1.
Wrist Pain: making the diagnosis
Adam C Watts
Consultant Upper Limb Surgeon, Wrightington
Hospital
Visiting Professor, University of Manchester

2.
Overview
• Anatomy and biomechanics
• Examination tips
• Pathology
• Clinical examination practical

3.
Contributors to Stability
• Bone architecture
• Structural
• Ligaments
• Structural
• Sensory
• Musculotendinous units
• Dynamic

4.
11 11
The Wrist

5.
12 12
The Wrist

6.
Torque Suspension

7.
ROW
COLUMN

8.
DART THROWERS MOTION

9.
Making the diagnosis: examination tips
• Palpation is key

10.
Scaphoid fracture: making the
diagnosis
• X-ray
• Limited sequence MRI

11.
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Aim of treatment of scaphoid fractures
Primary
Achieve sound
union
Secondary
shortest time with
lowest risk and
disruption to
patient
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Cast immobilisation
Inconvenient
Muscle
atrophy
Joint
stiffness
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Low risk
Low cost

13.
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Screw fixation
Early
return to
function
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Higher direct
costs
Greater risks

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Decision Making
Scaphoid tubercle fracture
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Decision Making
Trans-scaphoid perilunate dislocation
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Decision Making
Proximal pole fracture
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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?
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19.
Scapholunate Ligament

20.
Scapholunate
< 3mm

21.
Investigation

22.
Scapholunate

23.
Investigation
• XR
• Stress Radiograph
• CT
• Arthrogram
• MRI
• MR Arthrogram
• Arthroscopy

24.
Partial and Dynamic – a new way!

25.
Robert Kienbock
• 1910
• ? AVN of lunate
• Blood supply
• Dorsal
• Volar
• Internal Anastamosis
(Lee Acta Orthop Scand 1963)

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.
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.
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.
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.
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.
Radial Decompression

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.
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.
Salvage Procedures
• Wrist Arthrodesis
• Better long term
outcome than
limited fusion
(Tambe Int Orthop
2005, Level 3)

35.
Summary

36.
ECU Instability / tendinopathy
• Hypersupination of forearm
• Voluntary contraction of ECU
• Ulnar deviation of wrist
• Flexion

37.
Anatomy

38.
Anatomy

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.
Hayton Ice cream scoop test

41.
ECU synergy test

42.
Investigations
• Ultrasound
MacLennan et al JHSa 2008

43.
MRI scan
• Allende & Le Viet 2005

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.
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.
Linea Jugata

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Ulnar Sided Wrist Pain -TFCC

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50.
Hook of Hamate Fracture

51.
Physeal arrest in gymnast
www.wrightington.com

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.
Wrist Pain – making the diagnosis. Prof. Adam C Watts