Wrist pain: making the diagnosis

Wrist Pain: making the diagnosis

Adam C Watts

Consultant Upper Limb Surgeon, Wrightington HospitalVisiting Professor, University of Manchester

Overview

• Anatomy and biomechanics• Examination tips• Pathology

• Clinical examination practical

Contributors to Stability

• Bone architecture• Structural

• Ligaments• Structural• Sensory

• Musculotendinous units• Dynamic

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The Wrist

1212

The Wrist

Triquetrum

Lunate

Scaphoid

Triquetrum

Lunate

Scaphoid

Torque Suspension

ROW

COLUMN

DART THROWERS MOTION

Making the diagnosis: examination tips

• Palpation is key

Scaphoid fracture: making the diagnosis

• X-ray• Limited sequence MRI

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Aim of treatment of scaphoid fractures

PrimaryAchieve sound

union

Secondaryshortest time with

lowest risk and disruption to patient

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Cast immobilisation

InconvenientMuscle

atrophyJoint

stiffness

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Low riskLow cost


Screw fixation

Early return to function

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Higher direct costsGreater risks


Decision Making

Scaphoid tubercle fracture

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Decision Making

Trans-scaphoid perilunate dislocation

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Decision Making

Proximal pole fracture

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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?

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Scapholunate Ligament

Scapholunate

< 3mm

Investigation

Scapholunate

Investigation

• XR• Stress Radiograph• CT• Arthrogram• MRI• MR Arthrogram• Arthroscopy

Partial and Dynamic – a new way!

Robert Kienbock

• 1910

• ? AVN of lunate

• Blood supply• Dorsal• Volar• Internal Anastamosis(Lee Acta Orthop Scand 1963)

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

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

Lichtman Classification

0 Abnormal signal on MRI1 Linear or compression fracture on X-ray2 Increased lunate density on X-ray3 Lunate collapse

A) No carpal collapseB) Carpal collapse

4 OA changes presentLichtman, Hand Clinics 1993

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

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

Radial Decompression

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)

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)

Salvage Procedures

• Wrist Arthrodesis• Better long term

outcome than limited fusion (Tambe Int Orthop 2005, Level 3)

Summary

ECU Instability / tendinopathy

• Hypersupination of forearm• Voluntary contraction of ECU• Ulnar deviation of wrist• Flexion

Anatomy

Anatomy

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

Hayton Ice cream scoop test

ECU synergy test

Investigations

• Ultrasound

MacLennan et al JHSa 2008

MRI scan

• Allende & Le Viet 2005

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

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

Linea Jugata

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Ulnar Sided Wrist Pain -TFCC

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Hook of Hamate Fracture

Physeal arrest in gymnast


Summary

• History and examination give diagnosis in most cases

• Non-operative treatment often effective

• Surgery when not settling is aided by good rehab.


Wrist Pain – making the diagnosis. Prof. Adam C Watts

Healthcare

Wrist pain: making the diagnosis