Presentation
Hand distorsion, wrist pain
Patient Data
A forearm series was performed. No visible fracture. A positive pronator quadratus sign as a possible indirect sign for an occult fracture. The Gilula arcs appear disrupted - however, as this is the AP view of the forearm series and not a wrist or hand radiograph, this diagnosis must not be made.
To confirm the projectional effect of the "disrupted Gilula arcs" an additional regular PA view of the hand was performed. The anatomic variant lunate type II morphology with a proximally prominent hamate results in a step-off in the second and third Gilula arcs, however no pathologic disruption of the Gilula arcs. No fracture was identified.
To exclude an occult fracture a CT was proposed, but rejected by the patient. Instead, an x-ray of the other side was done and the same prominent pronator-quadratus-sign is seen.
Case Discussion
This case highlights several clinically relevant points:
on a forearm series, the Gilula arcs are not visualised as they would be on a dedicated wrist radiograph
anatomic variants exist that result in a step-off in the Gilula arcs that are physiological
a positive pronator-quadratus-sign does not have to be associated with a fracture
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