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1

List the ligaments of the wrist

INTRINSIC

  • VOLAR: SL, LTq, VIC
  • DORSAL: SL, LTq, DIC
  • Midcarpal: THC, SC, Strapezial 

Dorsal SL and Volar LTq are most important for stability

 

EXTRINSIC

  • VOLAR: RL (Long and short), RS, RSC, RU, UTq, UL, UC
  • DORSAL: RS, RL, RTq (DRC), RU

2

What is the space of poirier

  • located between RL long and RSC
  • space where perilunate dislocations can occur

3

what is the TFCC, location and function

Triangulofibrous Cartilage complex

  • located between ulna, carpus, contained wihtin RU ligaments, UL, UTq, ECU
  • Function
    • primary stabilizer of DRUJ
    • stabilizer of ulnocarpal joint
    • gliding surface of pronation/supination
    • suspends ulnar wrist from radius
    •  

4

aDescribe the vascular supply to the carpal bones and specific scaphoid blood supply

  • Derived from radial and ulnar palmar and carpal arches/branches
  • single Intraosseous vessel: scaphoid, lunate, capitate
  • Dual  supply, no anast; hamate trapezoid
  • Dual supply with anast: Trap Triq, Pisiform, lunate

 

SCAPHOID

- Dorsal scaphoid branch of radial artery -> retrograde flow to the scaphoid proximal pole **80% of blood flow

- Volar scaphoid branch of radial artery -> anterograde flow to tubercle

5

Describe your physical exam of the wrist

compare BOTH sides with elbow resting on the table

  • point of maximal tenderness
    • scaphoid tubercle - radial  to FCR, prominent in radial devaition
    • scaphoid waist - snuff box, prominent in ulnar 
    • scaphoid proximal pole - b/w 2nd and 4th compartment, distal to listers tubercle
    • Sl lig - b/w 2nd and 4th compartments
    • lunate - valley distal to lister's tubercle, check w wrist flexion
    • Tq - distal to ulnar head on dorsum
    • capitate - base of D3 MC
    • Trapezoid - base D2 MC
    • Hamate - base D4/5
    • TFCC - valley distal to ulnar head
    • STT - base of D2MC
  • ROM
    • ​dorsi/palmar flexion 75'
    • radial deviation 35'
    • ulnar deviation 25' 
    • pronation/supination 75'/80'
  • Special Tests
    • 1st CMC arthritis - grind test, shoulder sign
    • STT arthitis - thumb immobilized, wrist flex/ext moves ST - if painful, STT not CMC arthr.
    • scaphoid instability/SL lig - Watson's test: wrist movement from ulnar to radial, with thumb applying pressure on tubercle - with deviation and release will have clunk/pain when scaphoid clunks back
    • Lq instability
      • ballottment with dorsal pressure on Lunate and volar on Tq 
      • Kleinmann sheer test - dorsal pressure on Tq is painful
    • Dequervains - Finkelsteins 
    • MIdcarpal instability - Lichtman test
      • axial pressure into radial deviation, look for proximal clunk when in extension (catch up clunk)
    • DRUJ
      • pain/crepitus w pron/sup
      • ballottment- stabilize radius with elbow in neutral and trasnlate ulna back and forth- 5mm normal - none in extreme pron/sup

6

What is your DDX for radial sided wrist pain?

  • FCR tendonitis
  • Dequervains
  • intersection syndrome
  • ECRB/ECRL tenosynovitis
  • SL instability, tear
  • carpal F#: scaphoid, Tp, Tm
  • radial styloid F#
  • Kienbocks (lunate AVN)
  • Preiser's (scaphoid AVN) 
  • Arthritis 1st CMC, STT, RC
  • Ganglion
  • Vascular lesion - AVM/ischemia
  • Neuroma- wartenberg syndrome (DSRN neuritis)
  • Carpal Tunnel

7

What are normal features to identify on a wrist xray series

  • Series: PA, lateral, 45' oblique
  • pencil grip, scaphoid views
  • Alignment
    • Radial inclination 22' +/- 2
    • Radial volar tilt 11' +/- 22
    • Radial height 11mm +/-2
    • Ulnar variance 0-2mm
    • Gilula's lines
    • SL joint space<2mm
    • carpal height: capitate = 1/2 D3MC
    • ulnar translocation = >1/2 lunate ulnar to radius, occurs in SLAC wirst
    • CL angle <30
    • SL angle <60
      • based on volar max concexity of scaphoid, max convexity of lunate, max distal/proximal pt of capitate

8

DDX of ulnar sided wrist pain

  • FCU tendonitis
  • ECU subluxation
  • Arthritis PT, DRUJ, ulnar styloid
  • DRUJ instability (TFCC tear/injury)
  • L-Tq instability
  • Ulnar styloid F#, hamate/Tq#
  • ulnar carpal abutment
  • TILT (Triquetrail impingement lgament tear) (fibrous cuff displaced distally that impinges  on Tq - need ot remove fibrous cuff
  • hypothenar hammer syndrome
  • DSUbr neuritis

9

How do you tell if it is a true lateral xray

<3mm ulna showing beyond radius

SPC - pisiform lies beteen volar edge of scaphoid and dorsal edge of capitate

10

What is diagnostic for DISI and VISI on xray

  • DISI - lunate cup is pointed dorsal (extended) and capitate is dorsal, SL>60
  • VISI - lunate cup is pointed volar (flexed) and capitate is volar, SL <30

11

What F# is difficult to spot on xray

  • hook of hamate F#
  • Triquetrium F# in proximal radial corner =>key for mayfield class of periL dislocation
  • Trapezium - dorsal ulnar border

12

What are normal variations to see on xray for carpal bones?

 

  • carpal coalitiion  (lunate/Tq)
  • Lunate facets - type 1 - capitate only, type 2 - capitate and hamate
  • bipartite scaphoid (often bilateral)Os carpi centrale - accessory carpal bone adj to scaphoid/capitate

13

How do you classify distal radius fractures?

  • Barton - INTRA-articular fracture with radiocarpal displacement - dorsal or volar
  • shearing force with strong radiocarpal ligaments causing radiocarpal dislocation
  • Colles - EXTRA-articular fracture with dorsal disaplcement
  • Smith - EXTRA-articular or juxta-articular fractur with VOLAR displacmeent
  • for smith/colles, one cortex fails and other undergoes comminution
  • Chaffeur - INTRA-articular radial styloid F# ***associated with SL injury, Perilunate dislocation, ulnar styloid fracture ***must assess

14

How do you manage distal radius fractures?

Indications for non-operative Tx

  • loss of radius height >5mm
  • dorsal tilt >10'
  • articular incongruity

Indication for operative Tx

  • displaced, irreducible, unstblae F#

15

How do you perform a closed reduction of a colles fracture

 

  • extension of wrist to disengage fracture segment, volar pronated force
  • splint in 20’ulnar 20’flexion position for 3wks w wkly checks
  • early AROM 4-6wks

16

What are complications of a distal radius fracture?

ACUTE

  • nerve injruy: median, ulnar, radial sensory
  • compartment syndrome
  • DRUJ instability

CHRONIC

  • Arthritis
  • CRPS
  • stiffness
  • Malunion
    • ulnocarpal abutment syndrome (shortened radius)
    • midcarpal intability (excessive volar tilt)
    • Arthritis (excessive volar tilt)
    • DISI (excessive volar tilt)
  • Tendon rupture
    • EPL rupture (2’ attrition/ischemia post hematoma)
    • flexor/extensor 2’ attrition post hardware

17

WHat is the incidence of carpal bone F#

  • scaphoid 60-80%
  • triquetrum 15%
  • rest 1%
  • trapezoid most infrequent

18

What anaotmic location of the scaphoid is most likely to fracture

 

  • waist 70%
  • tubercle 20%
  • proximal pole 10%

19

What are clinical features of a scaphoid fracture

  • tenderness in snuffbox (waist), tubercle or proximal pole
  • tenderness worsened with resisted supination or axial compression of thumb
  • may have assocated + watsons test (SL tear)

20

How do you classify scaphoid fractures? 

Herbert

  • Type A= acute stable
    • tubercle
    • incomplete waist
  • Type B = Acute unstable
    • distal oblique
    • complete waist
    • proximal pole
    • trasnscaphoid perilunate F# dislocation
  • Type C = Delayed union
  • Type D = non-union (fibrous union or pseudoarthrosis

21

What xray view would you order for radial sided wrist pain?

 

  • PA, lateral, oblique, scphoid views
  • repeat in 10-21days as F# will not be evident until then

22

What are scaphoid/SL views?

  • ulnar deviation and extension of wrist
  • pencil grip view

23

How do you manage a pt w a suspected scaphoid fracture and neagtive xray?

  • short arm thumb spica x14days
  • re-xray 10-21days
  • if second xray negative and strong suspicion, CT scan 

24

What are signs on imaging of a scaphoid fracture and DISI?

  • SL angle >60
  • CL angle >15
  • dorsal translation of capitate

25

How do you define an UNSTABLE scaphoid fracture?

  • >1mm displacement
  • fracture angulation
  • carpal malalingment

26

What % of scaphoid fractures will go on to unite?

  • 95% of tubercle F#
  • 90% of waist fracture
  • 60% of proximal pole F#

27

How do you manage an acute scaphoid fracture (Type A/B herber classification)?

NON-OPERATIVE  (type A)

  • tubercle F# -> 2wks short arm thumb spica splint, IPj free, then 6wks cast. Xray q4wk
  • non-displaced waist F# -> 2wks short arm thumb spica splint, IPj free, then 6wks cast. Xray q4wk
  • *most require 8-12wks of immoblization
  • *if not healed at 6-8wks, (tender/xray showing sclerosis/cystic changes/resorption => ORIF
  • return to sports 6mths

 

OPERATIVE (type B)

  • proximal pole F#
  • displaced waist F# (angulation, >1mm displaced, carpal malalignment)
  • also for nondisplaced if athelete/refusal/inability to immoblize for 8-12wk
  • communited F# (requires BG)

 

OPERATIVE OPTIONS

kwire, compression scrw osteosynthesis (herbert screw), percutaneous screw fixation

volar approach if F# in distal 1/2, dorsal appraoch if F# in proximal 1/2

aim to place screw in central 1/3 of scaphoid

  • Volar approach (for distal 1/2 F#)
    • divide volar carpal ligaments
    • reduce fracture with joysticks
    • ST jt opened and segment of T removed to allow screw placement
    • alignment jig, drill guide, drill, tapp, screw
    • repair volar carpal ligament
    • xray check
    • 1wk thumb spica immobilization, then splint early ROM
  • contact sports 3-6mths

28

How do you manage scaphoid delayed union? Type c -

  • Defined as INCOMLPETE BONE UNION/ persistent symptoms after 4mths of adequate immobilization
  • If not yet 4mths, continue up to 4mth w cast immobilization
  • at 4-12mths wihtout union, ORIF + BG

29

How do you manage scaphoid nonunion (type d?)

  • Defined as failure of trabeculation across fracture site and sclerosis of bone ends
  • AVN of proximal pole can co-exist w non-union

INVESTIGATION

  • XRAY
    • sclerosis, cysts, flexion deformity (humpback for waist F#), resorption, DISI
  • CT
    • to measure extent of collapse
  • MRI
    • to assess for AVN **** low signal on T1 and T2 images 

TREATMENT

  • Goal: restore alignment and unite fracture
  • ORIF with Bone graft
  • Plan dependent on
    • location of non-union 
      • proximal -> dorsal approach
      • waist ->volar approach
    • AVN
      • if present, vascularized BG
      • if no AVN, corticocancellous IC bone with wedge (Fisk-Fernandez)
    • presence of SNAC
      • no restoration of scaphoid
      • PRC or 4corner fusion

SUMMARY

  • displaced Waist  non-union with humpback deformity=> volar approach, ICBG wedge
  • Proximal pole - dorsal approach:
    • vascularized: ICBG and internal fixation
    • AVN: vascularized BG (1,2ICSRA)
  • AVN + SNAC or fragmentation
    • PRC or Four corner fusion

30

What are risk factors for scaphoid non-union?

  • Delayed diagnosis >4wks
  • inadeqaute immobilization
  • proximal pole fracure
  • waist fracture with displacement >1mm
  • smoker
  • asssociated ligamentous injury