Hand radiographs are commonplace in the Emergency Department or the trauma reporting list.
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Systematic review
Choosing a search strategy and utilizing it consistently is a helpful method to overcome common errors seen in diagnostic radiology. The order in which you interpret the radiograph is a personal preference. A recommended systematic checklist for reviewing musculoskeletal exams is: soft tissue areas, cortical margins, trabecular patterns, bony alignment, joint congruency, and review areas. Review the entire radiograph, regardless of perceived difficulty. Upon identifying an abnormality, do not cease the review, put it to the side and ensure to complete the checklist.
Soft tissue
Assess all soft tissue structure for any associated or incidental soft tissue signs
Metacarpals
Assess the cortex of each metacarpal in turn:
pay particular attention to the 1st and 5th metacarpals
metacarpal injuries or those affecting several phalanges may coexist with injuries to other digits
if cortical disruption of the 5th metacarpal neck, think Boxer fracture
be wary of fractures involving the joint surface - they are unstable
if intra-articular cortical disruption of the 1st metacarpal base, think Bennett fracture dislocation or Rolando fracture
Phalanges
Assess the cortex of each phalanx in turn, proximal to distal:
pay particular attention to phalangeal tufts, shafts and ligamentous insertions
if lateral or medial bony fragment, think collateral ligament avulsion
if dorsal bony fragment, think extensor tendon avulsion
if palmar bony fragment, think volar plate avulsion
Alignment
Assess the alignment of the metacarpals and phalanges:
check each finger from metacarpal to distal phalanx
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malalignment and reduced joint space both point to dislocation
Joint spaces
Assess the carpal and carpometacarpal joint space:
1-2 mm joint space should be seen between the carpals and metacarpals
look specifically at the base of the 4th and 5th metacarpals
if the joint space is narrowed, think carpometacarpal dislocation
Assess the interphalangeal joint space:
metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints should be congruent and there should be a visible joint space
Review the wrist
A hand radiograph contains a PA and oblique view of the distal radius and ulna and the carpus.
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check the wrist as you would for a wrist radiograph (an approach)
distal radius
carpal alignment
carpometacarpal articulation
bone cortex
Common pathology
Interphalangeal joint dislocation
common upper extremity dislocation
usually a hyperextension injury
typically dorsal dislocation of PIP joint +/- bony avulsion
palmar bony fragment indicates avulsion of volar plate
Mallet finger
disruption of extensor mechanism at DIP joint leading to tendon injury +/- bony avulsion
extended finger struck at the tip or crushed
dorsal bony fragment indicates avulsion of the extensor tendon
more: Mallet finger
Boxer fracture
minimally comminuted, transverse fracture of the 5th metacarpal
25% of all metacarpal fractures
usually young male adults
caused by a direct blow when the fist is clenched
more: Boxer fracture
Bennett fracture
unstable intra-articular fracture of the base of 1st metacarpal
caused by forceful thumb abduction
large metacarpal fragment dislocated by a pull of abductor pollicis longus
small metacarpal fragment remains attached to MCP joint
more: Bennett fracture
Skier/gamekeeper thumb
rupture of ulnar collateral ligament of 1st MCP joint
there may be an associated bony avulsion
avulsion fracture occurs at the ulnar corner of the proximal phalanx base
caused by forceful thumb abduction
more: Gamekeeper's thumb
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Rolando fracture
base of 1st metacarpal intra-articular fracture - comminuted (3 fragments) and highly unstable
axial blow to partially flexed metacarpal
fracture line typically T or Y-shaped
more: Rolando fracture
Carpometacarpal dislocation
rare but significant injury to dominant hands of younger males
younger male predominance
often occur after a punch followed by a fall
reduction of joint space on the AP
best seen on an oblique study
Enchondroma
common benign medullary cartilaginous neoplasm
tend to be seen in young adults
50% lesions found in small tubular bones
complicated by pathological fracture
more: enchondroma