The wrist - muhadharaty.com
Download
Report
Transcript The wrist - muhadharaty.com
THE WRIST
symptoms
Pain:
eg. Localized to radial side; tenosinovitis of the
thumb tendons (De Quervain’s disease).
Localized to ulnar side; inferior radio-ulnar joint
disorders.
Swelling:
Of joints; eg rheumatoid arthritis.
Of tendons; tenosynovitis.
Localized; eg ganglion.
Stiffness.
Deformity: trauma, nerve injury (eg wrist drop).
Loss of function; decreased grip strength.
Signs
Look:
Skin; scars or sinuses.
Deformity, swelling.
Feel:
Warmth.
Tender points: tip of radial styloid in de
Quervain’s disease.
Claw hand of ulnar nerve
injury
Volkman’s ischemic
contracture
Swelling: tumor of the wrist
Wrist drop
Move: look for limitation of ROM
Passive: dorsi- and plantarflexion; press wrists
against each other.
Radial and ulnar deviation.
Pronation and supination.
Active: decreased in tendon rupture, nerve
injury, painful conditions.
Power grip- squeeze examiner’s hand.
Radiological evaluation
Lateral radiograph
Radial club hand
Partial or complete absence of the radius with
radial deviation of the hand.
May be associated with other congenital
anomalies or blood dyscrasias (eg
thrombocytopenia).
Treated by serial manipulation and casting
then surgical correction.
Radial club hand
Madelung deformity
Forward curvature of the lower radius and
backward subluxation of the lower ulna.
Cause: congenital or post-traumatic.
If symptomatic treated by radial osteotomy.
Instability of distal
radioulnar joint
Post-traumatic; after fracture of lower radius
(Galeazzi fracture dislocation).
Associated with rheumatoid arthritis.
Painful restriction of pronation and
supination.
Backward prominence of the lower ulna.
Piano key sign; balloting the lower ulna.
Kienbӧck’s disease
Ischemic necrosis of the lunate bone.
Associated with excessive loading of the
lunate.
Clinical features:
Pain and stiffness of the wrist.
Tenderness over the lunate bone.
Limitation of movement.
Kienbӧck’s disease
4 stages:
Ischemia without changes, normal x-ray, MRI
changes.
II. Trabecular necrosis, new bone formation, x-ray
show increased density.
III. Bone collapse; x-ray show small irregular lunate
bone.
IV. Secondary OA of the wrist.
I.
Kienbӧck’s disease
Early: splintage for 6-12 weaks.
Late: surgical treatment eg, wrist
arthrodesis.
De Quervain’s disease
Thickening of synovial sheath around
extensor polices brevis and abductor polices
longus in the first extensor compartment due
to overuse.
DE Quervain’s disease
De Quervain’s disease
Clinical features:
Middle aged, women > men.
Pain on radial side of the wrist.
Tenderness over the radial styloid.
Fenkelstein’s test; pain over the radial styloid
induced by flexing the thumb in the palm and
abduction of the wrist.
Tratment:
Splintage and corticosteroid injection locally.
Surgical slitting of the thickened synovium.
Swellings around the wrist:
Ganglion
Most common swelling around the wrist.
Leakage of synovium from joint or tendon
sheath.
Cyst containing glairy viscous fluid.
Usually on dorsum of the scapholunate
ligament.
Ganglion
Ganglion
Clinical features:
Swelling usually on the dorsum of the wrist.
Does not move with tendons.
Sometimes alongside radial artery.
Treatment:
Usually unnecessary.
If troublesome; surgical excision but recurrence is
possible.
Carpal tunnel syndrome
Entrapment neuropathy of the median nerve
under the transverse carpal ligament.
Compression and ischemia of the nerve.
Cause;
Idiopathic in most of cases.
Associated with: pregnancy, menopause,
rheumatoid arthritis, myxedema, chronic renal
failure, gout…
Carpal tunnel syndrome
Clinical features:
Age 40-50 years.
Female: male ratio 8:1
Pain and paresthesia in 3 and ½ radial fingers.
Burning, tingling and numpness.
Wake up the patient at nigtht.
Releived by shaking.
Weakness and clumpsiness in doing fine
movements (eg fastening bottoms).
Carpal tunnel syndrome
Carpal tunnel syndrome
Examination:
Tinel sign: symptoms reproduced by tapping over
the median nerve.
Phalen’s test: holding the wrist fully flexed for a
minute.
Wasting of thenar muscles.
Weakness in thumb abduction.
Paresthesia in median nerve territory.
Tinnel sign
Phalen test
Wasting of thenar muscles
Carpal tunnel syndrome
Electrodiagnosis for difficult cases.
Cervical spondylosis and radiculopathy is a
differential diagnosis.
Treatment
Light splint at night relieve night pain.
Corticosteroid injection in the carpal tunnel.
Surgical division of the transverse carpal
ligament.