Lecture 6- Wrist

Question 1

Fibrocartilage disc: function

Answer 1

• Main stabilizer of distal radioulnar joint, in addition to contributing to ulnocarpal stability
• It plays an important role in loading & stabilizing of distal radioulnar joint
In an uninjured joint, during axial loading, the radius carries the majority of load (82%), and the ulna a smaller load (18%)
Excision of the TFCC increases the radial load to 94%

Question 2

Carpal Tunnel Syndrome (CTS)

Answer 2

• Most common overuse injury at the wrist!
• CTS = symptoms and signs that occur with compression
of the median nerve within the carpal tunnel.
• Mean age 45-60 years; Female > Male
Symptoms
• Numbness, paresthesia, and pain in the median nerve distribution
• Loss of grip strength, dropping of objects (hand weakness) No definitive cause, though highly associated with
• Poor wrist ergonomics (extension, compression)
• Edema (eg. in pregnancy)
• Construction worker

Question 3

Carpal tunnel test: phalans test

Answer 3

Flexing both hands up against each other for 60sec

Looking for numbness/ tingling in the median nerve distribution

Question 4

Treatment and Rehabilitation Principles for carpal tunnel syndrome

Answer 4

Initial conservative treatment consists of:
• Cock-up wrist splints
• NSAIDs, manual therapy,
• Avoidance or limitation of aggravating activities, and
• Corticosteroid injection if required.

Question 5

Ulnar nerve entrapment

Answer 5

Occurs at Guyon’s Canal
• Depression between pisiform & hook of hamate is converted into fibro-osseous tunnel by pisohamate
ligament (contains ulnar nerve & artery)
Entrapment may cause motor, sensory, or mixed deficits, depending on the site of compression
• Commonincyclists–why?
• Decompressivesurgeryiscommon

Question 6

De Quervain’s Tenosynovitis

Answer 6

Consist of inflammation of the common tendon sheath (extensor pollicis brevis / abductor pollicis longus)
Usually result from repetitive ulnar deviation is most commonly but can arise spontaneously
It is not an inflammatory condition but rather a thickening of the tendon sheath (tenovaginitis)
Treatment
• Corticosteroid injection 78 – 89% success
• Conservative care 3 – 4 years …

Question 7

Intersection syndrome (peritendinitis)

Answer 7

• Painful condition of the forearm sometime mistaken for a tenosynovitis
• Occur where the first extensor compartment tendons (abductor pollicis longus and extensor pollicis brevis) intersect the second extensor compartment (extensor carpi radialis longus and brevis)
• Pain presentation is similar to De Quervain’s tenosynovitis
• Patient will complaint of pain associated with both thumb and wrist movement with crepitus

Question 8

Orthopaedic Testing for De Quervain’s Tenosynovitis • FinkelsteinTest

Answer 8

Patient places thumb under fingers and dr applies ulnar deviation of the wrist. Pain is positive

Question 9

Mechanism of injury for sprains or strains of the wrist

Answer 9

The literature tends to agree that the most likely MOI is a fall with the wrist in hyperextension either with ulnar or radial deviation

Question 10

SCAPHOLUNATE INSTABILITY (ULNAR DEVIATION)

Answer 10

• Dorsal* intercalated segment instability (DISI)

* Disruption of the scapholunate ligament
• Gap seen on X-ray

Question 11

Stages of SCAPHOLUNATE instability

Answer 11

Depending of the force
• Stage 1(Minor trauma) partial disruption of the SL complex
• Chronicwristpainand tenderness over the SL dorsal joint
• NoR-Xseparation
• Stage 2 (disruption of the SL)
• DiastasisvisualizeonR-X
• Wristpainwithlocal tenderness of the dorsal SL joint without swelling

Question 12

What things mimics scapholunate injury

Answer 12

Only 4 diagnoses mimic chronic SL injury and normal
wrist R-X
1. Scaphoid impaction
2. Occult dorsal carpal ganglion cyst
3. Dorsal carpal impingement syndrome (type II gymnast’s wrist)
4. Dynamic or pre-dynamic SL instability

Question 13

Lunatotriquetral instability (radial deviation)

Answer 13

• Complete separation of the SL unit from the triquetrum
• Associated collapse of the scaphoid and lunate in flexion
  Partial disruption of the joint complex is difficult because X-ray abnormalities are not present (bony separation).
  Needs to rely on provocative tests

Question 14

TRIANGULAR FIBROCARTILAGE COMPLEX

Answer 14

TFCC functions as cushion for the ulnar carpus as well as a sling support for the lunate and triquetrum.
Usual MOI = compression of the TFCC between the lunate and the head of the ulna, as in FOOSH, or from rotational forces as in racket and throwing sports
(Best place to palpate the TFCCis between the tendons of the extensor and flexor carpi ulnaris distal to the ulnar styloid process)

Question 15

Signs and symptoms of a TFCC

Answer 15

• Ulnar-side wrist pain & swelling, including point tenderness distal to the ulnar styloid in the area of the TFCC
• Loss of grip strength might be associated with a “click” with active ulnar deviation
• Pain with passive pronation and supination (rotation) as well as with ulnar deviation

Question 16

Ganglion /dorsal ganglion cyst

Answer 16

Its aetiology is still debated
Treatment of ganglion
• Immobilization,
• Corticosteroid injection (if symptomatic),
• Surgery (recurrence is likely)

Question 17

Trigger Finger

Answer 17

Also known as stenosing tenosynovitis
• A finger (or thumb) gets “stuck” in flexion then straightens with an associated
“snap” — (like a trigger being pulled and released).
• In severe cases, the finger remains locked in the flexed position.
Cause:
• Inflammation of the tendon which has difficulty gliding in the tendon sheath.
A palpable nodule is often present within the tendon due to telescoping of the sheath.
More common in females and diabetic patients

Question 18

Trigger finger treatment

Answer 18

• Rest
• Splint
• NSAID
• Corticosteroid injection

Question 19

Scaphoid fracture

Answer 19

The scaphoid is more susceptible to injury than any of the other carpal bones because of its unique position bridging the proximal and distal rows of the carpal bones
• Usual MOI is a FOOSH with extension and radial deviation

Question 20

What is avascular necrosis in relation to the scaphoid fracture

Answer 20

AVN is due to poor blood supply, with only one dorsoradial artery to the proximal pole, which results in a 30 - 100% of AVN in scaphoid fractures depending on location of the fracture.
AVN does not usually show on initial x-ray
Immobilization in a splint or cast indicated with re- evaluation by x-ray in 10-14 days

Question 21

Orthopaedic test for scaphoid fracture : scaphoid compression test

Answer 21

axial/longitudinal compression of the patient’s thumb along the line of the first metacarpal causes pain at the site of the scaphoid

Question 22

Thoracic outlet Syndrome

Answer 22

As a cause of whole hand symptoms:
TOS is an array of disorders that involves compression of the neurovascular structures in the “thoracic outlet”
• Space between the clavicle and 1st rib
• Close association with the scaleni muscles

Question 23

Thoracic outlet syndrome: three common sites of compression

Answer 23

• Scaleni
• Reduction in costoclavicular space • Accessory (cervical) rib
• Pectoralis minor

Question 24

Thoracic outlet syndrome: symptoms

Answer 24

1. Vascular (subclavian artery)
   • Vascular insufficiency sx’s to the upper limb esp. hand
2. Neurogenic (brachial plexus) or both
   • Sensory and/or motor disturbances to the entire hand due to generalized involvement of the
   brachial plexus
   • See how this differs to CTS??

Question 25

Fibrocartilage disc: what is it?

Answer 25

It originates from medial border of distal radius and inserts into the base of the ulnar styloid
It separates the radiocarpal from the distal radioulnar joint and blood supply is only to the peripheral 15 – 20%
The central disc is avascular