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Wrist

The wrist and hand form a continuum with the upper extremities and allow the body to reach out to perform a vast number of functions.

Medical Conditions
De Quervain's Disease

De Quervain’s disease is a painful wrist condition that affects the tendons on the thumb side of the wrist. The condition is often attributed to occupational or repetitive activities involving extending the thumb. It is most common among women between the ages of 30 and 50, including women who have recently had a baby or others who repetitively lift infants.

Presentation

Symptoms may include pain or tenderness when moving the thumb, turning the wrist, grasping something, or making a fist. Pain may radiate to the thumb or forearm. Some patients have swelling on the radial side of the wrist or difficulty holding objects.

Physical Exam

To determine whether or not the patient has de Quervain’s disease, the Finkelstein test may be performed: 

 - Tenderness over 1st dorsal compartment at level of radial styloid

On grasping the patient’s thumb and quickly abducting the hand in the ulnar direction, the styloid tip is painful.

Treatment

Most cases of de Quervain’s disease resolve with non-operative management:

 - Rest, NSAIDS, thumb spica splint, steroid injection

There is a high recurrence rate for cases treated nonoperatively. Overall, injection of corticosteroids into the tendon sheath is found to be superior to splinting.


Surgery may be recommended if symptoms are severe or do not improve.

Operative treatment involves:

 - Surgical release of 1st dorsal compartment

 - Permanent solution

Complications

Complications from surgery, or after surgery, are possible. Potential complications may include:

 - Sensory branch of radial nerve injury

 - Complex regional pain syndrome

De Quervain’s disease is a temporary condition. Treatment is generally successful when begun early.

Traumatic Conditions
Fractures
Carpal Bones

Scaphoid fractures are by far the most common of the carpal fractures. In some instances, they can be difficult to diagnose and can result in significant functional impairment. 

Presentation

The most common finding includes pain and tenderness in anatomical snuffbox dorsally. 

Imaging

X-rays usually confirm the presence of a carpal bone fracture. An MRI allows for a superior characterization of carpal fractures, especially in the first 24 hours following injury and provides a guide towards suitable treatment.

Treatment

Uncomplicated fractures are usually managed conservatively. Rest and immobilization with thumb spica cast is the non-operative treatment of choice. The duration of casting depends on location of fracture:

Distal - waist for 3 months

Mid - waist for 4 months

Proximal - third for 5 months

Athletes should not return to play until imaging shows a healed fracture. 

Surgery is required in significantly displaced fractures of the carpal bones. Other indications include proximal bone fractures and non-displaced waist fractures, to allow decreased time to union, as well as a faster return to work and sport activities. 

Fracture Complications

In case of complications e.g. nonunions, following a carpal bone fracture, surgery will involve the removal of the necrotic bone followed by the replacement with a bone graft. Other complications after carpal bone fracture include an advanced collapse and progressive arthritis of the wrist that results from a chronic scaphoid nonunion. 

Treatment

Observation is recommended for medically frail and low-functioning patients. 

Operative treatment may include:

 - Radial styloidectomy plus scapholunate reduction and stabilization

 -- Stage 1

 - Proximal row carpectomy (older patients)

 -- reduction of wrist motion and grip strength

 - Four-corner fusion (younger active patients)

 -- retains 60% of wrist motion and 80% of grip strength

 - Wrist fusion

 -- last resort, when all of the above fail

Traumatic Conditions
Hamate Fractures

Hook of hamate fractures often result from athletic activity involving the use of golf clubs, baseball bats, tennis rackets, etc. Most hook of hamate fractures heal if well immobilized immediately. 

Physical Exam

A hamate fracture can be diagnosed with a physical exam and x-rays. The most common symptom is pain in the palm aggravated by grasp. Other symptoms of a hamate fracture include diminished grip strength, dorsal wrist pain, and ulnar nerve paresthesia. 

Imaging

A CT scan is the best way to identify the hook of hamate fracture.

Treatment

Hamate fractures that are well immobilized immediately and are treated soon after injury have excellent outcomes. A fracture which does not heal will require excision of the hook of the hamate. Patients with excisions of hook of hamate usually return to their pre-injury level of activity. 

Carpal Ligament Injuries
Scapholunate Ligament

The scapholunate ligament is the most commonly injured carpal ligament. When it is torn, the bones separate in different directions, resulting in a painful loss of grip strength. 

Treatment

Non-surgical treatment options include anti-inflammatory medication, as well as wrist splinting and possible corticosteroid injections.

If conservative options are not effective, surgery may be recommended. The timing and and severity of the injury to the scapholunate ligament typically determine the appropriate method. Proximal row carpectomy may be recommended for an older, not very active patient. 

The following surgical options exist:

 - Excising entire proximal row of carpal bones (scaphoid, lunate and triquetrum)

 -- provides relative preservation of strength and motion

 - Scaphoid excision and four-corner fusion (younger patients, active)

 -- provides relative preservation of strength and motion

 - Wrist fusion (salvage procedure, everything else fails)

 -- gives best pain relief and good grip strength at the cost of wrist motion

Injuries that are left untreated can become more painful and restrictive with time. Chronic scapholunate ligament injuries often lead to progressive, degenerative, and arthritic conditions within the wrist. 

Carpal Ligament Injuries
Lunotriquetral Ligament

Lunotriquetral ligament is most often injured from a fall on an outstretched hand, and may also result from twisting, pulling, pushing, catching, or striking, as well as high-energy sports. Disruption leads to lunate flexion when the scaphoid is normally aligned, creating volar intercalated segmental instability (VISI) deformity. 
The symptoms may include ulnar-sided wrist pain and grip weakness. 

Treatment

The non-operative treatment of most lunotriquetral ligament injuries with mild symptoms includes observation and NSAID medications.

For patients with acute or chronic dissociation or chronic tears that have not responded to conservative management, surgical treatment is usually necessary:

LT fusion for chronic instability 

 - Nonunion is a known complication

 - Arthroscopic debridement of LT ligament with ulnar shortening

 - Chronic instability secondary to ulnar positive variance

 - Long ulna chronically impacts the triquetrum, resulting in LT tear with instability

Carpal Ligament Injuries
Perilunate Dislocations

Perilunate dislocations are potentially devastating closed wrist injuries, which typically occur in young adults with high-energy trauma.

Presentation

Examination will show a variable amount of swelling, deformity, and limited wrist movement. Median nerve symptoms may occur in approximately 25 percent of patients.

Imaging

Imaging plays an essential role in identifying perilunate dislocations. Plain x-rays are normally sufficient to diagnose the dislocation.

Treatment

Immediate management of a perilunate dislocation entails closed reduction or splinting, followed by an open reduction, ligament repair, fixation, and possible carpal tunnel release.  

Outcomes include:

 - Decreased risk of median nerve damage

 - Decreased risk of cartilage damage

 - Return to full function unlikely

 - Decreased grip strength and stiffness are common

Chronic injuries are often treated with proximal row carpectomy. Total wrist fusion may be performed in cases of chronic injuries with arthritic changes. 

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The Miami Institute for Joint Reconstruction
11801 sw 90th St, Suite 201 Miami, FL 3318
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