SURGERY | Orthopedics THE WRIST
The wrist
1
SURGERY | Orthopedics THE WRIST
Congenital &childhood deformities of the wrist:
1-Carpal fusion:
• is one of the commonest congenital wrist anomalies, in
which there is fusion of 2 or more of carpal bones, it is
inherited as autosomal dominant trait &may be bilateral,
• it rarely causes problem & needs no Ŗ.
2-Radial club hand(radial longitudinal deficiency):
• The whole of radius or part of it is absent with under developed 1st ray (thumb,
scaphoid &trapezium). There is severe radial deviation of the hand.
• It usually occurs as an isolated abnormality but may occur in association with
other abnormalities, (thrombocytopenia, Fanconi anemia, ASD).
• Ŗ→ Early, it needs manipulation &splint. Later, surgical centralization of the
carpus over the ulna before the age of 3years.
3-Ulnar club hand: ( ulnar longitudinal deficiency)
• Is a rare deformity in which part or whole of the ulna is missing sometime with the
ulnar rays leading to ulnar deviation of the hand.
• Ŗ→ Early: manipulation &splintage, later: surgical correction.
2
SURGERY | Orthopedics THE WRIST
4-Madelung’s deformity:
• this deformity the lower radius is curved forwards carrying the carpus
&hand with it leaving the lower ulna as a lump on the back of the wrist,
• the deformity is either congenital or acquired. In the congenital form the
abnormality present at birth but the deformity rarely appears before age of 10
yrs, it results from abnormal growth or traumatic damage to the anterior part of
the growth plate.
• Ŗ→ if deformity is severe the lower ulna can be excised, this can be
combined with corrective osteotomy of the distal radius.
Acquired deformities:
result from:
• Physeal injury: # separation of distal radial epiphysis may result in
partial fusion of the growth plate with subsequent asymmetrical
growth leading to deformity.
• Malunion of Colles # may lead to unsightly deformity.
• Rheumatoid deformities: may lead to radial deviation of the wrist
&distal radio-ulnar joint subluxation.
• Wrist drop: with radial n. palsy the wrist drops into flexion &active
extension is lost.
3
SURGERY | Orthopedics THE WRIST
Kienböck's Disease (crushing osteochondritis of the lunate)
Is avascular necrosis of the lunate bone, it occurs in young adult (20-30 yrs), women
are affected more than men.
Causes:
1- chronic stress or injury through the lunate may affect its blood supply leading
ischaemia;
2- relative shortening of the ulna(‘negative ulnar variance’) may cause stress overload
of the lunate between the radius &carpus.
Pathology & X-ray appearance: the disease is divided into:
Stage I: wrist pain, ischaemia without naked-eye or radiographic abnormality but
bone scan is +ve.
Stage II: trabecular necrosis with reactive new bone formation with ↑ lunate density
on x-ray but shape is preserved.
Stage III: collapse of the lunate.
Stage IV: secondary radio carpal osteoarthritis.
Clinical features :
• pain &stiffness.
4
SURGERY | Orthopedics THE WRIST
• O/E: tenderness over lunate & grip strength is diminished.
• Late: wrist mvt are painful &limited.
Ŗ:
stage I &II→ splint the wrist for 2-3 months.
Early stage III→ shortening of the radius.
Stage 3&4 may require arthrodesis or excisional arthroplasty.
Table 15.1 Keinbock’s disease: staging and treatment
Stage X-ray/MRI Treatment options
1 Normal X-ray, changes on MRI Splint
Vascularized bone graft
2 Lunate sclerosis in plain X-ray, fracture lines Vascularized bone graft
sometimes present If negative ulnar variance: radial shortening
If positive ulnar variance: radial tilting or capitate
shortening
3a Fragmented lunate, height preserved If negative ulnar variance: radial shortening
If positive ulnar variance: radial tilting or capitate
shortening Proximal row carpectomy
Scaphocapitate fusion
STT fusion
3b Collapse of lunate, proximal migration of Proximal row carpectomy
capitate, fixed scaphoid flexion Scaphocapitate fusion STT
fusion
4 Arthritis Proximal row carpectomy
Total wrist fusion
Wrist replacement
Rheumatoid arthritis (RA)
The wrist is the second most common site of RA after the MPJ.
It is divided into 3 stages:
5
SURGERY | Orthopedics THE WRIST
• Stage I: synovitis of the wrist &tenosynovitis of the tendon sheath, clinically there
is pain &swelling.
o Ŗ→ by rest, splint, NSAID, local steroid injection.
• Stage II: early destruction of the joint &tendon with beginning of the
deformity (radial deviation of the wrist).
o Ŗ→ synovectomy &tendon transfer to prevent deformity.
• Stage III: severe joint destruction &deformity.
o Ŗ→ arthrodesis or arthroplas
Carpal tunnel syndrome (CTS)
• is the most common compressive or entrapment neuropathy of
the upper extremity, in which there is compression of the median
nerve at the wrist as it passes through the carpal tunnel which is a
narrow fibro-osseous tunnel formed by carpal bones &roofed by
transverse carpal ligament( the flexor retinaculum).
• The carpal tunnel is a narrow space containing median n. & 9 flexor
tendons with their synovial sheaths,
6
SURGERY | Orthopedics THE WRIST
• so any increase in the size of the of tendons or their sheaths or
any space occupying lesion will lead to compression &ischemia
of the median n.
Causes:
it is often difficult to find a cause, however the condition is
common at menopause, in RA, in pregnancy & in
hypothyroidism (myxoedema).
CF:
• usual age group is 40-50 yrs; more common in women than
men(8x).
• The patient usually complains of pain &numbness occur in the
distribution of the median nerve in the hand in the thumb,
index, middle fingers &lateral ½ of the ring finger.
• The night pain& numbness are typical for CTS which might
awake the patient from sleep.
• Late, there is weakness in the hand during daily activities or
even thenar wasting.
• The numbness can be reproduced by tapping over median
n.(Tinel’s sign) or
• by holding the wrist fully flexed for 1-2 minutes(Phalen’s test).
• Hanging the arm over bed side or shaking the hand may relieve
the symptoms.
Investigations:
NCS &EMG will show slowing of the nerve conduction
across the wrist.
Ŗ:
• mild to moderate CTS: conservative (3wk night splint,
NSAID, diuretic, steroid injection). The same is used for pregnancy
related CTS.
• Severe CTS: surgical division of the transverse carpal ligament.
7
SURGERY | Orthopedics THE WRIST
De Quervian's disease (stenosing tenovaginitis)
• Is a painful inflammatory thickening of the tendon sheath of extensor policis brevis
&abductor policis longus.
• Causes: it may occur spontaneously but usually initiated by over use &repetitive
activity.
• CF: a women 40-50 yrs, has pain &tenderness over the radial styloid with
thickening of the tendons sheath, 2 clinical tests:
o 1-Extension of the thumb against resistant will produce pain.
o 2-Finkelstein’s test; by flexing the thumb then sharply adduct the wrist will
produce pain.
• Ŗ: Early→ wrist splint &steroid injection into the tendon sheath. Resistant cases
need surgical release of the thickened tendons sheath.
