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
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(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
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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:
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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
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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.