates with the lunate fossa. Small fragments of carpal bones are often intentionally left attached to the carpal ligaments to prevent injuring these important supportive soft tissue structures. Undesirable potential complications of this procedure are collapse of the capitate head and radiocapitate osteoarthritis.
tendon (arrow).
Triscaphe arthrodesis One of the most commonly
performed limited intercarpal arthrodeses is the scaphotrapeziotrapezoid (SIT) or triscaphe fusion (Fig. 10). It is utilized for the treatment of chronic scapholunate dissociation or Kienbock’s disease. Scapholunocapitate
arthrodesis
A scapholunocapitate (SLC) arthrodesis is an carpal arthrodesis performed for the treatment of scapholunate dissociation or a scaphoid fracture union with avascular necrosis of its proximal (Fig. 11).
intera late nonpole
91
Triquetrolunate arthrodesis
Ulnar shortening osteotomy
This procedure is performed for painful triquetrolunate dissociation resulting from a tear of the triquetrolunate interosseous ligament. The arthrodesis may be stabilized by crossed K-wires or a cancellous lag screw (Fig. 12). It is desirable that the screw threads do not lie across the lunotriquetral joint (unless the drill hole through the triquetrum is larger than the thread diameter) because screw threads crossing a joint ma.y keep the bones separate which may impair fracture healing.
An ulnar shortening or Milch osteotomy is performed to decrease the load transmission at the distal ulnocarpal articulation for treatment of a torn triangular fibrocartilage or ‘ulnar impingement syndrome’ (Fig. 15).
Wrist arthrodesis
A wrist arthrodesis is a salvage procedure which is most commonly utilized when wrist strength and pain relief are more important than motion (as in the case of manual laborers). Through a dorsal surgical approach, as much articular cartilage and subchondral bone as possible are removed from the radiocarpal and midcarpal articulating surfaces, and cancellous bone graft is packed into the denuded arthrodesis sites (Fig. 13). Residual articular cartilage (joint space) often remains along the volar aspect of the wrist. A corticocancellous strut may be screwed to the radius, capitate and third metacarpal; or a dorsal sideplate and screws may be utilized to support a cancellous bone graft.
Two stage flexor
tendon reconstruction
When extensive soft tissue injury is associated with a flexor tendon laceration, a two stage reconstruction is performed. In the first stage, a silastic rod is placed within the bed of the damaged flexor tendon which is resected (Fig. 16). The silastic rod is attached to the distal phalanx by a screw or suture and slides within the injured bed of the resected flexor tendon. This rod serves as a sliding stent until the tendon sheath is restored by granulation tissue. At that time, the rod is removed and a transplanted tendon (i.e., plantaris tendon) is implanted. Summary The normal and abnormal radiographic appearances of various hand and wrist surgical procedures have been presented. It is hoped that increased familiarity with these procedures and their radiographic features will lead to more meaningful radiographic interpretations by consulting radiologists.
Ulnar lengthening osteotomy
An ulnar lengthening osteotomy (Fig. 14) is performed to decrease load transmission through the radiolunate joint as a treatment for lunatomalacia (Kienbock’s disease) by surgical creation of a prominent distal ulnar articular surface (positive ulnar variance).
References I Taleisnik J. The Wrist. First Edn. New York: Churchill Livingstone, 1987. 2 Sennwald G. The Wrist. New York: Springer-Verlag, 1987. 3 Green DP. Operative Hand Surgery. Second Edn. New York: Churchill Livingstone, 1988. 4 Weismann BN, Sledge CB. Orthopedic Radiology. Philadelphia: Saunders, 1986.
EURRAD
85
00011
Pictorial essay
Radiographic features of hand and wrist surgery excluding arthroplasties Douglas K. Smith’, Karen S Baker’, Louis A. Gilula’, Bruce A. Kraemer2, Paul R. Manske3, William B. Strecker3, Paul M. Weeks2 and V. Leroy Young2 ‘MallinckrodtInstituteof Radiology, ‘Division of Plastic Surgery, ‘Divbion of Orthopedic Surgery, Department of Surgery and 4Washington UniversitySchool of Medicine, St. Louk, MO. U.S.A. (Accepted
4 August 1989)
Key words: Wrist, surgery; Wrist, radiography
Introduction
examples of some complications procedures.
Advances in hand surgical techniques have improved the management of hand and wrist disorders. In order to render more meaningful interpretations, radiologists must be familiar with an increasing number of hand and wrist surgical procedures. This article is designed to present a spectrum of common and unusual hand and wrist procedures (excluding prostheses), as well as
associated
with these
Digit replantation Most replantations involve several digits, since the replantation of a single digit (except the thumb) is not commonly performed (Fig. 1). Surgical hemoclips within the soft tissues at the base of a digit suggest a previous replantation.
Fig. 1. (a) Vascular hemoclips (black arrowheads) index through ring fingers. Bony stabilization: K-wire fixation (A), tension band wire fixation (B), and crossed K-wires with dorsal compression wiring(C). Swanson-type silastic PIP joint prosthesis (arrow). Jergen’s ball (white arrowhead) protects sharp end of protruding K-wire. (b) Replantation through the base of the proximal phalanx. Bony stabilization: crossed K-wires and right-angled intraosseous wiring. Fig. 2. (a) Soft tissues disproportionately
of second toe ‘wrapped around’ the degloved bony stump of injured the thumb. Transplanted soft tissues are smaller than the remainder of the thumb. (b) Second toe soft tissues ‘wrapped’ around curved iliac bone graft.
Address for reprints: Louis A. Gilula, M.D., Mallinckrodt U.S.A.
Institute of Radiology, 510 South Kingshighway
0720-048X/90/%03.50 0 1990 Elsevier Science Publishers
B.V. (Biomedical
Division)
Boulevard,
St. Louis, MO 63110,
Fig. 3. (a) Great toe impaled on the bony stump of an amputated thumb (arrow). Transplanted toe soft tissues are bulkier than a toe ‘wrap around’ graft or normal thumb. (b) Great toe transplantation with relatively sclerotic (hypovascular) metatarsal head. Clues to toe transfer: hemoclips in the thenar eminence, absence of sesamoid bones (retained in foot) and disproportionate size of the bones in thumb.
Thumb resu$acing or ‘wrap-around’ reconstruction After traumatic avulsion of the skin and neurovascular bundles of a digit (‘degloving injury’), the soft tissues of the great or second toe may be ‘wrapped around’ the remaining bony stump of the thumb (Fig. 2a). For a total thumb reconstruction, the soft tissues of the great toe are ‘wrapped around’ a reconstructed bony post
Fig. 4. Index finger to thumb transplantation on a vascular pedicle (no hemoclips). Disproportionately small ‘metacarpal head’ (arrow) from the index finger.
(Fig. 2b). This ‘wrap-around’ procedure combines a solid bony core with a relatively cosmetic soft tissue appearance. Toe to thumb transfer This procedure is performed for thumb amputation at the perimetacarpophalangeal joint level (Fig. 3). The
Fig. 5. Index finger MCP joint (arrow) and adjacent growth plates (arrowheads) replacing thumb MCP head and proximal phalanx.
87
Fig. 7. Lauenstein procedure: segmental resection of the distal ulna and radioulnar arthrodesis. Courtesy of Dr. Julio Taleisnik, Orange, California.
soft tissues and bone of the great or second toe are transferred to the thumb amputation site using microvascular techniques. Index finger to thumb pollicization Fig. 6. Full thickness groin flap with subcutaneous fat (arrows) applied to a severely burned hand. Longitudinal K-wires to prevent flexion contractures.
This reconstruction technique is utilized for amputations at the base of the thumb. A ‘thumb’ is reconstructed by transferring the closest remaining digit
b Fig. 8. (a) Hemi-resection
of the distal ulna: concave defect in the radial aspect of the distal ulna. (b) Line drawing: tendon ‘anchovie’ within the bony defect.
Skin coverage Skin grafts, pedicle flaps or free flaps are utilized to provide skin coverage for hand wounds with deep soft tissue loss, exposed tendons or exposed neurovascular structures. Pedicle or free flaps include skin and subcutaneous fat and are recognized radiographically by their bulky appearance and by the presence of subcutaneous fat (Fig. 6).
Fig. 9. Resection of proximal carpal row with intentionally retained carpal fragments attached to carpal ligaments (arrow).
(often the index finger) with its intact neurovascular pedicle (Fig. 4). Since there is no microvascular anastomosis, vascular hemoclips may be absent. The ‘metacarpal head’ of the reconstructed thumb is smaller than normal, since it actually represents a phalangeal head. Free joint transfer A relatively normal joint in an expendible or nonsalvageable ray may be utilized to replace a severely injured joint in a different ray (Fig. 5).
Lauenstein procedure A Lauenstein or Sauve-Kapandji procedure consists of a distal radiouhmr arthrodesis with a segmental resection of the distal ulna (Fig. 7). Pronation and supination is produced by motion through the ulnar pseudarthrosis. This procedure is most commonly performed to restore pronation and supination following distal radioulnar ankylosis, malunited Colles fractures, or malunited fractures of the radial shaft. Hemi-resection distal ulna A hemi-resection inter-positional arthroplasty of the distal ulna is performed for painful impingement of the carpal bones on a prominent distal ulna or a painful distal radioulnar articulation. The radial aspect of the distal ulna is resected leaving the triangular fibrocartilage complex and the ulnar styloid intact (Fig. 8). There may be sclerosis of the lunate or triquetrum from previous inpingement with the ulnar head, or osteophytes about the distal radius from previous distal radioulnar osteoarthritis. A soft tissue spacer or
Fig. 10. (a) Triscaphe fusion performed for a scaphohmate dissociation. (b) SIT fusion to prevent further proximal migration of the capitate following lunate resection. Retained bony fragments to volar carpal ligaments (arrow).
89
Fig. 11. SLC arthrodesis
performed
after unsuccessful
Fig. 12. Triquetrolunate Fig. 13. Corticocancellous
Herbert screw fusion (arrow) of a scaphoid nonunion. Bone graft donor site of distal radius (arrowhead). with single cancellous
screw fixation.
onlay graft (arrow) fixed by three screws. Previous unsuccessful
arthrodesis
triquetrolunate
arthrodesis
with fourth screw.
Fig. 14. (a) Ulnar lengthening with interposed bone graft, sideplate, and screws. Positive ulnar variance (arrow): distal surface of the ulnar head is distal to the lunate fossa (white arrowhead). Distal radial bone graft donor site (black arrowhead) and Kienbock’s disease of the lunate (open arrow). (b) A sliding ‘step-cut’ osteotomy of distal ulna (arrow). Fig. 15. Ulna minus variance (black arrow) with plate fixation of the ulnar osteotomy
(white arrow).
90
Fig. 16. (a,b) Silastic rod along the course of the flexor profundus
‘anchovie’ may be inserted into the bony defect to prevent radial migration of the ulnar head. Proximal row carpectomy
This procedure is utilized as a salvage procedure and involves resection of the scaphoid, lunate and triquetrum (Fig. 9). The capitate head articulates with the lunate fossa. Small fragments of carpal bones are often intentionally left attached to the carpal ligaments to prevent injuring these important supportive soft tissue structures. Undesirable potential complications of this procedure are collapse of the capitate head and radiocapitate osteoarthritis.
tendon (arrow).
Triscaphe arthrodesis One of the most commonly
performed limited intercarpal arthrodeses is the scaphotrapeziotrapezoid (SIT) or triscaphe fusion (Fig. 10). It is utilized for the treatment of chronic scapholunate dissociation or Kienbock’s disease. Scapholunocapitate
arthrodesis
A scapholunocapitate (SLC) arthrodesis is an carpal arthrodesis performed for the treatment of scapholunate dissociation or a scaphoid fracture union with avascular necrosis of its proximal (Fig. 11).
intera late nonpole
91
Triquetrolunate arthrodesis
Ulnar shortening osteotomy
This procedure is performed for painful triquetrolunate dissociation resulting from a tear of the triquetrolunate interosseous ligament. The arthrodesis may be stabilized by crossed K-wires or a cancellous lag screw (Fig. 12). It is desirable that the screw threads do not lie across the lunotriquetral joint (unless the drill hole through the triquetrum is larger than the thread diameter) because screw threads crossing a joint ma.y keep the bones separate which may impair fracture healing.
An ulnar shortening or Milch osteotomy is performed to decrease the load transmission at the distal ulnocarpal articulation for treatment of a torn triangular fibrocartilage or ‘ulnar impingement syndrome’ (Fig. 15).
Wrist arthrodesis
A wrist arthrodesis is a salvage procedure which is most commonly utilized when wrist strength and pain relief are more important than motion (as in the case of manual laborers). Through a dorsal surgical approach, as much articular cartilage and subchondral bone as possible are removed from the radiocarpal and midcarpal articulating surfaces, and cancellous bone graft is packed into the denuded arthrodesis sites (Fig. 13). Residual articular cartilage (joint space) often remains along the volar aspect of the wrist. A corticocancellous strut may be screwed to the radius, capitate and third metacarpal; or a dorsal sideplate and screws may be utilized to support a cancellous bone graft.
Two stage flexor
tendon reconstruction
When extensive soft tissue injury is associated with a flexor tendon laceration, a two stage reconstruction is performed. In the first stage, a silastic rod is placed within the bed of the damaged flexor tendon which is resected (Fig. 16). The silastic rod is attached to the distal phalanx by a screw or suture and slides within the injured bed of the resected flexor tendon. This rod serves as a sliding stent until the tendon sheath is restored by granulation tissue. At that time, the rod is removed and a transplanted tendon (i.e., plantaris tendon) is implanted. Summary The normal and abnormal radiographic appearances of various hand and wrist surgical procedures have been presented. It is hoped that increased familiarity with these procedures and their radiographic features will lead to more meaningful radiographic interpretations by consulting radiologists.
Ulnar lengthening osteotomy
An ulnar lengthening osteotomy (Fig. 14) is performed to decrease load transmission through the radiolunate joint as a treatment for lunatomalacia (Kienbock’s disease) by surgical creation of a prominent distal ulnar articular surface (positive ulnar variance).
References I Taleisnik J. The Wrist. First Edn. New York: Churchill Livingstone, 1987. 2 Sennwald G. The Wrist. New York: Springer-Verlag, 1987. 3 Green DP. Operative Hand Surgery. Second Edn. New York: Churchill Livingstone, 1988. 4 Weismann BN, Sledge CB. Orthopedic Radiology. Philadelphia: Saunders, 1986.