Sonja Cerovac - Wrist Pain - don't prolong the - St Anthony's Hospital

Wrist Pain – don’t prolong the agony
Sonja Cerovac MD MSc FRCS(Plast)
Consultant Plastic and Hand Surgeon

Wrist/Hand Pain
• Very common
• Very debilitating
• delayed presentation common
• lack of diagnosis for months
• delayed treatment
• prolonged absence from work
• unnecessary agony ?
Many conditions can be treated promptly and efficiently

Wrist pain needs ‘a title’
• Diversity of conditions = diversity of treatments
• Acute, inflammatory and degenerative conditions require
rest / analgesia / steroids movement/exercises
– tendonitis, arthritis, neuritis
– acute injury (first 1-2 weeks)
• stiffness, weakness, disuse require physiotherapy / splintage
– contractures
immobilisation/splint
– postoperative rehab (adhesions)
– scar therapy

Careful examination is crucial
• Diagnosis is clinical in 70- 80% cases
• Imaging is important, but secondary to
examination !
• capsulo-ligamentous injuries common
– often unrecognized
– recovery is very slow
• in 10-15% of cases no ethiology identified

Wrist pain
??
Radial or ulnar side ?

Radial wrist pain - the commonest causes
CTS
CMCJ arthritis
STT arthritis
Scaphoid non-union
SL ligament injury
deQuervain tenosynovitis

STT arthritis
VOLAR
CMCJ arthritis
deQuervain’s TS
DORSAL
SL ligament /
Kienbock’s

Ulnar wrist pain
Luno-triquetral instability
TFCC pathology
Long ulna
ECU tendinitis
DRUJ osteoarthritis

DRUJ
osteoarthritis
TFCC pathology
ECU tendinitis
Long ulna ?

Prominent ulna - ulno-carpal abutment
• Common
• Acute
– Post distal radius #
• Chronic
– Degenerate
• Ulno-lunate abutment
• TFCC degeneration

Ulna shortening

Other (rare) causes of wrist pain
• Tendinitis (ECRL, ECRB, FCR)
• intraosseous ganglions
• Kienbock’s disease
• neuroma
• Exostoses
• piso-triquetral OA

Wrist Arthroscopy
• Preoperative differential diagnosis essential
• Diagnostic / Therapeutic
– diagnosis
– assessment
– staging tool
– therapeutic

Arthroscopy

Ganglions
• synovium lined tissues
• Dorsal wrist ganglions (from SL joint)
• Volar wrist ganglions (STT joint)
• ‘top of the iceberg”
• Usually asymptomatic
– “comes and goes”

Wrist ganglions - treatment
• “Bible it ?!
• Observation
• Aspiration
– 19G needle at least !
– +/- steroid infiltration
– >90% recurrence rate
– infection !
• Surgery
– If painful
– General anaesthetic
– Excise piece of the capsule
– Recurrence up to 25% !!

deQuervain’s tenosynovitis
• Very common
– Postnatal
– hand overuse ?
• Very, very, very painful !
• Frinkelstain’s test is very sensitive and
specific
• Long term improvement after steroid
injections in approx 50%
– avoid superficial injections !
• Surgery under the local anaesthetic

Frinkelstain’s test

Thumb base (CMCJ) osteoarthritis
• Very common
• Females
• 5 th decade of life
• Debilitating
– pain
– weakness
• Often mixed with
CTS !

Thumb base (CMCJ) osteoarthritis
• 4 radiological stages
• Treat patient not X rays

Thumb basal joint (1 st CMCJ) OA
• typical pain on circumduction of the 1 st CMCJ

Treatment options
• Conservative vs. Surgery
– Steroid injection + splint+ activity modification
– approx. 4 months of symptoms relief
– repeat at 4-6 months intervals
• Surgical options
– Trapeziectomy only
– Trapeziectomy +/- LRTI ?
– Partial trapeziectomy + implant ?

Trapeziectomy
• Slow, but predictable recovery
• Good pain relief
• Good motion
• Highly satisfied patients
• Strength 70%
• One of the most ‘rewarding’ wrist operations

Tendon graft reconstruction still controversial

Interposition arthroplasty

Scapho-trapezo-trapezoidal (STT) arthritis
• More difficult than CMCJ arthritis
OPTIONS:
• Steroid injections
• STT joint fusion
• distal scaphoid pole excision
• interposition arhrthoplasty
• No option is easy and without problems !

STT joint arthritis
• Scapho-trapezoid OA
common source of residual pain

Carpal Tunnel Syndrome
• the commonest surgical procedure
• Diagnosis is clinical (‘rule of twos’)
• NCS
� History � Examination � NCS
– Specificity 85%
– Sensitivity 82%

CTS algorhythm
• Mild
– Conservative Mx
• Moderate
– Conservative or surgery
– Patient’s preference ?
• Severe
– Surgery

Steroid injection for CTS

Carpal tunnel decompression
• irreversible changes ?
(residual weakness/numbness)

Carpal Tunnel Syndrome - beware
• Could it be anything else ?
– arthritis / tendinitis
• More proximal compression ?
– forearm ?
– neck ?

Fall onto out-stretched hand (FOOSH)
Scaphoid fracture Scapho-lunate ligament tear

Diagnostic difficulties
Week 1
Week 3

Acute scaphoid fractures
Displaced surgery
Undisplaced splint vs. surgery
– Ongoing debate
(patient’s preference ?)
– Cast (6-12 weeks)
– Surgery: Percutaneous vs. Open screw fixation

Scaphoid non-union
• More complicated
• Bone graft required
• Outcome less predictable

Scapho-Lunate Dissociation (SLD)

Scapho-lunate ligament injury
• Devastating injury
• Most common carpal instability
• Often diagnosed late
(>6 months)
– “sprain which does not get better”
• Incredibly difficult management
• Known progression to SLAC wrist (OA)
Lunate
Scaphoid
R a d i u s

Advanced arthritis
Non-united scaphoid SL ligament untreated
• Proximal row carpectomy
• Partial wrist fusion
• Total wrist fusion
• Total wrist arthroplasty

Extensor tendon injuries
OFTEN MISSED:
• Mallet finger
• Extensor Pollicis Longus (EPL)
– inability to extend thumb
• Extensor digitorum communis (EDC)
– inability to extend fingers
• Trauma
– repairs are straight forward within the first week of injury
– delayed presentations require tendon transfers or
reconstructions
• Degenerative (attrition) rupture
– usually require tendon transfers

Flexor Tendon Injuries
• Lacerations or avulsions
• Often missed
• Flexor digitorum superficialis
– inability to flex PIPJ
• Flexor digitorum profundus
– inability to flex DIPJ
• Straight forward repairs possible up to 2 weeks post injury
• Delayed presentation requires complicated 2 staged reconstruction

Don’t prolong the agony
Earlier diagnosis = simpler treatments
+ better outcome

Thank you
St George’s Hospital
St Anthony’s Hospital
www. sonjacerovac.com
0845 026 7776