Original Communications: Wrist
The “clenched pencil” view: A modified clenched fist scapholunate stress view,☆☆,*

https://doi.org/10.1053/jhsu.2003.50046Get rights and content

Abstract

Traditional radiographic imaging of the scapholunate interval is complicated by the lack of a view that combines the dynamism of the clenched-fist stress view with the ability to reliably duplicate the precise angle of pronation that shows optimally the scapholunate interval. We describe a simple radiographic technique that combines these 2 criteria that we have found helpful in the office diagnosis of scapholunate dissociation. (J Hand Surg 2003;28A:414-418. Copyright © 2003 by the American Society for Surgery of the Hand.)

Section snippets

Technique

The required materials are a pencil (or wooden dowel), one 10 × 12 radiographic cassette, and a standard x-ray machine. The patient is instructed to grip the pencil with both fists. The index fingers should be apposed tightly to each other and the thumb metacarpals should be lying down on the cassette (Fig. 1A).

. (A, B) Photographs of the technique for clenched pencil scapholunate view. (A) Note that the hypothenar border is elevated above the cassette. (B) Note that the patient is gripping the

Discussion

Historically the diagnosis of scapholunate dissociation is made by history and physical examination and confirmed by posteroanterior and lateral radiographs (if static) or a clenched fist stress view (if dynamic).1 Findings on routine posteroanterior views include a widened scapholunate gap, foreshortening or flexion of the scaphoid (the ring sign), and an abnormal relationship of the proximal carpal row.2 Standard posteroanterior and lateral radiographs of the wrist may not reveal a defect.

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    The clenched fist stress view has become the most popular technique to assess SL diastases. To widen the SL interval, a compressive force, generated by making a full fist while grasping a pencil, is applied across the midcarpal joint.7,17,18 The dissociated lunate is expected to be pushed into dorsiflexion by the capitate, because of its wedge shape, while the scaphoid rotates into flexion.

  • CMC Mimickers: Differential Diagnosis and Work-Up for Radial-Sided Wrist Pain

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    Carpal alignment can be measured by the radiolunate angle (normal −20 ± 15°), SL angle (normal 30–70°), and radioscaphoid angle (normal 35–65°). If dynamic instability is suspected, a clenched-pencil PA view provides a comparison of both wrists while loading the SL interval with grip force.41,42 A radiographic motion series can help evaluate the mobility and reduction potential of the carpus.

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No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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Reprint requests: Guy D. Foulkes, MD, Macon Orthopaedic and Hand Center, 840 Pine St, Suite 500, Macon, GA 31201.

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0363-5023/03/28A03-0007$30.00/0

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