WRIST JOINT presentation.Dr J. Niazi 2.pdf

Wrist

1. Dr Mulaudzi
Department of Orthopaedics

2. ⦿Introduction
⦿Anatomy
⦿Pathologic anatomy
⦿Clinical assessment
⦿Radiology/Imaging
⦿Management
⦿References

3. ⦿Uncommon but devastating injuries
⦿16 -25 % of injuries missed on initial
presentation
⦿Perilunate dislocation
⦿Transcaphoid perilunate dislocation
⦿Early diagnosis and treatment is essential

4. Osseous Anatomy
⦿Wrist joint is the most complicated
joint, transmits forces through the
hand to the forearm
⦿Proximal row (three bones) is an
intercalated segment between the
distal radius, ulna and distal row
⦿Lunate is the carpal keystone

5. Extrinsic:
⦿Volar radial side
◼Radioscaphocapitate
ligament
◼Long and short
radiolunate
◼Radioscapholunate
⦿Volar ulnar side
◼Ulnolunate ligament
◼Ulnotriquetral ligament

6. Extrinsic:
⦿Dorsal
radiotriquet
ral ligament
⦿Dorsal
intercarpal
ligaments

7. Intrinsic:
⦿Scapho-lunate
interosseous
ligament is made
of 3 parts, dorsal
is strongest
⦿Lunato-triquetral
interosseous
ligament is made
up of 2 parts,
volar is the
strongest

8. Blood Supply
⦿Extra osseous blood supply by the
anastomosis formed between the
radial, ulnar and anterior
interosseous arteries
⦿Interosseus blood supply consists of
three groups on the basis of
number, location of the nutrient
vessels and interosseous
anastomosis
⦿Group 1: scaphoid, capitate and
20% of lunate is supplied by a single
vessel (high risk of osteonecrosis)
⦿Group 2: trapezium, triquetrium,
pisiform and 80% of lunate receive
two nutrient arteries and
intraosseous anastomosis
⦿Group 3: trapezoid and hamate lack
intraosseous anastomosis

9. ⦿Fall on an out-stretched
hand
⦿Axial compression force
with wrist in
hyperextension
⦿Palmar flexion (over the
handle bars motorcycle
accident)
⦿Twisting injuries (sports)
⦿Majority of the injuries
occur around the lunate

10. ⦿History (fall and painful wrist)
⦿Examination
◼Swelling
◼Deformity
◼Diffuse tenderness
◼Limited wrist motion
◼Paresthesia within the median nerve distribution

11. ⦿PA view xrays
⦿Lateral views
⦿Stress views (AP grip film, ulnar oblique and
radial oblique)
⦿MRI
⦿CT scan
⦿Ultrasound
⦿Arthroscopy

12. ⦿PA view
◼Terry Thomas
sign
◼Disruption of
Gilula’s lines
indicate
ligamentous
instability
◼Lunate
appears
triangular
instead of
trapezoidal

13. ⦿Lateral:
◼Radius, lunate,
capitate and
middle metacarpal
should be
relatively co-linear
◼scapho-lunate
angle (normal
30-60 average 47,
greater than 70
suggests instability
and greater than
80 is proof of
instability)

14. Lunate dislocation

15. Stress Views:
⦿Radial oblique
⦿Ulnar oblique
⦿AP Grip film
They may show abnormal
widening of the scapholunate
joint

16. ⦿MRI:
◼Helpful in occult fractures, osteonecrosis of the
carpal bones and ligament injuries

17. ⦿CT Scan
◼Helpful in evaluating carpal fractures, malunion,
nonunion and bone loss
⦿Ultrasound
◼Can be used as an adjunct to other diagnostic
measures when history and physical signs suggestive of
carpal injuries are present
◼High specificity but low sensitivity
⦿Arthroscopy
◼Helpful in diagnosis and treatment of:
?Carpal instability
?Ligaments tear
?Damaged articular cartilage
?Triangular fibrocartilage lesions

18. Goals
⦿Repair scapholunate ligament
⦿Proper alignment of carpal bones
⦿Maintenance of wrist mobility
Approaches:
⦿Dorsal approach
⦿Operative technique:
◼K wires used as joysticks
◼Suture anchor to repair scapholunate ligament
◼One K wire inserted from scaphoid to lunate and a second from
scaphoid to capitate
⦿Post-op care:
◼Backslab for 10 days
◼Removal of sutures for 10 days
◼Below elbow Colles cast for 6 weeks
◼K wires removed at 6 weeks
◼Physiotherapy started at 6 weeks

19. ⦿Early diagnosis is essential
⦿Open reduction and internal fixation with
repair of the ligaments is recommended to
achieve favourable outcome