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A TO Z of Wrist complex by usman


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wrist complex

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A TO Z of Wrist complex by usman

  1. 1. The Wrist Complex PRESENTED BY : USMAN FAROOQ
  2. 2. The Wrist Complex  The wrist (carpus) consists of two compound joints:  The radiocarpal and the  midcarpal joints, referred to collectively as the wrist complex
  3. 3. Wrist Complex
  4. 4.  The shoulder serves as a dynamic base of support; the elbow allows the hand to approach or extend away from the body; and the forearm adjusts the approach of the hand to an object.  The major contribution of the wrist complex seems to be to control length-tension relationships in the multi articular hand muscles and to allow fine adjustment of grip.
  5. 5.  The wrist has been called the most complex joint of the body, from both an anatomic and physiologic perspective.  The wrist complex as a whole is considered to be biaxial, with motions of  extension/flexion around a coronal axis  ulnar deviation/radial deviation around an anteroposterior axis.
  6. 6. Normal ranges are cited as  Wrist flexion, 65 to 85  extension 60 to85 ,  radial deviation 15 to 21  ulnar deviation 20 to 45
  7. 7. Radiocarpal Joint Structure  The radiocarpal joint is formed by the radius and radioulnar disk as part of the triangular fibrocartilage complex (TFCC) proximally and by the scaphoid, lunate, and triquetrum distally
  8. 8. Triangular fibrocartilage complex (TFCC)  The TFCC is essentially comprised of the fibrocartilage disc interposed between the medial proximal row and the distal ulna within the medial aspect of the wrist  The primary function of the TFCC is to improve joint congruency and to cushion against compressive forces  The TFCC transmits about 20% of the axial load from the hand to the forearm
  9. 9. Anatomy  The Wrist  Comprised of the distal radius and ulna, eight carpal bones, and the bases of five metacarpals  The carpal bones lie in two transverse rows  The proximal row contains (lateral to medial) the scaphoid (navicular), lunate, triquetrum, and pisiform  The distal row holds the trapezium, trapezoid, capitate, and hamate
  10. 10. Anatomy  Mid Carpal Joints  The midcarpal joint lies between the two rows of carpals  A ‘compound’ articulation because each row has both a concave and convex segment  The proximal row of the carpals is convex laterally and concave medially.  The scaphoid, lunate, trapezium trapezoid, and triquetrum present with a concave surface to the distal row of carpals
  11. 11. Anatomy  Carpal Ligaments  The major ligaments of the wrist include the palmar intrinsic ligaments, and the dorsal extrinsic and intrinsic ligaments  The extrinsic palmar ligaments provide the majority of the wrist stability  The intrinsic ligaments serve as rotational restraints, binding the proximal row into a unit of rotational stability
  12. 12. Anatomy  Radiocarpal Joint  Formed by the large articular concave surface of the distal end of the radius, the scaphoid and lunate of the proximal carpal row, and the TFCC
  13. 13. Anatomy  Antebrachial Fascia  A dense connective tissue ‘bracelet’ that encases the forearm and maintains the relationships of the tendons that cross the wrist
  14. 14. Anatomy  The Extensor Retinaculum  This retinaculum serves to prevent the tendons from ‘bow-stringing’ when the tendons turn a corner at the wrist
  15. 15. Anatomy  The extensor retinaculum compartments, from lateral to medial, contain the tendons of:  Abductor pollicis longus and extensor pollicis brevis  Extensor carpi radialis longus and brevis  Extensor pollicis longus  Extensor digitorum and indicis  Extensor digiti minimi  Extensor carpi ulnaris
  16. 16. Anatomy  The Flexor Retinaculum  Transforms the carpal arch into a tunnel, through which pass the median nerve and some of the tendons of the hand  Proximally, the retinaculum attaches to the tubercle of the scaphoid and the pisiform  Distally it attaches to the hook of the hamate, and the tubercle of the trapezium  In the condition known as ‘carpal tunnel syndrome’ the median nerve is compressed in this relatively unyielding space
  17. 17. Anatomy  Carpal Tunnel  Serves as a conduit for the median nerve and nine flexor tendons  The palmar radiocarpal ligament and the palmar ligament complex form the floor of the canal  The roof of the tunnel is formed by the flexor retinaculum (transverse carpal ligament)  The ulnar and radial borders are formed by carpal bones (trapezium and hook of hamate respectively)  Within the tunnel, the median nerve divides into a motor branch and distal sensory branches
  18. 18. Anatomy  Tunnel of Guyon  A depression superficial to the flexor retinaculum, located between the hook of the hamate and the pisiform bones  The palmar (volar) carpal ligament, palmaris brevis muscle, and the palmar aponeurosis form its roof  Its floor is formed by the flexor retinaculum (transverse carpal ligament), pisohamate ligament, and pisometacarpal ligament  The tunnel serves as a passage way for the ulnar nerve and artery into the hand
  19. 19. Biomechanics  The wrist contains several segments whose combined movements create a total range of motion that is greater than the sum of its individual parts
  20. 20. Biomechanics  Pronation  Approximately 90° of forearm pronation is available  During pronation, the concave ulnar notch of the radius glides around the peripheral surface of the relatively fixed convex ulnar head  Pronation is limited by the bony impaction between the radius and the ulna
  21. 21. Biomechanics  Supination  Approximately 85-90° of forearm supination is available  Supination is limited by the interosseous membrane, and the bony impaction between the ulnar notch of the radius, and the ulnar styloid process
  22. 22. Biomechanics  Wrist flexion and extension  The movements of flexion and extension of the wrist are shared among the radiocarpal articulation, and the intercarpal articulation, in varying proportions
  23. 23. Biomechanics  Wrist flexion and extension  During wrist flexion, most of the motion occurs in the midcarpal joint (60% or 40° versus 40% or 30° at the radiocarpal joint), and is associated with slight ulnar deviation and supination of the forearm  During wrist extension, most of the motion occurs at the radiocarpal joint (66.5% or 40° versus 33.5% or 20° at the midcarpal joint), and is associated with slight radial deviation and pronation of the forearm
  24. 24. Biomechanics  Radial Deviation  Radial deviation occurs primarily between the proximal and distal rows of the carpal bones  The motion of radial deviation is limited by impact of the scaphoid onto the radial styloid, and ulnar collateral ligament
  25. 25. Biomechanics  Ulnar deviation  Ulnar deviation occurs primarily at the radiocarpal joint  Ulnar deviation is limited by the radial collateral ligament
  26. 26. Clinical Examination of the Wrist Joint
  27. 27. HISTORY  Age  Chief complaint  Occupation  Previous injury  Previous surgery  What exacerbates  What improves  Frequency  Duration
  28. 28. HISTORY  4 principle mechanisms of injury  Throwing  Weight bearing  Twisting  Impact
  29. 29. PHYSICAL EXAM  Inspection  Palpation  Range of Motion  Neurologic Exam  Special Tests
  30. 30. Ganglion  Cystic structure that arises from synovial sheath  Discrete mass  Dull ache  Dorsal or Volar aspect
  31. 31. RANGE OF MOTION  Active range of motion  Passive range of motion if unable to actively move joint  Bliateral comparison  To determine degrees of restriction
  32. 32. RANGE OF MOTION Wrist  Flexion  Extension  Radial deviation  Ulnar deviation  Ulnar deviation is greater than radial
  33. 33. PALPATION of Wrist Dorsum  Radial Styloid  Scaphoid  1st MC/Trapezium jt  Lunate  Lister’s Tubercle  Ulnar Styloid  TFCC  Triquetrum  Pisiform  Hook of Hamate  Guyon’s Tunnel
  34. 34. Radial Styloid palpation Scaphoid Bone palpation Radial styloid
  35. 35. Scaphoid Fracture  Most commonly fractured carpal bone  70-80% of all carpal bone injuries  8% of all sports related fractures  1 in 100 college football players  Most susceptible to injury  Bridges proximal and distal rows of the carpal bones  Load to the dorsiflexed wrist as in fall onto outstretched hand
  36. 36. Scaphoid Fracture  Painful, swollen wrist after a fall  Tenderness in snuffbox  High frequency of nonunion and avascular necrosis  Initial x-rays often unremarkable
  37. 37. 1st MC/Trapezium joint palpation
  38. 38. Lunate Bone palpation
  39. 39. Scapholunate Dissociation  Diagnosis often missed  Pain, swelling, and decreased ROM  Pressure over scaphoid tuberosity elicits pain  Greatest pain over dorsal scapholunate area, accentuated with dorsiflexion  X-ray shows widening of scapholunate joint space by at least 3 mm
  40. 40. Ulnar Styloid palpation Lister’s Tubercle palpation Ulnar styloid
  41. 41. Triangular Fibro-Cartilage Complex palpation (TFCC)
  42. 42. Triangular Fibrocartilage Complex Injuries  Thickened pad of connective tissue that functions as a cushion for the ulnar carpus as well as a sling support for the lunate and triquetrum  Injury from compression between lunate and head of ulna  Breaking fall with hand  Rotational forces-racket and throwing sports
  43. 43. Triangular Fibrocartilage Complex Injuries  Ulnar sided wrist pain, swelling, loss of grip strength  “Click” with ulnar deviation  Point tenderness distal to ulnar styloid  TFCC load test
  44. 44. Carpal Tunnel  Deep to palmaris longus  Contains median nerve and finger flexor tendons  Most common overuse injury of the wrist
  45. 45. Carpal Tunnel Syndrome  Entrapment of the median nerve  Phalen’s and Tinel’s Test  2 point discrimination  Symptoms  Aching in hand and arm  Nocturnal or AM paresthesias  “Shaking” to obtain relief
  46. 46. Carpal Tunnel Tests  Neurologic exam  Median nerve sensation and motor  Phalen’s Test: both wrists maximally flexed for 1 minute  Tinel’s Test
  47. 47. NEUROLOGIC EXAM  Muscular assessment using grading system  Sensation testing  Bilateral comparison
  48. 48. NEUROLOGIC EXAM Muscle Testing  WRIST EXT C6 FLEX C7  FINGERS EXT C7 FLEX C8 ABD T1 ADD T1
  49. 49. Sensation Testing Dorsal hand Radial hand