Wrist

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    Anatomy

    • Only radius articulates with carpal bones.
    • The ulna has a nonosseous fibrocartilaginous union with triquetrum and radius. (triangular fibrocartilate complex (TFCC)
    • Wrist contains:
      • Intrinsic ligaments: join carpal bones to one another
      • Extrisic ligaments: join carpal bones to radius, ulna, metacarpals.
      • Volar ligaments are stronger than dorsal counterparts. Injury to them results in carpal instability.
    • Carpals:
    • Screen shot 2013-08-26 at 11.02.24 PM.png

     

    • Fracture to either hamate or capitate may result in neurovascular bundle damage and subsequent impairment of normal function.
    • Exam/Surface Anatomy:
      • Hand deviate in radial direction and thumb extended: snuff box:
        • Extensor pollicis longus, extensor pollicis brevis, and abductor pollicis longus.
        • At proximal border of snuff box is radial styloid
      • Palpate dorsum of wrist for Lister's tubercle on distal radius.
        • Move up from the tubercle to indentation of skin -- that is the capitate.
        • Flex wrist, and can palpate lunate just below capitate
      • Triquetrum can be palpated just distal to ulnar styloid (lateral ulnar part).
      • Pisiform can be palpated at base of hypothenar eminence.  Flexor carpi ulnaris inserts into pisiform. (examine with clenched hand).
      • Hook of hamate palpated by placing IP joint of one's thumb over pisiform with distal phalanx directed towards webbed space.... with deep palpation in that position can palate fullness -- hook of hamate.
    • Imaging
      • Minimal:
        • PA
        • Lateral
        • Oblique
        • (in neutral position)
      • on PA view:
        • Identify three carpal arcs
          • 1st arch: proximal surface of scaphoid, lunate, triquetrum.
          • 2nd arch: distal joint surfaces of proximal row.
          • 3rd arch: proximal articular surface of lunate and hamate.
        • Any disruption in archs suggests injury (fracture, dislocation or both).
        • NOTE: spacing between carpals constant and is independent of wrist position.
        • Measurements:
          • Normal width between scaphoid and lunate is 1-2mm in AP
            • (Terry Thomas Sign - like space between his teeth - old news anchor).  >3mm suggests carpal instability.
        • photo (7).JPG
      • On lateral view:
        • See distal scaphoid, trapezium, trapezoid, and 1st+2nd CMC joints.
        • Inadequate lateral film if ulna projects >2mm dorsal to radius.
        • Dorsal avulsion fracture of triquetrum is only seen on lateral view.
        • Carpal alignment: 
          • Radius, Lunate, Capitate make up straight line.
        • KEY TO LATERAL VIEW: APPLE IN CUP:  Radius, lunate, capitate make up straight line.
          • normal lateral wrist schematic.jpg
        • Measurements:  (important to intercalated segment stability in carpal dislocation- see below)
          • Scapholunate angle: Line drawn through center of lunate and center of scaphoid should make 30-60°
          • Capitolunate angle: Line through center of capitate and lunate <30°
      • Other views:
        • Scaphoid view: PA view with maximum ulnar deviation.
        • Carpal tunnel view: detect hook of hamate and pisiform fractures. (Wrist hyperextended, and shoot beam across volar aspect).
        • Oblique film with hand supinated 45° allows view of  pisiform and palmar aspect of triquetrum and hamate.
      • 90% of fractures are seen in plain films.  CT + MRI are much better, but not routine.

     

    Carpal Fractures

    • Frequency:
      • 1. Scaphoid is most frequently fractured and most frequently missed.
      • 2. Triquetrum
      • 3. Lunate
    • Complications:
      • Other injuries: second fracture/ligamentous injury
      • Nerve Injury: Fractures of hook of hamate or pisiform may be complicated by ulnar nerve compromize.
      • Poor healing: Non-union and avascular necrosis common (especially scaphoid).  Need proper immobilization to minimize risk!!

     

    Scaphoid

    • Most commonly fractured carpal bone (60-70% of carpal injuries).
    • NOTE: Radial deviation or dorsiflexion of hand is normally limited by impingement of the scaphoid.  With stress, scaphoid fractures result.
    • Blood supply to the scaphoid penetrates the cortex on sursal surface near tubercle.
      • Therefore: no direct blood supply to the proximal scaphoid.
      • Tendency for non-union and avascular necrosis.
    • IMPORTANT: The more proximal the scaphoid fracture the greater likelihood that it will develop avascular necrosis.
    • Many pts with "sprained wrist" have occult scaphoid fracture.
      • Usually can be excluded on basis of examination.  
      • Imaging does NOT exclude fracture
    • Patients presenting with symptoms of sprained wrist must have scaphoid fracture rulled out (physical exam!!).
    • Fracture Classification:
      • 1. Middle Third (aka Waist) (70-80%)
      • 2. Proximal third (10-20%)
      • 3. Distal third (most occur in children)
      • 4. Tubercle
      • The more proximal the fracture line the higher incidence of complications:
        • proximal > waist > distal > tubercle.
    • Mechanism:
      • forceful hyperextension of the wrist.
      • Types depend on position of wrist (middle third #'s occur 2ndary to radial deviation - pinches the scaphoid waist against radial styloid).
    • On Exam:
      • Maximum tenderness over anatomical stuff box.
        • (90% sensitive for detecting scaphoid fractures, and 40% specificity)
      • Palpation scaphoid tubercle for tenderness
        • (87% sensitivity and 57% specificity)
        • Done by radially deviating the wirst and palpating over the palmar aspect of scaphoid.
    • Imaging: If suspected clinically: obtain an ulnar deviation film.
      • Often fracture not seen until 6weeks post-injury.
      • In a study: 30% of scaphoid fractures not demonstrated on any view in acute scenario
      • MRI is 100% sensitive for scaphoid fractures.
      • Fracture often involves displacement of distal fragment dorsally
        • Often proximal fragment and lunate well articulated with radius.
      • Do not confuse acute fracture with "bipartite scaphoid" and old non-unioned fracture (sclerotic fragment margins + radioluscent space btwn chronic fragments is similar to other carpals).
    • Treatment:
      • Controversial, many complications.
      • Immobilize (but best method controversial).
        • Use thumb-spica cast.
        • HUGE debate between short and long-arm cast.
          • (one study compared time to union (9.5w vs 12.7w) and rate of non-union.  Both variables favoured the long-arm cast, but results not very significant..debate continues.)
          • (Another study with 292 patients showed no benefit for immobilization of thumb - However many ortho surgeons still advocate thumb immobilization).
        • Treatment depends on three types of fractures:
          • 1. Clinically suspected scaphoid fracture without radiologic evidence
            • Up to 30% will ultimately diagnosed with scaphoid fracture.
            • Treat as scaphoid fracture..place in long-arm spica splint.
              • Thumb should be inposition as if pt holding wine glass.
              • Wrist splinted in slight flexion (NO ulnar or radial deviation).
            • After 7-10d repeat exam and xrays.
              • If fracture: use long-arm spica cast x4-5w then short-arm spica until union.
              • If no fracture found, but suspicious on exam: re-apply splint and re-examine 7-10d intervals.
              • Can use CT/MRI for dx.  Can use bone-scan, but high rate of false positives.  CT no better than bone scan.
                •  MRI is best!
          • 2. Nondisplaced scaphoid fracture
            • Long-arm spica splint.
            • Splint should extend from IP joint of thumb to area proximal to the elbow with elbow in 90d flexion.  
            • F/U with hand sugeon in 5-7d.
            • Can re-apply short-arm spica cast for 6 additional weeks.
            • D/C cast when union present.
            • NOTE: proximal-third fractures are immobilized for longer (12-16w) due to high rate of complications.
              • Many authors suggest surgery for proximal scaphoid fractures even if non-displaced b/c non-union common.  15% non-union after proper immobilization.
          • 3. Displaced Scaphoid Fractures:
            • Non-union rate of 50%
            • Put in splint and refer to surgery for ORIF
            • Absolute indications for ORIF:
              • 1mm or 15° of angulation.

     

    Distal Radius Fractures

    • Classified as:
      • Extension Fractures (Colles)
      • Flexion Fractures (Smith)
      • Push-off fractures (Hutchinson and Baron)
    • Take three measurements:
      • Volar Tilt: (1-23° with average of 11°)
        • Fractures with volar angulation ==> good functional recovery.
        • Dorsal angulation --> poor recovery.
      • Radial Tilt: (15-30°)
        • Radial tilt is essential to ulnar motion (ulnar deviation)
      • Radial Length:  (12mm)
        • Distance from tip of radial styloid to distal articular surface of ulna. 
        • Loss of radial length after closed reduction = surgery.
        • In a study, radial length (surgery) was more strongly correlated with improved functional status than radial or volar tilt.
    • Classification:
      • Many types, generally intra vs extra-articular.
      • However Fernandez and Juniper proposed classification to guide treatment.
        • Type I: Extra-articular metaphyseal bending fractures.
          • Colles (Dorsal angulation) and Smith (Volar Angulation)
        • Type II: Intra-articular shearing
          • Barton (dorsal or volar)
        • Type III: Intra-articular compression fractures.
          • Complex articular and radial pilon fractures.
        • Type IV: Avulsion fractures.  (Radiocarpal fracture/dislocations)
        • Type V: High-velocity mechanism with extensive injury.
      • Often complicated by ulnar styloid avusion fractures (ulnar collateral ligament complex avulses)
    • Treatment:
      • Type I: reduced by ER physician.
      • Type II-V: may undergo closed reduction, but recommended ortho surgeon performs reduction.
      • Absolute surgery criteria:
        • 2mm of articular offset
        • 10° dorsal tilt.
        • 3-5mm of radial shortening.

     

    Flexion-Type (Colles') Frature

    • Extension-type Colles fracture.
    • Most common type of radius fracture.
    • On Exam:
      • Dinner fork deformity.
      • Assess for median nerve function (can be compromised).
    • On Imaging:
      • 1. R/O associated ulnar head and neck fracture (often ulna fractures if also supanating force).
      • 2. Does fracture involve radioulnar or radiocarpal joint?
        • Can lead to post-traumatic arthritis (especially if step-off deformity).
      • 3. Measure volar tilt (lateral), radial tilt (PA) and radial length (PA)
      • 4. Distal radioulnar subluxation on lateral radiograph.
      • Screen shot 2013-08-27 at 3.27.25 PM.pngScreen shot 2013-08-27 at 3.27.46 PM.png
    • Tx:
      • If non-displaced with regular measurements:
        • Sugar-tong splint x4-6w.
      • If displaced + angulated, with loss of normal aligntment:
        • Need Reduction:
          • 1. Distraction
          • 2. Disengagement.
          • 3. Reapposition.
          • 4. Release
        • Casting:
          • TEST MEDIAN NERVE!
          • Use Sugar-tong splint, x 6-12w.
          • See ortho in 1 week.
          • Avoid too much padding, or fiberglass. (less likely to reduce).
          • Typical immobilization position:
            • Slight supination or mid position  (some surgeons like pronation)
            • 15° flexion.
            • 15° ulnar deviation.
          • Radiographs at 3 days and 2 weeks post-injury.
          • Reduction difficult if delayed (days..)
          • F/U with orthopedic surgeon
      • Indications for surgery:
        • Displaced and surgeon preference.
        • Severely comminuted.
        • Displaced >2mm intra-articular
        • >3mm of dorsal displacement or >10° dorsal angulation after attempt at closed reduction.
        • (Cannot operate if wait 2-3w, hard to move fragments).
    • Complications:
      • Limitation of wirst function in up to 90%.
      • Complication rate 20-31% - early fixation and reduction is important!!\

     

     

    Flexion-Type (Smith's) Fracture

      • Reverse of Colle's fracture.
      • Colles outnumbers smith's fracture 10:1
      • Mechanism:
        • Direct blow
        • Fall to supinated forearm.
        • Pnch with clenched first and slightly flexed wrist.
      • On Exam:
        • Garden spade deformity.
        • Document function of Radial Artery and Median nerve.
      • Imaging
        • Screen shot 2013-08-27 at 3.27.58 PM.png
      • Tx:
        • Need to be reduced - consult ortho for reduction.
        • If ortho not available - can try yourself with weights and finger traps. (8-10lb weights).
        • Unstable fractures require plate/pins.
        • Immobilize with sugar-tong splint.

     

    Dorsal and Volar Rim (Barton's) Fracture

    • These #'s are intra-articular, involve dorsal or volar rim of the radiusScreen shot 2013-08-27 at 3.28.17 PM.png
    • Classified as a Type II shearing mechanism (Fernandez and Juniper classification)
    • Generally require operative repair if the fragment is large or unstable
    • Commonly involve dorsal rim, often triangular bone fragment noted.
    • Mechanism:
      • Extreme dorsiflexion + pronating force (dorsal rim).
    • Exam:
      • Dorsal radius tender.
      • Radial nerve sensory branches may be compromised (pain/parasthesias).
    • Imaging:
      • See Lateral film:
    • Treatment:
      • Nondisplaced: Place in sugar-tong splint with forearm in neutral position.
      • Displaced: need procedural sedation and closed manipulative reduction.
        • If reduced, place in sugar tong splint w/ neural forearm position.
      • Unstable or cannot be reduced: ORIF surgery
        • (Small fragment: percutaneous pin)

     

    Radial Styloid (Hutchinson's) Fracture

    • Radial Styloid Fracture.
    • Known as chauffer's fracture (backfire fracture) b/c it was commonly caused by crank-starting automobile.  When car backfired, the crank was pushed into thenar eminence and wrist resulting in radial styloid fracture.
    • photo (8).JPG

     

    • Mechanism:
      • Similar to saphoid (transmitted to radial styloid).
    • Treatment:
      • Sugar-tong splint with ice+elevation.
      • Urgent ortho referral as percutaneous fixation is required.

     

     Soft Tissue Injury & Dislocations

    Ligamentous Injury

    • Complex array of ligaments linking wrist bones together.
    • Volar ligaments are stronger than dorsal ones.
    • Mechanism: fall on outstretched arm.
    • Carpal instabilities are difficult to assess.  Radiologic abnormality only noted after stress (clenched first) "dynamic instability".
      • Dynamic instability is partial ligament disruption that can become complete over time.
    • Mayfield carpal bone instability
      • Found ligamentous injuries that occur when he loaded cadaver wrists:
        • Stage Tear Result
          1st Stage

          - Scapholunate Interosseous Ligament

           

          - Radioscapholunate ligament

          - Scapholunate dissociation

          or 

          - Dorsal intercalated segment instability (DISI) can occur

          2nd Stage

          - Volar Capitolunate ligament.

          - Additional instability of scaphoid and capitate.
          3rd Stage

          - Lunotriquetral interosseus ligament.

          - Instability of scaphoid, capitate, and triquetrum with respect to lunate.

          - Dorsal perilunate dislocation

          4rth stage - Dorsal radiolunate ligament ruptured

          - Lunate dislocation or volar intercalated segment instability (VISI)

          (lunate displaces usually anteriorly b/c volar radiolunate ligament is intact)

     

     

    Intercalated Segment Instability

    • Can be thought of as midcarpal joint collapse.
    • When scapholunate ligament is disrupted, unopposed force of the lunotriquetral ligament causes the lunate to tip dorsally (Dorsal intercalated segment instability - DISI).
      • On lateral film: distal articular surface of lunate tilts dorsally and scaphohid tilts volarly.
      • Increased Capitolunate angle >30°
      • Increased Scapholunate >60°

     

    • Voral intercalated segment instability - VISI.. present when lunotriquetral ligament is disrupted. (less common than DISI)
      • Distal articular surface of lunate now tilts volarly
      • Increased capitolunate angle >30°
      • Decreased scapholunate angle <30°
    • Any intercalated segment instability = ligamentous disruption.
      • Reapproximation and repair.  Need to fix unevent loads onc arpal joints.
      • Complications:
        • Degenerative arthritis.
        • Scapholunate advanced collapse (SLAC) is a degenerative condition that follows.

     

    Scapholunate Dissociation

    • Commonly missed - scaphoid dissociates from lunate... moves..
    • Displasement of scaphoid in more vertical position in proximal row of carpal bones.
    • When scapholunate ligament ruptured (gap between lunate and scaphoid produced).
      • Rotary subluxation of scaphoid results (rotation of scaphoid with palmar rotation).
    • Mechanism: forceful extension of wrist.
    • Exam:
      • Wrist pain + swelling, worse with extremes ROM.
      • Can do "scaphoid shift" test.  Push on scaphoid to sublux, and "click" is felt/heard when is back in place.
        • Sometimes pain is more reliable rather than "click".
    • Imaging:
      • Widening of scapholunate joint space.
      • Always measure this joint space!!!
      • If >3mm --> "Terry Thomas sign" (British comedian with gap between two front teeth).
      • On lateral view: scapholunate angle >60° due to volar rotation of scaphoid.
      • Screen shot 2013-08-27 at 11.25.49 PM.png
    • Tx:
      • if <6wks post-injury --> acute.
      • if >6wks --> subacute.
      • Put in thumb spica cast and refer to hand surgeon for surgery.
        • Degenrative arthritis w/o proper treatment.

     

    Screen shot 2013-08-27 at 11.26.02 PM.png

     

    Perilunate and Lunate Dislocations

    • Normal articulation of radius, lunate, capitate, and third metacarpal make straight line.
    • Perilunate dislocation: Capitate dislocated (usually dorsally) in relation to lunate.
    • Lunate dislocation: Lunate is volarly dislocated (capitate is normally placed).
    • Mechanism:
      • excessive hyperextension, ulnar deviation, and intercapral supination.
    • Exam:
      • Decreased flexion 
      • Perilunate: dorsal fullness palpated.
      • Lunate: volar fullness palpated.
      • Check median nerve (commonly injured).
    • Imaging:
      • Lateral radiograph single most important one!!!
      • Carpal arcs disrupted in PA
      • Images:
        • A - lunate dislocation (volar);
        • B - Perilunate dislocation (capitate to dorsal)
      • Screen shot 2013-08-27 at 11.26.08 PM.png
      • Screen shot 2013-08-27 at 11.26.23 PM.pngScreen shot 2013-08-27 at 11.26.41 PM.pngScreen shot 2013-08-27 at 11.25.49 PM.png
      • See above (A - lunate, B - perilunate, C - shows arcs disrupted with both).
    • Treatment:
      • Immobilize in neural position in volar splint
      • REFER for reduction and definitive care.
      • To reduce:
        • Requires wrist block or procedural sedation.
        • Can use finger traips with 10lb weight x10min before reduction.
        • Reduction simple, but should be done by someone experienced.

     

    Triangular Fibrocartilage Complex Tear

    • Triangular Fibrocartilage Complex (TFCC) describes major ligamentous stabilizers of:
      • Radioulnar joint
      • Ulnar Carpal Bones.
    • Mechanism:
      • Fall
      • Overuse.
    • Exam:
      • Hollow btwn pisiform and ulnar styloid.
      • "supination lift test" - place palm on underside of table and lift. Positive if pain.
    • Treatment:
      • NSAIDs
      • Immobilize in slight flexion and ulnar deviation.
      • Physiotherapy.
      • Refer to ortho for potential arthroscopic repair (maybe).

     

    Common Soft-Tissue Conditions

    Carpal Tunnul Syndrome

    • Compression of median nerve at wrist.  (most common peripheral neuropathy).
    • Transverse carpal ligament confines carpal tunnel.
    • Most common in postmenopausal women (usually idiopathic).
    • Etiology: any condition causing chronic swelling of wrist:
      • Crush injuries
      • Rheumatoid arthritis.
      • Pregnancy
      • Diabetes
      • Thyroid disease.
    • Presentation:
      • Paresthesias and numbness over distribution of median nerve.
      • May awaken from sleep (nightly fluid retention) - instruct to elevate hand in bed.
      • Symptoms worsen after repetitive gripping for long periods (driving car, operating tool, mouse).
      • Earliest sensory finding: Decreased vibratory sensation (256-Hz fork).
      • Severe sensory finding: Diminished 2-point discrimination.
      • Signs; (usually late findings)
        • Tinel's Sign - Tapping volar aspect of wrist.  Parasthesias = postiive.
        • Phalen's Sign - Flex wrists for 1 min.  Parasthesias/pain = positive.
        • Tourniquet test - BP cuff inflate to 200mmHg (over wrist?) x2min produces symptoms.
      • Most sensitive signs:
        • symptoms over median nerve distribution
        • diminished pain on palmar aspect of index finger
        • weak thumb abduction
    • Treatment:
      • Avoid repetitive wrist/hand motions.
      • Wrist splinting.
      • NSAIDs.
      • Oral or local steroid injections.  (oral more effective 20mg/day x2weeks).
        • Injection = diagnostic and therapeutic (40mg methylprednisolon + local anesthetic)
          • Inject proximal to transverse carpal ligament so not to damage median nerve.  Inject at 20° angle to skin btween palmaris longus tendon and flexor carpi radialis and 4cm proximal to the skin crease.
          • If parasthesias sensed once start injecting - you found right place.  Withdraw needle 1-2mm and inject remainder.
      • Most respond conservatively, but 80% recur in 1 year. 
      • Surgical release is an option.

     

    Ulnar tunnel syndrome

    TODO  - sounds rare

     

     

    Ganglion Cyst

    • Most common tumor of hand.
    • It is a synovial cyst originating from joint or synovial lining of tendon --> has herniated.
    • Jelly-like fluid inside.  Sometimes traumatic onset.
    • Three most common:
      • Dorsal wrist ganglion (60-70% of all soft-tissue tumors).
      • Volar wrist ganglion
      • Flexor tendon sheath ganglion.
    • Can produce chronic wrist pain.
    • On Hx:
      • Chronic stress/ or traumatic.
      • Dull ache/mild pain over ganglion.
      • Hx of changing size as filling/emptying.
    • On exam:
      • Firm, non-tender (usually), cystic lesion like a bead in the skin.
      • Aspiration discloses gelly-like material if dx in question.
    • Treatment:
      • Most resolve spontaneously (no tx).
      • If in ED: can aspirate with large bore needle.
      • Initial treatment: steroid injection of dorsal capsule followed by immobilization. (recurrence rate very high).
      • Reassure that is not malignant (most important).
      • Surgery to resect it - last resort.

     

    De Quervain'sTenosynovitis

    • De Quervain's stenosing tenosynovitis.
      • Involves abductor pollicis longus and extensor pollicis brevis in first dorsal wrist compartment.
      • More common in women 10:1.
      • Superficial branch of radial nerve passes over the tendons.
    • Hx:
      • Pain over radial aspect of wrist radiation proximal and distal.
    • Exam:
      • Localized tenderness over styloid.
      • Finkelstein's Test - Examiner holds thumb in palm + passively ulnar-deviates wrist.  
      • (Distinguish from CMC arthritis of thumb).
    • Treatment:
      • Inject local anesthetic and steroid (90% success).
        • Should see visible swelling proximal to extensor retinaculum. (indicates needle in right spot)
        • Note: Inject steroid after anesthetic (not mixed in same cyringe) to ensure proper needle placement.
        • Thumb splint  x10days.  
        • (Can also use NSAID and longer period of thumb splinting).
        • U/S-guided injection shows better results (confirms both sheath and both tendons injected).
      • Surgery: if fails two injections in one year.

    Other - rare

    Radiocarpal Dislocation

    • Rare, require significant force, often with fractures.
    • Closed reduction:
      • If volar dislocation: splint in wrist flexion.
      • If dorsal dislocation: splint in wrist extension.
    • Can be treated with closed reduction, but most require surgery.
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