Hey Docs, take a look at my xray - something bad here?

the · 07-06-2007, 10:05 AM

Took a pretty good fall snowboarding this winter. I think it was around February.

Now it's July, and my wrist still hurts somewhat, and has maybe 85% flexibility.

I have a friend with access to an xray machine (the ultimate set of tools!), here the xray.

See anything wrong? I think I see it, but I'll hold it back to not cloud your judgment.

Noah930 · Noah930's Garage

Looks like you had an intraarticular distal radius fracture. Scapholunate interval may also be a bit wide (or possibly a natural variant from normal range).

KFC911 · 07-06-2007, 10:31 AM

I can't disagree with that opinion

Joeaksa · 07-06-2007, 10:33 AM

BS, you have been masturbating again! More kitties dead!

Is that a chip by the base of the radius ?

masraum · 07-06-2007, 10:44 AM

I think the problem is a crappy scanner!

Noah930 · Noah930's Garage

The big long bone on the left, that's the radius. At the very tip of it, where it meets the many small wrist bones, there's a shallow cleft. It should be smooth. The cleft is a sign of an old fracture. Because the fracture line goes into a joint (between the radius and the carpal/wrist bones), it's classified as intraarticular.

The scaphoid and lunate are the two small wrist bones with which the distal radius articulates (contacts). The scaphoid is on the left, and the lunate on the right. The space between them is the scapholunate (SL) interval. It is typically 3-4 mm wide. The SL interval depicted is a little bit on the wide side. If there is a tear of the SL ligament holding the scaphoid and lunate together, the bones tend to spread apart. The interval widens. But, at the same time, there's tremendous variation of what "normal" is, so for all anyone knows, that's what the SL interval looked like before the injury. Most people are pretty symmetric, so you can x-ray the other side to see what a "healthy" SL interval (for the) is like for comparison.

azasadny · azasadny's Garage

Avascular necrosis of the lunate... (just kidding!)

the · 07-06-2007, 11:07 AM

Thanks. That all sounds right. The pain I have is right where the fracture is. The fracture is fuzzy in the scan, but pretty clear in the original.

The fracture happened in February.

Is there anything I can do, or do I just have to wait and let it heal naturally now?

Tobra · Tobra's Garage

Too late to do much about it now. You will have premature degenerative disease of that joint.

Noah930 · Noah930's Garage

Most likely the fracture is healed by now. Like it or not. If you fall again and break your wrist in the same spot, it would have broken whether or not you sustained that original injury in February.

The issue now is the intraarticular stepoff. That line along the distal edge of the radius should be smooth. Well, it should look like 2 shallow concavities (one articulating surface/facet for the scaphoid, and the other for the lunate). But, taken as a whole, there should be smoothness where you see that little cleft.

The problem is that with time/years, there will be accelerated wear and tear at that "highpoint." The cartilage there will wear quicker than the cartilage would otherwise normally do. So that predisposes you to premature arthritis down the road. Whether that's 5 years, 10 years, or 20 years from now is anyone's guess. But that's what you need to watch out for.

On your side, though, is the appearance that the stepoff is pretty small. There's a famous paper that everyone quotes (? and Jupiter were the authors) that says that as long as the stepoff is < 2mm, you'll probably be OK. Jupiter has since (unofficially) retracted that old study as flawed. But we all quote it anyway. However, it goes to point out that the closer you can get to perfect, the better. But if you're off by 1-2 mm, maybe it's not bad enough to operate on.

Another x-ray you don't show is the lateral view (you show the anterior-posterior view). There's a parameter (radial tilt), there, that gets assessed as well to see how out of alignment the joint may be. Again, the more out of line, the higher the chance for early arthritis. This parameter can tolerate quite a bit of being "off" before it's considered problematic.

Finally, there's the issue of the SL ligament. The AP view is a touch on the wide side. That may be normal for you, or it could be the result of an SL ligament tear. On one hand, there's no way to know for certain unless that part of the anatomy is visualized directly (aka: surgically--either by arthroscopy or open/cut the skin). But there are other x-rays to obtain that can help figure that out, noninvasively. And an exam of the wrist (to pinpoint your pain) is worthwhile. Some people advocate MRIs. MRIs aren't the bees knees. In my experience, it's about a 50:50 proposition for a proper diagnosis. Maybe a little higher if they inject contrast (MR arthrogram) into the wrist joint while doing the test. But there have been many times when the reading on the MRI was exactly opposite of what was found when the patient actually went to surgery.

Similar to the problem with the fracture, a torn SL ligament will predispose you to early arthritis. The bones aren't held in the alignment that God (*if you believe in Him) intended, and as your wrist goes through its arc of motion, there's abnormal wear on the cartilage. With time, the cartilage wears away to expose the underlying bone, and you wind up with pain, stiffness, and weakness in that joint.

Of course, these are worst-case scenarios. You may very well not have a torn SL ligament. And while the bony stepoff will lead to early arthritis, that may be a very slow process which may or may not cause you pain. But, at the very least, I'd have a hand surgeon check that out a little more. If you still have pain and decreased motion, it might be worthwhile to see a hand therapist (they're a subset of occupational therapists, not physical therapists).

the · 07-06-2007, 11:54 AM

Quote:

Originally posted by Noah930

Another x-ray you don't show is the lateral view (you show the anterior-posterior view).

Thanks for your help! Here's some other views.

HardDrive · 07-06-2007, 12:22 PM

Thats quite a friend you have there.

"So I borrowed my buddys electron microscope over the weekend....."

Noah930 · Noah930's Garage

The oblique film doesn't tell much--it rarely does.
The lateral isn't perfect (maybe use a bit more supination), but it's close enough to show that radial tilt is pretty close to normal (roughly 10-11 degrees palmar tilt).
So, looking at these x-rays, it doesn't look like there's much to do (surgically) for your fracture. That doesn't take into account your physical exam. But, based on just the films, I'd have a hard time thinking that a corrective osteotomy (breaking the bone and resetting it) would be worth your while.

the · 07-06-2007, 12:36 PM

G* damn snowboarding.

To this day, my son enjoys telling everyone the choice words I was muttering after that fall.

t951 · t951's Garage

Quote:

Originally posted by KC911
I can't disagree with that opinion

I concurr. I should've concurred....

alf · 07-06-2007, 04:27 PM

Quote:

Originally posted by the

Well, it looks like your hand is severed about 4 inches from your wrist. It is probably just phantom pain. And if you are having problems masturbating it is probably because your stump arm is not able to get a grip, try the other hand.

Zeke · 07-06-2007, 04:47 PM

Well, beyond the smart asses, I think it's great to be able to come here and get an *unofficial* medical opinion. Can you imagine the rigamorrow that one would have to go thru just to get a simple opinion?

So, what are the chances of getting the cup blended smooth? I've got some sanding and filing (filling, too) experience.

Oh wait, now I'm one of the smart asses.

Dan in Pasadena · Dan in Pasadena's Garage

Quote:

Originally posted by milt
...Oh wait, now I'm one of the smart asses.

Now milt, with all due respect and in friendship.....was this ever NOT the case? ...and pretty much with ALL of us?!

P.S. I agree; I am also impressed that you can come to this website and get an actual valid medical opinion. I guess it pays to drive the same car a lot of doctors do, huh? I'm only partially kidding about that.

89911 · 07-07-2007, 03:38 AM

My brother had a simlar injury to his wrist that is common to those that fall in cases like snowboarding. It turned out to be a fractured navicular bone that would not heal. He ended up having surgery with a graft from his hip bone to correct it. Maybe these symptons pertain:

Symptoms of a scaphoid fracture:
The symptoms of a scaphoid fracture are pain on the thumb side of the wrist, swelling in that area, and difficulty gripping objects. Many patients are diagnosed with a wrist sprain, when in actuality they have a broken scaphoid bone. The diagnosis is difficult because x-rays taken right after the injury may show no abnormality. A scaphoid fracture that is not displaced may only show up on x-ray after healing has begun, which can be one to two weeks after the injury. Because of this, it is not uncommon to treat a wrist injury with immobilization (as though it were a scaphoid fracture) for a week or two and then repeat x-rays to see if the bone is broken. An MRI or bone scan is also a possible means to diagnose this injury, but usually not needed.

Problems with scaphoid fracture healing:
When a scaphoid fracture heals slowly (delayed union), or does not heal at all (non-union), the injury may remain painful, and deformity and arthritis of the bone may result. The risk of developing a non-union of the scaphoid depends most importantly on the location of the fracture in the bone. Other factors that can contribute to non-union are smoking, certain medications, and infections.

Treatment of scaphoid fractures:
There are two general approaches for treatment of a scaphoid fracture. Often, orthopedists will initially treat the injury in a cast to see if the fracture heals in a timely manner. So long as the scaphoid fracture is not badly displaced (out of position), this is an excellent approach. By obtaining repeat x-rays over several weeks and months, your doctor can look for signs of healing. Healing of this fracture usually takes 10 to 12 weeks. If it does not heal, surgery can be considered.

If the scaphoid fracture is displaced, the risk of nonunion is higher, and your doctor may recommend initial surgery to reposition the bones, and fix them into place. Or if the fracture does not heal with cast treatment (immobilization), surgery will be recommended. The surgery involves using either a screw or small pins to hold the bone together in the proper position. A bone graft may also be used to promote healing at the scaphoid fracture site. The surgical incision will be between two and five centimeters, depending on the dissection necessary to properly position the fracture and place bone graft (if needed). After surgery, a cast is used to immobilize the scaphoid bone and allow for healing.

livi · 07-07-2007, 05:57 AM

Noah is the man in this department. I have nothing to add to his excellent interpretation of the pics. I am glad I am not into radiology or orthopedics for that matter. I have no vision for x-ray pics what so ever. Of course I get no training as we never see any broken bones. However we look at several heart and lung pics every day. I am happy I do not have to interpret them myself. It is all a blur to me, no matter how many years I have been looking at them.