Wrist pain: making the diagnosis
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1. The document discusses making diagnoses for various causes of wrist pain through thorough history taking and physical examination. 2. Key aspects to examine include palpating the wrist to identify sources of tenderness, and performing stress radiographs and MRI to diagnose ligament injuries or fractures when initial radiographs are inconclusive. 3. Treatment options are discussed for various conditions, including cast immobilization for most scaphoid fractures and surgical fixation for displaced fractures, as well as joint leveling procedures for Kienbock's disease and salvage procedures for advanced cases.
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Wrist pain: making the diagnosis
- 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
- 6. Contributors to Stability • Bone architecture • Structural • Ligaments • Structural • Sensory • Musculotendinous units • Dynamic
- 11. 11 11 The Wrist
- 12. 12 12 The Wrist
- 21. ROW COLUMN
- 23. Making the diagnosis: examination tips • Palpation is key
- 36. Scaphoid fracture: making the diagnosis • X-ray • Limited sequence MRI
- 37. 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
- 38. 38 www.wrightington.com Cast immobilisation Inconvenient Muscle atrophy Joint stiffness 38 Low risk Low cost
- 39. 39 www.wrightington.com Screw fixation Early return to function 39 Higher direct costs Greater risks
- 40. 40 www.wrightington.com Decision Making Scaphoid tubercle fracture 40
- 41. 41 www.wrightington.com Decision Making Trans-scaphoid perilunate dislocation 41
- 42. 42 www.wrightington.com Decision Making Proximal pole fracture 42
- 44. 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
- 47. Investigation
- 48. Scapholunate
- 49. Investigation • XR • Stress Radiograph • CT • Arthrogram • MRI • MR Arthrogram • Arthroscopy
- 50. Partial and Dynamic – a new way!
- 51. Robert Kienbock • 1910 • ? AVN of lunate • Blood supply • Dorsal • Volar • Internal Anastamosis (Lee Acta Orthop Scand 1963)
- 52. 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
- 53. 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
- 55. 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
- 56. 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
- 58. 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
- 60. 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)
- 61. 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)
- 62. Salvage Procedures • Wrist Arthrodesis • Better long term outcome than limited fusion (Tambe Int Orthop 2005, Level 3)
- 63. Summary
- 64. ECU Instability / tendinopathy • Hypersupination of forearm • Voluntary contraction of ECU • Ulnar deviation of wrist • Flexion
- 65. Anatomy
- 66. Anatomy
- 67. 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
- 68. Hayton Ice cream scoop test
- 69. ECU synergy test
- 70. Investigations • Ultrasound MacLennan et al JHSa 2008
- 71. MRI scan • Allende & Le Viet 2005
- 72. 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
- 73. 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
- 74. Linea Jugata
- 79. 79 www.wrightington.com 79 Ulnar Sided Wrist Pain -TFCC
- 82. Hook of Hamate Fracture
- 83. Physeal arrest in gymnast www.wrightington.com
- 84. 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
- 85. Wrist Pain – making the diagnosis. Prof. Adam C Watts