Download Etiology of painful wrist

Wrist Pain
Objectives:
I. Recall anatomy of the wrist joint.
II. Etiology of painful wrist.
III. Diagnostic approach.
IV. Ganglion
V. De Quervian syndrome.
VI. Keinbock,s disease.
Wrist Joint:
(radiocarpal) joint
Articulation between the distal end of the radius and the articular disc above and the
scaphoid , lunate, and triquetral bones below
Type: Synovial condyloid joint.
Ligaments: Anterior (palmar) and posterior (dorsal) ligaments strengthen the
capsule. The median (ulnar collateral) ligament is attached to the styloid process of the
ulna and to the triquetral bone. The lateral (Radial collateral ) ligament is attached to
the styloid process of the radius and to the scaphoid bone
Movements:
Flexion.
Extension.
Abduction
Adduction.
Circumduction.
BLOOD SUPPLY OF WRIST JOINT:
Branches of the dorsal and palmar carpal arches.
INNERVATION OF WRIST JOINT:
Anterior interosseous and the deep branch of radial neve
branch of the median nerve.
Etiology of painful wrist:
1. NEUROLOGIC CAUSES OF PAIN
1. Carpal tunnel syndrome.
2. Pronator teres syndrome
3. Superficial radial neuropathy
4. Compression of the Ulnar Nerve at the Wrist (Guyon Canal Syndrome).
2. MUSCLO-JOINT RELATED CAUSES OF PAIN
1. Intersection syndrome
2. DeQuervain’s tenosynovitis.
3. Arthritis, eg, rheumatoid arthritis, osteoarthritis, reactive arthritis (Reiter’s syndrome),
psoriatic arthritis, gout or pseudogout, septic arthritis.
4. Triangular fibrocartilage complex (TFCC) injury 3. VASCULAR CAUSES OF PAIN
1. Keinbock’s disease.
4. FRACTURES
1. Lunate fracture or dislocation, scaphoid fracture (snuffbox pain).
2. Colles (distal radius) fracture.
Diagnostic approach:
History.
Physical Examination.
a. Look:
b. Feel:
c. Move:
d. Measure:
e. Special tests:
Provocative Testing
• Neurological Examination.
• LAB: If infection is suspected.
•IMAGING
X-rays
A-P and lateral views are obtained routinely.
Special views may be necessary to show a scaphoid fracture or carpal instability.
Arthrography
Defects in the triangular fibrocartilage,
scapho-lunate ligaments or luno-triquetral ligaments can be identified by arthrography.
Computed tomography
CT is the ideal method for assessing congruity of the distal radio-ulnar joint.
Magnetic resonance imaging
MRI is particularly useful for detecting changes associated with scaphoid fractures, avascular necrosis of
the lunate, occult dorsal ganglia and intra-osseous ganglia.
Radionuclide scan
A localized area of increased activity may reveal An occult scaphoid fracture or early osteoarthritis.
Fluoroscopy
Fluoroscopic examination may be needed to demonstrate some patterns of carpal instability
Other methods:
Aspiration or Arthroscopy
Ganglion
•The ganglion cyst is the most common swelling in
the wrist. It arises from leakage of synovial fluid from
a joint or tendon sheath and contains a glairy, viscous
fluid. Although it can appear anywhere around the
carpus, it usually develops on the dorsal surface of
the scapho-lunate ligament
•
T
•
Not related to neural ganglion or ganglionic cell.
•
Women are more likely to be affected than men.
•
Ganglia are common among athletes
he average size of these cysts is 2.0 cm.
De Quervain syndrome
Tenovaginitis syndrom (tenosynovitis)
Common and well recognized condition characterized by pain over
styloid process of radius and palpable nodule in the course of abductor
pollicis longus and extensor pollicis brevis tendon.
De Quervain's is more common in women
It may be initiated by overuse
but it also occurs spontaneously,
particularly in middle-aged women,
and sometimes during pregnancy
Pathology:
* The fibrous sheath of abductor pollicis longus & extensor pollicis
brevis tendons are thickened where they cross the tip of radial styloid
process
*Tendons themselves appear NORMAL.
Clinical features:
- The condition is commonest in middle – aged women
-Pain , local tenderness , swelling and difficulty gripping
Diagnosis:
Finkelstein's test:
grasps the thumb (place it in the palm) and the hand is ulnar deviated
sharply , If pain occurs along the distal radius then test is +ve and
vice versa.
Complications:
May interfere mechanically with normal movement of thumb or
lateral distal part of radial aspect.
Treatment:
The early case can be relieved by a corticosteroid injection into the
tendon sheath, sometimes combined with splintage for symptoms
relief.
Resistant cases need an operation, which consists of slitting the
thickened tendon sheath.
Ischemic necrosis of the lunate bone, due to chronic
stress or injury. ( traumatic softening )
More common in patients with abnormally short
ulnas (at wrist).
Young adult (usually affects the dominant
wrist of men aged 20-40 years.)
Ache and stiffness
Localized tenderness over the lunate
Grip strength is diminished
Later stages wrist movement is limited and
painful.
Pathology:
stage 1, ischemia without naked-eye or
radiographic abnormality.
stage 2, trabecular necrosis with reactive new
bone formation and increased radiographic
density, but little or no distortion of shape.
stage 3, collapse of the bone.
stage 4, disruption of radio-carpal congruence
and secondary osteoarthritis
Kienbock’s disea
X - RAY
Stage 2. (Left) This illustration
shows that the lunate has hardened
with more than one fracture line.
(Right) The lunate is brighter than
the surrounding bones, which
indicates that the bone is dying.
Stage 3. Both the illustration
and x-ray image show that the
lunate has begun to collapse
and several bones in the wrist
have shifted out of position.
Stage 4. (Left) This illustration shows damage to
several bones in the wrist. (Right) This CT scan
also shows deterioration in the bones of the
wrist
Treatment
stag
e
X-ray , MRI
Tx
1
Normal x-ray, changes on MRI
Cast for 3 months
Vascularized bone graft
2
Lunate sclerosis on plain x-ray, fracture lines
sometimes present without collaps
Vascularized bone graft
If negative ulnar
variance: radial
shortening
If positive ulnar
variance: radial dome
osteotomy
3a
Fragmentation of lunate; height preserved
Proximal row
carpectomy
3b
Collapse of lunate, proximal migration of
capitate, fixed scaphoid rotation
Scapho-capitate fusion
Scapho-trapeziumtrapezoid fusion
Proximal row
Reference