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Flashcards in Wrist Conditions Deck (47):

What is ulnar variance?

  • Measured on PA wrist-  with shoulder in 90o abduction/elbow felxion 90o, forearm neutral , hand aligned w forearm



How do you measure ulnar variance?

on PA wrist- shoulder 90, elbow flexed 90, neutral forearm rotation

Draw- 1 line tangential to articular surface of the ulna- pink

1 line tangential to articular surface of radius- green

if ulnar tangent is distal to radial = +ve

If ulnar is proximal to radial= -ve

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What is the length difference in a ulnar positive variance?

How does this affect the load thru the wrist?

  • Ulnar- radial Length difference +2.5mm
  • Normal is 0 (<1mm)
  • normal load thru radius = 80%, ulna 20%
  • +Ve UV= radius 60%, ulna 40%


What is the length difference in an ulnar negative variance ?  How does this affect the mechanical load thru the wrist?

Ulnar- radial length difference -2.5mm

normal is 0 (<1mm)

normal load thru radius = 80%, ulna is 20%

-Ve UV= 95% thru radius, 5% ulna


What is the epidemiology of ulnar variance?

  • UV is lower in males than Females
  • UV increases with age
  • Risk Factor- Positive UV present in child gymnast- distal radial plate injury->premature closure of distal radial physis



Described the pathophysiology of Ulnar variance?

  • Congential - Madelung's deformity ( +UV), reverse Madelung's deformity ( -UV)
  • Acquired
    • Trauma/Mechanical- distal radius Frac w shortening, growth arrest SH frac, DRUJ ( galeazzi/Essex-Lopresti)
    • Iatrogenic- joint leveling procedures( radial/ulnar shortening/lengthening),Radial head excision


Name some associated conditions of positive Ulnar variance?

Positive UV

  • Ulnar abutment syndrome
  • SLD
  • TFCC tears
  • arthrosis- radial head, lunate, triquetrum
  • Lunotriquetral ligament tears


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Name some associated conditions of negative Ulnar variance?

Negative UV

  • Keinbocks disease
  • Ulnar impingment syndrome- ulna impinges on radius prox to sigmoid notch


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Describe the problems with Positive UV?

  • Ulnar sided wrist pain from increased impact stress on lunate and triquetrum
  • UV increases in Pronation/  during Grip 


What is the tx of ulnar variance?

Depends on specific condition

ulnar abutment syndrome

Tfcc tears

Keinbock's disease


What is ulnocarpal abument syndrome?

  • Syndrome caused by excessive impact stress between the ulna and carpal bones ( primarily the lunate)
  • Positive ulnar variance


What is the pathoanatomy of ulnocarpal abutment syndrome?

Abnormal loading thru ulna

In +ve ulnar variance wrist -

  • 40% load thru ulna
  • 60% thru radius
  • cf normal wrist radius 80% , ulna 20%


Can you name the associated conditions?

  • Scapholunate dissociation
  • TFCC tears
  • Lunotriquetral ligament tears
  • Radial shortening from previous trauma


What are the symptoms of ulnocarpal abutment syndrome?

  • Pain on dorsal side of DRUJ
  • Increased pain w  ulna deviation of the wrist
  • Pain with axial loading
  • ULNA sided wrist pain


What are the signs at examination of the ulnocarpal abutment syndrome?

Ballottement test- for lunotriquetral instability- examiners holds lunate between thumb and second finger and triquetrium between thumb adn second finger and sees if they can move and cause pain

Fovea test- use to evaluate the TFCC- palpation of the wirst between styloid and FCU tendon


What xrays views are useful in DX of ulnocarpal abutment syndrome?

  • Ap radiographs w wrist in Neutral supination/pronation adn zero rotation
  • Pronated grip view- increase radiographic impaction
  • See ulnar positive wrist
  • Sclerosis of the lunate


To evaluate TFCC tear- caused by ulnocarpal impingement


What is the DDx of ulnar sided wirst pain?

  • DRUJ instability or arthritis
  • TFCC tear
  • LT ligament tear
  • Pisotriqeutral arthritis
  • CU tendonitis or instability


What is the tx of ulnocarpal abutment syndrome?

Non operative

supportive measures- nsaids, splint


  • Ulnar shortening osteotomy- most cases of +ulnar variance/ DRUJ incongruity often with arthroscopy of wrist to repair TFCC
  • Wafer procedure- 2-4mm of cartilage and bone removed under TFCC arthroscopy
  • Darrach Procedure- ulnar haead resection- low demand pts-> ulnar stump instability
  • SAuve-KApandji- gd option for labourers- create a radioulna fusion and a pseudoarthrosis proximal to fusion.
  • Ulnar hemiresection arthroplasty-intact TFCC required- post traumatic DRUJ with distal ulnar degeneration
  • Ulnar head prosthesis- severe ulnocarpal arthrosis/salavge fo rfailed darrach



What is Kienbock's Disease?

Avascular necrosis of the lunate -> to abnormal carpal motion


Describe the epidemiology of Kienbock's disease?

Incidence- most common Men 20-40 yrs

Risk  Factors- Hx of Trauma



Describe the pathophysiology of Kienbock's?

Multiple factors

Biomechanical factors

  • ULNA Negative Variance- > increase radial lunate contact stress
  • Repetitive Trauma

Anatomic Factors

Geometry of lunate

Vascular supply to lunate- different patterns of arterial blood


Describe the blood supply to lunate?

  • Y pattern
  • X pattern
  • I pattern- 31% of pts highest risk of AVN


Name and describe the classification of Kienbock's Disease?


  • Stage 1- No change on xray. Changes on MRI = Immobilisation and NSAIDs
  • Stage 2- Sclerosis of lunate xray- Joint levelling procedure- ulna negative

Radial wedge osteotomy/STT fusion - ulna +ve

         Core decompression/revascularisation procedures

  • Stage 3A= Lunate COLLAPSE, no scaphoid rotation- TX same as above
  • Stage 3B= lunate collapse, FIXED SCAPHOID Rotation= Proximal row carpectomy

                           STT fusion

  • Stage 4- Degenerative adj intercarpal joints= Wrist fusion/proximal row carpectomy limited intercarpal fusion


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What are the symptoms of Kienboch's?

  • Usually Activity related
  • More often Dominant hand


  • Wrist swelling
  • Tender over Radiocarpal joint
  • Decreased Flexion/extension
  • Decreased grip strength


What investigations are useful in Kienboch's?

Xrays- AP, Lateral and oblique view

CT most helful when lunate collapse- extent of necrosis, trabecular destruction, lunate geometry

MRI - best in early disease- Increase intensity T1 weighted image, reduced vascularity


Describe the tx of Kienboch's disease?

Non operative

Immobilisation/nsaids- stage 1 disease


adolscent w xray changes= Temporary Scaphotrapeziotrapezoidal pinning

Stage 1/2/3a

  • Joint Levelling- for UV negative
  • Radial wedge osteotomy- UV positive
  • vascularised bone graft- early result promising. gd results stage 2
  • Distal radius core decompression-> local healing response

Stage IIIa/B

  • STT fusion - must address DISI collapse

Stage IIIB/ IV

  • Proximal row carpectomy- superior results over STT fusion in studies of type IIIb

​Stage IV

  • Wrist fusion
  • Total wrist Arthroplasty- long term results not available


Can you describe a technique for vascularised bone grafts?

many have been described

  • Transfer of pisiform
  • Transfer of distal radius on a vassculasired pedicle of Poronator quadratus
  • transfer branchies of 1st,2nd, 3rd dorsal metacarpal arteries
  • Temporary pinning of STT joint, SC joint or external fixation may be used to unloas lunate after revascularisation


What is avn of the scaphoid aka?

Preiser's Disease

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What is the epidemiology of Preiser's disease?

  • Rare condition
  • Av Age onset 45 yrs


Symptoms of Preiser's Disease?

Dorsal wrist pain


What investigations are useful in Preiser's disease?

  • Radiographs= sclerosis and fragmentation of PROXIMAL POLE
  • MRI- confirms complete or partial involvement

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What is the TX for Preiser's disease?

Non operative

Immobilisation- effective in 20% cases


  • Microfracture drilling, revascularisation procedure or allograft replacement
  • Salvage procedure= proximal row carpectomy or scaphoid excision with 4 corner fusion


What is Gymnat's wrist?

What is the epidemiology?

Distal Radial Phsyeal Stress Syndrome

where overuse of the wrist primarily in young gymnasts   -> premature closure of distal radial physis

Up to 25% in NON elite gymnasts


What is the Pathophysiology of gymnasts's wrist?

  • wrist undergoes supraphysiological loads due to use as Weight bearing joint
  • Repetitive stress-> inflammation at growth plate of  distal radius
  • Microtrauma can lead to premature closure of distal radius physis -> secondary overgrowth of ulna and positive ulnar variance


What are the signs and symptoms of gymnast's wrist?


  • Radial sided wrist pain
  • ? chronic in nature


  • Swelling at wrist
  • Tenderness to palpation at distal radius
  • Decreased flexion/extension


What investigations are useful in Gymnasts wrist?

  • Xrays- ap and lateral= widening of distal radial growth plate with ill defined borders

Positive ulna variance in chronic cases

  • MRI= paraphsyeal oedema

Early physeal bridging

Brusing of radius

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What is the tx of gymnast's wrist?

Non operative

  • NSaids, rest immobilisation for 3-6 months


Resection of Physeal Bridge- small physeal closures

Ulnar epiphysiodesis and shortening with radial osteotomy - of physeal closure >50%


What are the mechanism of TFCC tear

  • Type 1- Mechanical

Fall onto extended wrist w pronated forearm- most common

Traction injury to wrist

  • Type 2- Degenerative
  • assoc Positive UV- ulnocarpal impaction


What is the TFCC made up of?

  • Dorsal radioulnar ligament
  • Volar radioulnar ligament
  • Central Articular disc
  • Meniscus Homolog
  • Ulnar collateral ligament
  • ECU subsheath
  • Orgin of ulnolunate and ulnotriquetral ligaments

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Name the TFCC blood supply? 

Can you name the origin adn insertion of the FFCC?

Blood supply

Peripheral is well Vascularised

Central portion is ASVASCULAR


Origin= dorsal and volar radioulnar ligaments originate at Sigmoid notch of radius

Insertion= dorsal and volar radioulnar ligaments converge at base of ulnar styloid


Can you describe the classification of TFCC tears?

Class 1- Traumatic

1A= Central perforation tear

1B= Ulnar avulsion ( wout ulnar styloid)

1C= Distal Avulsion ( origin of UL and UT ligaments)

1D= Radial Avulsion

Class 2- Degenerative

2A- TFCC wear and thining

2B- Lunate +/- Ulnar chrondormalacia + 2A

2C- TFCC perforation +2B

2D- Ligament disrutpion + 2C

2E-  Ulnocarpal and DRUJ arthritis + 2d



What are the symptoms and signs of TFCC tear?

  • Wrist pain- turning a door key 


Positive Fovea sign- tenderness in soft spot between ulnar styloid and FCU, between the volar surface of the ulnar head and pisiform

Pain w ulnar deviation (TFCC compression)  

Pain w radial deviation (TFCC tension)


Investigations used in TFCC tear idenfication are?

  • Radiographs- usually negative, may show ulnar variance
  • Arthrography- shows extravasation
  • MRI- replaced arthrography- tear at ulnar indicates ulnocarpal impaction, sensitivity 74-100%
  • Arthroscopy- most accurate method of dx
  • indicated in pt who fail consx tx


What is DDX of ulnar sided wrist pain?

  • TFCC tear
  • Ulnacarpal abutment syndrome
  • Ulnar styloid impaction syndrome
  • Fracture-  Ulnar styloid

Hook of hamate

  • Ulnar nerve entrapment at Gyon's canal
  • ECU subluxation
  • Pisotriquetral arthritis

NB= The Unopened Umbrella Fell Under Eve's Purse


TX of TFCC tears

Non operative

 Type 1 and 2 acute = Immobilistion/ NSAIDs/Steriod injections


Types 1B, 1C, 1D= Arthroscopic repair- generall y acute- reagin 80% motion/ grip strength if acute ( <3/12)

Types 2

  • Ulnar disaphyseal shortening- +UV >2mm - tightens the ulnocarpal ligaments
  • Wafer procedure- +UV <2mm- types 2A-C
  • Limited Ulnar head resection- Type 2D
  • Darrach - CI due to problems of ulnar stump INSTABILITY !!!


Can you describe the anatomical location for a wrist athroscopy?

Arthroscopic approach to the wrist thru portals 3/4 and 6R