1. Wrist Pain

2. Objectives: Recall anatomy of the wrist joint.
Etiology of painful wrist.
Diagnostic approach.
Ganglion
De Quervian syndrome.
Keinbock,s disease.

3. Wrist Joint: (radiocarpal) joint
Articulation between the distal end of the radius and the articular disc above and the scaphoid , lunate, and triquetral bones below
Type: Synovial condyloid joint.
Ligaments: Anterior (palmar) and posterior (dorsal) ligaments strengthen the capsule. The median (ulnar collateral) ligament is attached to the styloid process of the ulna and to the triquetral bone. The lateral (Radial collateral ) ligament is attached to the styloid process of the radius and to the scaphoid bone

7. Movements:
Flexion.
Extension.
Abduction
Adduction.
Circumduction.
BLOOD SUPPLY OF WRIST JOINT:
Branches of the dorsal and palmar carpal arches.
INNERVATION OF WRIST JOINT:
Anterior interosseous and the deep branch of radial neve branch of the median nerve.

8. Etiology of painful wrist:
NEUROLOGIC CAUSES OF PAIN
Carpal tunnel syndrome.
Pronator teres syndrome
Superficial radial neuropathy
Compression of the Ulnar Nerve at the Wrist (Guyon Canal Syndrome).
MUSCLO-JOINT RELATED CAUSES OF PAIN
Intersection syndrome
DeQuervain’s tenosynovitis.
Arthritis, eg, rheumatoid arthritis, osteoarthritis, reactive arthritis (Reiter’s syndrome), psoriatic arthritis, gout or pseudogout, septic arthritis.
Triangular fibrocartilage complex (TFCC) injury -
VASCULAR CAUSES OF PAIN
Keinbock’s disease.
FRACTURES
Lunate fracture or dislocation, scaphoid fracture (snuffbox pain).
Colles (distal radius) fracture.

9. Diagnostic approach: History. LAB: If infection is suspected.
Physical Examination.
Look:
Feel:
Move:
Measure:
Special tests:
Provocative Testing
Neurological Examination.
LAB: If infection is suspected.

11. IMAGING Other methods: X-rays
A-P and lateral views are obtained routinely.
Special views may be necessary to show a scaphoid fracture or carpal instability.
Arthrography
Defects in the triangular fibrocartilage,
scapho-lunate ligaments or luno-triquetral ligaments can be identified by arthrography.
Computed tomography
CT is the ideal method for assessing congruity of the distal radio-ulnar joint.
Magnetic resonance imaging
MRI is particularly useful for detecting changes associated with scaphoid fractures, avascular necrosis of
the lunate, occult dorsal ganglia and intra-osseous ganglia.
Radionuclide scan
A localized area of increased activity may reveal An occult scaphoid fracture or early osteoarthritis.
Fluoroscopy
 Fluoroscopic examination may be needed to demonstrate some patterns of carpal instability
Other methods:
Aspiration or Arthroscopy

13. Ganglion
The ganglion cyst is the most common swelling in the wrist. It arises from leakage of synovial fluid from a joint or tendon sheath and contains a glairy, viscous fluid. Although it can appear anywhere around the carpus, it usually develops on the dorsal surface of the scapho-lunate ligament
Not related to neural ganglion or ganglionic cell. T
he average size of these cysts is 2.0 cm.
Women are more likely to be affected than men.
Ganglia are common among athletes

14. Treatment:
- A ganglion is harmless and in the absence of pain or complications, it may safely left alone.
- In children , high rate to be resolved spontaneously.
- Aspiration with “wide- bore needle ” provide temporary relief effect.+ inject steroid .
- Lasting cure option can be ensured only by “complete excision” of the ganglion, may lead to tearing of near tendon or joint capsule.

15. De Quervain syndrome Tenovaginitis syndrom (tenosynovitis)
Common and well recognized condition characterized by pain over styloid process of radius and palpable nodule in the course of abductor pollicis longus and extensor pollicis brevis tendon.
De Quervain's is more common in women
It may be initiated by overuse
but it also occurs spontaneously,
particularly in middle-aged women,
and sometimes during pregnancy
Pathology:
* The fibrous sheath of abductor pollicis longus & extensor pollicis brevis tendons are thickened where they cross the tip of radial styloid process
*Tendons themselves appear NORMAL.

16. Clinical features:
- The condition is commonest in middle – aged women
Pain , local tenderness , swelling and difficulty gripping
Diagnosis:
Finkelstein's test:
grasps the thumb (place it in the palm) and the hand is ulnar deviated sharply ,  If pain occurs along the distal radius then test is +ve and vice versa.
Complications:
May interfere mechanically with normal movement of thumb or lateral distal part of radial aspect.
Treatment:
The early case can be relieved by a corticosteroid injection into the tendon sheath, sometimes combined with splintage for symptoms relief.
Resistant cases need an operation, which consists of slitting the thickened tendon sheath.

17. Ischemic necrosis of the lunate bone, due to chronic stress or injury
Ischemic necrosis of the lunate bone, due to chronic stress or injury. ( traumatic softening )
More common in patients with abnormally short ulnas (at wrist).
Young adult (usually affects the dominant wrist of men aged years.)
Ache and stiffness
Localized tenderness over the lunate
Grip strength is diminished
Later stages wrist movement is limited and painful.
Pathology:
stage 1, ischemia without naked-eye or radiographic abnormality.
stage 2, trabecular necrosis with reactive new bone formation and increased radiographic density, but little or no distortion of shape.
stage 3, collapse of the bone.
stage 4, disruption of radio-carpal congruence and secondary osteoarthritis
Kienbock’s disease

18. X - RAY
Stage 3. Both the illustration and x-ray image show that the lunate has begun to collapse and several bones in the wrist have shifted out of position.
Stage 2. (Left) This illustration shows that the lunate has hardened with more than one fracture line. (Right) The lunate is brighter than the surrounding bones, which indicates that the bone is dying.

19. Stage 4. (Left) This illustration shows damage to several bones in the wrist. (Right) This CT scan also shows deterioration in the bones of the wrist

20. Treatment stage X-ray , MRI Tx 1 Normal x-ray, changes on MRI
Cast for 3 months
Vascularized bone graft 2
Lunate sclerosis on plain x-ray, fracture lines sometimes present without collaps
If negative ulnar variance: radial shortening
If positive ulnar variance: radial dome osteotomy 3a
Fragmentation of lunate; height preserved
Proximal row carpectomy 3b
Collapse of lunate, proximal migration of capitate, fixed scaphoid rotation
Scapho-capitate fusion
Scapho-trapezium-trapezoid fusion 4
Midcarpal or radio-carpal arthritis
Total wrist fusion
Wrist replacement

21. Reference