symptoms  Pain:  eg. Localized to radial side; tenosinovitis of the thumb tendons (De Quervain’s disease).  Localized to ulnar side; inferior radio-ulnar joint disorders.  Swelling:  Of joints; eg rheumatoid arthritis.  Of tendons; tenosynovitis.  Localized; eg ganglion.

 Stiffness.  Deformity: trauma, nerve injury (eg wrist drop).  Loss of function; decreased grip strength.

Signs  Look:  Skin; scars or sinuses.  Deformity, swelling.  Feel:  Warmth.  Tender points: tip of radial styloid in de Quervain’s disease.

Claw hand of ulnar nerve injury

Volkman’s ischemic contracture

Swelling: tumor of the wrist

Wrist drop

 Move: look for limitation of ROM  Passive: dorsi- and plantarflexion; press wrists against each other.  Radial and ulnar deviation.  Pronation and supination.  Active: decreased in tendon rupture, nerve injury, painful conditions.  Power grip- squeeze examiner’s hand.

Radiological evaluation

Lateral radiograph

Radial club hand  Partial or complete absence of the radius with radial deviation of the hand.  May be associated with other congenital anomalies or blood dyscrasias (eg thrombocytopenia).  Treated by serial manipulation and casting then surgical correction.

Radial club hand

Madelung deformity  Forward curvature of the lower radius and backward subluxation of the lower ulna.  Cause: congenital or post-traumatic.  If symptomatic treated by radial osteotomy.

Instability of distal radioulnar joint  Post-traumatic; after fracture of lower radius (Galeazzi fracture dislocation).  Associated with rheumatoid arthritis.  Painful restriction of pronation and supination.  Backward prominence of the lower ulna.  Piano key sign; balloting the lower ulna.

Kienbӧck’s disease  Ischemic necrosis of the lunate bone.  Associated with excessive loading of the lunate.  Clinical features:  Pain and stiffness of the wrist.  Tenderness over the lunate bone.  Limitation of movement.

Kienbӧck’s disease  4 stages: I. Ischemia without changes, normal x-ray, MRI changes. II. Trabecular necrosis, new bone formation, x-ray show increased density. III. Bone collapse; x-ray show small irregular lunate bone. IV. Secondary OA of the wrist.

Kienbӧck’s disease  Early: splintage for 6-12 weaks.  Late: surgical treatment eg, wrist arthrodesis.

De Quervain’s disease  Thickening of synovial sheath around extensor polices brevis and abductor polices longus in the first extensor compartment due to overuse.

DE Quervain’s disease

De Quervain’s disease  Clinical features:  Middle aged, women > men.  Pain on radial side of the wrist.  Tenderness over the radial styloid.  Fenkelstein’s test; pain over the radial styloid induced by flexing the thumb in the palm and abduction of the wrist.  Tratment:  Splintage and corticosteroid injection locally.  Surgical slitting of the thickened synovium.

Swellings around the wrist: Ganglion  Most common swelling around the wrist.  Leakage of synovium from joint or tendon sheath.  Cyst containing glairy viscous fluid.  Usually on dorsum of the scapholunate ligament.

Ganglion

 Clinical features:  Swelling usually on the dorsum of the wrist.  Does not move with tendons.  Sometimes alongside radial artery.  Treatment:  Usually unnecessary.  If troublesome; surgical excision but recurrence is possible.

Carpal tunnel syndrome  Entrapment neuropathy of the median nerve under the transverse carpal ligament.  Compression and ischemia of the nerve.  Cause;  Idiopathic in most of cases.  Associated with: pregnancy, menopause, rheumatoid arthritis, myxedema, chronic renal failure, gout…

Carpal tunnel syndrome  Clinical features:  Age years.  Female: male ratio 8:1  Pain and paresthesia in 3 and ½ radial fingers.  Burning, tingling and numpness.  Wake up the patient at nigtht.  Releived by shaking.  Weakness and clumpsiness in doing fine movements (eg fastening bottoms).

Carpal tunnel syndrome

 Examination:  Tinel sign: symptoms reproduced by tapping over the median nerve.  Phalen’s test: holding the wrist fully flexed for a minute.  Wasting of thenar muscles.  Weakness in thumb abduction.  Paresthesia in median nerve territory.

Tinnel sign

Phalen test

Wasting of thenar muscles

Carpal tunnel syndrome  Electrodiagnosis for difficult cases.  Cervical spondylosis and radiculopathy is a differential diagnosis.

Treatment  Light splint at night relieve night pain.  Corticosteroid injection in the carpal tunnel.  Surgical division of the transverse carpal ligament.