Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

of

Wrist pain: making the diagnosis Slide 1 Wrist pain: making the diagnosis Slide 2 Wrist pain: making the diagnosis Slide 3 Wrist pain: making the diagnosis Slide 4 Wrist pain: making the diagnosis Slide 5 Wrist pain: making the diagnosis Slide 6 Wrist pain: making the diagnosis Slide 7 Wrist pain: making the diagnosis Slide 8 Wrist pain: making the diagnosis Slide 9 Wrist pain: making the diagnosis Slide 10 Wrist pain: making the diagnosis Slide 11 Wrist pain: making the diagnosis Slide 12 Wrist pain: making the diagnosis Slide 13 Wrist pain: making the diagnosis Slide 14 Wrist pain: making the diagnosis Slide 15 Wrist pain: making the diagnosis Slide 16 Wrist pain: making the diagnosis Slide 17 Wrist pain: making the diagnosis Slide 18 Wrist pain: making the diagnosis Slide 19 Wrist pain: making the diagnosis Slide 20 Wrist pain: making the diagnosis Slide 21 Wrist pain: making the diagnosis Slide 22 Wrist pain: making the diagnosis Slide 23 Wrist pain: making the diagnosis Slide 24 Wrist pain: making the diagnosis Slide 25 Wrist pain: making the diagnosis Slide 26 Wrist pain: making the diagnosis Slide 27 Wrist pain: making the diagnosis Slide 28 Wrist pain: making the diagnosis Slide 29 Wrist pain: making the diagnosis Slide 30 Wrist pain: making the diagnosis Slide 31 Wrist pain: making the diagnosis Slide 32 Wrist pain: making the diagnosis Slide 33 Wrist pain: making the diagnosis Slide 34 Wrist pain: making the diagnosis Slide 35 Wrist pain: making the diagnosis Slide 36 Wrist pain: making the diagnosis Slide 37 Wrist pain: making the diagnosis Slide 38 Wrist pain: making the diagnosis Slide 39 Wrist pain: making the diagnosis Slide 40 Wrist pain: making the diagnosis Slide 41 Wrist pain: making the diagnosis Slide 42 Wrist pain: making the diagnosis Slide 43 Wrist pain: making the diagnosis Slide 44 Wrist pain: making the diagnosis Slide 45 Wrist pain: making the diagnosis Slide 46 Wrist pain: making the diagnosis Slide 47 Wrist pain: making the diagnosis Slide 48 Wrist pain: making the diagnosis Slide 49 Wrist pain: making the diagnosis Slide 50 Wrist pain: making the diagnosis Slide 51 Wrist pain: making the diagnosis Slide 52 Wrist pain: making the diagnosis Slide 53 Wrist pain: making the diagnosis Slide 54 Wrist pain: making the diagnosis Slide 55 Wrist pain: making the diagnosis Slide 56 Wrist pain: making the diagnosis Slide 57 Wrist pain: making the diagnosis Slide 58 Wrist pain: making the diagnosis Slide 59 Wrist pain: making the diagnosis Slide 60 Wrist pain: making the diagnosis Slide 61 Wrist pain: making the diagnosis Slide 62 Wrist pain: making the diagnosis Slide 63 Wrist pain: making the diagnosis Slide 64 Wrist pain: making the diagnosis Slide 65 Wrist pain: making the diagnosis Slide 66 Wrist pain: making the diagnosis Slide 67 Wrist pain: making the diagnosis Slide 68 Wrist pain: making the diagnosis Slide 69 Wrist pain: making the diagnosis Slide 70 Wrist pain: making the diagnosis Slide 71 Wrist pain: making the diagnosis Slide 72 Wrist pain: making the diagnosis Slide 73 Wrist pain: making the diagnosis Slide 74 Wrist pain: making the diagnosis Slide 75 Wrist pain: making the diagnosis Slide 76 Wrist pain: making the diagnosis Slide 77 Wrist pain: making the diagnosis Slide 78 Wrist pain: making the diagnosis Slide 79 Wrist pain: making the diagnosis Slide 80 Wrist pain: making the diagnosis Slide 81 Wrist pain: making the diagnosis Slide 82 Wrist pain: making the diagnosis Slide 83 Wrist pain: making the diagnosis Slide 84 Wrist pain: making the diagnosis Slide 85
Upcoming SlideShare
Types of injuries
Next
Download to read offline and view in fullscreen.

9 Likes

Share

Download to read offline

Wrist pain: making the diagnosis

Download to read offline

The Arm Clinic (Manchester) teaching programme lecture on how to diagnose wrist problems.

Related Books

Free with a 30 day trial from Scribd

See all

Related Audiobooks

Free with a 30 day trial from Scribd

See all

Wrist pain: making the diagnosis

  1. 1. Wrist Pain: making the diagnosis Adam C Watts Consultant Upper Limb Surgeon, Wrightington Hospital Visiting Professor, University of Manchester
  2. 2. Overview • Anatomy and biomechanics • Examination tips • Pathology • Clinical examination practical
  3. 3. Contributors to Stability • Bone architecture • Structural • Ligaments • Structural • Sensory • Musculotendinous units • Dynamic
  4. 4. 11 11 The Wrist
  5. 5. 12 12 The Wrist
  6. 6. Torque Suspension
  7. 7. ROW COLUMN
  8. 8. DART THROWERS MOTION
  9. 9. Making the diagnosis: examination tips • Palpation is key
  10. 10. Scaphoid fracture: making the diagnosis • X-ray • Limited sequence MRI
  11. 11. 37 www.wrightington.com Aim of treatment of scaphoid fractures Primary Achieve sound union Secondary shortest time with lowest risk and disruption to patient 37
  12. 12. 38 www.wrightington.com Cast immobilisation Inconvenient Muscle atrophy Joint stiffness 38 Low risk Low cost
  13. 13. 39 www.wrightington.com Screw fixation Early return to function 39 Higher direct costs Greater risks
  14. 14. 40 www.wrightington.com Decision Making Scaphoid tubercle fracture 40
  15. 15. 41 www.wrightington.com Decision Making Trans-scaphoid perilunate dislocation 41
  16. 16. 42 www.wrightington.com Decision Making Proximal pole fracture 42
  17. 17. 43 www.wrightington.com 43
  18. 18. 44 www.wrightington.com 5 Questions Yes to any consider surgery 1.Is there an associated ipsilateral wrist injury? 2.Is there a proximal pole fracture? 3.Is there a waist fracture that is displaced on scaphoid series radiographs? 4.Is there a waist fracture that is shown to have more than 2mm displacement on CT/MRI? 5.Is there a waist fracture that is shown to have up to 2mm displacement in an individual who requires early wrist motion? 44
  19. 19. Scapholunate Ligament
  20. 20. Scapholunate < 3mm
  21. 21. Investigation
  22. 22. Scapholunate
  23. 23. Investigation • XR • Stress Radiograph • CT • Arthrogram • MRI • MR Arthrogram • Arthroscopy
  24. 24. Partial and Dynamic – a new way!
  25. 25. Robert Kienbock • 1910 • ? AVN of lunate • Blood supply • Dorsal • Volar • Internal Anastamosis (Lee Acta Orthop Scand 1963)
  26. 26. Aetiology • Raised Intra-Osseous Pressure • secondary to altered biomechanics • Ulnar minus • Hulten 1928 – Normal population 23% ulnar minus, 50% neutral – 18/23 Kienbock’s patients ulnar minus – 5/23 Ulnar neutral • Lunate Shape (Zapico 1966) • Multifactorial
  27. 27. Diagnosis • Presentation • Males 20-40 years • Pain • Tenderness • Swelling dorsally over lunate • Limitation of movement • Reduced grip strength • Rarely » Carpal tunnel » Extensor tendon rupture • Radiology • plain radiographs • MRI • CT
  28. 28. Lichtman Classification 0 Abnormal signal on MRI 1 Linear or compression fracture on X-ray 2 Increased lunate density on X-ray 3 Lunate collapse A) No carpal collapse B) Carpal collapse 4 OA changes present Lichtman, Hand Clinics 1993
  29. 29. Non-operative Treatment • Cast Immobilisation (6-12/52) • Progressive lunate deformity • Progressive carpal collapse • However radiological signs do not correlate with symptoms • up to 80% may be asymptomatic – May be appropriate for children under the age of 12 years
  30. 30. Operative • Joint Levelling - Radial Shortening • Unloading lunate • Carpus left undisturbed • Good outcomes in long term studies • 2mm-4mm shortening is enough (Trumble) • BUT can produce DRUJ incongruity – Outcome good at a minimum of 16 years (Raven CORR 2007, level 4) • 90% grip strength • Mean Pain score 2.4, Mean DASH 14
  31. 31. Radial Decompression
  32. 32. Operative • Capitate Shortening (Almquist Hand Clin 1993) • Review of 14 cases in Lichtman grade II or IIIA disease showed good outcomes at an average of 41 months (Waitayawinyu et al JHS 2008) • Capitate-Hamate Arthrodesis (Inoue Acta Orthop Scand 1992) • Scaphocapitate arthrodesis (Sennwald JHS-Am 1995)
  33. 33. Salvage Procedures • Proximal Row Carpectomy • Less pain, 72% grip strength, movement unchanged or better (Begley JHS-Am 1994, level 4) • results maintained to 15 years (Lumsden JHS-Am 2008, level 4)
  34. 34. Salvage Procedures • Wrist Arthrodesis • Better long term outcome than limited fusion (Tambe Int Orthop 2005, Level 3)
  35. 35. Summary
  36. 36. ECU Instability / tendinopathy • Hypersupination of forearm • Voluntary contraction of ECU • Ulnar deviation of wrist • Flexion
  37. 37. Anatomy
  38. 38. Anatomy
  39. 39. Presentation • Symptoms – Young athletes – Racket or stick sports – Painful snapping – Clicking over dorso-ulnar wrist during rotation – Acute – Chronic • Signs: – Ice cream scoop test – ECU synergy test
  40. 40. Hayton Ice cream scoop test
  41. 41. ECU synergy test
  42. 42. Investigations • Ultrasound MacLennan et al JHSa 2008
  43. 43. MRI scan • Allende & Le Viet 2005
  44. 44. Management • Conservative – Rest – NSAIDs – Physiotherapy – Local steroid – Splint Immobilisation – Plaster (Patterson 2011) long-arm cast elbow flexed 90°, wrist 30° extension, radial deviation, and pronation
  45. 45. Operative • Symptomatic subluxation or dislocation • Direct repair (Inoue) in acute cases (Radial) • But sheath retraction and tendon thickening • Osteo-fibrous sheath Reconstruction: – Retinaculum flap – FCU tendon – Free graft – Deepening of the groove
  46. 46. Linea Jugata
  47. 47. 79 www.wrightington.com 79 Ulnar Sided Wrist Pain -TFCC
  48. 48. www.wrightington.com
  49. 49. www.wrightington.com
  50. 50. Hook of Hamate Fracture
  51. 51. Physeal arrest in gymnast www.wrightington.com
  52. 52. Summary • History and examination give diagnosis in most cases • Non-operative treatment often effective • Surgery when not settling is aided by good rehab. www.wrightington.com
  53. 53. Wrist Pain – making the diagnosis. Prof. Adam C Watts
  • GeetanPathak

    Dec. 16, 2020
  • vireeshgadgimath

    Dec. 2, 2020
  • ankitjose

    Oct. 30, 2020
  • PriyadharshiniUp

    Apr. 30, 2020
  • KimSunGo1

    Jun. 27, 2018
  • alisharifi21

    Mar. 14, 2018
  • bstuananh83

    May. 19, 2017
  • AmanyElsharkawy

    Mar. 29, 2017
  • HilaryEvansKay

    Mar. 24, 2016

The Arm Clinic (Manchester) teaching programme lecture on how to diagnose wrist problems.

Views

Total views

2,378

On Slideshare

0

From embeds

0

Number of embeds

16

Actions

Downloads

84

Shares

0

Comments

0

Likes

9

×