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1. Common wrist problems Assoc. Prof. Dr.MD Tajul Islam Unit chief Blue unit II National Institute of Traumatology & Orthopaedic Rehabilitation

2. Carpal tunnel syndrome Carpal tunnel syndrome is a term used to describe a group of symptoms associated with compression of median nerve at the wrist

3. Anatomy - Carpal tunnel Boundaries: flexor retinaculum , carpal bones Contains: Median nerve, flexor tendons (FDS, FDP, FPL) Diameter: 2 cm

4. Anatomy- Median nerve Median nerve lies beneath flexor retinaculum . Distal end of flexor retinaculum , Median nerve gives recurrent motor branch and then divides in to digital branches ( extraligamentous pattern).

5. Although this can vary and less commonly it can emerge in subligamentous or transligamentous patterns. Palmar cutaneous branch has been reported to branch through palmaris tendon proximal to palmar fascia.

6. Causes Endocrine- Hypothyroidism Myxoedema Acromegaly Inflammation RA TB Gout

7. Pregnancy Menopause Chronic renal failure Trauma Lunate dislocation Complication of Colle’s fracture Tumour/Ganglion

8. Clinical findings  Simptoms : parasthesia and numbness in median nerve distribution. Aches in thenar eminence. Signs: of thenar muscle atrophy. Tests: Tinel's test, Phalen's test Investigations: Nerve conduction studies.

9. Management Non-operative Operative

10. Non-operative management Wrist Splinting in neutral position, especially during night time Steroid injection Nerve gliding and stretching exercises

11. Nerve gliding & stretching

12. Steroid injection site

13. Operative management Open Technique Endoscopic Technique: Advantage - small incision Disadvantage - iatrogenic nerve injury, poor visualisation, inability to identify anatomic variations, and incomplete release.

14. Open technique Anaesthesia: simple local, regional(Biers block) rarely general. Incision: curvilinear incision of 2 or 3 cm made 6 mm ulnar to t henar crease. Dissect and identify flexor retinaculum and completely divide it. Closure with 4 '' nylon. Bulky dressings for 48 hours

15. Post-Operative management Bulky dressing up to 48 hours for comfort Removal of sutures in 10 to 12 days Wrist splint neutral position used at night for 3 weeks 1 month post op return to work with 2 lb limitation. 2 months back to normal work

16. Compound Palmar Ganglion P rogressive swelling and inflammation of the tendon sheath that distends the sheath proximal & distal to flexor retinaculum with limitation of excursion of the involved tendons is classically called Compound Palmar Ganglio n

17. Etiology Tubercle Bacillus. Rheumatoid arthritis. Commonly flexor sheaths of lower forearm & hand are affected. Affected sheaths are greatly thickened and show the changes of chronic inflammation.

18. The lining membrane is replaced by tubercular granulation tissue. The swelling may contain serous fluid, masses of fibrinous material, melon seed bodies or caseous material. Melon seed bodies resemble grains of boiled sago. They are composed of collection of fibrin cellular debris, and occasional tubercle bacilli The visceral as well as the parietal layer of the sheath is affected so that the tendons itself becomes involved

19. Clinical features Gradual onset Mild aching pain Swelling: Surface: irregular, Consistency: soft and cystic, On deep palpation: multiple nodular particles may be felt / Melon seed bodies ( Tubercular fibrinous exudates that contain TB bacilli )

20. Cross fluctuation: (+) ve , Transillumination: (- ) ve  Initially range of movements of fingers and thumb impaired. Moderate restriction of flexion extension of digits .

21. Investigations CBC CRP MT RA test Chest X-ray X-ray of wrist joint

22. Treatment Anti TB therapy, Rest in plaster cast over forearm and hand in palmer flexion, Surgery {if conservative treatment fails}: Longitudinal division of flexor retinaculum . Removal of flexor sheath after careful dissection.

23. Curvilinear incision - starting from lower forearm, skirts over the thenar crease and continues distal ly in direction of head of fourth metacarpal Radial bursa- mid lateral in cision.

24.  Brunners zig zag incision – visualise lesion and retention of pulleys from flexor fibrous sheath In case of FDS rupture, excised and stump is restored to the FDP by t ransfering intact distal stump to adjacent tendo n Long term follow up

25. de Qervain’s tenosynovitis Named after a Swiss surgeon, Fritz de Quervain , who first described the problem in 1895. De Quervain disease is a stenosing tenosynovitis of the first dorsal compartment of the wrist containing Abductor pollicis longus and Extensor pollicis brevis . It is characterised by degeneration and fibrosis of the tendon sheath.

26. Occurs most often in individuals age between 30 and 50 years It affects women up to six times more often than men Is commonly associated with dominant hand.

27. Etiology The e tiology is thought to be secondary to repetitive or sustained tension on the tendons of the first dorsal compartment Possible etiologies include Trauma Increased frictional forces Anatomic Variations that include septation of the first dorsal compartment and the presence of multiple slips of the APL and, occasionally, of the EPB tendon

28. Biomechanical compression, Repetitive microtrauma v Inflammatory disease, and Increased volume states, such as occurs during pregnancy

29. Pathophysiology Resisted gliding of the APL and the EPB within the narrowed canal Fibroblastic response, resulting i n thickening and swelling of the compartment Degeneration

30. Microanatomic findings of the tendon sheaths and synovium showed thickening of the tendon sheaths to be up to five times because of deposition of dense fibrous tissue, increased vascularity of the tendon sheaths, and accumulation of mucopolysaccharides, which are indicators of myxoid degeneration

31. Notably, the synovial linings were preserved and were histologically normal. These changes indicate that de Quervain's is a result of an intrinsic degenerative mechanism rather than an inflammatory one.

32. Clinical features  L ocali z ed pain along the radial side of the wrist  Gradual in onset  Aggravating on grasping and raising objects with the wrist in neutral rotation  Localized swelling may be seen.

33. Tenderness along the radial styloid The Finkelstein test is positive: (on grasping the patient's thumb and quickly abducting the hand ulnarward produces excruciating pain over the styloid tip)

34. Differential diagnosis Intersection syndrome Radial styloid fracture Scaphoid fracture Basilar arthritis of the thumb and Radial neuritis

35. Investigations Diagnosed is mainly through clinically Wrist imaging is required only in the presence of associated processes such as previous distal radius or scaphoid fracture, arthritis of the thumb, and instability of the wrist

36. Conservative treatment Nonsurgical treatment should be the first course of action for de Quervain disease. The patient presenting with mild to moderate pain that does not limit activities of daily living may be treated with - Rest, Splinting, Nonsteroidal anti-inflammatory drugs or corticosteroid injection.

37. Corticosteroid injection technique Corticosteroid injection into the first dorsal compartment is perhaps the most common and effective treatment of de Quervain disease. Failure of response to corticosteroid injection has been attributed to poor technique and anatomic variations within the first dorsal compartment

38. With the wrist in neutral radioulnar deviation, a rolled-up towel is placed under the wrist to position it in slight ulnar deviation The course of the APL and EPB tendons along the radial styloid is palpated, and the borders of the first dorsal compartment are straddled with the opposite thumb and index finger.

39. A 25-gauge needle is introduced into the tendon sheath at the level of the styloid, parallel to the tendons.. The needle is carefully backed out while maintaining pressure on the plunger of the syringe. The injectable medication should flow smoothly and easily, with both visual and palpable inflation of the compartment.

40. Complications Neuritis, Fat necrosis, and Postinjection flare Sub dermal atrophy and Hypopigmentation

41. Surgical treatment Surgical treatment is based on release of the fibro-osseous roof of the first dorsal compartment and decompressing the stenosed APL and EPB tendons

42. • Under local anesthesia, with or without intravenous sedation, and tourniquet control, a transverse or oblique incision is given over radial st y loid

43. The skin is retracted and careful blunt dissection will reveal branches of the radial sensory nerve in the subcutaneous tissue Radial sensory nerve is identified and protected with blunt retractors

44. Dissection is then carried down to the first dorsal compartment. The retinaculum of the first dorsal compartment is completely incised with in line with the APL and EPB tendons

45. Any intra-compartmental septae should be released and excised. Anatomic variations of the compartment are the rule rather than the exception. Active and free thumb abduction and extension then can be performed on the awake patient

46. Postoperatively, thumb and hand motion is immediately encouraged except for forceful wrist flexion which may predispose the tendons toward subluxation during the first 2 weeks after surgery

47. Complications Radial sensory nerve injury Incomplete decompression  Volar subluxation of the tendons

48. Thank You All