PRAMONO ARI WIBOWO,MD

HAND DIVISION

WRIST PAIN ORTHOPEDIC & TRAUMATOLOGY

DEPARTMENT
FK UNAIR / RSUD DR.SOETOMO HOSPITAL
2018
 Epidemiology
OUTLINE Anatomy hand
Radial Sided Pain
Ulnar sided pain
EPIDEMIOLOGI
EPIDEMIOLOGI
SURFACE
ANATOMY OF
THE HAND
SURFACE
ANATOMY OF
THE HAND
SURFACE ANATOMY
OF THE HAND
SURFACE ANATOMY
OF THE HAND
SURFACE ANATOMY
OF THE HAND
SURFACE ANATOMY
OF THE HAND
SURFACE ANATOMY
OF THE HAND
SURFACE ANATOMY
OF THE HAND
SURFACE ANATOMY
OF THE HAND
 PATHOLOGY
ON THE
WRIST

R U
RADIAL SIDED PAIN

• CMCJ Osteoarthritis • Distal radius fracture

• STT joint arthritis • Scapholunate Ligament insufficiency

• Scaphoid Fracture • RadioScaphoid Capitate Ligament

Injury
• Non-Union Scaphoid Fracture
• Wrist Osteoarthritis
• Occult Ganglion
• SLAC/SNAC wrist
• DeQuervain Tenosynovitis
• FCR tendinitis
• CTS
• Wartenberg Syndrome
EXAMINATION OF THE RADIAL SIDED OF THE PAIN
 • A Stenosing tenosynovial inflammation of the 1st
dorsal compartment
• Woman > men
• 30-50 y.o.
• Most common dominant wrist
DE QUERVAIN’S
• Risk factor : overuse, post-traumatic, postpartum
TENOSYNOVITIS
• Pathoanatomy : Myxoid degeneration –
Thickening tendon sheath(accumulation
mucopolysaccharides and increase vascularity) –
Increase tendon friction.
• Prognosis : Usually resolve with conservative.
 DE QUERVAIN’S
TENOSYNOVITIS
• Symptoms : Radial side pain
• Physical examination : Tenderness 1st
dorsal compartment
• Neurovascular normal
• Finkelstein test (+)
DE QUERVAIN’S TENOSYNOVITIS
TREATMENT : CONSERVATIVE – INJECTION GUIDING USG - OPERATIVE
SCAPHOID FRACTURE

• Scaphoid is the most common fracture in

carpal bone (15% of acute wrist injuries)
• Anatomy : Waist (65%); Proximal (25%);
distal (10%)
• Pathoanatomy : Axial load +
hyperextended + radial deviated wrist
• Associated condition : SNAC
• Prognosis : High risk AVN
 SCAPHOID FRACTURE

• Physical exam : tenderness anatomic

snuffbox
• Radiology : AP/Lat view, Scaphoid
view, CT scan
 SCAPHOID
FRACTURE
• Treatment :
• Non operative, Indication :
• Stable nondisplaced
• Normal Xray but have
symptom
• Operative, Indication :
• Displaced fracture
• Non union
 SCAPHO-LUNATE DISSOCIATION

• SL ligament is the important for carpal

stability
• Incidence :
• Occur in 10-30% of Intra-articular distal radius
fracture
• Degenerative tears in >50% over the age of 80
y.o.
• Associated injuries : DISI
• If left untreated can progress into SLAC wrist
 SCAPHO-LUNATE DISSOCIATION

• History : Acute FOOSH injury or Degenerative rupture

• Symptoms :
• Dorsal and radial Sided Wrist Pain
• Pain increased with loading across the wrist
• Clicking in the wrist
• May be associated with wrist instability

• Physical exam :
• Swelling over dorsal aspect of the wrist
• Tenderness over the dorsal Scapholunate interval or Anatomical snuffbox
• Motion : pain increased with extreme wrist extension and radial deviation

• Provocative test : Watson test

 SCAPHOLUNATE
DISSOCIATION
• Imaging :
• AP/Lat view (Terry Thomas
sign), DISI
• CT-scan
• Treatment
• Non operative. Indication :
Undisplaced injury
• Operative : SL repair/SL
reconstruction/Wrist fusion
 SCHAPOID NON UNION ADVANCE COLLAPS
(SNAC)

• Condition characterized by advance

collapse and progressive arthritis of the
wrist
• Prognosis : Scaphoid non union of >5years
duration have poor outcomes
CARPAL TUNNEL SYNDROME (CTS)

• Most common Compressive neuropathy

• Affect 0.1-10% of general population
• Risk factor : Female, obesity, pregnancy, hypothyroidism, RA, Smoking, Alcoholism, repetitive
motion activities, mucopolysaccharidosis, mucolipidosis.
• Associated conditions : DM, hypothyroidism, RA, pregnancy, amyloidosis.
• Pathophysiology : Repetitive motion and vibration, certain activities i.e cycling, tennis,
throwing.
• Pathoanatomy : Compression may be due to repetitive motion or space occupying lesions
CARPAL TUNNEL SYNDROME (CTS)
 CARPAL TUNNEL SYNDROME (CTS)

• Symptoms :
• Numbness and tingling in radial 3-1/2 digits
• Pain and paresthesia that awaken patient at night

• Physical exam :
• May show thenar atrophy
• Durkan’s test
• Phalen test
• Tinel’s test
 CARPAL TUNNEL SYNDROME (CTS)

• Imaging : not necessary for diagnosis

except if malunion of distal radius suspected.
• EMG NCV : often the only objective
evidence of a compressive neuropathy.
• Treatment :
• Non operative : NSAID, Splints, activity
modifications
• Steroid injection
• Operative : release Carpal Tunnel.
 CARPO-METACARPAL-JOINT ARTHRITIS (CMCJ
ARTHRITIS)
• Arthritis of the Carpal-metacarpal joint
• Pathoanatomy : attenuation of anterior oblique
ligament(Beak ligament)
• Symptoms: Pain at base of thumb; Difficult pinch
and grasping
• Physical exam : Grind test; swelling and crepitus
• Radiographs : Joint space narrowing,
osteophytes
 GANGLION CYST

• A mucin-filled synovial cyst caused by either trauma,

mucoid degeneration or synovial herniation.
• It’s the most common hand mass (60-70%)
• Location : Dorsal carpal, volar carpal, volar retinaculum,
dorsal DIP joint
• Associated condition : Ulnar nerve compression
GANGLION CYST

• Symptoms : Usually asymptomatic, cosmetic

• Physical exam :
• Transillumination
• Firm and well circumscribed
• Often fixed to deep tissue
• Allen’s test
• Imaging : not routinely indicated
• Biopsy : Not routinely indicated
• Treatment : Observation, Aspiration, Surgical
ULNAR SIDED PAIN

• TFCC tear
• DRUJ disruption
• ECU tendinitis
• Ulnar tunnel syndrome
• Hook of hamate fracture
• Luno-triquetrum dissociation
 TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC)

• Mechanism of injury : Type 1 and Type 2

• Presentation : wrist pain, painful in turning a door
key
• Physical exam : Fovea Sign, TFCC compression
test
• Imaging :
• Radiology : usually negative
• Arthrography
• MRI : sensitivity 74-100%
• Arthroscopy : Gold standard (most accurate)
 ULNAR TUNNEL
SYNDROME
• Ulnar nerve compression neuropathy caused by direct
compression in Guyon’s canal (Handlebar palsy)
• Cause of compression :
• Ganglion cyst
• Lipoma
• Repetitive trauma
• Aneurysm
• Hook of Hamate Fracture
• Inflammatory arthritis
• Palmaris brevis hypertrophy
• Idiopathic
 ULNAR TUNNEL SYNDROME

• Borders of Guyon Canal :

• Transverse carpal ligament
• Volar carpal ligament
• Pisiform + pisohamate ligament
• Hook of hamate
ULNAR TUNNEL SYNDROME

• Symptoms: Pain and paresthesia in

ulnar 1-1/2 digits
• Physical exam :
• Clawing of RF and LF
• Weakened grasp
• Weakened pinch
• Froment Sign + Jeanne Sign
• Wartenberg sign
ULNAR TUNNEL SYNDROME

• Radiographs : to evaluate Hook of Hamate

• CT-scan : If suspicious if fracture
• MRI : Useful to evaluate for a ganglion of other
soft tissue problems
• Arteriogram : If thrombosis and aneurysm is
suspected
• EMG NCV : Establishing diagnosis and prognosis
ULNAR TUNNEL SYNDROME

• Treatment :
• Non operative
• Local decompression
• Tendon transfer
• Carpal tunnel release
HOOK OF HAMATE
FRACTURE
• Incidence 2% of carpal fracture
• Risk factor : golf, baseball, hockey
• Symptoms : Hypothenar pain
• Physical exam : Hook of hamate pull test
• Neurovascula exam
• Imaging : X-ray, CT-scan
• Treatment :
• Non operative
• Excision hamate
 • Common pain source in ulnar side of the wrist
• Diagnosis may challenging because ECU is aposed
closely to other structure including TFCC
• When examining the ECU, it’s important to differentiate
EXTENSOR
between ECU tendinitis and pain secondary to
CARPI ULNARIS subluxation
TENDINITIS
• Pain is localized over the ulnar side of the wrist and
worsen with gripping and other heavy activities. But
usually the patient may be unable to localize the site of
the pain easily
• ECU tendinitis is often seen in non athletes.
 EXTENSOR CARPI ULNARIS
TENDINITIS
• ROM may not be restricted, but resisted ulnar deviation when
the forearm is pronation OR resisted wrist extension when
the forearm is supinated.
• Rolling the tendon under the examiner’s finger may elicit
crepitus
• The ECU synergy test is helpful in differentiating between
ECU pathology and intra-articular.
• Patients are assessed for subluxation of ECU tendon
• The examiner moves the patient’s wrist from a supination and
extension to flexion and ulnar devviation
 • Plain radiographs PA grip view to evaluate
ulnar positive. Also ulnar impaction as an
alternative source of pain
EXTENSOR CARPI
ULNARIS TENDINITIS • USG or MRI may be used to confirm
- DIAGNOSIS tendinopathy, or other pathology
• Diagnostic criteria can be improved by
injecting local anesthethis into ECU sheath
 • Conservative :
• Rest
EXTENSOR CARPI • Activity modification
ULNARIS TENDINITIS • Physical therapy
- MANAGEMENT • NSAID or steroid injection

• Surgical :
• Remove fibro-osseus structure
• Creating a pulley in subluxation case
THANK YOU