Diagnostic Imaging of the Hand E-Book

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1326

Veröffentlichungsjahr: 2007

Beschreibung

In this text an interdisciplinary team of specialists in radiology, surgery, and rheumatology presents a practical guide to imaging of the hand. Complete with detailed discussion of the complex anatomy, common diseases, and injuries of the hand, this text covers examination techniques and state-of-the-art imaging modalities, including multiline spiral CR, with 2-D displays and 3-D reconstructions, and contrast-enhanced MRI with multi-channel, phased-array coils. Designed to help clinicians develop the most effective strategies for their patients, Diagnostic Imaging of the Hand provides a systematic approach to understanding each disease, outlining pathogenesis and clinical symptoms according to a graduated diagnostic plan. More than 1,000 crisp, high-quality images and line drawings, summary tables, handy checklists, and a heavily cross-referenced appendix of differential diagnoses make this text an ideal reference for the clinician seeking the most up-to-date information on how to diagnose and treat disorders of the hand.

Leseprobe

Library of Congress Cataloging-in-Publication Data

Bildgebende Diagnostik der Hand. English.

Diagnostic imaging of the hand / [edited by] Ulrich Lanz, Rainer Schmitt ; with contributions by Wolfgang Buchberger ... [et al. ; translator, Adele Barbara Herzberger ; illustrators, Piotr and Malgorzata Gusta].

  p. ; cm.

Authorized and revised translation of the German edition published and copyrighted 2004 by Georg Thieme Verlag, Stuttgart, Germany.

Includes bibliographical references and index.

ISBN 978-3-13-140581-4 (TPS : alk. paper) -- ISBN 978-1-58890-453-9 (TPN : alk. paper) 1. Hand--Radiography. I. Lanz, Ulrich, M.D. II. Schmitt, Rainer, 1954- III. Buchberger, Wolfgang. IV. Title.

[DNLM: 1. Hand Injuries--diagnosis. 2. Bone Diseases--diagnosis. 3. Diagnostic Imaging--methods. 4. Joint Diseases--diagnosis. WE 830 B595 2007a]

RC951.B5215 2007

617.5'75075--dc22

2007017382

This book is an authorized and revised translation of the German edition published and copyrighted 2004 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Bildgebende Diagnostik der Hand.

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers' leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata willbe posted at www.thieme.com on the product description page.

Translator: Adele Barbara Herzberger, MD, Munich, Germany

Illustrator: Piotr and Malgorzata Gusta, Paris, France

© 2008 Georg Thieme Verlag, Rüdigerstrasse 14, 70469 Stuttgart, Germanyhttp://www.thieme.de Thieme New York, 333 Seventh Avenue, New York, NY 10001, USAhttp://www.thieme.com

Cover design: Thieme Publishing Group Typesetting by Fotosatz Sauter, Donzdorf, Germany Printed by Druckerei Grammlich, Pliezhausen, Germany ISBN 978-3-13-14058-4 (TPS, Rest of World) ISBN 978-1-58890-453-9 (TPN, The Americas)

1 2 3 4 5 6

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher's consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

Preface

The last decade has witnessed considerable changes in radiological diagnosis of the hand. First, the spectrum of radiological procedures was extended by the introduction of multidetector spiral CT with the acquisition of nearly isotropic voxels, contrast-enhanced MRI with phased-array coils that enable the softtissues of the hand to be imaged in finest anatomical detail, and finally by ultrasound and skeletal scintigraphy. Second, the spectrum of therapeutic options significantly increased at about the same time, especially with the establishment of microsurgical procedures. Third, there was a significant increase in knowledge of the biomechanics and pathophysiology of the carpus.

Meanwhile, this increase in knowledge has led to the need for information among the different specialties that are involved in the diagnosis and treatment of hand diseases. Furthermore, modern radiology does not only provide many possibilities in depicting the small parts of the hand, but also has simultaneously created some uncertainty regarding the correct indication, examining procedures, and image interpretation of the complex hand anatomy and pathology. We authors have found ourselves in the fortunate position of being able to reciprocally measure the findings of our imaging routine with the clinical reality tested directly in the operating room and in the long-term follow-up. On the other hand, many therapeutic decisions were decisively influenced by the results produced with the help of modern imaging techniques.

The goal of our interdisciplinary team was to closely correlate radiological signs of hand diseases with the underlying pathoanatomy, the clinical presentation, and the therapeutic options. This approach seemed the only successful waytoimpart the enormous amount of knowledge concerning the entities of hand diseases in a unified manner. Our book is intended to help the clinicians (hand surgeons, orthopedists, rheumatologists) to understand the many possible interpretations of modern imaging and also to provide radiologists with clinical information for the correct implementation and interpretation of resulting images.

The book is composed of four main sections. The methods section (Chapters 1–9) introduces the different examining methods. The following section (Chapters 10–16) presents the anatomical and functional foundations of hand imaging, the variants and malformations included. In the main section (Chapters 17–48), all important disease entities of the hand are discussed in a nosologic manner. Following definition, pathogenesis, and clinical symptoms, the diagnostic imaging of each disease issystematically explained. The final section with differential diagnostic tables (Chapters 49–62) presents even rare entities according to their symptoms in key words and with cross references to figures of this book. The terminology used in this book corresponds to the standardized nomenclature in Terminology for Hand Surgery published 2001 by the International Federation of Societies for Surgery of the Hand (IFSSH).

The production of this book was only possible with the help of many diligent co-workers. We would like to express our gratitude to the staff at Thieme, first and foremost to Susanne Huiss, Gabriele Kuhn, and Elisabeth Kurz for their continual patience and consideration throughout the project. We would also like to thank Dr. Herzberger and Ms. Garrison for their excellent translation of the German text into English.

We shall have attained our personal goal if this book leads to an improvement in diagnostic imaging in the anatomically special field of the hand, thus the usually young patients suffering from hand diseases would be the “winners.”

Rainer Schmitt and Ulrich Lanz

List of contributors

Wolfgang Buchberger, MD Professor of Radiology Medical Director University Hospital Innsbruck Innsbruck, Austria

Georgios Christopoulos, MD Senior Consultant Department of Radiology Hospital for Cardiovascular Diseases Bad Neustadt an der Saale, Germany

Franz Fellner, MD Associate Professor of Radiology Department of Radiology General Hospital Linz Linz, Austria

Steffen Froehner, MD Senior Consultant Department of Radiology Hospital for Cardiovascular Diseases Bad Neustadt an der Saale, Germany

Peter Hahn, MD Associate Professor of Surgery Department of Hand Surgery Vulpius Clinic Bad Rappenau, Germany

Thomas Helmberger, MD Professor of Radiology Department of Radiology and Nuclear Medicine Municipal Hospital Bogenhausen Munich, Germany

Andreas Heuck, MD Professor of Radiology Radiology Center Munich-Pasing Munich, Germany

Alfred Horwitz, MD Senior Consultant Department of Pediatric Radiology Municipal Hospital Krefeld Krefeld, Germany

Hermann Krimmer, MD Associate Professor of Surgery Department of Hand Surgery Ravensburg Hospital Ravensburg, Germany

Gerwin Lingg, MD Head Department of Radiology Rheuma-Heilbad AG Bad Kreuznach, Germany

Viktor Metz, MD Professor of Radiology Department of Radiology University Hospital Vienna Vienna, Austria

Karl-Josef Prommersberger, MD Associate Professor of Orthopedics Department of Hand Surgery Hospital for Cardiovascular Diseases Bad Neustadt an der Saale, Germany

Nicole Reutter, MD Radiologic Consultant Medical Treatment Center Theresientor Straubing, Germany

Herbert Rosenthal, MD Senior Consultant Department of Radiology Hanover Medical School Hanover, Germany

Gerhard Schindler, MD Professor Emeritus Department of Radiology University Hospital Würzburg Würzburg, Germany

Joerg van Schoonhoven, MD Associate Professor of Orthopedics Department of Hand Surgery Hospital for Cardiovascular Diseases Bad Neustadt an der Saale, Germany

Sieglinde Spindler-Thiele, MD Senior Consultant Department of Radiology and Nuclear Medicine Klinikum Sozialstiftung Bamberg Bamberg, Germany

Joerg Spitz, MD Associate Professor of Nuclear Medicine Society for Medical Information and Prevention Schlangenbad, Germany

Axel Staebler, MD Associate Professor of Radiology Department of Radiology Orthopedic Hospital Harlaching Munich, Germany

Table of Contents

Imaging Techniques of the Hand

1 Projection Radiography: General Information and Positioning TechniquesR. Schmitt

General Techniques for Radiologic Diagnosis of Hand Abnormalities

Special Imaging Techniques

Radiographs of the Entire Hand

Radiographs of the Wrist

The Scaphoid Quartet Series

Radiographs of the Other Carpal Bones

Radiological Stress Views of the Carpus and Thumb

Radiographs of the Metacarpal Region

Radiographs of the Thumb and Finger

2 Special Radiographic ProceduresR. Schmitt, S. Froehner

Digital Radiographic Procedures

Digital Luminescence Radiography (DLR)

Direct Radiography with Flat Detectors

Image-intensifying Radiography

Radiography with Mammography Films

Techniques in Magnification Radiography

Magnification Radiography with Mammography Equipment

Magnification Radiography with the DIMA Technique

Low-kilovoltage Technique

Conventional Tomography

Cineradiography

3 ArthrographyV. Metz, R. Schmitt, G. Christopoulos

Anatomical Considerations

Arthrography of the Large Joint Spaces

Arthrography of the Small Joint Spaces

Arthrography of the Pisotriquetral Joint

Arthrography of the Saddle Joint of the Thumb

Arthrography of the Finger Joints

Indications and Assessment

4 ArthroscopyH. Krimmer, P. Hahn

Necessary Equipment

Arthroscopic Access

Normal Arthroscopic Findings

The Radiocarpal Joint

The Midcarpal Joint

The Distal Radioulnar Joint

Indications for Diagnostic Arthroscopy

Indications for Therapeutic Arthroscopy

Contraindications and Complications

5 ArteriographyT. Helmberger, R. Schmitt

Anatomy and Variants of Hand Arteries

Forearm Arteries

Arteries in the Palm

Arteries of the Finger

Arteries of the Dorsum of the Hand

Diagnostic Imaging

Catheter Angiography

MR Angiography

Specific Differential Indications

6 Skeletal ScintigraphyJ. Spitz

Physical-Technical Foundations

Biological Foundations

Factors Influencing Scintigraphic Images

Indications for Skeletal Scintigraphy

Scintigraphic Peculiarities among Children

7 UltrasonographyW. Buchberger, R. Schmitt, G. Christopoulos

Physical Principle

B-scan Ultrasonography

Doppler Ultrasonography and Color-coded Doppler Ultrasonography

Special Prerequisites for Ultrasonographic Examination of the Small Parts of the Hand

Normal Ultrasonographic Findings

Examination Procedure

Indications

8 Computed TomographyR. Schmitt, S. Froehner

General Principle of CT

Spiral CT Technique

Imaging Parameters

Artifacts in CT Imaging

Examination Techniques for CT of the Hand

Image Postprocessing from CT Volume Datasets

Normal Anatomy with Evaluation of the Slice Planes

CT Arthrography

Osteoabsorptiometry

Indications

9 Magnetic Resonance ImagingF. Fellner, R. Schmitt

MR Imaging Basics

Pulse Sequences

Spin-Echo Technique

Fast Spin-Echo Technique

Inversion Recovery Technique

Gradient-Echo Technique

GRE Sequences with Dephasing of the Transverse Magnetization

GRE Sequences with Rephasing of the Transverse Magnetization

GRE Sequences of Special Design

Three-dimensional Technique (3D Technique)

Fat-Saturation Techniques

Parallel Imaging

Contrast Medium

Contrast Medium Effects

Contrast Medium Administration for Standard Investigations

Contrast-Enhanced MR Angiography

MR Arthrography

Nephrogenic Systemic Fibrosis (NSF)

Dynamic MR Imaging of the Carpus

Planning of the Examination Volume

Recommendations for MR Imaging Sequences for Examining the Hand

Sequence Protocols

Basic MR Imaging Protocol

MR Imaging Protocol in Carpal Trauma

MR Imaging Protocol in Scaphoid Trauma

MR Imaging Protocol in Nonunion of the Scaphoid

MR Imaging Protocol in Lesions of the Ligaments and the Tri-angular Fibrocartilage Complex

MR Imaging Protocol in Carpal Osteonecrosis (Lunate Osteonecrosis)

MR Imaging Protocol in Arthritic Joint Diseases

MR Imaging Protocol for Identification of Ganglia

MR Imaging Protocol for Diagnosis of Soft-tissue Tumors and Bone Tumors

Normal MR Anatomy of the Hand

Anatomic and Functional Prerequisites for Diagnostic Imaging of the Hand

10 Carpal LigamentsR. Schmitt

Fundamental Anatomy

Interosseous Ligaments

Palmar V-shaped Ligaments

Ligaments of the “Proximal V”

Ligaments of the “Distal V”

Ligaments of the “Dorsal V”

Carpal Collateral Ligaments

Pathoanatomical Principles

Diagnostic Imaging

Magnetic Resonance Imaging

Arthrography

Arthroscopy

11 Triangular Fibrocartilage ComplexR. Schmitt

Fundamental Anatomy

Pathoanatomic Principles

Diagnostic Imaging

Magnetic Resonance Imaging

Arthroscopy

Arthrography

Radiographic Diagnosis

Computed Tomography

12 Carpal Morphometry and FunctionR. Schmitt, K. J. Prommersberger

Morphometry and Function of the Distal Forearm

Joint Angle of the Distal Radius Segment

Relative Lengths of the Radius and the Ulna

Radioulnar Translation

Rotation of the Forearm (Pronosupination)

Morphometry and Function of the Carpus

Radiographic Carpal Arches

Carpal Angles

Carpal Height

Ulnar Deviation of the Carpus

Carpal Movement Planes and Axes

Flexion and Extension

Radial and Ulnar Inclination

Concepts of Carpal Stability and Instability

13 Postsurgical RadiographyH. Krimmer, P. Hahn, R. Schmitt

Partial Arthrodesis of the Wrist

Surgery of the Distal Ulna

Shortening of the Radius and Ulna

Surgery for Fractures and Nonunion of the Scaphoid

Surgery for Radius Fractures and Corrective Osteotomy of the Radius

Surgery for Carpal Instability, Dislocations, and Dislocation Fractures

Surgical Salvage Procedures on the Phalangeal Joints

Surgery of Phalangeal Fractures

Arthrodesis

Soft-Tissue and Callus Distractions

Surgery of Traumatic Amputations

Growth, Normal Variants, and Malformations of the Hand

14 The Growing Skeleton of the HandA. Horwitz, G. Schindler

Normal Development of the Skeleton of the Hand

Disturbances in Skeletal Maturation

Legal and Forensic Considerations

Evaluation Methods in Diagnostic Imaging

Age-dependent Factors

Determination of Skeletal Age

Determination of the Prospective Mature Body Height

15 Normal Variants of the Skeleton and the Soft Tissues of the HandR. Schmitt, G. Schindler

Normal Variants of the Skeleton of the Hand

Sesamoid Bones

Coalescence of the Carpals

Divided Carpals

Accessory Carpal Bones

Notches and Depressions in Carpal Bones

Variants in the Shape of the Lunate

Normal Variants of the Soft Tissues of the Hand

Variants of the Extrinsic and Intrinsic Muscles

Duplication of Tendons and Manifold Tendons

High Division of the Median Nerve

Persisting Median Artery

16 Malformations and DeformitiesJ. van Schoonhoven, R. Schmitt, A. Horwitz, H. Rosenthal, U. Lanz

Failure of Formation

Transverse Arrest

Longitudinal Arrest

Failure of Differentiation (Separation) of Parts

Symphalangy

Camptodactyly

Clinodactyly

Pollex Flexus

Arthrogryposis Multiplex Congenita

Syndactyly

Duplication

Radial (Preaxial) Polydactyly

Ulnar (Postaxial) Polydactyly

Central Polydactyly

Mirror Hand

Overgrowth

Undergrowth

Hypoplasia and Aplasia of the Thumb

Brachydactyly

Constriction-Ring Syndrome

Malformation Syndromes (Generalized Abnormalities)

Skeletal Deformities

Skeletal Dysostosis

Skeletal Dysplasia (Osteochondrodysplasia)

Congenital Sclerosing and Hyperostotic Skeletal Changes

Primary Metabolic Disorders of the Skeleton (Dysostosis Multiplex)

Injuries of the Hand and Traumatic Sequelae

17 Trauma of the Distal ForearmK. J. Prommersberger, S. Froehner, J. van Schoonhoven, R. Schmitt

Acute Fractures and Dislocation Fractures of the Distal Forearm

Malunion of Distal Radius Fractures

Nonunion after Distal Radius Fractures

Dislocations in the Distal Radioulnar Joint

Differential Diagnosis

18 Lesions in the Ulnocarpal CompartmentR. Schmitt, G. Christopoulos, H. Krimmer

Lesions of the Triangular Fibrocartilage Complex

Ulnocarpal Impaction Syndrome (Ulnolunate, Ulnolunotriquetral)

Differential Diagnosis

Therapeutic Options

19 Fractures of the ScaphoidR. Schmitt, H. Krimmer, J. Spitz

Pathophysiology and Clinical Symptoms

Special Considerations in Childhood

Diagnostic Imaging

Differential Diagnosis

Therapeutic Options

20 Scaphoid NonunionR. Schmitt, H. Krimmer

Pathogenesis and Clinical Symptoms

Diagnostic Imaging

Differential Diagnosis

Therapeutic Options and Posttherapeutic Diagnosis

Diagnostic Strategy

21 Fractures of the Carpus Excluding the ScaphoidG. Christopoulos, R. Schmitt, J. Spitz

Fractures of the Triquetrum

Fractures of the Pisiform

Fractures of the Lunate

Fractures of the Capitate

Fractures of the Hamate

Fractures of the Trapezium

Fractures of the Trapezoid

Combined Carpal Fractures

Special Features of Carpal Fractures in Children

Differential Diagnosis

Therapeutic Options

22 Carpal Dislocations and Fracture-DislocationsA. Staebler, R. Schmitt, H. Krimmer

Perilunate and Lunate Dislocations

Perilunate Fracture-Dislocations

Transscaphoid Perilunate Fracture-Dislocation (de Quervain)

Perilunate Dislocations with Other Accompanying Fractures

Scaphoid-Capitate Fracture Syndrome (Fenton)

Axial Dislocations and Fracture-Dislocations

Differential Diagnosis

Therapeutic Options

23 Carpal InstabilityR. Schmitt, A. Staebler, H. Krimmer

Dissociative Carpal Instability (CID)

Scapholunate Dissociation (SLD)

Lunotriquetral Dissociation (LTD)

Nondissociative Carpal Instability (CIND)

Radiocarpal Instability

Midcarpal Instability

Capitolunate Instability

Ulnar Translocation of the Carpus

Carpal Translocations to the Radial, Palmar, or Dorsal Aspect

Differential Diagnoses

24 Carpometacarpal Dislocations and Fracture-DislocationsR. Schmitt, P. Hahn

Dorsal Carpometacarpal Dislocations

Palmar Carpometacarpal Dislocations

Dorsal Carpometacarpal Fracture-Dislocations

Palmar Carpometacarpal Fracture-Dislocations

Differential Diagnoses

Therapeutic Options

25 Metacarpal FracturesH. Krimmer, G. Schindler

Fractures Close to the Base of Metacarpal I

Fractures of the Bases of the Metacarpals II-V

Fractures of the Metacarpal Shafts

Subcapital Metacarpal Fractures

Fractures of the Metacarpal Heads

Differential Diagnoses

Therapeutic Options

26 Fractures and Dislocations of the FingersP. Hahn, R. Schmitt, N. Reutter

Extra-articular Fractures

Fractures of the Tuberosity of the Distal Phalanx

Fractures of the Finger Shafts

Intra-articular Finger Fractures

Avulsion Fractures

Dorsal Fracture of the Base of the Distal Phalanx (Avulsion Lesion of the Extensor Tendon)

Palmar Fracture of the Base of the Distal Phalanx (Avulsion Lesion of the Deep Flexor Tendon)

Dorsal Fracture of the Base of the Middle Phalanx

Palmar Fractures of the Bases of the Middle and Distal Phalanges

Pediatric Fractures of the Fingers

Finger Dislocations

Fracture-Dislocations of the Fingers

Differential Diagnosis

Therapeutic Options

Diseases of the Hand Caused by Local or Systemic Degeneration

27 OsteoarthritisA. Staebler, R. Schmitt, H. Krimmer

Osteoarthritis of the Finger Joints

Osteoarthritis of the Carpal Joints

Osteoarthritis of the Carpometacarpal Joint I (“Rhizarthrosis”)

Osteoarthritis of the Scaphotrapeziotrapezoid Joints (STT Osteoarthritis)

Osteoarthritis of the Pisotriquetral Joint

Osteoarthritis Associated with Carpal Collapse (SLAC Wrist and SNAC Wrist)

Osteoarthritis of the Distal Radioulnar Joint

Special Forms of Osteoarthritis of the Hand

Inflammatory (Erosive) Osteoarthritis

Combined Degenerative-Rheumatoid Osteoarthritis

Chondrocalcinosis (Pseudogout, CPPD Deposition Disease)

Hemochromatosis

Acromegaly

Therapeutic Options

28 EnthesopathyN. Reutter, S. Spindler-Thiele

Predominantly Fibro-ostotic Changes

Degenerative Diseases

Osteoarthritis

Carpal Humps

Endocrine Diseases

Diabetes Mellitus

Acromegaly

Hypoparathyroidism

Hyperparathyroidism

Metabolic Diseases

Chondrocalcinosis, Peritendinitis Calcarea, Alcaptonuria

Fluorosis

Predominantly Fibro-ostitic Changes

Inflammatory Diseases

Resorptive Fibro-ostitis

Productive Fibro-ostitis

Combined Forms of Fibro-ostitic Lesions

Rheumatoid and Seronegative Arthritides

Bacterial Arthritis

Rare Affections of the Fibro-osseous Junction

Differential Diagnoses

Therapeutic Options

29 Soft-Tissue Lesions Caused by Overuse and SportsA. Heuck, R. Schmitt, P. Hahn

Tendinosis and Tenosynovitis

Tendinosis and Tenosynovitis of the Extensor Tendons

Tendinosis and Tenosynovitis of the Flexor Tendons

Tendon Rupture

Injuries of the Anular Pulleys

Gamekeeper's Thumb

Lesions of the Second to Fifth Metacarpophalangeal Joints

Bursitis of the Ulnar (Prestyloid) Recess

Muscular Lesions

Differential Diagnosis

30 Osteonecrosis of the Hand SkeletonR. Schmitt, H. Krimmer

Lunate Osteonecrosis (Kienböck Disease)

Scaphoid Osteonecrosis (Preiser Disease)

Osteonecrosis of the Capitate Head

Osteonecrosis of the Hook of the Hamate

Osteonecrosis of All Metacarpals (Caffey Disease)

Osteonecrosis of the Metacarpal Heads (Mauclaire Disease)

Osteonecroses of the Phalangeal Bases (Thiemann Disease)

31 Osteopenic Diseases in the HandsN. Reutter, A. Heuck, V. Metz

Osteoporosis

Rickets/Osteomalacia

Hyperparathyroidism

Renal Osteopathy

Differential Diagnosis

32 Algodystrophy (Reflex Dystrophy, Complex Regional Pain Syndrome Type I)N. Reutter, J. Spitz

Pathogenesis and Clinical Symptoms

Diagnostic Imaging

Differential Diagnosis

Therapeutic Options

Diseases of the Hand Related to Systemic Metabolic Diseases

33 Osteopathies Caused by Hormones, Vitamins, Medications, or ToxinsA. Heuck, H. Rosenthal

Endocrine Osteopathies

Acromegaly

Hypopituitarism

Adrenogenital syndrome (AGS)

Hyperparathyroidism

Hypoparathyroidism

Pseudohypoparathyroidism and Pseudopseudohypoparathyroidism

Hypothyroidism

Hyperthyroidism

Osteopathies Caused by Hypovitaminosis or Hypervitaminosis

Vitamin D-deficiency Rickets

Vitamin D-resistant Rickets

Hypervitaminosis D

Vitamin C Deficiency (Scurvy, Möller-Barlow Disease)

Drug-induced and Toxic Osteopathies

Corticoid Osteopathy

Prostaglandin Osteopathy

Fluorosis

Aluminum Osteopathy

Lead Osteopathy

Therapeutic Options

34 Crystal-induced Osteoarthropathies and Related DiseasesT. Helmberger, A. Staebler, R. Schmitt

Gouty Arthritis/Hyperuricemia

Calcium Pyrophosphate Dihydrate (CPPD) Deposition Disease (Pyrophosphate Arthropathy)

Chondrocalcinosis of the Ligaments and the Triangular Fibrocartilage Complex (TFCC)

Destructive Osteoarthropathy of the Wrist

Tumorous Chondrocalcinosis

Further Manifestations of CPPD Deposition Disease

Hydroxyapatite (HA) Deposition Disease (“Acute Calcium Deposition“)

Hemochromatosis

Wilson Disease

Alkaptonuria (Ochronosis)

Oxalosis (Hyperoxaluria)

35 Miscellaneous OsteoarthropathiesS. Spindler-Thiele, R. Schmitt, A. Staebler

Sarcoidosis (Boeck Disease)

Neurogenic Osteoarthropathy and Charcot Osteoarthropathy

Hemophilic Osteoarthropathy (“Bleeders' Joints”)

Amyloid Osteoarthropathy

Hereditary Hemoglobinopathies

Multicentric Reticulohistiocytosis (Lipoid Arthrodermatitis)

Hypertrophic Osteoarthropathy

Radiation-induced Osteoarthropathy

Foreign-body Synovitis and Arthritis

Synovial Chondromatosis

Inflammatory Diseases of the Hand

36 Rheumatoid ArthritisG. Lingg, R. Schmitt

Special Forms of Rheumatoid Arthritis

Adult Still Syndrome

Felty Syndrome

Sjögren Syndrome

Caplan Syndrome

Juvenile or Special Forms of Rheumatic Arthritis

Radiographic Classification of Stages of Rheumatoid Arthritis

Differential Diagnosis

Therapeutic Options

37 Seronegative SpondylarthropathiesS. Spindler-Thiele, A. Staebler, G. Lingg

Psoriatic Arthritis (Psoriatic Osteoarthropathy)

Reiter Syndrome (Reiter disease)

Reactive Arthritis

Arthritis with Ankylosing Spondylitis (Marie-Strümpell Disease, Bechterew Syndrome)

Enteropathic Arthritis

Osteoarthropathies Associated with Dermatoses

Rare Seronegative Arthritides

Antibody-deficiency Syndrome

Hashimoto Autoimmune Thyroiditis

Behçet Disease

Familial Mediterranean Fever

Stevens-Johnson Syndrome

38 Rheumatic Fever (Poststreptococcal Reactive Arthritis)S. Spindler-Thiele, G. Lingg

Pathoanatomy and Clinical Symptoms

Radiography

Differential Diagnosis

Therapeutic Options

39 CollagenosesS. Spindler-Thiele, R. Schmitt

Systemic Lupus Erythematosus (SLE)

Scleroderma, Progressive Systemic Sclerosis (PSS)

Polymyositis and Dermatomyositis

Panarteritis Nodosa

Wegener Granulomatosis

Sjögren Syndrome

40 Infectious ArthritisS. Spindler-Thiele, R. Schmitt

Acute Bacterial Arthritis

Tuberculosis of the Hand

Syphilis

Gonococcal Arthritis

Leprosy

Lyme Arthritis

Bilharziosis Arthropathy

Viral Arthritides (Hepatitis B, Rubella, Mumps, Variola, Parvo-B19, Vaccinia)

Fungal Arthritis

Inflammatory Diseases of the Bones and Soft Tissues

41 OsteomyelitisH. Rosenthal, R. Schmitt, J. Spitz

Hematogenous Osteomyelitis

Tuberculous Osteomyelitis

Secondary Osteomyelitides

Phalangeal Osteomyelitis

Posttraumatic Osteomyelitis

Bites

Special Forms of Osteomyelitis

Plasma-cell Osteomyelitis, Brodie Abscess, Garré Chronic Sclerosing Osteomyelitis

Osteomyelitides Caused by Rare Organisms

Chronic Recurrent Multifocal Osteomyelitis

Differential Diagnosis

Therapeutic Options

42 Infections of the Soft TissuesP. Hahn, R. Schmitt

Infections of the Fingertips and Paronychia

Pyogenic Flexor Tenosynovitis

Deep Space Infections in the Palm

Tuberculosis of the Tendon Sheath

Acute Calcium Deposition

Gangrenous Infection

Differential Diagnosis

Therapeutic Options

Tumorous and Tumorlike Diseases of the Hand

43 Cystic Bone LesionsN. Reutter, F. Fellner

Bone Cysts with No Pathological Relevance

Vasa Nutricia

Posttraumatic Hemorrhagic Cysts

Necrobiotic Pseudocysts, Idiopathic Carpal Cysts

Avascular Osteonecroses of the Carpus

Enthesopathic and Arthritic Diseases

Signal Cysts and Arthritic Erosions

Bone Cysts Induced by Infection

Bone Cysts in Systemic Diseases

Metabolic Diseases That are Associated with Deposits

Gout

Chondrocalcinosis (CPPD Deposition)

Amyloidosis

Hemochromatosis

Xanthomatosis

Bone Cysts in Other Systemic Diseases

“Brown Tumors”

Sarcoidosis (Osteitis Multiplex Cystices Jüngling)

Gaucher Disease

Fibrous Dysplasia (Jaffé-Lichtenstein Disease)

Neurofibromatosis type I (Recklinghausen Disease)

Tuberous Sclerosis (Pringle-Bourneville Disease)

Cystic Bone Tumors

Differential Diagnosis

Therapeutic Options

44 Bone TumorsH. Rosenthal, R. Schmitt, A. Staebler

Bone Tumors of Chondrogenous Origin

Enchondroma (Chondroma)

Osteochondroma (Cartilaginous Exostosis)

Chondroblastoma, Chondromyxoid Fibroma

Chondrosarcoma

Bone Tumors Originating from Osseous Tissue

Osteoid Osteoma

Osteoblastoma

Osteosarcoma

Bone Tumors Originating from Connective Tissue

Nonossifying Fibroma, Desmoplastic Fibroma

Giant-cell Tumor (Osteoclastoma)

Malignant Fibrous Histiocytoma (MFH), Fibrosarcoma

Bone Tumors Originating from the Endothelium

Hemangioma

Hemangioendothelioma, Angiosarcoma

Bone Tumors Originating from the Bone Marrow

Ewing Sarcoma

Multiple Myeloma (Plasmacytoma), Malignant Lymphoma, Hodgkin Disease, and Leukemia

Tumorlike Bone Lesions of the Hand

Enostoma, Bone Island

Aneurysmal Bone Cyst

Solitary Bone Cyst (Juvenile Bone Cyst)

Reparative Giant-cell Granuloma

Miscellaneous Joint Diseases and Intraosseous Ganglion Cyst

Intraosseous Epidermal Cyst

“Brown Tumor” in Hyperparathyroidism

Other Bone Tumors

Bone Metastases

Soft-tissue Tumors with Osseous Infiltration

Therapeutic Options

45 Soft-tissue TumorsR. Schmitt

Tumors of Cutaneous Origin

Epidermal Inclusion Cyst

Cutaneous Carcinomas

Tumors Originating from Connective Tissue

Ganglion Cyst

Lipoma

Fibroma

Leiomyoma

Giant-cell Tumor of the Tendon Sheath (“Xanthoma”)

Aggressive Fibromatosis (Desmoid Tumor)

Soft-tissue Sarcomas

Tumors Originating from Blood Vessels and Lymphatic Vessels

Hemangiomas

Malignant Vascular Tumors

Glomus Tumor

Lymphangiomas

Tumors Originating from Neural Tissue

Neurinoma (Schwannoma) and Neurofibroma

Intraneural Fibrolipoma

Malignant Neurinoma (Neurofibrosarcoma)

Posttraumatic Neuroma

Differential Diagnosis

Therapeutic Options

Neuropathies and Vasculopathies of the Hand

46 Carpal Tunnel SyndromeW. Buchberger, R. Schmitt

Preliminary Remarks on Anatomy

Pathophysiology and Clinical Symptoms

Diagnostic Imaging

Postsurgical Findings

Therapeutic Options

47 Ulnar Tunnel Syndrome (Guyon's Canal Syndrome)R. Schmitt, P. Hahn

Preliminary Remarks on Anatomy

Pathoanatomy and Clinical Symptoms

Diagnostic Imaging

Therapeutic Options

48 Vascular Diseases of the Hand and FingersH. Rosenthal, R. Schmitt

Peripheral Vascular Disease (Atherosclerosis)

Peripheral Embolism

Endangiitis Obliterans (Winiwarter-Buerger Disease)

Raynaud Disease

Collagenoses and Rheumatoid Arthritis

Scleroderma (Progressive Systemic Sclerosis)

Lupus Erythematosus

Panarteritis Nodosa

Rare Vascular Diseases

Rheumatoid Arthritis

Vascular Injuries and Postsurgical Angiographic Findings

Chronic Vibration Injury

Hypothenar (Ulnar) Hammer and Thenar Hammer Syndrome

Radiation-induced Arteriopathies

Vascular Injuries and False Aneurysms

Postsurgical Follow-up

Tumors of the Bones and Soft Tissues

Congenital Malformations

Arteriovenous Malformations

Genuine Diffuse Phlebectasia

Klippel-Trénaunay Syndrome

Weber Arteriovenous Malformation

Servelle–Martorell Arteriovenous Malformation

Maffucci Syndrome

Therapeutic Options

Differential Diagnostic Tables: Diseases of the Hand

49 Congenital and Acquired Alterations in Form and Structure of the EpiphysesA. Horwitz

50 Congenital and Acquired Alterations in Form and Structure of the MetaphysesA. Horwitz

51 Malformation SyndromesG. Schindler, R. Schmitt

52 Dysplasias (Osteochondrodysplasias)G. Schindler, A. Horwitz

53 Primary Metabolic Disorders of the SkeletonG. Schindler, A. Horwitz

54 ArthritisS. Spindler-Thiele

55 Acro-osteolysesR. Schmitt, S. Spindler-Thiele

56 Cystic Bone InclusionsN. Reutter

57 Polyostotic Bone LesionsH. Rosenthal, R. Schmitt

58 Lesions of the Periosteum and Cortical BoneN. Reutter

59 HyperostosesN. Reutter

60 OsteopeniaN. Reutter

61 Soft-tissue CalcificationsR. Schmitt, G. Christopoulos

62 Secondary Raynaud PhenomenaH. Rosenthal

Index

Imaging Techniques of the Hand

1 Projection Radiography: General Information and Positioning Techniques

2 Special Radiographic Procedures

3 Arthrography

4 Arthroscopy

5 Arteriography

6 Skeletal Scintigraphy

7 Ultrasonography

8 Computed Tomography

9 Magnetic Resonance Imaging

1 Projection Radiography: General Information and Positioning Techniques

R. Schmitt

Radiographs of the hand are acquired according to standardized techniques in which positioning and centering must be carried out with great precision to avoid malalignment in the three spatial planes. To prevent pronosupination, the dorsopalmar and lateral views must be exposed in their respective neutral positions. With the elbow flexed, the forearm should be adducted for a lateral view, whereas for the dorsopalmar view the upper arm is placed in abduction at the shoulder level. Because of to the superpositioning of skeletal parts in projection radiography, several special positions and projections are used for the carpus. Injuries to the ligaments of the carpus and the thumb can be demonstrated indirectly in stress views.

General Techniques for Radiologic Diagnosis of Hand Abnormalities

Examining Instruments

Radiographs of the hand are acquired either on the universally usable Bucky table or on a special work surface for imaging of the hand (the Lysholm table). In the overtable technique, the x-ray cassette is placed on the surface of the table, and the patient's hand is positioned on top of the cassette. The film—focus distance (FFD) is 105cm; the fine focus is individually set (focus size 0.6mm or less). A scattered radiation grid is not used.

Auxiliary Materials

For radiation protection, a lead coat and apron, as well as lead gloves for stress views.A positioning block made of light wood or plastic with the dimensions 25×35×50cm. For dorsopalmar projections, the patient's hand and forearm are placed on this positioning block at shoulder level (Fig. 1.2a) A positioning splint with vertical sides for strictly lateral views.Wedged pads made of foam rubber (Bocollo) in various sizes and angles (30°, 45°, and 60°).Small sacks filled with rice meal, Velcro bands, and adhesive tape for stable positioning and fixation of the patient's hand.Markers to indicate “R” and “L” on the x-ray film.Lead strips to cover the nonexposed segments of the cassette.

Radiation Protection Measures

The patient wears a lead apron or a lead coat for radiation protection and sits beside the examining table; the patient's legs are not under the table.

Recording Systems and Exposure Parameters

For projection radiography, cassettes sized 18×24cm and 24×30cm are used. Three different recording systems are available:

In film—screen radiography for diagnosis in adults, the cassettes have intensifying screens with a sensitivity value of 400 (dose required: 5 μGy). Depending on the size of the hand, a tube voltage between 45 and 55 kV and a current—time product between 3 and 6 mAs are selected for any exposure (without automatic exposure timer). According to the guidelines of the German Federal Medical Chamber, high-resolution film—screen systems can also be used for special clinical indications.In digital luminescence radiography, storage screens based on phosphorus compounds serve as detectors. The exposure parameters are about the same as for film–screen radiography. A characteristic of the digital luminescence technique is the higher range on a linear gradiation curve, permitting corrections of the image brightness and contrast during postprocessing. For diagnostic imaging of the hand, so-called K2 systems with 2048×2048 pixels are recommended.With flat-panel detectors, the x-ray pattern is recorded directly onto silicate- or selenium-based detectors so that an intermediate read-out procedure is no longer necessary (direct radiography). This procedure offers improved quantum efficiency with increased signal-to-noise ratio (SNR) at the same radiation dose: in practice this means that the same image quality can be achieved with a lower radiation dose. Direct radiography systems are now used with increasing frequency.

Peculiarities in Childhood

Aside from the use of high-gain intensifying screens with a sensitivity value of 400, the guidelines of the German Federal Medical Chamber require additional filtering with 1 mm aluminum and 0.1 mm copper for pediatric radiographic imaging.According to radiation protection regulations in Germany, storage screens can be exposed at a lower radiation dose in children, although the result is poorer (decreased) SNR.

Special Examination Techniques

The following situations and techniques require modifications to the standard diagnostic procedure.

If the patient is immobile as a result of polytrauma or when postsurgical follow-up radiographs are being taken, auxiliary equipment is necessary for correct positioning and setup, such as placing the cassette laterally on the patient's hand.For imaging with mammography films, film–screen combinations with a sensitivity value of 25 are used (dose requirement: 40 μGy). The same film–focus distance of 105cm requires an 8-fold higher radiation dose than with standard diagnostic techniques. This technique therefore cannot be applied routinely but only when specially indicated, as in the diagnosis of the initial stages of arthritis.In magnification and low-kilovoltage techniques, the film–focus distance is generally 65 cm. When conducted with a mammography unit using film–screen combinations, the exposures range from 35 to 41 kV, or 10 to 20 mAs (magnification technique) and between 28 and 35 kV or 25–40 mAs (low-kilovoltage). The digital alternative of magnification radiography using fine-focus tubes (direct radiographic magnification [DIMA] technique) is discussed in Chapter 2.

Diagnosis of congenital abnormalities of the hand and determination of the skeletal age are performed with the dorsopalmar projection only.

Special Imaging Techniques

  Radiographs of the Entire Hand

As survey views, these include the distal section of the forearm, the carpus, the metacarpus, and all fingers. In addition to the dorsopalmar view (Fig. 1.1a), an oblique view is exposed as a second plane, namely the 45° semipronated oblique view (zither-player projection, (Fig. 1.1b) and the 45° semisupinated oblique view (Nørgaard projection, (Fig. 1.1c). Indications for a survey view of the hand are acute injury distal of the carpus, diagnosis of inflammatory joint diseases (often with the Nørgaard projection as the second plane), and diagnosis of systemic bone diseases, using the hand as an indicator.

  Radiographs of the Wrist

Indications for radiographic imaging of the wrist in two planes are pathologies of the distal forearm, the wrist, and the carpus. These include acute traumas, carpal instability, chronic degenerative and inflammatory diseases of the joints, and equivocal complaints at the wrist.

Fig. 1.1a–cPositioning methods for radiographs of the entire hand.

Table 1.1 Positioning methods for radiographs of the entire handViewPositionAlignmentQuality CriterionDorsopalmarPlace the palm on the cassette with fingers slightly splayedMiddle finger points along the longitudinal axis of the forearmPerpendicular to the cassetteAlign to the metacarpophalangeal joint IIIEntire hand and distal part of forearm includedSemipronatedoblique (zither-player position)Place the palm on a 45° wedgeshaped cushionFingers spread like a fanFingertips touch the cassettePerpendicular to the cassetteAlign between metacarpophalangeal joints II and IIIMetacarpals are seen largely free of superimpositionPhalanges are seen completely free of superimpositionSemisupinated oblique (Nørgaard)Place the back of the hand on a 45° wedged cushionSpread the fingers like a fanPerpendicular to the cassetteAlign between metacarpophalangeal joints II and IIIMetacarpals are seen largely free of superimpositionPhalanges are seen completely free of superimposition

For radiologic diagnosis, an exact analysis of the radiograph of the distal section of the forearm and the carpus is only possible when the anatomical position is identical in both projection planes, i.e., without pronosupination between the two exposures. The so-called neutral position, which is the middle rotation of the forearm between the extreme positions of pronation and supination Fig. 1.2c–e, is best suited to this purpose. Standardized radiographs of the wrist in neutral position have the following prerequisites:

For the dorsopalmar view, the upper arm is abducted 90° in the shoulder and placed on a positioning block so that the forearm and the hand are at shoulder level with the elbow flexed Fig. 1.2a.For the lateral view, the upper arm is adducted in the shoulder and the elbow is flexed 90° so that the forearm and the ulnar edge of the hand lie on the Bucky table Fig. 1.2b

A rotational movement of 90° must be avoided when acquiring the views in two planes.

The particular height between the abducted arm and the Bucky table is achieved for each patient individually by the use of a positioning block of appropriate height.

Whether the radiographs have been taken in neutral position without rotational movements in the proximal and distal radioulnar joints can be ascertained by the following radiological signs:

The ulnar styloid only appears in profile on the outer edge of the head of the ulna if the hand is in the neutral position (Fig. 1.2f). In all other positions, the styloid process appears in an “en-face” projection, namely in pronation at the level of the ulnar section and in supination in the middle of the head of the ulna.Pronosupination changes the apparent length of the radius and ulna (translatory shift). In pronation, the ulna is in a more distal position in relation to the radius, whereas it is located more proximally in supination.Table 1.2 Positioning methods for radiographs of the wrist and the radiocarpal jointViewPositionAlignmentQuality CriterionDorsopalmarArm abductedPalm at shoulder level on the positioning blockMiddle finger lengthens axis of forearmPerpendicular to the cassetteAlign to the middle of the radiocarpal jointUlnar styloid in profile on the outer edge of the head of the ulnaLateralArm adductedUlnar edge of the hand positioned vertically on the Bucky tablePlace back of hand on perpendicular positioning aidPerpendicular to cassetteAlign to the middle of the radiocarpal jointPisiform projects halfway between distal pole of the scaphoid and the capitateRadius and ulna overlapMetacarpals II–V overlap

Fig. 1.2a–gPositioning methods and schematic diagrams for radiographic views of the radiocarpal joint and the wrist.

a Dorsopalmar view with the hand positioned at shoulder height.b Position for the lateral view of the wrist. Adduction of the upper arm and placement of the back of the hand against a vertical positioning aidc Articulation of the distal radioulnar joint during a dorsopalmar view in neutral position. Notice the congruence of the joint surfaces. The arrow symbolizes the central ray.d Articulation of the distal radioulnar joint during lateral view with the wrist in neutral position. The joint surfaces remain congruent. The arrow symbolizes the central ray.e Articulation of the distal radioulnar joint during dorsopalmar view with the hand pronated. The joint surfaces are no longer congruent. The arrow symbolizes the central ray.f Dorsopalmar view of the wrist in neutral position. Note the ulnar styloid process in lateral profile.g Lateral view of the wrist in neutral position. The palmar aspect of the pisiform projects halfway between the front of the capitate and the distal pole of the scaphoid.

  The Scaphoid Quartet Series

The scaphoid appears shortened in standard projections because of its oblique alignment. When a fracture or nonunion of the scaphoid bone is suspected, and for follow-up, scaphoid quartet views can be acquired to complement the standard films of the carpus. The aim of the scaphoid series is to align the scaphoid parallel to the film plane insofar as possible. Radiographs of the scaphoid series are taken in four different exposures with dedicated positioning of the wrist, as well as alignment of the central ray (Fig. 1.3a–d). The focus is on the radial side of the carpus.

Together with the standard views, complete projection radiography of the scaphoid comprises six radiological settings. Stecher's view is the most reliable of the quartet series for diagnosis of a scaphoid fracture.

It has proved efficient in diagnosing fractures or nonunions to complement standard films only with a Stecher's projection. Afterwards, the indications for additional diagnostic imaging with computed tomography (CT), magnetic resonance (MR) imaging, or both, should be considered. For further procedures, see Chapters 18 and 19.

Fig. 1.3a–dPositioning methods for the scaphoid quartet series.

a Position for Stecher's projection: closed fist and ulnar inclination.b Position for Schreck's projection: quill-holding position on a 45° wedge.c Position for Bridgeman's projection: extension with the palm lying on a 30° wedged pad.d Position for the hyperpronation projection: closed fist and ulnar side elevated on a 30°wedged pad.

Table 1.3 Positioning method for radiographs of the scaphoid (quartet series)ViewPositionAlignmentQuality CriterionStecher's projectionFist closed, thumb outsideMaximal ulnar inclinationPlace the palmar side of the fist on the cassettePerpendicular to cassetteAlign to the radial third of the carpusScaphoid shown in its entire lengthSchreck's projectionOblique position (quill-holding position) with hand placed on 45° wedged padPerpendicular to cassetteAlign to the radial third of the carpusScaphoid tuberosity visualizedBridgeman's projectionPlace palm in extension on 30° wedged padPerpendicular to table surfaceAlign on the radial third of the carpusProximal scaphoid pole shownScaphocapitate joint seen free of superimpositionHyperpronationClosed fist and ulnar inclinationPalm placed on 30° wedged padPerpendicular to cassetteAlign to the radial third of the carpusScaphoid is straight along the longitudinal axis of the forearm

  Radiographs of the Other Carpal Bones

The five most important of the many projections described in the literature are discussed below. It is recommended to limit special projections of the wrist to two or three and then, if necessary, to proceed to CT or MRI. Special radiographs of the carpus are indicated for the following reasons:

To determine the effective width of the scapholunate joint space by taking Moneim's swear-hand view (Fig. 1.4a).To confirm suspicion of a fracture of the triquetrum with the semipronated oblique view (“triquetrum special”) (Fig. 1.4b).For diagnosis of a fracture of the pisiform and, especially, osteoarthritis of the pisotriquetral joint with the semisupinated oblique view (“pisiform special”) (Fig. 1.4c).Table 1.4 Positioning method for special radiographs of the wristViewPositionAlignmentQuality CriterionSwear-hand view (“Moneim”)Fingers IV and V flexedPlace palm with flexed fingers IV and V on cassettePerpendicular to cassetteAlign to the middle of the radiocarpal jointMaximal width of scapholunate jointSemipronated oblique view (“triquetrum special”)Place palm on 45° wedged padPerpendicular to cassetteAlign to ulnar third of carpusDorsal side of triquetrum shown tangentiallySemisupinated oblique view (“pisiform special”)Place back of hand on 60° wedged padSlight extensionPerpendicular to cassetteAlign to ulnar third of carpusPisotriquetral joint seen free of superimpositionAxial oblique view (“trapezium special”)Thumb abductedPlace thumb laterally on cassettePlace cushion under fingerPerpendicular to cassetteAlign to distal third of carpusBoth sesamoid bones overlapCarpal tunnel viewTraction loop around the fingers and metacarpusTension on the loop provides maximal extensionX-ray tubes angled at 45° from distal to proximalAlign on the base of metacarpal IIITrapezium tuberosity seen free of superimpositionHook of hamate seen free of superimpositionPisiform seen free of superimposition

Fig. 1.4a–ePositioning methods for special radiographs of the other carpal bones.

a Position for the Moneim swear-hand view; free projection of the scapholunate gap.b Position for the semipronated oblique view (“triquetrum special”).c Position for the semisupinated oblique view (“pisiforme special”)d Position for Kapandji's axial oblique view (“trapezium special”).e Position for the inferosuperior carpal tunnel view.(“trapezium special”).

To obtain a survey view of the trapezium and the adjacent scaphotrapeziotrapezoid (STT) joint and the carpometocarpal joint I with Kapandji's axial oblique view (“trapezium special”) when a trapezium, Bennett, or Rolando fracture or osteoarthritis of the STT joint or the carpometacarpal joint I is suspected (Fig. 1.4d).To exclude stenosis of the carpal tunnel when carpal tunnel syndrome is present clinically. The so-called “carpal tunnel views” (superoinferior and inferosuperior) provide only limited information in comparison with cross-sectional images acquired with CT or MRI (Fig. 1.4e).

  Radiological Stress Views of the Carpus and Thumb

The integrity of the ligaments is tested with stress views. Increased mobility between two articular opponents provides indirect information about the condition of the stabilizing ligaments. If results are equivocal, the other hand should be examined to provide a comparison.

Stress views of the carpus are either active (the examined hand applies its own muscular strength) or passive (the noninjured hand or the examiner's hand applies traction). The most common clinical questions in carpal instability concern the scapholunate ligament and the dynamic form of the ulnocarpal impaction syndrome. Both questions can be answered simply by a dorsopalmar stress view with the injured hand gripping a ball tightly (Fig. 1.5a). The other stress views of the carpus (Fig. 1.5b–e) are only for special indications.The stress view of the first metacarpophalangeal joint is taken while the examiner applies traction to the radial side of the thumb (Fig. 1.5f). The examiner wears a lead coat and gloves while performing the stress view of the thumb.

Fig. 1.5a–fPositioning methods for stress views of the wrist and the thumb.

a Stress position for the dorsopalmar grip view.b Stress position for the dorsopalmar view in ulnar inclination.c Stress position for the dorsopalmar view in radial inclination.d Stress position for the lateral view in extension.e Stress position for the lateral view in flexion.f Stress position of the thumb held in radial traction to the metacarpophalangeal joint.

Table 1.5 Positioning methods for stress radiographs of the wrist and thumbStress viewPositionAlignmentQuality CriterionGripping ballTennis ball held tightlyPlace gripping hand on cassettePerpendicular to cassetteAlign to the middle of the carpusUlnar styloid process in profileLunate bone appears as triangleRadial inclinationPlace palm on cassetteMaximal radial inclinationPerpendicular to cassetteAlign to middle of carpus“Ring sign” of the scaphoid“High position” of triquetrumUlnar inclinationPlace palm on cassetteMaximal ulnar inclinationPerpendicular to cassetteAlign to middle of carpusFull length of scaphoid“Low position” of triquetrumFlexionPlace ulnar side of hand on cassetteMaximal flexionPerpendicular to cassetteAlign to middle of carpusRadius and ulna overlapMetacarpals II–V overlapExtensionPlace ulnar side of hand on cassetteMaximal extensionPerpendicular to cassetteAlign to middle of carpusRadius and ulna overlapMetacarpals II–V overlapRadioduction of the thumb rayPlace cushion under palmar side of thumbPlace palmar side of thumb on cassetteExaminer puts ulnar stress on first metacarpophalangeal jointPerpendicular to cassetteAlign to first metacarpopharyngeal jointThumb shown in strict dorsopalmar position

  Radiographs of the Metacarpal Region

These are acquired for detection and follow-up of fractures of the metacarpal bones. Radiographs are focused on an area covering the distal row of the carpus to the proximal phalanges in dorsopalmar (Fig. 1.6a) and semipronated oblique views (Fig. 1.6b). If a palmar deviation of the axis of the distal fragment is suspected, a strictly lateral film must also be taken.

The Brewerton projection (Fig. 1.6c) is useful for assessment of the metacarpophalangeal joints II to V with traumatic or inflammatory changes. This view provides good visualization of the grooved transition on the outer aspect of the metacarpal head to the bony attachment of the collateral ligaments.

  Radiographs of the Thumb and Finger

Survey views of the entire hand are taken for diagnosis of systemic inflammatory diseases, such as rheumatoid arthritis (Chapter 36), and in the acutely injured hand.

Special views are needed for subtle assessment of thumb and finger joints (Fig. 1.7a–d). Requirements include focusing the central ray on the diseased finger joint and a strictly lateral projection in the second plane. Indications for special radiographs of the finger are an intra-articular fracture and the presurgical diagnosis of Heberden's and Bouchard's osteoarthritis, as well as congenital abnormalities of the finger joints (such as camptodactyly and clinodactyly). Intra-articular fractures of the fingers occasionally require a third radiographic projection with an oblique beam path for evaluation of the joint contours (Fig. 1.7e).

Fig. 1.6a–cPositioning methods for radiographs of the metacarpus and the metacarpophalangeal joints.

a Position for the dorsopalmar view.b Position for the semipronated oblique view (zither-player projection).c Position of the metacarpophalangeal joints II to V in the Brewerton projection.

Fig. 1.7a–fPositioning methods for radiographs of the thumb and fingers.

a Position for the palmodorsal view of the thumb.b Position for the lateral view of the thumb.c Position for the dorsopalmar view of a finger.d Position for the lateral view of a finger.e Dorsopalmar view of a finger with correct visualization of the proximal interphalangeal joint space.f Lateral view of a finger with complete overlapping of the condyles of the middle phalanx.

Further Reading

Birkner R. Das typische Röntgenbild. Munich: Urban & Schwarzenberg. 1977:258–285.

Brewerton DA. tangential radiographic projection for demonstrating involvement of metacarpal heads in rheumatoid arthritis. Br J Radiol. 1967;40:233–234.

Epner RA, Bowers WH, Guilford WB. Ulna variance: The effect of wrist positioning and roentgen filming technique. J Hand Surg. 1982;7:298–305.

Hardy DC, Totty WG, Reinus WR, Gilula LA. Posteroanterior wrist radiography: Importance of arm positioning. J Hand Surg. 1987;12A: 504–508.

Jedlinski A, Kauer JM, Jonsson K. X-ray evaluation of the true neutral position of the wrist: The groove for extensor carpi ulnaris as Acta landmark. J Hand Surg. 1995;20A:511–512.

Kindynis P, Resnick D, Kang HS, Haller J, Sartoris DJ. Demonstration ofthe scapholunate space with radiography. Radiology. 1990;175:278–280.

Levis CM, Yang Z, Gilula LA. Validation of the extensor carpi ulnaris groove as a predictor for the recognition of standard posteroanterior radiographs of the wrist. J Hand Surg. 2002;27A:252–257.

Linn MR, Mann FA, Gilula LA. Imaging the symptomatic wrist. Orthop Clin North Am. 1990;21:515–543.

Mann FA, Wilson AJ, Gilula LA. Radiographic evaluation of the wrist: What does the hand surgeon want to know? Radiology. 1992;184:15–21.

Moneim MS. The tangential posteroanterior radiograph to demonstrate scapholunate dissociation. J Bone Joint Surg. 1981;63A:1324–1326

Norgaard F. Earliest roentgenological changes in polyarthritis of the rheumatoid type: Rheumatoid arthritis. Radiology. 1965;85:325–329.

Palmer AK, Glisson RR, Werner FW. Ulnar variance determination. J Hand Surg. 1982;7:376–379.

Saffar P. Carpal Injuries. Anatomy, Radiology, Current Treatment. Heidelberg: Springer. 1990:17–27.

Schernberg F. Roentgenographic examination of the wrist: A systematic study of the normal, lax and injured wrist. Part 1: The standard and positional views. J Hand Surg. 1990;15B:210–219.

Schernberg F. Roentgenographic examination of the wrist: A systematic study of the normal, lax and injured wrist. Part 2: The stress views. J Hand Surg. 1990;15B:220–228.

Sonmez M, Turaclar UT, Tas F. Sabanciogullari V. Variation of the ulnarvariance with powerful grip. Surg Radiol Anat. 2002;24:209–211.

Stecher WR. Roentgenography of the carpal navicular bone. Am J Roentgenol. 1937;37:704–705.

Taleisnik J. The Wrist. New York: Churchill Livingstone; 1985;79–104.

Tomaino MM, Rubin DA. The value of the pronated grip view radiograph in assessing dynamic ulnar positive variance Am J Orthop. 1999;28:180–181.

Toth F, Mester S, Cseh G, Bener A, Nyarady J, Lovasz G. Modified carpal box technique in the diagnosis of suspected scaphoid fractures. Acta Radiol. 2003;44:319–325.

Totty WG, Gilula LA. Imaging of the hand and wrist. In: Gilula LA ed. The Traumatized Hand and Wrist. Philadelphia, Pa: Saunders; 1992:1–18.

Truong NP, Mann FA, Gilula LA, Kang SW. Wrist instability series: Increased yield with clinical-radiologic screening criteria. Radiology. 1994;192:481–484.

Wicke L. Röntgendiagnostik. Einstelltechnik. Munich: Urban & Schwarzenberg; 1983:418–433.

Wilson AJ, Mann FA, Gilula LA. Imaging the hand and wrist. J Hand Surg. 1990:15B:153–167.

Yang Z, Mann FA, Gilula LA, Haerr C, Larsen CF. Scaphopisocapitate alignment: Criterion to establish a neutral lateral view of the wrist. Radiology; 1997;205:865–869.

Yin Y, Mann FA, Gilula LA. Positions and techniques. In: Gilula LA, Yin Y, eds. Imaging of the Wrist and Hand. Philadephia: Saunders;1996:93–158.

Zimmer EA, Zimmer-Brossy M. Lehrbuch der Röntgendiagnostischen Einstelltechnik. 3rd ed. Heidelberg: Springer; 1982:74–97.

Ziter FM. A modified view of the carpal navicular. Radiology. 1973;3:706–707.

2 Special Radiographic Procedures

R. Schmitt, S. Froehner

Digitally acquired projection radiographs can be postprocessed and transmitted electronically by a picture archiving and communication system (PACS) and filed. For diagnosis of skeletal abnormalities, digital luminescence radiography with phosphorus storage screens, as well as digital image-intensifier cinefluorography, is employed. Direct radiography with flat-panel detectors, which at present is not widely used, is a very promising method. Magnification techniques for high-definition images can demonstrate early stages of inflammatory and metabolic diseases. Magnifying radiography with mammography films and the direct radiographic magnification (DIMA)technique are available for this purpose. Inflammatory changes of soft tissue can be visualized with low-kilovoltage radiography with a tube current of 28–30kV. All these methods are reserved for special indications. Conventional tomography with multidimensional blurring figures is no longer used. Pathologic movements in dynamic carpal instabilities can be documented at high temporal resolution with cineradiography.

Digital Radiographic Procedures

Aside from the sectional imaging techniques of ultrasonography, computed tomography (CT), and magnetic resonance (MR) imaging, digital imaging systems are also employed with increasing frequency in projection radiography.

The typical characteristic of all digital techniques is the separation of the process of acquisition of the signal from the object under examination and the display of the signal as a luminance distribution in a computer system. The following quality parameters in combination provide good perception of image details.

The resolution and thereby the image definition are limited by the image matrix and the pixel size. In comparison to film–screen systems, digital imaging techniques are characterized by reduced spatial resolution. The spatial resolution of digital systems depends on the size of the matrix and the image format employed. To ensure good diagnostic detail recognition of bony structures, 2K systems (image matrix 2048×2048) are recommended for projection radiography of the hand. A matrix of 2048×2048 in a cassette format of 18×24cm results in a resolution of 5 line pairs (Lp)/mm, and in a cassette format of 24×30cm gives resolution of 3.3 Lp/mm. In comparison, conventional film–screen systems deliver a spatial resolution between 5 and 8 Lp/mm.This is contrasted with the advantages of improved contrast resolution of digital imaging systems. Digital images are generally stored with an image depth of 10 or 12 bytes/pixel. Digitally acquired images offer the possibility of subsequent postprocessing of the brightness and contrast. Overlapping of the image signal by interference signals (noise) is primarily caused by quantum mottle. A direct relationship exists between the noise and the applied dose.Further advantages, apart from postprocessing, are the possibilities of telecommunication, making a diagnosis on the monitor, and filing without film on RAID-array storages, laser disks, and tape recorder in a picture archiving and communication system (PACS). Alternatively, a hard copy can be made.

The three different imaging systems in digital projection radiography are explained below.

  Digital Luminescence Radiography (DLR)

The Principle

In digital luminescence radiography, the film–screen system is replaced as a data-storage medium by a storage screen