Wrist Pain to primary care physicians We will focus on acute, - PDF document

10/21/2013 Disclosures Common and Commonly I have no commercial involvement or financial interest in any medications or tests or procedures or durable Missed Orthopedic Problems medical equipment described in this lecture UCSF Primary Care Medicine: Principles Graphics included under use license or attributed and Practice 2013 I wish to thank Carlin Senter, MD, UCSF Dept. of Orthopedics and Division of General Internal Medicine for reviewing major parts of this lecture to Paul L. Nadler, MD ensure accuracy and practice standards Professor of Medicine Director- UCSF Screening and Acute Care Clinic Objectives  Discuss the initial assessment and management of orthopedic problems that commonly present Wrist Pain to primary care physicians  We will focus on acute, orthopedic problems  Review physical exam techniques commonly used in orthopedic assessment, as well as specialized orthopedic examination techniques necessary to make the diagnosis  Review significant conditions that are easily missed on standard x-rays 1

10/21/2013 Wrist Pain Wrist Anatomy Wrist is most injured joint in the upper extremity History PPQRST- (precipitating, palliating, quality, radiation, • severity, timing) Previous injuries and treatment • Workplace or leisure activities • Wrist Anatomy Wrist Pain Trauma History • Force of impact • Injury involving radial side or extended wrist (Fall on Outstretched Hand “FOOSH”)  Scaphoid injury • Injury loading ulnar side (Fall Backwards)  Lunate or triquetrum injury 2

10/21/2013 Wrist Pain Wrist Pain “Pain Pattern” Wrist Swelling 1) Pain over the Dorsum of the Wrist with flexion and  If localized extension - Ganglion Cyst  Ligament injury  Fracture if post-traumatic  If generalized - Complex 2) “Stiffness” Regional Pain  Rheumatoid arthritis Syndrome (RSD)  Carpal Tunnel Wrist Pain Wrist Pain Parasthesia s “Pain Pattern” Thumb and thenar  Decreased Grip Strength • eminence  Tendonitis- often felt in forearm - median nerve  Strength reduced secondary to pain compression (CTS)  Radial Side Pain (no recent fall) Small and ring finger  De Quervain’s tenosynovitis • -ulnar nerve  Ulnar Side Pain compression  Hook of hamate fracture (uncommon)  Triangular Fibrocartilage Complex injury 3

10/21/2013 Wrist Pain Wrist Pain Physical Exam Physical Exam- Do “Specialized Physical Exam”  Inspection, palpation, grip strength Finkelstein Test for De Quervains Tenosynovitis 1.  Compare to uninjured side Palpation of the scaphoid bone “snuff box 2. tenderness”  Range of Motion (flexion 90 degrees, extension 80 degrees) “Watson Test” or scaphoid shift test 3.  Confirm normal radial pulse, capillary refill Ulnar Loading to assess for Triangular 4. Fibrocartilage Complex Injury  Confirm normal neurologic function Wrist Pain Wrist Pain – Case 1 “Finklestein Test”  A first year orthopedic resident was roller- blading and fell onto her outstretched left  De Quervains Tenosynovitis hand  Initially, the pain was quite intense, but subsided over 24 hours  While smoothing a plaster splint on Monday, she notes that the wrist pain has worsened substantially 4

10/21/2013 Wrist Pain – Case 1 Wrist Pain – Case 1 Based on this history and physical  There is mild swelling over the wrist with point tenderness distal to the radius and presented, what do you suspect? proximal to the first MCP joint 1) Wrist sprain  There is full range of motion of the wrist 2) Occult Radial Head Fracture  X-ray is negative for fracture 3) Scaphoid Fracture 4) Scapholunate Dissociation Wrist Pain – Case 1 Scaphoid Fracture  Most common fracture Based on this history and physical of the carpal bones presented, what do you suspect?  The scaphoid bridges the proximal and distal rows of carpal bones 1) Wrist sprain  One dorsoradial artery 2) Occult Radial Head Fracture -100% incidence of avascular necrosis in 3) Scaphoid Fracture proximal fractures 4) Scapholunate Dissociation -30% in distal fractures Gutierrez G. Office management of scaphoid fractures. Phys SportsMed 1996;24(8):60-70. Rettig AC. Wrist injuries: avoiding diagnostic pitfalls. Phys SportsMed 1994;22(8):33-9 5

10/21/2013 Scaphoid Fractures Scaphoid Fracture • Seventy percent are • Non-union of scaphoid fracture (occurs through the waist in 5% of fractures) • Twenty percent are proximal • Wrist arthrosis and pain • Ten percent are distal • Long term occupational disability – delay in diagnosis of one to two weeks increases risk of non-union and subsequent arthrosis Tiel-van Buul MM, van Beek EJ, Borm JJ, Gubler FM, Broekhuizen AH, van Royen EA. The value of radiographs and bone scintigraphy in suspected scaphoid fracture. A Richard JR. Office orthopedics: thumb spica statistical analysis. J Hand Surg [Br] 1993;18:403-6. casting for scaphoid fractures. Am Family Physician 1995;52: 1113-9. Scaphoid Fracture Scaphoid Palpation Tenderness in anatomic snuff-box – bordered medially by the tendon of the extensor pollicis longus – laterally (radially) by the tendons of the extensor pollicis brevis and the abductor pollicis longus 6

10/21/2013 Scaphoid Fracture Scaphoid Fracture Treatment • X-rays should I) Snuff box pain and x-ray is POSITIVE for fracture include a scaphoid  Urgent Ortho Consultation view – antero-posterior II) Snuff box pain and x-ray is NEGATIVE for fracture with 30 degree  Urgent Ortho Consultation supination and ulnar deviation Discharge patient with Thumb Spica Splint Richard JR. Office orthopedics: thumb spica casting for scaphoid fractures. Am Fam Physician 1995;52: 1113-9. Gultierrez G. Office management of scaphoid fractures. Phys SportsMed 1996;24(8):60-70 Thumb Spica Splint Wrist Pain – Case 2 Fortunately for this ortho resident, careful follow-up showed no scaphoid fracture • But the wrist pain persists • The pain is worse with dorsiflexion • There is point tenderness over the dorsal mid-wrist, on the ulnar side of the scaphoid snuff box 7

10/21/2013 Wrist Pain – Case 2 Wrist Pain – Case 2 Based on the history and physical Based on the history and physical presented, what do you suspect? presented, what do you suspect Injury to the distal radial ulnar joint (DRUJ) Injury to the distal radial ulnar joint (DRUJ) 1) 1) Occult Scaphoid Fracture Occult Scaphoid Fracture 2) 2) Scapholunate dissociation Scapholunate dissociation 3) 3) Injury to the Triangular Fibrocartilage Complex Injury to the Triangular Fibrocartilage Complex 4) 4) Scapholunate Dissociation Scapholunate Dissociation Disruption of the Physical Exam scapholunate Maneuver- interosseous ligament  “Watson” or Scaphoid Shift Test 8

10/21/2013 Scapholunate Dissociation Terry Thomas (1911-1990) Specialized X-ray Views • Bilateral “clenched fist views” • Abnormal scapholunate gapping can be shown with and AP clenched-fist view (“Terry Thomas Sign”) – A scapholunate gap of 3 mm, or greater than the opposite wrist suggests disruption Another way to remember? Wrist Pain – Case 3 • A 40 year old man joins his friend for a game of tennis at the club • He hasn’t played for over a year • He is rusty at first, but soon he is serving and returning the ball with a little “uummph” • After the game, the wrist of his dominant hand is quite sore 9

10/21/2013 Wrist Pain – Case 3 Wrist Pain – Case 3 • X-ray is negative for fracture • At first, a little RICE (rest, ice, • Wrist pain is primarily on the lateral wrist (ulnar compression, elevation) seems to side) help • There is some localized swelling and loss of grip • But later, at work, he has trouble strength • With active ulnar deviation, he (and you) feels a writing because of wrist pain “click” • He consults you for evaluation • There is point tenderness distal to the ulnar styloid • There is significant pain with ulnar deviation of the wrist and axial loading Wrist Pain – Case 3 Wrist Pain – Case 3 Based on this history and physical exam, Based on this history and physical exam, what do you suspect? what do you suspect? Ulnar Styloid Fracture Ulnar Styloid Fracture 1. 1. Hook of Hamate Fracture Hook of Hamate Fracture 2. 2. Acute Ulnar Nerve Neuropathy Acute Ulnar Nerve Neuropathy 3. 3. Triangular Fibrocartilage Complex Injury (TFCC) Triangular Fibrocartilage Complex Injury (TFCC) 4. 4. 10

10/21/2013 Triangular Fibrocartilage Triangular Fibrocartilage Complex Injury (TFCC) Complex  The TFCC functions as a cushion for the carpus, and a sling for the lunate and triquetrum  Injury occurs with “fall on outstretched hand” and rotational force Physical Exam findings TFCC Injury suggestive of TFCC injury • Ulnar-side wrist pain, swelling, loss of grip • Physical Exam strength - Axial loading • There also may be a "click" with active of the wrist ulnar deviation while in ulnar- • Point tenderness distal to the ulnar styloid in deviation the area of the TFCC • MRI • Pain with passive pronation and supination • Arthrogram (as well as ulnar deviation) 11