Sonja Cerovac - Wrist Pain - don't prolong the - St Anthony's Hospital
Sonja Cerovac - Wrist Pain - don't prolong the - St Anthony's Hospital
Sonja Cerovac - Wrist Pain - don't prolong the - St Anthony's Hospital
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<strong>Wrist</strong> <strong>Pain</strong> – don’t <strong>prolong</strong> <strong>the</strong> agony<br />
<strong>Sonja</strong> <strong>Cerovac</strong> MD MSc FRCS(Plast)<br />
Consultant Plastic and Hand Surgeon
<strong>Wrist</strong>/Hand <strong>Pain</strong><br />
• Very common<br />
• Very debilitating<br />
• delayed presentation common<br />
• lack of diagnosis for months<br />
• delayed treatment<br />
• <strong>prolong</strong>ed absence from work<br />
• unnecessary agony ?<br />
Many conditions can be treated promptly and efficiently
<strong>Wrist</strong> pain needs ‘a title’<br />
• Diversity of conditions = diversity of treatments<br />
• Acute, inflammatory and degenerative conditions require<br />
rest / analgesia / steroids movement/exercises<br />
– tendonitis, arthritis, neuritis<br />
– acute injury (first 1-2 weeks)<br />
• stiffness, weakness, disuse require physio<strong>the</strong>rapy / splintage<br />
– contractures<br />
immobilisation/splint<br />
– postoperative rehab (adhesions)<br />
– scar <strong>the</strong>rapy
Careful examination is crucial<br />
• Diagnosis is clinical in 70- 80% cases<br />
• Imaging is important, but secondary to<br />
examination !<br />
• capsulo-ligamentous injuries common<br />
– often unrecognized<br />
– recovery is very slow<br />
• in 10-15% of cases no ethiology identified
<strong>Wrist</strong> pain<br />
??<br />
Radial or ulnar side ?
Radial wrist pain - <strong>the</strong> commonest causes<br />
CTS<br />
CMCJ arthritis<br />
STT arthritis<br />
Scaphoid non-union<br />
SL ligament injury<br />
deQuervain tenosynovitis
STT arthritis<br />
VOLAR<br />
CMCJ arthritis<br />
deQuervain’s TS<br />
DORSAL<br />
SL ligament /<br />
Kienbock’s
Ulnar wrist pain<br />
Luno-triquetral instability<br />
TFCC pathology<br />
Long ulna<br />
ECU tendinitis<br />
DRUJ osteoarthritis
DRUJ<br />
osteoarthritis<br />
TFCC pathology<br />
ECU tendinitis<br />
Long ulna ?
Prominent ulna - ulno-carpal abutment<br />
• Common<br />
• Acute<br />
– Post distal radius #<br />
• Chronic<br />
– Degenerate<br />
• Ulno-lunate abutment<br />
• TFCC degeneration
Ulna shortening
O<strong>the</strong>r (rare) causes of wrist pain<br />
• Tendinitis (ECRL, ECRB, FCR)<br />
• intraosseous ganglions<br />
• Kienbock’s disease<br />
• neuroma<br />
• Exostoses<br />
• piso-triquetral OA
<strong>Wrist</strong> Arthroscopy<br />
• Preoperative differential diagnosis essential<br />
• Diagnostic / Therapeutic<br />
– diagnosis<br />
– assessment<br />
– staging tool<br />
– <strong>the</strong>rapeutic
Arthroscopy
Ganglions<br />
• synovium lined tissues<br />
• Dorsal wrist ganglions (from SL joint)<br />
• Volar wrist ganglions (STT joint)<br />
• ‘top of <strong>the</strong> iceberg”<br />
• Usually asymptomatic<br />
– “comes and goes”
<strong>Wrist</strong> ganglions - treatment<br />
• “Bible it ?!<br />
• Observation<br />
• Aspiration<br />
– 19G needle at least !<br />
– +/- steroid infiltration<br />
– >90% recurrence rate<br />
– infection !<br />
• Surgery<br />
– If painful<br />
– General anaes<strong>the</strong>tic<br />
– Excise piece of <strong>the</strong> capsule<br />
– Recurrence up to 25% !!
deQuervain’s tenosynovitis<br />
• Very common<br />
– Postnatal<br />
– hand overuse ?<br />
• Very, very, very painful !<br />
• Frinkelstain’s test is very sensitive and<br />
specific<br />
• Long term improvement after steroid<br />
injections in approx 50%<br />
– avoid superficial injections !<br />
• Surgery under <strong>the</strong> local anaes<strong>the</strong>tic
Frinkelstain’s test
Thumb base (CMCJ) osteoarthritis<br />
• Very common<br />
• Females<br />
• 5 th decade of life<br />
• Debilitating<br />
– pain<br />
– weakness<br />
• Often mixed with<br />
CTS !
Thumb base (CMCJ) osteoarthritis<br />
• 4 radiological stages<br />
• Treat patient not X rays
Thumb basal joint (1 st CMCJ) OA<br />
• typical pain on circumduction of <strong>the</strong> 1 st CMCJ
Treatment options<br />
• Conservative vs. Surgery<br />
– <strong>St</strong>eroid injection + splint+ activity modification<br />
– approx. 4 months of symptoms relief<br />
– repeat at 4-6 months intervals<br />
• Surgical options<br />
– Trapeziectomy only<br />
– Trapeziectomy +/- LRTI ?<br />
– Partial trapeziectomy + implant ?
Trapeziectomy<br />
• Slow, but predictable recovery<br />
• Good pain relief<br />
• Good motion<br />
• Highly satisfied patients<br />
• <strong>St</strong>rength 70%<br />
• One of <strong>the</strong> most ‘rewarding’ wrist operations
Tendon graft reconstruction still controversial
Interposition arthroplasty
Scapho-trapezo-trapezoidal (STT) arthritis<br />
• More difficult than CMCJ arthritis<br />
OPTIONS:<br />
• <strong>St</strong>eroid injections<br />
• STT joint fusion<br />
• distal scaphoid pole excision<br />
• interposition arhrthoplasty<br />
• No option is easy and without problems !
STT joint arthritis<br />
• Scapho-trapezoid OA<br />
common source of residual pain
Carpal Tunnel Syndrome<br />
• <strong>the</strong> commonest surgical procedure<br />
• Diagnosis is clinical (‘rule of twos’)<br />
• NCS<br />
� History � Examination � NCS<br />
– Specificity 85%<br />
– Sensitivity 82%
CTS algorhythm<br />
• Mild<br />
– Conservative Mx<br />
• Moderate<br />
– Conservative or surgery<br />
– Patient’s preference ?<br />
• Severe<br />
– Surgery
<strong>St</strong>eroid injection for CTS
Carpal tunnel decompression<br />
• irreversible changes ?<br />
(residual weakness/numbness)
Carpal Tunnel Syndrome - beware<br />
• Could it be anything else ?<br />
– arthritis / tendinitis<br />
• More proximal compression ?<br />
– forearm ?<br />
– neck ?
Fall onto out-stretched hand (FOOSH)<br />
Scaphoid fracture Scapho-lunate ligament tear
Diagnostic difficulties<br />
Week 1<br />
Week 3
Acute scaphoid fractures<br />
Displaced surgery<br />
Undisplaced splint vs. surgery<br />
– Ongoing debate<br />
(patient’s preference ?)<br />
– Cast (6-12 weeks)<br />
– Surgery: Percutaneous vs. Open screw fixation
Scaphoid non-union<br />
• More complicated<br />
• Bone graft required<br />
• Outcome less predictable
Scapho-Lunate Dissociation (SLD)
Scapho-lunate ligament injury<br />
• Devastating injury<br />
• Most common carpal instability<br />
• Often diagnosed late<br />
(>6 months)<br />
– “sprain which does not get better”<br />
• Incredibly difficult management<br />
• Known progression to SLAC wrist (OA)<br />
Lunate<br />
Scaphoid<br />
R a d i u s
Advanced arthritis<br />
Non-united scaphoid SL ligament untreated<br />
• Proximal row carpectomy<br />
• Partial wrist fusion<br />
• Total wrist fusion<br />
• Total wrist arthroplasty
Extensor tendon injuries<br />
OFTEN MISSED:<br />
• Mallet finger<br />
• Extensor Pollicis Longus (EPL)<br />
– inability to extend thumb<br />
• Extensor digitorum communis (EDC)<br />
– inability to extend fingers<br />
• Trauma<br />
– repairs are straight forward within <strong>the</strong> first week of injury<br />
– delayed presentations require tendon transfers or<br />
reconstructions<br />
• Degenerative (attrition) rupture<br />
– usually require tendon transfers
Flexor Tendon Injuries<br />
• Lacerations or avulsions<br />
• Often missed<br />
• Flexor digitorum superficialis<br />
– inability to flex PIPJ<br />
• Flexor digitorum profundus<br />
– inability to flex DIPJ<br />
• <strong>St</strong>raight forward repairs possible up to 2 weeks post injury<br />
• Delayed presentation requires complicated 2 staged reconstruction
Don’t <strong>prolong</strong> <strong>the</strong> agony<br />
Earlier diagnosis = simpler treatments<br />
+ better outcome
Thank you<br />
<strong>St</strong> George’s <strong>Hospital</strong><br />
<strong>St</strong> Anthony’s <strong>Hospital</strong><br />
www. sonjacerovac.com<br />
0845 026 7776