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Musculoskeletal
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Trauma
Wrist and Hand
Introduction and Overview
Wrist and Hand Overview
Wrist and Hand Overview
Kambiz Motamedi, MD, FACR; Carol L. Andrews, MD
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Overview

  • The distal upper extremity, i.e., the distal forearm, wrist, hand, and fingers, includes discrete separate anatomic entities that function as and are often injured as a unit. This section reviews the common bony and soft tissue injury patterns associated with each anatomic region with attention to the interplay between these regions. Radiography (XR) is recommended as the initial exam and, with CT, serves to delineate bony injuries and assess for soft tissue calcification. MR can reveal radiographically occult fractures but, with US, primarily is useful for demonstration of soft tissue abnormalities.

Terminology and Conventions

  • In this text, the anatomically medial aspect of the wrist and hand is referred to as ulnar, and the anatomically lateral aspect is referred to as radial, with few exceptions, to avoid confusion. The palmar aspect of the wrist and hand is described as volar, as opposed to the dorsal aspect.
  • Tendon tears may be complete or partial in acute trauma. More gradual degenerative changes, commonly related to chronic repetitive microtrauma, are referred to as tendinopathy rather than tendinosis or tendinitis.
  • The literature is replete with eponyms and acronyms used in conjunction with wrist and hand trauma. One section is dedicated to a summary of the most commonly used terms, as incorrect application of eponyms is common. One example is the term Colles fracture, which is frequently used to describe distal radius fractures regardless of actual fracture pattern, involvement of the joint, and patient age. However, "Colles fracture" should be reserved to describe a fracture of the distal radius with dorsal angulation and without intraarticular extension, usually in an osteoporotic adult. An accurate description of the components of an injury, including location, angulation, displacement, apposition, and articular surface involvement, is far more important to the care of the patient than assigning the correct eponym.
  • Common types of hardware are described with an emphasis on common complications of the plates, screws, and wires. One should realize that ORIF should be reserved for fracture fixations with an actual longitudinal skin incision and application of plates and screws. Thus, pinning of a fracture (e.g., of a phalanx) falls into the category of closed reduction and percutaneous fixation with internal splinting.

Anatomy

  • The distal forearm refers to the distal 1/3 of the radius and ulna as they articulate with the proximal carpal row and each other. The wrist refers to the distal radioulnar joint (DRUJ), proximal and distal carpal rows, and the carpometacarpal (CMC) joints. The hand variably refers to the metacarpal (MC) bones, MCP joints, phalanges, and the interphalangeal (IP) joints. The thumb has 1 IP joint, whereas the fingers have both the PIP and the DIP joints. There may be substantial overlap of the regions with regard to imaging, and it is important to have a clear understanding of the portion of the anatomy that needs to be evaluated. To avoid confusion, individual digits are referred to by their names, such as index finger, long finger, ring finger, or small finger, rather than by numbers. However, the MCs and rays (ray = MC + finger) are numbered.
  • There are many ossicles and sesamoids in the wrist and hand that can be mistaken for pathology if not recognized as anatomic variants. A summary of the most common sesamoids and ossicles is provided.
  • The intrinsic (interosseous) and extrinsic (capsular) ligaments of the wrist are essential for stability and mobility. Intrinsic ligaments are defined as those that connect 1 carpal bone to another carpal bone. Though there are many intercarpal ligaments, the scapholunate ligament (SLL), which resists volar flexion of the scaphoid and dorsal flexion of the lunate, and the lunotriquetral ligament (LTL), which balances proximal carpal row motion in the opposite direction, are the most important. Extrinsic ligaments are defined as those that connect the carpal bones to adjacent structures, such as the distal radius, distal ulna, and MCs. The extrinsic ligaments provide gross stability to the wrist, whereas the intrinsic ligaments fine-tune wrist motion.
  • The triangular fibrocartilage complex (TFCC) is typically considered separately from the remainder of the wrist ligaments for ease of clinical evaluation and treatment. It is composed of the triangular fibrocartilage proper (TFC, articular disc) interposed between the distal ulna and the proximal carpal row, dorsal and volar radioulnar ligaments, (ulno)meniscal homologue, volar ulnotriquetral and ulnolunate ligaments, and ulnar collateral ligament. The latter is not a true ligament but is variably considered a component of the extensor carpi ulnaris subsheath &/or a medial portion of the ulnotriquetral ligament. The TFCC is integral to the stability of the DRUJ.
  • The flexor tendons course from the distal forearm into the wrist, where the flexor digitorum profundus and superficialis tendons and flexor pollicis longus tendon pass through the carpal tunnel and into their respective digits. In each digit, the superficial tendon splits at the MCP joint, encircles the profundus tendon at the PIP joint, and inserts on the volar base of the middle phalanx. The profundus tendon continues distally to insert on the distal phalanx base. The flexor apparatus is enclosed in a fibroosseous synovium-lined tunnel created by annular and cruciate pulleys, which provide mechanical advantage in finger motion.
  • The extensor tendons travel from the distal forearm into 6 discrete fibroosseous compartments along the dorsal wrist. They continue to the digits where each extensor digitorum tendon splits into proximal, central, and lateral bands, continuing distally to form the extensor hood, and inserting on the proximal, middle, and distal phalanx bases to produce extension of the finger.
  • The principal nerves in the hand and wrist include the median, ulnar, and radial nerves. The median nerve is at risk for compression as it passes through the confines of the carpal tunnel. The ulnar nerve is vulnerable to injury as it enters Guyon canal in the volar ulnar wrist. Superficial (sensory) radial nerve compression occurs along the radial aspect of the wrist.
  • The radial and ulnar arteries branch into deep and superficial arches in the palmar aspect of the hand. The ulnar artery is at particular risk for injury in a 2-cm segment as the superficial branch leaves Guyon canal and passes over the flexor retinaculum prior to entering the palmar aponeurosis. The radial artery is at risk as its superficial branch runs deep to the abductor pollicis brevis tendon just over the trapezoidal ridge.

Injury Patterns

  • The forearm, wrist, and hand are at high risk of injury, with fractures of the forearm accounting for up to 18% of all fractures in an emergency setting. These injuries may result from a high-energy trauma, such as a motor vehicle crash, but most commonly result from low-energy injuries, such as injury during participation in sports. The common causative mechanism across all trauma patterns in the distal upper extremity is a fall on outstretched hand (FOOSH).
  • The border digits (1st and 5th rays) are commonly injured because they are more exposed to catching and twisting trauma than are the middle 3 fingers.
  • The various bony and soft tissue injury patterns are separated for ease of consideration and discussion. Fractures and injuries to the ligaments and tendons commonly occur in combination. It is important to remember this when evaluating a case and be wary of the error of the satisfaction of search, in which identifying 1 abnormality diminishes likelihood of finding additional abnormalities.
  • There is a plethora of grading and staging classification systems in use in orthopedic radiology, especially in trauma. These exist as a way of describing an injury to assist in appropriate clinical management. For example, many classification schemes exist for describing a comminuted distal radius fracture, from simple to extremely detailed. These were devised to categorize the injury and determine the most effective and successful way to treat the patient. If the person interpreting the imaging does not know the specifics of each classification scheme but can effectively describe the components of the injury, that description will facilitate clinical decisions.

Imaging

  • Radiologic evaluation is essential for evaluation of the injured distal upper extremity. The posteroanterior (PA), oblique, and lateral XR of the wrist, hand, and thumb are essential for adequate evaluation. Additional scaphoid, clenched-fist, ulnar- or radial-deviated views, and the like may be added as deemed necessary. True PA and lateral views of each injured digit are essential; an additional oblique view commonly is recommended.
  • Fluoroscopic arthrography of the wrist is nowadays mostly performed in conjunction with MR. Fluoroscopic examination of the wrist and hand is occasionally used to assess alignment and stability, preferably with presence of the treating physician, or to guide surgery in the operation room.
  • Multidetector CT provides accurate and detailed imaging of the wrist, hand, and fingers. CT may be obtained with a patient in a cast or splint. Positioning the patient with the extremity away from the body center will substantially decrease motion and splay artifact and will improve the quality of the images. Placing the patient prone with the affected extremity above the head (superman position) will reduce these artifacts. Though imaging can be acquired with the patient in an external fixation device, care should be taken to acquire thin-section images at an angle to the hardware to reduce metal artifact. Reformation and postprocessing software can provide additional detail to the imaging assessment. Reformatting direct long-axis oblique images of the scaphoid may provide improved visualization of scaphoid fractures. Additional 3D reconstruction aids in detailed visualization of fracture alignment and exact location of displaced fracture fragments for surgical planning.
  • US provides real-time evaluation of the integrity and function of tendons and flexor pulleys as well as synovial spaces. Use of Doppler sonography aids in evaluation of vascularity and, thus, acuity/activity of the lesion. US of the wrist and hand is ideally acquired with a > 12-MHz small footprint linear probe. Attention should be paid to acquire proper US images with the US beam perpendicular to the structures as to avoid anisotropy (directional dependency) artifact, which may lead to incorrect assessment of the tendon or ligament.
  • MR is a key imaging technique for evaluation of soft tissue abnormalities in the upper extremity. Many studies indicate that MR imaging following injection of dilute gadolinium into the radiocarpal joint (direct MR arthrography), along with acquisition of fluoroscopic spot views during the injection, increases the sensitivity and specificity for ligament injuries in the wrist as well as the nature of a TFCC lesion, i.e., tear vs. perforation. Proper positioning is essential for obtaining a high-quality study. Most manufacturers offer dedicated wrist coils that allow scanning the patient in prone position with the extremity at the side. If such a coil is not available, the wrist should be positioned in magnetic isocenter with the arm overhead in the pronated superman position. Some patients cannot tolerate this position because of shoulder or elbow pain. When positioning the wrist and hand, care must be taken to keep the wrist alignment in a neutral position. Ulnar or radial deviation of the wrist may result in apparent carpal alignment that suggests an instability pattern when no such abnormality exists.
  • Direct MR arthrography increases sensitivity and specificity of detection of ligament injuries. However, intravenous gadolinium injection (indirect arthrography) may be useful in evaluation of ligaments as well and additionally can provide information regarding inflammation (e.g., tenosynovitis), soft tissue masses, ganglia, and viability of scaphoid fracture fragments.
  • Imaging protocols for the wrist and hand MR vary widely. A standard set of sequences usually includes coronal T1- and fat-suppressed fluid-sensitive sequences, at least 1 sagittal (fluid-sensitive) sequence, and usually 1-2 axial sequences (fat suppressed and possibly T1). Thin-cut gradient-echo imaging, usually acquired in the coronal plane, may aid in evaluation of ligaments of the wrist and hand. The FOV should be restricted to the anatomical site to ensure acquisition of high-resolution images, i.e., to the wrist (distal radius to proximal MCs) and hand (proximal MCs to the finger tips). Thumb imaging requires special attention in order to adjust the imaging planes to the actual orientation of the thumb, which is at an angle in relation to the other digits. Thin-slice thickness is a key factor in providing diagnostic images.

Selected References

  1. Expert Panel on Musculoskeletal Imaging:. et al: ACR Appropriateness Criteria® acute hand and wrist trauma. J Am Coll Radiol. 16(5S):S7-17, 2019
  2. Lovalekar M et al: Descriptive epidemiology of musculoskeletal injuries in naval special warfare sea, air, and land operators. Mil Med. 181(1):64-9, 2016
  3. Rainbow MJ et al: Functional kinematics of the wrist. J Hand Surg Eur Vol. 41(1):7-21, 2016
  4. Crosby NE et al: Ulnar-sided wrist pain in the athlete. Clin Sports Med. 34(1):127-41, 2015
  5. Howe BM et al: High-resolution imaging of upper limb neuropathies. Semin Musculoskelet Radiol. 19(2):160-7, 2015
  6. Weber CD et al: Major trauma in winter sports: an international trauma database analysis. Eur J Trauma Emerg Surg. 42(6):741-7, 2015
  7. Fallahi F et al: Explorative study of the sensitivity and specificity of the pronator quadratus fat pad sign as a predictor of subtle wrist fractures. Skeletal Radiol. 42(2):249-53, 2013
  8. Davis KW et al: Imaging the ligaments and tendons of the wrist. Semin Roentgenol. 45(3):194-217, 2010
  9. Fayad LM et al: Pediatric skeletal trauma: use of multiplanar reformatted and three-dimensional 64-row multidetector CT in the emergency department. Radiographics. 29(1):135-50, 2009
  10. Lisle DA et al: MR imaging of traumatic and overuse injuries of the wrist and hand in athletes. Magn Reson Imaging Clin N Am. 17(4):639-54, vi, 2009
  11. Kaewlai R et al: Multidetector CT of carpal injuries: anatomy, fractures, and fracture-dislocations. Radiographics. 28(6):1771-84, 2008
  12. Bencardino JT et al: Sports-related injuries of the wrist: an approach to MRI interpretation. Clin Sports Med. 25(3):409-32, vi, 2006
  13. Cerezal L et al: MR imaging findings in ulnar-sided wrist impaction syndromes. Magn Reson Imaging Clin N Am. 12(2):281-99, vi, 2004
  14. Rosner JL et al: Imaging of athletic wrist and hand injuries. Semin Musculoskelet Radiol. 8(1):57-79, 2004
  15. Clavero JA et al: MR imaging of ligament and tendon injuries of the fingers. Radiographics. 22(2):237-56, 2002
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Tables

Overview

  • The distal upper extremity, i.e., the distal forearm, wrist, hand, and fingers, includes discrete separate anatomic entities that function as and are often injured as a unit. This section reviews the common bony and soft tissue injury patterns associated with each anatomic region with attention to the interplay between these regions. Radiography (XR) is recommended as the initial exam and, with CT, serves to delineate bony injuries and assess for soft tissue calcification. MR can reveal radiographically occult fractures but, with US, primarily is useful for demonstration of soft tissue abnormalities.

Terminology and Conventions

  • In this text, the anatomically medial aspect of the wrist and hand is referred to as ulnar, and the anatomically lateral aspect is referred to as radial, with few exceptions, to avoid confusion. The palmar aspect of the wrist and hand is described as volar, as opposed to the dorsal aspect.
  • Tendon tears may be complete or partial in acute trauma. More gradual degenerative changes, commonly related to chronic repetitive microtrauma, are referred to as tendinopathy rather than tendinosis or tendinitis.
  • The literature is replete with eponyms and acronyms used in conjunction with wrist and hand trauma. One section is dedicated to a summary of the most commonly used terms, as incorrect application of eponyms is common. One example is the term Colles fracture, which is frequently used to describe distal radius fractures regardless of actual fracture pattern, involvement of the joint, and patient age. However, "Colles fracture" should be reserved to describe a fracture of the distal radius with dorsal angulation and without intraarticular extension, usually in an osteoporotic adult. An accurate description of the components of an injury, including location, angulation, displacement, apposition, and articular surface involvement, is far more important to the care of the patient than assigning the correct eponym.
  • Common types of hardware are described with an emphasis on common complications of the plates, screws, and wires. One should realize that ORIF should be reserved for fracture fixations with an actual longitudinal skin incision and application of plates and screws. Thus, pinning of a fracture (e.g., of a phalanx) falls into the category of closed reduction and percutaneous fixation with internal splinting.

Anatomy

  • The distal forearm refers to the distal 1/3 of the radius and ulna as they articulate with the proximal carpal row and each other. The wrist refers to the distal radioulnar joint (DRUJ), proximal and distal carpal rows, and the carpometacarpal (CMC) joints. The hand variably refers to the metacarpal (MC) bones, MCP joints, phalanges, and the interphalangeal (IP) joints. The thumb has 1 IP joint, whereas the fingers have both the PIP and the DIP joints. There may be substantial overlap of the regions with regard to imaging, and it is important to have a clear understanding of the portion of the anatomy that needs to be evaluated. To avoid confusion, individual digits are referred to by their names, such as index finger, long finger, ring finger, or small finger, rather than by numbers. However, the MCs and rays (ray = MC + finger) are numbered.
  • There are many ossicles and sesamoids in the wrist and hand that can be mistaken for pathology if not recognized as anatomic variants. A summary of the most common sesamoids and ossicles is provided.
  • The intrinsic (interosseous) and extrinsic (capsular) ligaments of the wrist are essential for stability and mobility. Intrinsic ligaments are defined as those that connect 1 carpal bone to another carpal bone. Though there are many intercarpal ligaments, the scapholunate ligament (SLL), which resists volar flexion of the scaphoid and dorsal flexion of the lunate, and the lunotriquetral ligament (LTL), which balances proximal carpal row motion in the opposite direction, are the most important. Extrinsic ligaments are defined as those that connect the carpal bones to adjacent structures, such as the distal radius, distal ulna, and MCs. The extrinsic ligaments provide gross stability to the wrist, whereas the intrinsic ligaments fine-tune wrist motion.
  • The triangular fibrocartilage complex (TFCC) is typically considered separately from the remainder of the wrist ligaments for ease of clinical evaluation and treatment. It is composed of the triangular fibrocartilage proper (TFC, articular disc) interposed between the distal ulna and the proximal carpal row, dorsal and volar radioulnar ligaments, (ulno)meniscal homologue, volar ulnotriquetral and ulnolunate ligaments, and ulnar collateral ligament. The latter is not a true ligament but is variably considered a component of the extensor carpi ulnaris subsheath &/or a medial portion of the ulnotriquetral ligament. The TFCC is integral to the stability of the DRUJ.
  • The flexor tendons course from the distal forearm into the wrist, where the flexor digitorum profundus and superficialis tendons and flexor pollicis longus tendon pass through the carpal tunnel and into their respective digits. In each digit, the superficial tendon splits at the MCP joint, encircles the profundus tendon at the PIP joint, and inserts on the volar base of the middle phalanx. The profundus tendon continues distally to insert on the distal phalanx base. The flexor apparatus is enclosed in a fibroosseous synovium-lined tunnel created by annular and cruciate pulleys, which provide mechanical advantage in finger motion.
  • The extensor tendons travel from the distal forearm into 6 discrete fibroosseous compartments along the dorsal wrist. They continue to the digits where each extensor digitorum tendon splits into proximal, central, and lateral bands, continuing distally to form the extensor hood, and inserting on the proximal, middle, and distal phalanx bases to produce extension of the finger.
  • The principal nerves in the hand and wrist include the median, ulnar, and radial nerves. The median nerve is at risk for compression as it passes through the confines of the carpal tunnel. The ulnar nerve is vulnerable to injury as it enters Guyon canal in the volar ulnar wrist. Superficial (sensory) radial nerve compression occurs along the radial aspect of the wrist.
  • The radial and ulnar arteries branch into deep and superficial arches in the palmar aspect of the hand. The ulnar artery is at particular risk for injury in a 2-cm segment as the superficial branch leaves Guyon canal and passes over the flexor retinaculum prior to entering the palmar aponeurosis. The radial artery is at risk as its superficial branch runs deep to the abductor pollicis brevis tendon just over the trapezoidal ridge.

Injury Patterns

  • The forearm, wrist, and hand are at high risk of injury, with fractures of the forearm accounting for up to 18% of all fractures in an emergency setting. These injuries may result from a high-energy trauma, such as a motor vehicle crash, but most commonly result from low-energy injuries, such as injury during participation in sports. The common causative mechanism across all trauma patterns in the distal upper extremity is a fall on outstretched hand (FOOSH).
  • The border digits (1st and 5th rays) are commonly injured because they are more exposed to catching and twisting trauma than are the middle 3 fingers.
  • The various bony and soft tissue injury patterns are separated for ease of consideration and discussion. Fractures and injuries to the ligaments and tendons commonly occur in combination. It is important to remember this when evaluating a case and be wary of the error of the satisfaction of search, in which identifying 1 abnormality diminishes likelihood of finding additional abnormalities.
  • There is a plethora of grading and staging classification systems in use in orthopedic radiology, especially in trauma. These exist as a way of describing an injury to assist in appropriate clinical management. For example, many classification schemes exist for describing a comminuted distal radius fracture, from simple to extremely detailed. These were devised to categorize the injury and determine the most effective and successful way to treat the patient. If the person interpreting the imaging does not know the specifics of each classification scheme but can effectively describe the components of the injury, that description will facilitate clinical decisions.

Imaging

  • Radiologic evaluation is essential for evaluation of the injured distal upper extremity. The posteroanterior (PA), oblique, and lateral XR of the wrist, hand, and thumb are essential for adequate evaluation. Additional scaphoid, clenched-fist, ulnar- or radial-deviated views, and the like may be added as deemed necessary. True PA and lateral views of each injured digit are essential; an additional oblique view commonly is recommended.
  • Fluoroscopic arthrography of the wrist is nowadays mostly performed in conjunction with MR. Fluoroscopic examination of the wrist and hand is occasionally used to assess alignment and stability, preferably with presence of the treating physician, or to guide surgery in the operation room.
  • Multidetector CT provides accurate and detailed imaging of the wrist, hand, and fingers. CT may be obtained with a patient in a cast or splint. Positioning the patient with the extremity away from the body center will substantially decrease motion and splay artifact and will improve the quality of the images. Placing the patient prone with the affected extremity above the head (superman position) will reduce these artifacts. Though imaging can be acquired with the patient in an external fixation device, care should be taken to acquire thin-section images at an angle to the hardware to reduce metal artifact. Reformation and postprocessing software can provide additional detail to the imaging assessment. Reformatting direct long-axis oblique images of the scaphoid may provide improved visualization of scaphoid fractures. Additional 3D reconstruction aids in detailed visualization of fracture alignment and exact location of displaced fracture fragments for surgical planning.
  • US provides real-time evaluation of the integrity and function of tendons and flexor pulleys as well as synovial spaces. Use of Doppler sonography aids in evaluation of vascularity and, thus, acuity/activity of the lesion. US of the wrist and hand is ideally acquired with a > 12-MHz small footprint linear probe. Attention should be paid to acquire proper US images with the US beam perpendicular to the structures as to avoid anisotropy (directional dependency) artifact, which may lead to incorrect assessment of the tendon or ligament.
  • MR is a key imaging technique for evaluation of soft tissue abnormalities in the upper extremity. Many studies indicate that MR imaging following injection of dilute gadolinium into the radiocarpal joint (direct MR arthrography), along with acquisition of fluoroscopic spot views during the injection, increases the sensitivity and specificity for ligament injuries in the wrist as well as the nature of a TFCC lesion, i.e., tear vs. perforation. Proper positioning is essential for obtaining a high-quality study. Most manufacturers offer dedicated wrist coils that allow scanning the patient in prone position with the extremity at the side. If such a coil is not available, the wrist should be positioned in magnetic isocenter with the arm overhead in the pronated superman position. Some patients cannot tolerate this position because of shoulder or elbow pain. When positioning the wrist and hand, care must be taken to keep the wrist alignment in a neutral position. Ulnar or radial deviation of the wrist may result in apparent carpal alignment that suggests an instability pattern when no such abnormality exists.
  • Direct MR arthrography increases sensitivity and specificity of detection of ligament injuries. However, intravenous gadolinium injection (indirect arthrography) may be useful in evaluation of ligaments as well and additionally can provide information regarding inflammation (e.g., tenosynovitis), soft tissue masses, ganglia, and viability of scaphoid fracture fragments.
  • Imaging protocols for the wrist and hand MR vary widely. A standard set of sequences usually includes coronal T1- and fat-suppressed fluid-sensitive sequences, at least 1 sagittal (fluid-sensitive) sequence, and usually 1-2 axial sequences (fat suppressed and possibly T1). Thin-cut gradient-echo imaging, usually acquired in the coronal plane, may aid in evaluation of ligaments of the wrist and hand. The FOV should be restricted to the anatomical site to ensure acquisition of high-resolution images, i.e., to the wrist (distal radius to proximal MCs) and hand (proximal MCs to the finger tips). Thumb imaging requires special attention in order to adjust the imaging planes to the actual orientation of the thumb, which is at an angle in relation to the other digits. Thin-slice thickness is a key factor in providing diagnostic images.

Selected References

  1. Expert Panel on Musculoskeletal Imaging:. et al: ACR Appropriateness Criteria® acute hand and wrist trauma. J Am Coll Radiol. 16(5S):S7-17, 2019
  2. Lovalekar M et al: Descriptive epidemiology of musculoskeletal injuries in naval special warfare sea, air, and land operators. Mil Med. 181(1):64-9, 2016
  3. Rainbow MJ et al: Functional kinematics of the wrist. J Hand Surg Eur Vol. 41(1):7-21, 2016
  4. Crosby NE et al: Ulnar-sided wrist pain in the athlete. Clin Sports Med. 34(1):127-41, 2015
  5. Howe BM et al: High-resolution imaging of upper limb neuropathies. Semin Musculoskelet Radiol. 19(2):160-7, 2015
  6. Weber CD et al: Major trauma in winter sports: an international trauma database analysis. Eur J Trauma Emerg Surg. 42(6):741-7, 2015
  7. Fallahi F et al: Explorative study of the sensitivity and specificity of the pronator quadratus fat pad sign as a predictor of subtle wrist fractures. Skeletal Radiol. 42(2):249-53, 2013
  8. Davis KW et al: Imaging the ligaments and tendons of the wrist. Semin Roentgenol. 45(3):194-217, 2010
  9. Fayad LM et al: Pediatric skeletal trauma: use of multiplanar reformatted and three-dimensional 64-row multidetector CT in the emergency department. Radiographics. 29(1):135-50, 2009
  10. Lisle DA et al: MR imaging of traumatic and overuse injuries of the wrist and hand in athletes. Magn Reson Imaging Clin N Am. 17(4):639-54, vi, 2009
  11. Kaewlai R et al: Multidetector CT of carpal injuries: anatomy, fractures, and fracture-dislocations. Radiographics. 28(6):1771-84, 2008
  12. Bencardino JT et al: Sports-related injuries of the wrist: an approach to MRI interpretation. Clin Sports Med. 25(3):409-32, vi, 2006
  13. Cerezal L et al: MR imaging findings in ulnar-sided wrist impaction syndromes. Magn Reson Imaging Clin N Am. 12(2):281-99, vi, 2004
  14. Rosner JL et al: Imaging of athletic wrist and hand injuries. Semin Musculoskelet Radiol. 8(1):57-79, 2004
  15. Clavero JA et al: MR imaging of ligament and tendon injuries of the fingers. Radiographics. 22(2):237-56, 2002