Lecture 6- Wrist Flashcards
Fibrocartilage disc: function
• 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%
Carpal Tunnel Syndrome (CTS)
• 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
Carpal tunnel test: phalans test
Flexing both hands up against each other for 60sec
Looking for numbness/ tingling in the median nerve distribution
Treatment and Rehabilitation Principles for carpal tunnel syndrome
Initial conservative treatment consists of:
• Cock-up wrist splints
• NSAIDs, manual therapy,
• Avoidance or limitation of aggravating activities, and
• Corticosteroid injection if required.
Ulnar nerve entrapment
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
De Quervain’s Tenosynovitis
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 …
Intersection syndrome (peritendinitis)
• 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
Orthopaedic Testing for De Quervain’s Tenosynovitis • FinkelsteinTest
Patient places thumb under fingers and dr applies ulnar deviation of the wrist. Pain is positive
Mechanism of injury for sprains or strains of the wrist
The literature tends to agree that the most likely MOI is a fall with the wrist in hyperextension either with ulnar or radial deviation
SCAPHOLUNATE INSTABILITY (ULNAR DEVIATION)
- Dorsal* intercalated segment instability (DISI)
* Disruption of the scapholunate ligament
• Gap seen on X-ray
Stages of SCAPHOLUNATE instability
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
What things mimics scapholunate injury
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
Lunatotriquetral instability (radial deviation)
- 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
TRIANGULAR FIBROCARTILAGE COMPLEX
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)
Signs and symptoms of a TFCC
• 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
Ganglion /dorsal ganglion cyst
Its aetiology is still debated
Treatment of ganglion
• Immobilization,
• Corticosteroid injection (if symptomatic),
• Surgery (recurrence is likely)
Trigger Finger
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
Trigger finger treatment
• Rest
• Splint
• NSAID
• Corticosteroid injection
Scaphoid fracture
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
What is avascular necrosis in relation to the scaphoid fracture
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
Orthopaedic test for scaphoid fracture : scaphoid compression test
axial/longitudinal compression of the patient’s thumb along the line of the first metacarpal causes pain at the site of the scaphoid
Thoracic outlet Syndrome
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
Thoracic outlet syndrome: three common sites of compression
• Scaleni
• Reduction in costoclavicular space • Accessory (cervical) rib
• Pectoralis minor
Thoracic outlet syndrome: symptoms
- Vascular (subclavian artery)
• Vascular insufficiency sx’s to the upper limb esp. hand - 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??
Fibrocartilage disc: what is it?
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
