Wrist

History and Examination summary

History

1. pain: where,rad,type,when,nocte,agg,rel,how long
2. other: stiffness,defor,numb,click,clunk,catch,weak,,giveway
3. function: back pocket,toilet,opp. underarm,eat,comb,rise from chair, dress,pull,throw,work,sport,recr
4. past history: neck,treatment,injury,surgery,similar,episodes

Exam Neck, Shoulder and Wrist

Exam

1. look: swelling,wasting,deformity,scars,ulnar styloid,red,
2. feel: warmth,tenderness,bony landmarks
3. move: crepsact &pass,DF(50),PF(60),UD(50),RD(15) sup, pro,
4. spec: Watsons,,Shuck,L/T ballot,midcarpal,piano key, TFCC load,Tinnel,
5. power,neuro,vascular: (incl. grip strength)

Special tests

Watsons test

ref: Watson and Black "Instabilities of the Wrist" Hand Clin 3: 103, 1987.
examiner places 4 fingers of the dorsum of the radius and the thumb on the scaphoid tuberosity. Ulnar deviation of the wrist aligns the scaphoid with the long axis of the forearm. Keeping thumb pressure on the tubercle of the scaphoid , the wrist is brought into radial deviation. If the scaphoid is unstable the prox pole is driven dorsally and pain results

Watsons "catch up clunk"

- evaluates rotatory instability of the scaphoid.
As the wrist under load moves into ulnar deviation the scaphoid aligns with the long axis of the forearm ie extends smoothly. If rotatory instability is present the lunate remains in a volar flexed and dorsal position until suffficient pressure is applied so that it catches up with the scaphoid with a clunk

Pseudoinstability Test

ref: Kelly and Stanley " arthroscopy of the wrist" J Hand Surg 15B: 236-242, 1990

where there is loss of normal forward glide of the carpus- lack of this motion is equivalent to the apprehension sign of shoulder or patellar instability- is due to protective spasm

Pivot shift test for Midcarpal instability

ref: Lichtman etal " Ulnar midcarpal instability: Clinical and laboratory analysis" J Hand Surg 6: 515-523, 1981

a painful click on ulnar deviation, compression, and pronation of the wrist

Ballotement Test S-L or L-T

ballotement may reveal specific jt instability

Madelung's deformity

Inheritance:

Autosomal dominant
associated anomalies

scoliosis
cervical ribs
general anomalies eg Hurlers, Turners, Olliers

Incidence:

Male : Female 4:1

Aetiology:

Disorder of the lower radial growth plate and may follow trauma but most cases are bilateral and associated with a general dysplasia
Dyschondrosteosis (variant of mesomelc dwarfism) where girls are more severely affected
? related to a vascular anomaly

Clinically:

Deformity rarely seen before the age of 10 years and increases until growth is complete
Usually seen in adolescence 6 - 13 years old
Retardation of distal volar aspect of radial epiphysis; ulnar subluxation dorsally, the radius curves forwards leaving the lower ulna prominent as a bump on the back of the wrist
limitation of wrist motion esp extension and supination
Relative shortening of tibia (moderate short stature) and radius
Tibial deformity may be associated with genu varum

Pathology:

Failure of normal growth of the ulnar and volar 1/2 of the distal distal radial growth plate with a backward subluxation of the distal end of the ulna
Carpus becomes wedged bw radius and ulna

Treatment:

deformity usually brings the pt for treatment
it not essential to treat mild deformities- they are usually painless and operation does not increase ROM
if deformity severe or if pain a feature-surgery is indicated

1. correction of the too long ulna eg

   Darrachs procedure
   ulna shortening
   Lauensteins procedure

2. correction of the radial deformity eg

   epiphyseodesis of rest of physis
   osteotomy
   

Kienbock's disease

Blood supply of the Lunate

receives supply from both dorsal and palmar surfaces in 80% but volar surface only in 20%
dorsal supply from

1. dorsal radiocarpal arch
2. dorsal intercarpal arch
3. occas from dorsal branches of the ant interosseous artery

volar supply from

1. palmar radiocarpal arch
2. palmar intercarpal arch
3. anastomosing vessels from ant inteross art and the ulnar recurrent artery

both volar and dorsal supplies freely anastomose intraosseously

Aetiology:

May be precipitated by a single significant trauma or multiple minor episodes of trauma ® interruption of already tenuous blood supply (single palmar nutrient vessel in 20% of fresh cadavers studied)
Often the ulna is short relative to the radius ? significance in aetiology due to less support of the carpus and increased pressure on the lunate.
Increased incidence of AVN in people with the radius extended > 2mm beyond the ulna

Classification: (Lichtman)

Stage I:

Lunate normal on X-Ray (may show either a linear or compression fracture)

Stage II:

Sclerosis of the Lunate relative to the other carpal bones and significant fracture lines may be noted

Stage III:

Fragmentation of the lunate and collapsed in the frontal plane and elongated in the lateral plane; carpal shortening and instability but no osteoarthritis Some have used ratio of carpal height from base of 3rd metacarpal to distal articular surface of radius and the length of the 3rd metacarpal to assess collapse (0.54 +/- 0.03 in normal individuals)

Stage IV:

Fragmentation and collapse with secondary OA of the radio carpal joint

Incidence:

Usually 20 - 40 years of age Male : Female 2:1

Clinically:

Pt usually a young adult with ache or localised tenderness of the wrist with decreased dorsi-flexion
Bilateral Kienbock's disease is extremely rare
Early the patient may appear to have a simple wrist strain with synovitis and later frank arthritis
Invariably the grip strength is significantly decreased

X-Rays

May acutely be normal (See Classification)
Ulna variance should be evaluated with the patient seated, the shoulder abducted to 90o and the elbow flexed to 90o with the wrist in neutral rotation

Treatment:

reduction of lunate compressive forces is thought to promote revascularisation - methods to unload the lunate fossa and redistribute the load to the scaphoid fossa include

1. STT fusion
2. radial shortening
3. ulnar lengthening- high nonunion rate- 15%

Radial shortening or Ulnar lengthening results in 45% decrease in load transferred to the radio-lunate fossa
Some advocate revascularisation procedures (transfer of portion of pronator quadratus with bone on pedicle to the volar surface of the lunate) for Stage I and II disease
Stage

1. no treatment- symptomatic only
2. if ulnar minus or neutral - radial shortening 2-3 mm
3. a. if ulnar minus or neutral - radial shortening 2-3mm +/-
   b. STT fusion to transfer load to scaphoid column
4. prox row carpectomy- less restriction of motion than fusion

ref: Imbriglia etal "Proximal row carpectomy- a clinical evaluation" J Hand Surg 15A: 426- 430, 1990

Carpal tunnel syndrome

Compression of the median nerve in the carpal tunnel at the wrist

Aetiology:

Several factors are associated eg, pregnancy, rheumatoid arthritis, amyloidosis, common in menopausal women etc

Incidence:

Male : Female 1:8
Usually 40 - 50 years old
Younger patients usually find associated factors eg pregnancy or rheumatoid arthritis

Clinically:

Pain and paraesthesia in the distribution of the median nerve
Often woken in the early hours of the morning with burning pain, tingling and numbness
Sensation relieved by hanging the arm out the side of the bed or getting up and walking around
Pain may radiate up the arm
Pressure on the carpal tunnel may reproduce the pain or tingling
Late cases may be associated with wasting of the thenar muscles
Tinel sign
Phalens test: forced palmar flexion may reproduce the pain or tingling

Investigations:

Nerve conduction studies are usually diagnostic

Treatment:

Conservative treatment; wearing a resting splint or the injection of steroids
Resistant cases; decompression

Ganglions

Aetiology:

Not synovial herniations but small bursae within the substance of the joint capsule or fibrous tendon sheath
Cysts become distended after trauma or increased activity

Clinically:

Patient often a young adult presents with a lump
Occasionally there is a slight ache or discomfort
The dorsum of the wrist is the commonest site
Pressure from the cyst may occasionally cause neurological problems

Treatment:

If recurrence is troublesome resection may be indicated

De Quervain's Tenovaginitis

a stenosing tenosynovitis of the 1st dorsal compartment

Aetiology:

A tendon tunnel syndrome where the sheath containing the tendons of abductor pollicus longus and extensor pollicus brevis is thickened

Clinically:

Commonest in women aged 40 - 50 years
Complain of pain on the radial side of the wrist
Tenderness is precisely localised to the radial styloid over the tunnel of these tendons
May feel crepitus = wet leather sign
Pain is felt when the patient extends the thumb against resistance or if it is passively adducted across the palm (Finkelsteins test)

Treatment:

Hydrocortisone injection may help along with splintage
Resistant cases ® release of the tendon sheath

Carpal instability

ref: Taliesnik "Current Concepts Review: Carpal Instability" JBJS 70A:1262-1267, 1988
Stanley and Trail " Carpal instability" JBJS 76B: 691-700, 1994

Definition:

Situation where the normal alignment of the carpal bones is lost

Anatomy:

Two major groups of ligaments ® stability of the carpus (Intrinsic and Extrinsic)
The extrinsic ligaments course between the carpal bones and the radius or metacarpals whereas the intrinsic ligaments originate and insert in the carpus
The extrinsic ligaments are stiffer while the intrinsic ligaments are capable of greater elongation before permanent deformation occurs
Extrinsic: The palmar extrinsic ligaments consist of 2 V-shaped ligamentous bands - one is proximal and connects the forearm to the prox carpal row, one is distal and connects the forearm to the distal carpal row. The distal limb of the palmar extrinsic ligs consists of the radioscaphocapitate lig laterally and the ulnocapitate lig medially. The prox limb consists of the radiolunotriquetral and radioscaphoid ligs laterally and the ulnolunate and ulnotriquetral ligs medially. The dorsal extrinsic ligs are the radiotriquetral and scaphotriquetral
Intrinsic: the intrinsic ligs connect adjacent carpal bones. In the prox row the ligs are intraarticular, connecting scaphoid to lunate and lunate to triquetrum
Thes ligs are strong and are critical for carpal stability
The TFCC separates the ulna from the carpus
Made up of the TFC, dorsal and volar radio-ulna ligaments, the ulnar collateral ligament, the meniscus homologue, the articular disc and the sheath of ECU
Variable thickness of TFC from 1 - 5mm depending on the station of the ulna (ulna variance)
No tendons are directly attached to the carpus

Rows or columns?

Traditional view: proximal and distal row of carpal bones- scaphoid joining them

Taliesnik: three columns with the scaphoid being the radial column, the triquetral the ulnar column and the lunate and capitate with the remaining carpal bones making up the middle column

Navarro: modification of this with the scaphoid, trapezium and trapezoid making up the radial column, the triquetral the ulnar column and the capitate and lunate along with the hamate the middle column

Classification:

Four major types of carpal instability;

1. Dorsi-flexion (Dorsal Intercalated Segment Instability or DISI) is the most common where the lunate is rotated into dorsi-flexion (zig zag alignment of the radiolunatocapitate alignment)
2. Palmar flexion (Volar Intercalated Segment Instability or VISI)
3. Ulnar Translocation- abnormal translocation of the lunate ulnarward
   a. Type 1 the entire carpus is translocated ulnarward
   b. Type 2 the relationship bw radius and scaphoid is normal but the scapholunate gap is wide
   
4. Dorsal Subluxation- malunion # distal radius with reversal of normal palmar tilt
   

Instabilities may be

1. Static- loss of normal alignment can be seen on XR
2. Dynamic- routine XR within normal limits and the instability can be produced by either voluntary movement or manipulation eg bw scaphoid + lunate, bw lunate + triquetrum, or at midcarpal jt

Instabilities may also be termed

1. Dissociative- S-L or L-T dissociation leading to DISI or VISI respectively
2. Nondissociative- may also result in VISI or DISI but the 3 bones (S,L,T) act as a unit
   eg dorsal carpal subluxation, mid-carpal instability, Type1 ulnar translocations
   

Aetiology:

DISI is due to disruption of the scapho-lunate articulation
VISI is secondary to disruption of the lunate and triquetral
Ulnar translocation rarely results from injury but is commonly seen in wrists affected by rheumatoid arthritis

Clinically:

Patient presents with a painful wrist
May experience clicking or clunking
Ballottement test often positive and Watson test for scaphoid instability may be present

X-Rays

AP:

done with the wrist under axial load (clenched fist) and with the hand in radial and ulnar deviation
May demonstrate increased distance between the scaphoid and lunate or lunate and triquetral

DISI pattern:

increased scapholunate gap
ring sign with the flexed scaphoid seen end on
scaphoid foreshortened- distance bw ring and prox pole less than 7mm
the flexed scaphoid is seen with a dorsiflexed lunate
(quadrilateral) and with the triquetrum in a distal (dorsiflexed) position

VISI pattern:

ring sign
scaphoid foreshortened
lunate volar flexed (triangular)
triquetrum distal in relation to the hamate ( dorsiflexed)
distance bw the ulnar head and the triquetrum is reduced ( Mayersbach sign)
the convex outline of the prox carpal row (= the Shentons line of the wrist) is interrupted by a step off bw lunate and triquetrum

Ulnar Translocation

Carpal-Ulnar distance - is the distance from the centre of the head of the capitate ( ie the centre of rotation of the carpus) and a line produced along the line of the centre of the ulna
Normally ratio of C-U distance/ length of 3rd metacarpal = .30 +/- .03
with ulnar translocation the ratio is less

Lat:

to assess opposite rotations of the scaphoid and lunate-

DISI pattern:

when the scapholunate jt is dissociated the scaphoid is palmar flexed and the lunate is dorsiflexed Scapho-lunate angle usually 30- 60^o (av 46^o) and with DISI it is greater than 70^o

VISI pattern:

lunate palmar flexed
if the lunate and triquetrum can be seen the normal lunotriquetral angle of ~ -16 deg becomes neutral or +ve

Ulnar Translocation

often assoc with VISI

SLAC wrist (scapho-lunate advanced collapse relates to degenerative process that results from chronic scapho-lunate dissociation) degeneration between radial styloid and scaphoid and subsequently the luno-capitate joint (commonest pattern of degeneration 55%) With S-L dissocation get all load going through the Radioscaphoid jt - thus OA
Next commonest pattern is triscaph degeneration between the scaphoid, trapezium + trapezoid

Other Investigations:
Bone scan is useful to identify pathology
When a bone scan is negative it suggests either that there is no injury or more frequently that the problem is minor and can be treated non operatively
Arthrography is helpful in finding ligament tears but ? significance as these may not necessarily be the result of trauma but may indicate age related degenerative change
NB: need to compare with normal side
Arthroscopy- can directly visualise pathology

Treatment:

of the chronic instability depends on the pts symptoms. For those with little disability and greater than 80% of ROM and grip strength surgical treatment is not indicated

Scapholunate dissociation

Acute: either closed manipulation or open reduction with pinning

Chronic: if no assoc OA
reattachment of the scapholunate lig
dorsal capsuloligamentodesis (Blatt)- dorsal capsular flap used to prevent the scaphoid from subluxing in a palmar direction
ref : Blatt and Nathan " Dorsal Capsulodesis for rotatory subluxation of the scaphoid: a review of the long term results" Proc Am Soc of Surgery of the Hand 1992
STT fusion- problem is with radial impingement
S-L or S-C fusion

if assoc OA ( ie SLAC )

Excise (?replace) scaphoid and perform a mid carpal fusion that is fusion of the capitate, hamate, triquetral and lunate
(= a 4 - corner fusion)
total wrist fusion

Lunatotriquetral instability

Acute: either immobilisation in BEPOP or direct repair of ligament
Chronic: Lunatotriquetral arthrodesis

Ulnar Translocation

Acute: Repair of the disrupted volar and dorsal radiocarpal ligs
Chronic: ligament repair unreliable
relocation of the carpus and maintenance of reduction by radiolunate arthrodesis more reliable

Dynamic VISI and DISI

trial of nonop management with AEPOP/ NSAIDS/ local injection of steroids
Stabilisation of the midcarpal jt limited fusion
capsuloligamentodesis
tenodesis

Distal Radioulnar jt

anatomy

is a trochoid jt. The sigmoid notch is semicylindrical and concave- it has distal, ant and post borders - the distal borders the lunate fossa

The ulnar head is also semicylindrical- inclined 15 deg to the ulna and the artic surface covers 130 deg of the surface. The ulnar head is flattened distally as it faces the underside of the TFC

The radius of arc of the sigmoid notch is greater than the radius of arc of the distal ulna ie the artic surfaces are not congruent - thus supination and pronation must include a sliding as well as a rotational component

The TFC originates along the border bw the sigmoid notch and lunate fossa and attaches at the base of the ulnar styloid

The peripheral margins of the TFC are lamellar collagen arranged concentrically
( resists tensile loads). The central thin part of the TFC is fibrocartilage
( resists compressive loads)- it may be occas absent and is often thin.

Compressive force across the ulno-carpal articulation is partly transmitted via the TFC to the ulna dome- the TFC load shares by virtue of the concentric fibres at its periphery and also acts to prevent the distal radius and ulna being spread by axial force

Load depends on relative length of radius and ulna- in ulna neutral- 80% of load is transmitted to the distal radius vs 20% to distal ulna. In ulna -2mm only 5% is transmitted to the ulna. In ulna +2.5mm 40% is transmitted to the distal ulna

The volar margin of the TFC is taut in pronation- if the volar margin was torn dorsal subluxation of the distal ulna would occur in pronation
- the dorsal margin is taut in supination - if this is torn then get volar subluxation of the distal ulna in supination

TFCC refers to the TFC plus the Ulnocarpal ligs ( combined ulnolunate and ulnotriquetral ligs)

DRUJ disorders- classification and treatment

1. Fractures- treat: reduction
2. Acute jt disruption
   a. TFCC disruption in assoc with other #/ dislocations
   treat: reduction + repair TFCC
   b. TFCC disruption - isolated
   treat: CR/ POP
   ORIF if unsatisfactory
   c. TFC tears - no instability
   treat: ulnar recession if +ve variance
   +/- debride tear
   
3. Chronic ( or late appearing ) jt disruption
   a. TFC tears - no instability
   treat: as above
   b. TFCC disruption - recurrent dislocation or instability
   treat: either repair / reconstruct TFCC
   or Darrach/ HIT/ Sauve-Kapandji
   
4. Jt disorders
   a. ulnocarpal impaction syndrome
   treat: ulnar recession
   b. arthritis
   treat: Darrach/ HIT/ Sauve-Kapandji
   
5. Other
   a. snapping or dislocating ECU
   treat: stabilisation
   b. fixed rotational deformity
   treat: either release of contracture
   or bony stabilisation ( radioulnar arthrodesis)
   or Darrach/ HIT/ Sauve-Kapandji

Wrist Arthroscopy

Portals

3-4 portal

initial viewing portal
bw EPL and EDC
see: scaphoid and lunate
intrinsic S-L lig and TFCC
extrinsic RSC, RLT, RSL ligs

4-5 portal

initial instrument portal
bw EDC and EDM - ~1 cm ulnar to 3-4 portal

6R portal

used most commonly as as outflow portal
radial to ECU

Indications

persistent symptoms with evidence of mechanical wrist derangement
to confirm diagnosis
to debride tears of TFC
to assist in # reduction

Rheumatoid arthritis

Bilateral and symmetrical disease is a feature

The wrist gradually drifts into radial and volar subluxation which contributes to the gradual ulna drift of the fingers

Synovectomy

? Prophylactic effect to reduce the incidence of extensor tendon rupture

Indicated if persistent tenosynovitis of at least 6 months duration despite good medical treatment

Common sites are the extensor surface of the wrist, the volar surface of the wrist and the volar aspect of digits (synovectomy of the digits has no proven benefit)

Synovectomy of the wrist: pass half or all of the extensor retinaculum beneath the tendons to give them a smooth bed on which to travel

Flexor synovectomy involves a release of the carpal tunnel (75% of rheumatoid patients will have experienced median nerve compression symptoms at some stage)

Radio-carpal disease causes destruction of deep volar radio-carpal ligament and eventually a rotatory instability of the scaphoid

Scaphoid volar flexion and then radial rotation of the carpus on the radius (results in 'Z' deformity of wrist and fingers) which is thought to be one of the important factors in development of ulna deviation of the MCP joints

Prominent, subluxated and painful ulna head: excision (Darrach procedure = excision of distal 2.5cm preserving the styloid)

Arthrodesis if pain, impaired function, instability and deformity and historically the procedure of choice in association with synovectomy and excision of the ulna head Wrist is the foundation for good hand function and deformities of the wrist may be extrinsic or intrinsic

Rupture of ECU: radial deviation which may accentuate ulnar deviation of fingers (primary pathology * treatment)

Extensor tendon ruptures: drop fingers and flexion deformity

Erosive changes, synovitis and ligament laxity resulting in carpal translocation

Arthrodesis of the wrist may be limited or pan carpal depending on the disease process and its extent

Swanson TWR: maintain motion, metal and polyethylene components now available with better results (short term).

Distal radio-ulna joint: Darrach procedure useful (excision of distal end of ulna leaving ulna styloid)

Osteoarthritis

Carpo-metacarpal joint of the thumb is a much more common site of OA than the wrist joint * excision arthroplasty or arthrodesis

X-Rays Irregular narrowing of the radio-carpal joint
Bone sclerosis

Wrist arthrodesis

The extent of the arthrodesis in the wrist is governed by the extent of the disease process

Limited Arthrodesis

ref: Viegas etal "Evaluation of the Biomechanical efficacy of limited intercarpal fusions for the treatment of scapholunate dissociation"
J Hand Surg 15A: 120-128, 1990
STT or SC fusion did not alter the load across the scaphoid fossa
SL, SLC or LC fusions transmit load proportionally through both the scaphoid and lunate fossae

Triscaph arthrodesis indications:

1. Degenerative arthritis of the triscaph joint with good thumb and carpo-metacarpal joint
2. Radial hand dislocations
3. Rotary subluxation of the scaphoid

Medial column fusion also has a place (Capitate, hamate, lunate and triquetral) particularly to unload replacement or reconstruction of the scaphoid

Metacarpal-carpal arthrodesis generally restricted to the thumb but other joints may be included (index and middle) if significant degeneration is present

Scapho-radial and luno-radial arthrodesis have been performed and are generally only indicated in post traumatic situations

Total Wrist Fusion

Optimal position is in 10 - 15o dorsi-flexion (extension) and slight ulnar deviation
Bilateral arthrodesis * fuse one in extension and one in flexion in order to maintain the ability of perineal care

Wrist arthroplasty

Contraindicated if

extensor tendons ruptured
severe bone loss
narrow third metacarpal shaft
previous infection
needs a walking stick (ie becomes a weight bearing joint)

Indicated in low demand patients (Rheumatoid arthritis) with bilateral disease where there is a case for arthrodesis of the dominant hand and arthroplasty of the non dominant hand.

ref: Figgie etal "Trispherical wrist arthroplasty in RA" J Hand Surg 12A: 217-223, 1987
35 TWA in 34pts, 28/35 good or excellent av FU 9 yrs
2 pts required revision