Wrist & Hand Injuries PDF

Wrist & Hand Injuries Samer Ali, MD, EBOT Associate Professor of Orthopaedic Surgery Mansoura University Objectives Distal radial fr. Flexor tendon injuries.  Distal radial fractures ▪ One of the most common orthopaedic injuries. A bimodal distribution: ✓Younger patients (high energy)....

Wrist & Hand Injuries Samer Ali, MD, EBOT Associate Professor of Orthopaedic Surgery Mansoura University Objectives Distal radial fr. Flexor tendon injuries.  Distal radial fractures ▪ One of the most common orthopaedic injuries. A bimodal distribution: ✓Younger patients (high energy). ✓Older patients (low energy, falls). ▪ High incidence of distal radius fractures in women >50 ▪ Distal radius fractures are a predictor of subsequent fractures ▫ DEXA scan is recommended in woman with a distal radius fracture  Frykman classification Ulna Fracture Radius Fracture Absent Present Extraarticular I II Intraarticular involving III IV radiocarpal joint Intraarticular involving V VI distal radioulnar joint Intraarticular involving both radiocarpal & distal VII VIII radioulnar joints ▪ Colles fracture: Low energy, dorsally displaced, extraarticular fr. ▪ Smith fracture: low energy, volar displaced extraarticular fr. Diagnosis History of trauma. Pain. Swelling. Deformity.  Imaging X-ray. CT. ▫ Important to evaluate intra-articular involvement and for surgical planning MRI: Useful to evaluate soft tissue injury ✓DRUJ injuries. ✓Scapholunate lig. injuries. Nonoperative Closed reduction UGA & cast immobilization ✓Indications: ▫ Extraarticular fractures. ▫ Minimal displaced fractures. Rehabilitation: No significant benefit of physical therapy over home exercises for simple fr. treated with cast immobilization. Operative Treatment Surgical fixation (CRPP, External Fixation, ORIF). Operative Treatment Indications: Radiographic findings indicating instability ✓Displaced intraarticular fr. ✓Volar or dorsal comminution. ✓Severe osteoporosis. ✓Progressive loss of volar tilt & loss of radial length following closed reduction & casting. ✓Associated ulnar styloid fr.  Percutaneous pinning  Mild angulation extraarticular fr External fixation  Usually combined with percutaneous pinning technique or plate fixation  Unstable wrist joint after fixation ORIF  Significant articular displacement (>2mm)  Comminution  Associated distal ulnar shaft fxs Complications Median nerve neuropathy (CTS), most frequent neurologic complication (1-12% in low energy fr. Vs. 30% in high energy fr.) ✓Prevention: Avoiding immobilization in excessive wrist flexion & ulnar deviation. ✓Treatment: Acute carpal tunnel release if: ✓Progressive paresthesias, weakness in thumb opposition. ✓Paresthesias not responding to reduction & lasting > 24-48 h. Complications Ulnar nerve neuropathy seen with DRUJ injuries. EPL rupture: nondisplaced fr. have a higher rate of spontaneous rupture. Radiocarpal arthrosis (2-30%): 90% of young adults will develop symptomatic arthrosis if articular stepoff > 1-2 mm (may be asymptomatic). Complications Malunion & Nonunion. Compartment syndrome. Scaphoid Fractures  Incidence: ▪ Scaphoid is the most frequently fr. carpal bone. ▪ 15% of acute wrist injuries. ▪ 60% of all carpal fractures. Location: ▪ Waist: 65%. ▪ Proximal third: 25%. ▪ Distal third: 10%. Anatomy The wrist is composed of 2 rows of bones that provide motion & transfer forces. ✓Capitate ✓Hamate ✓Lunate ✓Scaphoid ✓Triquetrum ✓Pisiform ✓Trapezoid ✓Trapezium  Pathoanatomy: ✓The most common mechanism of injury is axial load across hyper-extended & radially deviated wrist. ✓Common in contact sports. Blood Supply ▪ Major blood supply: dorsal carpal branch (branch of the radial artery) supplying proximal 80% of scaphoid via retrograde blood flow. ▪ Minor blood supply: superficial palmar arch (branch of volar radial artery) supplying distal 20% of scaphoid. Mayo Classification Russe Classification Diagnosis History Examination ▫ Wrist swelling ▫ Rarely any ecchymosis, hematoma, or gross deformity ▫ Worsened wrist pain with circumduction ▫ Pain with resisted pronation Provocative tests ▫ Anatomic snuffbox tenderness dorsally ▫ Scaphoid tubercle tenderness volarly ▫ Scaphoid compression test  Positive test when pain reproduced with axial load applied through thumb metacarpal 87-100% sensitivity and 74% specificity when all three tests positive within 24 hours of injury  Anatomical snuffbox tenderness dorsally. Scaphoid tubercle tenderness volarly. Pain with resisted pronation. Imaging X-Ray: ✓AP & lateral views. ✓Scaphoid view (30° wrist extension, 20° ulnar deviation).  If radiographs are negative & there is a high clinical suspicion repeat x-ray in 14-21 days ▪Bone scan: Effective to diagnose occult fr. At 72 h. ▪MRI: The most sensitive method to diagnose occult fr. Within 24 h. It allows immediate identification of fr. & Lig. Injuries Assessment of vascular status of bone (vascularity of proximal pole). ▪CT: Less effective than bone scan & mri to diagnose occult fr. It can be used to evaluate location of fr., Size of fragments, extent of collapse & progression of union after surgery Nonoperative Treatment Thumb spica cast immobilization for 2-3 m. Indications: ✓Stable nondisplaced fr. (majority of fr.). ✓If patient has normal x-rays but there is a high level of clinical suspicion, immobilize in thumb spica & reevaluate in 12-21 d. Outcomes: Scaphoid fr. with 1 mm without significant angulation or deformity Non-displaced waist fractures ▫ To allow decreased time to union, faster return to work/sport, similar total costs compared to casting Outcomes ▫ Union rates of 90-95% with operative treatment of scaphoid fractures ORIF Indications: Unstable fr. Proximal pole fr. Displacement > 1 mm. 15° scaphoid humpback deformity. Radiolunate angle > 15° (DISI). Intrascaphoid angle of > 35°. Scaphoid fr. associated with perilunate dislocation. Comminuted fr. Unstable vertical or oblique fr. Complications Nonunion: 5-15% Malunion: Humpback Deformity. AVN of proximal pole. Wrist OA. Complex Regional Pain Syndrome (CRPS). Flexor Tendon Injries Anatomy Flexor digitorum profundus (FDP): Functions as a flexor of the DIP joint. Shares a common muscle belly in the forearm. Flexor digitorum superficialis (FDS): Functions as a flexor of the PIP joint. Individual muscle bellies exist in the forearm. Flexor pollicis longus (FPL): Located within the carpal tunnel as the most radial structure. Anatomy Flexor carpi radialis (FCR): 1ry wrist flexor. Inserts on the base of the 2nd metacarpal. Closest flexor tendon to the median nerve. Flexor carpi ulnaris (FCU) 1ry wrist flexor. Inserts on the pisiform, hook of hamate & the base of the 5th metacarpal. Classification Diagnosis Symptoms: Loss of active flexion strength or motion of the involved digit(s). Physical Exam.: ✓Inspection. ✓Observe resting posture of the hand & assess the digital cascade. ✓Evidence of malalignment or malrotation may indicate a fr. ✓Assess skin integrity to help localize potential sites of tendon injury. Diagnosis Range of Motion: ✓Passive wrist flexion & extension allows for assessment of the tenodesis effect: Normally wrist extension causes passive flexion of the digits at the MCP, PIP & DIP joints. Maintenance of extension at the PIP or DIP joints with wrist extension indicates flexor tendon discontinuity. ✓Active PIP & DIP flexion is tested in isolation for each digit. Diagnosis Neurovascular Exam.: ✓Important given the close proximity of flexor tendons to the digital neurovascular bundles. Nonoperative Treatment Wound care & early range of motion Indications: Partial lacerations < 60% of tendon width. Outcomes: May be associated with gap formation or triggering. Operative Treatment Flexor tendon repair & controlled mobilization Indications: Lacerations > 60% of tendon width. Outcomes: Depends on zone of injury. Flexor tendon reconstruction & intensive postoperative rehabilitation Indications: Failed 1ry repair. Chronic untreated injuries. Operative Treatment Timing of repair: within 3 w of injury (ideal 2 w). Waiting longer leads to difficulty due to tendon retraction. Operative Treatment Rehabilitation Postoperative controlled mobilization has been the major reason for improved results with tendon repair esp. in zone II. Improved tendon healing biology. Limits restrictive adhesions & leads to increased tendon excursion. Rehabilitation Early active motion protocols: ✓Moderate force & potentially high excursion. ✓Dorsal blocking splint limiting wrist extension. Rehabilitation Early passive motion protocols: ✓Duran protocol. ✓Low force & low excursion. ✓Active finger extension with patient-assisted passive finger flexion. Rehabilitation Kleinert protocol: ✓Low force & low excursion. ✓Active finger extension, dynamic splint-assisted passive finger flexion. Rehabilitation Mayo synergistic splint: ✓Low force & high tendon excursion. ✓Adds active wrist motion which increases flexor tendon excursion the most. Rehabilitation Immobilize children & noncompliant patients after repair. Casts or splints are applied with the wrist & MCP joints positioned in flexion & the IP joints in extension. Complication Tendon adhesions: ✓Most common complication. Rerupture: ✓15-25% rerupture rate. ✓Treatment: ✓If 1cm of scar is present, perform tendon graft. THANK YOU