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Wrist

Orthopedics

QuestionAnswer
Dorsal Wrist Compartment I APL & EPB
Dorsal Wrist Compartment II ECRL, ECRB
Dorsal Wrist Compartment III EPL
Dorsal Wrist Compartment IV extensor digitorum comunis (four tendons) & extensor indicis (EDC, EI)
Dorsal Wrist Compartment V extensor digiti minimi (EDM)
Dorsal Wrist Compartment VI extensor carpi ulnaris (ECU)
Median nerve: Motor Wrist flexors, thumb opposition
Median nerve: Sensory Volar thumb, radial 2 ½ digits
Ulna nerve: Motor Intrinsics, Adductor Pollicis
Ulna nerve: Sensory Ulnar 1 ½ digits volar & dorsal
Radial nerve: Motor Wrist extensors, APL, EPB
Radial nerve: Sensory Dorsal thumb & radial half of hand
Wrist Hx: includes: Handedness; Occupation; trauma; location of pain; numbness, paresthesias
Wrist Exam: Inspect for: swelling, scars, masses
Wrist Exam: Specific tests Tinel, Phalen; Finkelstein; Foveal; Watson
Watson Test for S-L dissociation: Stabilize volar scaphoid w/ thumb & bring wrist from ulnar to radial deviation; there will be a clunk or pain
Wrist ROM: radial deviation: 20 degrees
Wrist ROM: ulnar deviation: 55 degrees
Wrist ROM: flexion : 90 degrees
Wrist ROM: extension: 70 degrees
Wrist Radiographs AP, Lateral, Oblique
Wrist Radiographs: clenched fist: Scapholunate dissociation
Wrist Radiographs: Scaphoid Ulnar deviation
Wrist Radiographs: Carpal Tunnel Hamate, pisiform injuries
Wrist Radiographs: Comparison views Growth plate injuries
Wrist Radiographs: Lateral View: Check 2-20 degree palmar tilt of articular surface of radius; dorsal aspect of distal radius is smooth; capitate sits in lunate
Wrist Radiographs: PA View: Check radius lies distal to ulna; radial border of Scaphoid is intact; No more than 2mm of intercarpal joint space; no abnormalities of radius or ulna cortex;
Wrist Radiographs (PA): Impact fx may only show: increased density at radial metaphysis
Wrist Radiographs: beak, bulge or density at fused epiphyseal line is: not a fracture; IS a physeal scar
Gilula Arcs: articular surfaces of carpal bones s/b: parallel, joint spaces similar width & parallel cortical margins
Gilula Arcs: any break in the lines or overlapping of normally parallel joint spaces suggestive of: joint injury
De Quervain Tenosynovitis: Hx: Radial wrist pain
De Quervain Tenosynovitis: Anatomy: 1st Dorsal compartment; APL & EPB tendon moves over radial styloid
De Quervain Tenosynovitis: Dx: Pos Finkelstein
De Quervain Tenosynovitis: Tx: Ice, thumb spica, rest, ionto
De Quervain Tenosynovitis: Injection: Marcaine/ Kenalog In 1st dorsal compartment; directed toward radial styloid
De Quervain Tenosynovitis: last intervention: Surgical release
CTS: Hx: Pain, numbness, paresthesia in median n. distn
CTS: Anatomy: 10 structures pass through carpal tunnel (9 tendons, 1 (median) n.)
CTS: PE: Positive Tinel’s and Phalen’s
CTS: Consider: EMG, Neurometrics
CTS: Tx: Splinting, ergonomics
CTS: Injection: 1ml Marcaine/40mg Kenalog; ulnar to palmaris longus at proximal wrist crease at 30 degrees
CTS: Surgical release cut transverse carpal ligament
Tinel Sign Percuss over median n. carpal tunnel; tingling or pain in median n. distn = Pos
Phalen Test Acute flexion of wrists for 60-90 sec => numbness & tingling over median n. distn
Ganglion Cysts: Sx: Painful or painless
Ganglion Cysts: Distribution: 65% Dorsal (SL joint), 25% radio-volar, 10% other flexor tendon sheaths (retinacular), occult
Ganglion Cysts: Aspiration: 18 g needle & 10 cc syringe; instill 40 mg Kenalog; compressive bandage; surg excision for recurrence
Ganglion Cysts: recurrence 10 % recurrence after excision
Scapholunate Dissociation = Traumatic SL ligament tear; >2mm space at SL joint
Scapholunate Dissociation: S/S Wrist pain & instability; Letterman sign; Watson Test
Scapholunate Dissociation: dorsal rotary subluxation leads to: dorsal intercalated segment instability (DISI) & SL advanced collapse (SLAC)
SL dissociation: Rx: SL ligament repair, PRC, Arthrodesis
TFCC Tear = Triangular Fibrocartilage Complex
TFCC fn: Stabilizes distal radioulnar joint
TFCC Tear: MOA = Acute or repetitive overuse
TFCC Tear: PE: TTP over TFCC; (+) Foveal sign
TFCC Tear: dx tests X-Ray (Look for ulnar variance); MRI / Arthrogram
TFCC Tear: Rx: Splint, NSAIDs, PT; injection; arthroscopic repair
Ulna Impaction Syndrome S/S: Ulnar wrist pain, swelling & weakness
Ulna Impaction Syndrome MOA: Ulna head impinges carpi
Ulna Impaction Syndrome: X-ray shows: cystic or sclerotic changes of the lunate &/ or triquetral
Ulna Impaction Syndrome: leads to: lunotriquetral ligament attrition
Ulna Impaction Syndrome: Rx: Ulna shortening
Kienbock Dz = Lunatomalacia
Kienbock Dz: MOA Repetitive microtrauma => lunate collapse secondary to vasc insuff & avascular necrosis
Kienbock Dz: S/S Radiating wrist pain & swelling over lunate; pain on middle finger dorsiflexion
Kienbock Dz: Rx: Surgical unloading, fusion, vascular implantation
Monteggia fx = Ulna shaft fx; Proximal radius dislocation
Monteggia fx: tx ORIF vs long arm cast for 6 weeks
Galeazzi fx = Radial fracture; distal Ulna dislocation
Galeazzi fx: tx ORIF vs long arm cast 6 weeks
MUGR = monteggia = ulna; Galeazzi = radial
Greenstick fx = Incomplete fx
Greenstick fx: MOA thick periosteum in children prevents displacement; dorsal cortex intact
Greenstick fx: tx Reduction (if needed) & short arm cast for 3-4 weeks
Night Stick fx = Isolated Ulna fracture
Night Stick fx: tx = Cast or splint for 4 wks; then functional splint for several wks
Both Bone Forearm Fx: MOA Fall or direct hit
Both Bone Forearm Fx: Displacement or angulation > 10 degrees: needs ORIF
Both Bone Forearm Fx: Non displaced, non-angulated fx: may be put in long arm cast 6 wks
Colles Fx: MOA FOOSH injury; dorsal angulation of distal fragment
Colles Fx : if < 15 degrees angulation: acceptable; short arm cast for 4-6 wks
Colles Fx : if > 15 degrees or sig displaced: reduction, CRPP, ORIF
Smith Fx: MOA Fall on back of hand; Hyperflexion injury; volar angulation of distal fragment
Smith Fx: minor angulation = acceptable; short arm cast 4-6 wk
Smith Fx: significant angulation = Reduction, CRPP, ORIF
Barton Fx = Intra-articular fracture; displaced radial articular fragment
Barton Fx: tx ORIF
Chauffeur Fx: MOA Oblique fx through the base of the radial styloid
Chauffeur Fx: Tx Long arm cast for 1 mo. followed by short arm cast for 2 wks
Torus Fracture = Buckle fracture with intact periosteum
Torus Fracture: Common in: children
Torus Fracture: Tx 3-4 weeks immobilization in a short arm cast; young kids need long arm cast (lest they take cast off)
Scaphoid Fx: MOA FOOSH injuries
80% of scaphoid fx occur at: waist
Scaphoid Fx: 1/3 will develop: osteonecrosis
Scaphoid Fx: Healing time: Distal 6 weeks
Scaphoid Fx: Healing time: Waist 3 months
Scaphoid Fx: Healing time: Proximal 4 months
Scaphoid Fx: Healing time: RX: Percutaneous screw fixation; ORIF w/ bone graft
Scaphoid Fx: Imaging: AP, Lat, oblique, scaphoid views; MRI; Bone scan 72 hrs post injury
Scaphoid Fx: If initial imaging neg: Immobilize in thumb spica or cast; repeat radiographs in 10-14 days
Both Bone Forearm Fx: Displacement or angulation > 10 degrees: tx needs ORIF
90% of distal radial fractures are: Colles Fx; FOOSH injury; dorsal angulation of distal fragment
Most common carpal fx = Scaphoid Fx (2/2 FOOSH)
Ganglion Cysts: Hx: Swelling at wrist (usually dorsal); Leak of joint fluid
Created by: Abarnard