Carpometacarpal Osteoarthritis <ul><li>Trapezio- metacarpal  joint is the commonest to be affected in postmenopausal women...
<ul><li>Plain X-ray:  Shows classical features of OA. </li></ul><ul><li>Treatment: </li></ul><ul><li>Conservative : { Rest...
De Quervain's Disease <ul><li>Pathology: </li></ul><ul><li>Thickening of the sheath around the tendons this initiated by o...
Clinical features   <ul><li>Women  aged 40-50 years, also in pregnancy. </li></ul><ul><li>Gradual pain at the radial side ...
Treatment   <ul><li>Conservative:  Early stages with splintage and local long acting steroid injection. </li></ul><ul><li>...
Ganglion Cysts (Dorsal Ganglion) <ul><li>Commonest cause of localized swelling around the wrist. </li></ul><ul><li>Patholo...
Treatment   <ul><li>Conservative:  It is safe to be left, some time disappear spontaneously. </li></ul><ul><li>Operative: ...
Carpal Tunnel Syndrome   <ul><li>Compression and ischemia of the median nerve as it passes through the carpal tunnel at th...
Causes   <ul><li>Most of the cases no definite cause. </li></ul><ul><li>Pregnancy. </li></ul><ul><li>Rheumatoid arthritis....
Clinical features   <ul><li>{ Pain ,  Sensory  changes and  Motor  disturbances} </li></ul><ul><li>Young & middle age, ♀-♂...
Examination  <ul><ul><li>Late:  Diminished sensation at median nerve distribution. </li></ul></ul><ul><ul><li>Late:   Obvi...
Investigations  (Confirm)  <ul><li>Plain X-ray:  Exclude bony problems. </li></ul><ul><li>Nerve conduction studies : Decre...
Treatment   <ul><li>Definitive treatment is surgery (carpal tunnel release): </li></ul><ul><li>Through a volar incision, t...
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Orthopedics 5th year, 4th lecture/part two (Dr. Ariwan)

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The lecture has been given on Feb. 16th, 2011 by Dr. Ariwan.

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Orthopedics 5th year, 4th lecture/part two (Dr. Ariwan)

  1. 1. Carpometacarpal Osteoarthritis <ul><li>Trapezio- metacarpal joint is the commonest to be affected in postmenopausal women in combination with heberden's nodes of the DIP joints. </li></ul><ul><li>Clinical features: </li></ul><ul><li>Usually bilateral and part of generalized OA. </li></ul><ul><li>Middle age women. </li></ul><ul><li>Diffuse pain around thumb base. </li></ul><ul><li>Weak pinch and grip. </li></ul><ul><li>Tender swollen joint, adducted, grinding test painful. </li></ul>
  2. 2. <ul><li>Plain X-ray: Shows classical features of OA. </li></ul><ul><li>Treatment: </li></ul><ul><li>Conservative : { Rest, NSAID, Temporary splintage}. </li></ul><ul><li>Operative: {Excision and replacement by silicone spacer, Arthrodeses}. </li></ul>
  3. 3. De Quervain's Disease <ul><li>Pathology: </li></ul><ul><li>Thickening of the sheath around the tendons this initiated by over use or spontaneously. </li></ul><ul><li>Inflammation of the synoveal lining </li></ul><ul><li>Tenosynovits of the first extensor wrist compartment containing tendons of (extensor polices brevis and abductor polices longus) . </li></ul>
  4. 4. Clinical features <ul><li>Women aged 40-50 years, also in pregnancy. </li></ul><ul><li>Gradual pain at the radial side of the wrist. </li></ul><ul><li>History of unaccustomed activities. </li></ul><ul><li>Tenderness over the radial styloid. </li></ul><ul><li>Swelling and thickening over the distal radius. </li></ul><ul><li>Finkelstein's test is pathognomonic. </li></ul>
  5. 5. Treatment <ul><li>Conservative: Early stages with splintage and local long acting steroid injection. </li></ul><ul><li>Operative: Resistant cases; slitting the thickened tendon sheath, be careful not to injure the superficial branch of radial nerve . </li></ul>
  6. 6. Ganglion Cysts (Dorsal Ganglion) <ul><li>Commonest cause of localized swelling around the wrist. </li></ul><ul><li>Pathology: </li></ul><ul><li>Leakage of synoveal fluid from a joint or tendon sheath contains glairy, viscous gelatinous fluid. </li></ul><ul><li>Clinical features: </li></ul><ul><li>Young adult. </li></ul><ul><li>Progressively enlarging painless lump. </li></ul><ul><li>Commonest site s the dorsum, less common volar near the radial artery </li></ul><ul><li>Well defined, cystic, not tender, transilluminated. </li></ul>
  7. 7. Treatment <ul><li>Conservative: It is safe to be left, some time disappear spontaneously. </li></ul><ul><li>Operative: If very large, painful, compress nearby nerve; surgical excision. </li></ul><ul><li>Never give promise that it will not recurs. </li></ul>
  8. 8. Carpal Tunnel Syndrome <ul><li>Compression and ischemia of the median nerve as it passes through the carpal tunnel at the wrist joint. </li></ul><ul><li>Anatomy: Carpal tunnel is oval in shape bounded posteriorly by the carpal bones, anteriorely by the transverse carpal ligament. </li></ul><ul><li>Contents : </li></ul><ul><li>Median nerve. </li></ul><ul><li>Tendons of flexor digitorum superficials. </li></ul><ul><li>Tendons of flexor digitorum profundus. </li></ul><ul><li>Tendon of flexor polices longus. </li></ul><ul><li>Branch of the radial artery. </li></ul>
  9. 9. Causes <ul><li>Most of the cases no definite cause. </li></ul><ul><li>Pregnancy. </li></ul><ul><li>Rheumatoid arthritis. </li></ul><ul><li>Trauma: </li></ul><ul><li>Fractures around the wrist {Colle's, Smith's, Barton's, Scaphoid}. </li></ul><ul><li>Dislocations {Lunate, Perilunate}. </li></ul><ul><li>Soft tissue injuries. </li></ul><ul><ul><li>Occupational {carpenters, pneumatic drill users, typewriters, PC users}. </li></ul></ul><ul><li>Local tumors {Ganglion, Fibroma, Lipoma, Osteoma…}. </li></ul><ul><li>Hormonal disorders {DM, Myxodema…}. </li></ul>
  10. 10. Clinical features <ul><li>{ Pain , Sensory changes and Motor disturbances} </li></ul><ul><li>Young & middle age, ♀-♂ ratio is 8:1 . </li></ul><ul><li>Pain in the radial side of the hand, radiating to elbow or shoulder, usually at night awaking the patient, relieved by shaking the hand and lifting it up. </li></ul><ul><li>Parasthesia & numbness along the median nerve distribution. </li></ul><ul><li>Weakness and </li></ul><ul><li>clumsiness in the hand. </li></ul>
  11. 11. Examination <ul><ul><li>Late: Diminished sensation at median nerve distribution. </li></ul></ul><ul><ul><li>Late: Obvious wasting of the thener muscles especially abductor pllicis brevis {Shelf Sign}. </li></ul></ul><ul><ul><li>Flexion of the wrist for a wile causes numbness and parasthesia in the median nerve distribution {Phallen's Test}. </li></ul></ul><ul><ul><li>Tapping the median nerve,sensation of electric shock in its distribution {Tinel's Sign}. </li></ul></ul>
  12. 12. Investigations (Confirm) <ul><li>Plain X-ray: Exclude bony problems. </li></ul><ul><li>Nerve conduction studies : Decreased conduction velocity in the affected part. </li></ul><ul><li>Electromyography: Deinnervation potentials. </li></ul>
  13. 13. Treatment <ul><li>Definitive treatment is surgery (carpal tunnel release): </li></ul><ul><li>Through a volar incision, the transverse carpal ligament is incised and the nerve decompressed, this done under general or regional anesthesia, followed by physiotherapy. </li></ul><ul><li>Conservative therapy: when surgery is contraindicated, as in pregnancy and its only temporary {Splintage, Analgesics, Local steroid injection (dangerous)}. </li></ul><ul><li>Recently carpal tunnel release is an endoscopic procedure. </li></ul>

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