acute wrist injuries - fisiokinesiterapiawrist injury (scaphoid, radius, ulnar styloid fracture)...
TRANSCRIPT
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Acute Wrist Injuries
OUCH!
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Case – the athlete
FOOSH from sporting event 2 days agoC/O wrist swelling, pain, worse with movement
Hmmm…Wrist pain
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Exam of the wrist - basics
AppearanceSwelling, bruising, deformity
FunctionRange of motion, grip, neurovascular status
PainWith motion, palpation
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Anatomy review – honing in
THINKDorsal vs VentralRadial vs. Ulnar
FlexorCarpi
Radialis
Pisiform
Hook of Hamate
PalmarisLongus
FlexorCarpi
Ulnaris
AnatomicSnuffbox
UlnarStyloid
DRUJ
E. PollicisLongus
E. PollicisBrevis
Radial Styloid
Lister’sTubercle
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Carpals
TTCHSLTP
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Differential Diagnosis
Benign StuffSprainTendonitisContusion
Can’t Miss StuffFracturesTendon ruptureLigament disruptionsCarpal dislocation
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Imaging – review of normal
PA LateralOblique
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Additional views
Clenched fist PA Clenched fist Oblique
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Additional views
Tunnel View
Scaphoid View
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Key measures on X-ray
Radial inclination - 23°Volar Tilt – 11°Radial Height -12mmScapholunate angle – 30° to 60°Scapholunate joint width – 2mmCapitate-Lunate angle <10°-20°
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Radial Inclination & Height
23°
12mm
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Volar tilt - 11°
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Scapholunate angle & joint width
2mm
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Captitate - Lunate association/angle
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Fractures
Radius / UlnaCarpals
Scaphoid*TriquetriumHamate
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Distal Radius FractureRED FLAGSRED FLAGS
Inclination < 20°Dorsal TiltShortening > 5mm
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Other Radius / Ulna fracturesDistal ulnaUlnar styloidRadial styloid
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Carpal Fractures
Scaphoid #1TriquetriumThen the rest
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Scaphoid
Check snuffbox tendernessOrder scaphoid viewMay not be seen on initial x-rayConsider alternate imaging (CT, Bone scan, MRI)Treat until ruled outHigh incidence of non-union with proximal fx
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Scaphoid x-raysInitial
2 month f/u
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Triquetrium
Pain ulnar sided and dorsalAssociated with ulnar styloid fxand TFCC injuryOblique film with slight pronationbest viewDorsal chip avulsion most common
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Hamate
Pain ulnar sided and palmarHook of hamatecommon siteTunnel view xrayAssociated with club/racquet use
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Hamate - xray
Don’t confusewith pisiform
Hamatehook
Pisiform
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Pisiform
Similar to hamateUlnar and palmar pain
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Ligament Injury
Scapholunate dissociationLunate dislocationPerilunate dislocationTFCC injuryDRUJ injury
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Scapholunate dissociation
Terry Thomas or ‘Newman’ sign
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Tests to assessscapholunate instability
Watson test showing the starting position (A) and end position (B) testing for scapholunate instability
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Perilunate & Lunate dislocation
Associated with significant wrist injury (scaphoid, radius, ulnar styloidfracture)
Remember the lunate-capitate association on lateral film
Capitate–lunate lines < 20°Triple C
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Perilunate dislocation
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Lunate dislocation
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The Shuck Test for perilunateinstability
(Left) The wrist is held in flexion by the physician, and the patient extends his or her fingers. (Right) The physician resists this movement. Significant parascaphoid inflammation, radial carpal, or midcarpalinstability may cause considerable pain with this maneuver.
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TFCC injury
Triangular Fibrocartilage ComplexMechanism: ulnar loading with rotational stress (FOOSH)Symptoms: ulnar wrist pain, worse with extension, pronation/supinationExam: TFCC compression, Press test, supination lift testImaging: MRI (Xray typically normal)
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TFCC anatomy
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TFCC exam tests
Palpate TFCC – elicits tendernessTFCC Compression:
ulnar deviation, axial load, flex and extend –produces pain or clicking in TFCC
Press test:Lift self from chair while bearing wt on extended wrists – produces pain
Supination lift test:Attempt to lift table/desk with palm flat on underneath side
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DRUJ injury/dislocation
Distal Radioulnar JointClosely associated with TFCCMechanism: axial load and rotational stress (FOOSH)Symptoms: Ulnar wrist painExam: Loss or prominence of ulnar styloidImaging: Xray PA/LAT
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DRUJ – volar dislocation
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Tendon injury
Extensor tendon rupture
Flexor tendon rupture
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Management points
Recognition!Fracture, ligament/tendon injury
Basic acute managementsplinting
Ortho referral
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Back to our case
ExamSlightly swollen dorsallyPain with supination/pronation & flexionAble to flex/extend fingerNo obvious deformity or bruising
Any other exam tests?
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Further exam tests
Radial testingSnuffbox palpationDistal radius/styloid palpation
Ulnar testingPisiform/hamate palpationTFCC testing (compression,press,supination lift)
Ligament stabilityScapholunate – Watson test / Shuck testDRUJ – grip, direct palp
Tender!
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Film
Scaphoid fx-proximal pole
High incidence AVN –ortho consult to consider initial operative rx
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Treatment
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If you miss it…..
…AVN chronic wrist pain, loss of mobility, unhappy patient