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Proper interpretation of wrist radiography requires a standardized radiographic technique. We obtained posteroanterior (PA) radiographs of the wrist in nine patients in three different arm positions to study the effect of arm position on ulnar styloid process orientation. An appearance simulating a normal anteroposterior (AP) wrist radiograph was present in six of nine PA radiographs when the arm was positioned next to the trunk, and the elbow was flexed to a 90% angle. The orientation of the ulnar styloid was not helpful in differentiating either pronated from supinated wrist positions or AP from PA projections. We concluded that radiographic screening of the carpus should be performed with standardized wrist positioning and nomenclature as described in modern radiographic technological texts. Supplemental projections should be exposed and interpreted with an understanding of the position of the arm and the direction of the incident radiographic beam at the time of examination.

Erosions on the triquetrum and pisiform are frequent in early rheumatoid arthritis and occur characteristically at 3 sites. (a) A shallow erosion on the proximal medial triquetral "bare" area is related to synovial proliferation at the margin of the radiocarpal cavity, although compressive forces from an adjacent long ulnar styloid may be contributory; (b) an erosive abnormality on the distal medial triquetrum is related to synovial proliferation along the margin of the midcarpal joint; and (c) ring-like erosions on apposing surfaces of the triquetrum and pisiform are produced by pannus within the pisiform-triquetral compartment.

Patients with Colles' fractures have serious complications more frequently than is generally appreciated. A study of 565 fractures revealed 177 (31 per cent) with such complications as persistent neuropathies of the median, ulnar, or radial nerves (forty-five cases), radiocarpal or radio-ulnar arthrosis (thirty-seven cases), and malposition-malunion (thirty cases). Other complications included tendon ruptures (seven), unrecognized associated injuries (twelve), Volkmann's ischemia (four cases), finger stiffness (nine cases), and shoulder-hand syndrome (twenty cases). In many patients, incomplete restoration of radial length or secondary loss of the reduction position caused the complications.

In five patients with fracture-dislocation of a radiocarpal joint, the wrist injury was severe and associated with injuries to other systems. Typically there was neurovascular impairment and closed reduction was performed as soon as possible to relieve pressure to tension on vessels and nerves. Fracture of the radial and ulnar styloid processes, fracture of the dorsal rim of the radial articular surface, and a multitude of carpal and intercarpal injuries were present in all cases. Early open reduction, internal fixation of the fractures, and repair of all torn ligaments appeared to be the treatment of choice.

It has been postulated that cubitus altus promotes Kienbock's disease. The inconstant value of the radioulnar index must be underlined. Our index is measured on sagittal X-rays. This study showed that the angle formed between the horizontal line which passes through the junction of the lower and ulnar borders of the radius and the line drawn from this same ulnar pole of the radius to the lower ulnar styloid (Fischer's angle) on posteroanterior projections was not reliable. In an initial study of 41 men and 36 women, the following mean values were found : 1.06 for men ; 0.65 for women. The minus sign indicates that the ulna was shorter than the radius. A second study showed that there was in fact very little difference between men (-2.08 mm) and women (-1.91 mm). Based on the study of 150 normal wrists, it seems possible to state that the physiological radioulnar index ranges from 0.5 mm to 2 mm on sagittal X-rays. The ulna was always shorter thant the radius, was slightly shorter in men than in women. We suggest that values of greater than 2.5 mm are necessary to define cubitus altus.

A case of dislocation of the left pisiform occurred in bilateral fractures of the distal radius with fracture of the right ulna and fracture of the left ulnar styloid was reported.The patient was a 14-year-old male. Closed reduction, pinning and splinting were performed, followed by excellent results. To be exact, this case seemed to be subluxation according to the description of Vasilas. The dislocation or subluxation of the pisotriquetral joint is easily overlooked. Meticulous attention should be paid to this disorder. The roentgenograms in semisupine position elucidate more distinct pathology.

Errors in the radiologic diagnosis of skeletal injuries may occur because of inadequate clinical history, incorrect ordering of films, incomplete radiologic examination, or errors in interpretation. In extremity injuries, the area of point tenderness or local soft tissue swelling should be noted on the request form. Multiple examinations of areas such as elbow, forearm, and wrist should be performed individual, and not by utilizing long films which include multiple areas. Correlation of suspicious findings with clinical history and physical evaluation is frequently helpful.

Contrast opacification of the joint cavities (arthrography) and tendon sheaths (tenography) of the hand and wrist is not routinely employed in many hospitals although useful information may be derived from these procedures. This chapter summarizes indications, techniques, and normal and abnormal findings of arthrography and tenography of the hand and wrist.

A 23-year-old black man was seen for a fracture of the ulnar styloid. X-ray films of the wrist revealed an absent navicular and hypertrophic styloid process of the radius. This radiologic finding has not been reported to date.

A kindred with an unusual congenital hand and foot anomaly is presented. It is an autosomal dominant hereditary disorder characterized by brachymesophalangia, slight clinodactyly, deformed metacarpal heads, osteochondritis dissecans in metacarpophalangeal joints, absence or hypoplasia of the ulnar styloid processes, and brachyhypophalangia in the feet.

A case of bilateral distal radio-ulnar dislocation following a forced extension-pronation injury of both wrists with bilateral fractures of the ulnar styloid is presented. The diagnosis was not made at the initial evaluation; and closed reduction under general anesthesia was performed 11 days after injury. A review of the literature, problems in diagnosis, and methods of treatment are discussed.

It is difflcult to deal with this topic; several steps are involved: a review of the known techniques, an analysis of tested techniques, an explanation of the reasons for our choices, suggestion of new techniques.

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The ulnar styloid bursa is a pea-sized recess or bursa situated at the tip of the styloid process of the ulna and connected with the joint cavity of the wrist. This anatomical detail was first demonstrated by Kessler and Silberman (1961) in an arthrographic study using contrast medium. These authors pointed out that the frequently described “calcifications about the flexor carpi ulnaris tendon” were presumably often associated with this bursa. An illustrative case is now reported. This, incidentally, demonstrates the value of arthrography in the investigation of injured wrists. The arthrographic technique was previously described in this Journal (Thoms, 1962).

R.W., a 21-year-old football player, was injured while tackling. One of his team mates, simultaneously tackling the same opponent from the opposite side, struck the patient's wrist with his helmet.

Increase in the soft-tissue thickness of the wrist is said to be a sensitive indicator of early oedema due to generalised or local arthritic disease. No normal values are available. Measurement of the soft-tissue thickness opposite the radial and ulnar styloid processes in a random population demonstrated a large normal range which was not related to obesity. This large normal variation calls into question the accuracy of radiological evaluation of early wrist oedema.

In Reply.— Dr Radoff's concerns about the accuracy and reproducibility of our conduction technique are understandable. Regarding the location of the recording electrode, this is standardized at 3 cm proximal to the metacarpophalangeal joint of the fifth finger; however, hands will, of course, vary in size, making the actual anatomical location of the recording electrode slightly different. Regarding the location of the site of stimulation, the 2- to 3-cm variability of location is to some extent unavoidable, since the dorsal cutaneous branch of the ulnar nerve arises at a variable distance proximal to the ulnar styloid process.1 The lack of an absolutely constant interelectrode distance does make for a greater degree of inaccuracy when comparing latency values; therefore, we would place greater value on conduction velocity values, as well as the presence or absence of a recordable nerve action potential. We would also stress the necessity of very careful measurement of the

Eleven patients with chronic pain on the ulnar side of the wrist and roentgenographic evidence of a hypertrophic ulnar styloid nonunion were treated with subperiosteal excision of the nonunion fragment. This procedure relieved the localized pain without changing either radiocarpal or distal radioulnar joint stability.

History. —Mrs. R., aged 36, Feb. 28, 1910, fell down-stairs and in some way hurt her left wrist. She immediately came to my office three blocks distant. Walking into the consultation room she held out her forearm in medium pronation, the hand and fingers slightly flexed. the patient thinks now that the hand was somewhat drawn to the ulnar side. I noticed an abnormal protuberance on the dorsum of wrist and made a hasty (before examination) diagnosis of Colles' fracture. Examination and Treatment —I examined the wrist and soon discovered that there was not a Colles' fracture; now could I make out any fracture, except possibly one of the ulnar styloid. It was discovered that the ulna was dislocated forward and that it was easily reduced, but that when the pressure which was needed to reduce it was released, dislocation recurred. Motion in all directions was somewhat limited

This study was undertaken to show: (1) the usual roentgenologic displacements in Colles' fracture with an accompanying fracture of the styloid process of the ulna and the practical therapeutic value of such information, and (2) the probable mechanism of fracture of the ulnar styloid. According to Schinz, 1 this fracture occurs in 58 per cent of all Colles' fractures. A study of the table will demonstrate the most frequent positions of the lower radial fragment (Darrach 2 ) in this series of cases, as follows: From these statistics it may be inferred that, generally speaking, Colles' fractures with accompanying ulnar styloid fractures have enough roentgenologic displacements to warrant their reduction. Experience has taught that lack of gross deformity does not necessarily mean a lackof roentgenologic displacement. Since, in Colles' fracture in particular, roentgenologic fragment reduction of the radius is so important in the majority of cases for production of good

"Fractures in children are different," and forearm fractures offer many examples in proof of this theme. They must not be considered along with fractures of adults under anatomic classifications which take no account of the growth factor. They are different as to pathologic conditions, treatment and prognosis. Intelligent management must recognize this fact. The common forearm fracture in the adult is that described by Colles 1 with impaction of the lower end of the radius and with a fracture of the tip only of the ulnar styloid. In children, on the other hand, the commonest fracture is one of both bones at a higher level, 1 or 2 inches above the wrist joint. Greenstick fractures are common in children and rarely occur in adults. Perhaps the best example of the differences in the pathologic condition and in the prognosis with diametrically opposed principles of treatment is at the proximal end

The majority of distal radius fractures are associated with an ulnar styloid fracture [1-3]. There is solid evidence in the literature that this association may ultimately affect the clinical outcome causing instability, disability, and pain in the distal radioulnar joint (DRUJ) [2,4-7]. The main reasons for the worse outcome are: (1) DRUJ instability, (2) impingement with the triquetrum, and (3) Extensor Carpi Ulnaris (ECU) tenosynovitis. Because of its close association with the Triangular Fibrocartilage Complex (TFCC), fractures of the ulnar styloid might indicate possible TFCC disruption with subsequent DRUJ instability [4,8,9]. Studies on the clinical relevance of ulnar styloid fractures have produced conflicting results. However, when considering size and displacement of the fracture, May et al [2] found that, after distal radius fracture stabilization, a fracture through the base of the ulnar styloid that involves most part of the TFCC attachment and stays in a deviated more radial position (2 mm or more) indicates DRUJ instability. In an ulnar styloid fracture model, Shaw et al [4] found that K-wire fixation of the ulnar styloid fracture restored stability to the DRUJ regardless the integrity of other supporting structures. Bone fragments resulting from non-union could also provoke irritation and pain [5,10] due to impingement with the triquetrum [11]. Twenty-six percent of ulnar styloid fractures develop non-union [12]. From those, just a few becomes symptomatic [5]. If the DRUJ is stable, simple removal of the fragment usually solves the problem [5,11]. Extensor carpi ulnaris tendon impingement caused by malalignment of a fibrous nonunion may also be responsible for a poor clinical outcome. [13,14]. This condition is rarely found after a distal radius fracture and it is successfully treated with excision of the bony prominence and reconstruction of the floor of the sixth compartment. Hence, fixation of a small sized ulnar styloid in the acute setting of a distal radius fracture is probably unnecessary. As the results of treatment of chronic instability of DRUJ following a distal radius fracture are more unpredictable [4], it is advisable to take all measures in the acute setting to prevent this complication. Therefore, fixation of the ulnar styloid is indicated when there are large sized fragments that persist deviated after stabilization of the radius or when the distal radioulnar joint is grossly unstable. Immobilization with a sugar tong splint for four weeks or until proper healing is necessary when the surgeon chooses not to fix a reduced ulnar styloid large fragment that is acceptably reduced.

Fractures of the ulnar styloid frequently accompany fractures of the distal radius, however, there is no conclusive evidence whether it influences the final outcome of the treatment. The majority of studies show no negative effect of ulnar styloid fractures on final outcome, when the fracture of the distal radius is fixed, preferably by a locking plate [1,2]. Some authors, however, report on frequent non-unions of the ulnar styloid, distal radio-ulnar joint (DRUJ) instabilities, triangular fibrocartilage complex (TFCC) tears, and other complications which may cause ulnar wrist pain, reduced mobility and power of the hand [3,4]. No studies are available that address this issue for K-wire fixation of the distal radius fractures.