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Igo Goldberg M.D, Hand Surgeon Tel-Aviv, Israel Clinical Examination of the Wrist.

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Presentation on theme: "Igo Goldberg M.D, Hand Surgeon Tel-Aviv, Israel Clinical Examination of the Wrist."— Presentation transcript:

1 Igo Goldberg M.D, Hand Surgeon Tel-Aviv, Israel Clinical Examination of the Wrist

2 MOST COMMON CAUSES OF WRIST PAIN - 1 Chondritis/Osteochondritis/ Posttraumatic arthritis SNAC SLAC Piso-triquetral arthrosis Hamate-triquetral arthrosis Hyperextension radioscaphoid impingement (Gymnast’s wrist) Ulno-carpal impingement Nonunion Scaphoid Capitate Hamate Fracture and Malunion Radius-ulna Scaphoid Other carpal bones Traumatic Disorders Extensor Carpi Ulnaris Tendon Subluxation Ligamentous Injuries and Instability Perilunate (scapholunate,lunotriquetral) Midcarpal (intrinsic,extrinsic) Radiocarpal (ventral or dorsal subluxation,ulnar translocation) Dorsal wrist syndrome Distal radioulnar joint (luxation,subluxation,TFCC injury) Carpo-metacarpal j (1 st CMC;2 nd -3 rd CMC;carpal boss;4 th -5 th CMC) Chondritis/ Primary Arthrosis Tendonitis Tenosynovitis Repetitive Strain Injury Metabolic diseases Gout /pseudogout Hyperparathyroidism Chondrocalcinosis Connective Tissue Diseases Rheumatoid arthritis Systematic lupus erythematosus Degenerative Inflammatory Disease

3 MOST COMMON CAUSES OF WRIST PAIN - 2 Specific Granulomatous DiseaseCommon Bacterial/Atypical AgentInfective Disorders Malignant Tumors Soft Tissue Tumors Pigmented villonodular synovitis, Giant cell tumor,etc Bone Tumors Enchondroma, Osteoid osteoma, Chondromatosis,etc. Ganglia (extraosseous/ Intraosseous/occult) Tendon Cysts Neoplastic Disorders Carpal Coalition Scapholunate Scaphotrapezial Lunotriquetral Muscular Anomalies Extensor brevis manus Madelung’s deformitySimple Osseous CystCongenital and Developmental Disorders Compressive Carpal tunnel syndrome (CTS) Wartenberg’s syndrome Guyon’s syndrome T.O.S Radicular compression Traumatic Palmar branch median n. (from section) Sens.branch radial n. (from injection) Dorsal sens.branch ulnar n. (direct contusion) Distal post.interosseous n. (recurrent ganglion) Neurological Disorders Aneurysm/thrombosis of the ulnar artery Avascular necrosis of the lunate (Kienbock’s disease) ; of the scaphoid (Preiser’s disease) ; Of the capitate; of the triquetrum Vascular Disorders

4 What constitutes the first part of every thorough physical examination? A thorough history


6 CLINICAL EXAMINATION ROM active, passive Grip - Jamar dynamometer (flat curve, rapid exchange grip strength, coefficient of variation) Pinch - Pinchmeter Circumference measurements (Volumetric measurements) Palpation Provocative tests Anaesthetic examination DASH Questionnaire Mayo evaluation score

7 RANGE OF MOTION (ROM) “The wrist is a key joint of the hand” – Starling Bunnel Wrist movement occurs around three principal functional axes: yet all of them are complex and are not restricted to a fixed geometric axis. Flexion-Extension : transverse axis, sagital plane Radial-Ulnar deviation: sagital axis, coronal (frontal) plane Pronation-Supination : longitudinal axis, horizontal plane What is their relative contribution to the upper extremity (UE) function?

8 WRIST MOTION IMPAIRMENT - 1 The wrist functional unit represents 60% of the upper extremity (UE) function. Flexion-Extension unit: 70% of wrist function:70%x60%=42% of UE function. Radial-Ulnar deviation unit: 30% of wrist function: 30%x60%=18% of UE function לשמירה על טווח כיפוף-ישור חשיבות גדולה יותר מאשר לשמירה על טווח ההטיות לצדדים Normal ROM F-E Functional ROM: F-E Normal ROM R-U Functional ROM: 0-10 R-U Wrist fusion: 10 extension 10 ulnar deviation

9 WRIST MOTION IMPAIRMENT - 2 Pronation-Supination Impairments of pronation-supination are ascribed to the elbow because the major muscles for this function are inserted about the elbow. This applies even if the loss of rotation results primarily from the wrist involvement in the presence of an intact elbow The relative value of this motion unit is 28% of the UE function Normal ROM : P-S Functional position: 20 P

10 WRIST MOTION IMPAIRMENT - 3 The relative contribution of various motion units to the upper extremity (UE) function: F-E 42% P-S 28% R-U 18%

11 How much wrist motion is required for most activities of daily living (ADL) ? Ruy (1991)PALMER (1985) Flexion Extension 10 0 Radial deviation Ulnar deviation

12 האם טווח התנועה בשורש היד חשוב בכל מחיר ? תקנות המל"ל "קשיון נוח" שורש יד - 20% נכות[תקנה 41(10)(ב')] קשיון ברוטציה של האמה במנח נוח - 10% נכות[תקנה 41(10)(ז')] "קשיון נוח" של כל האצבעות (במצטבר)- 31% נכות[תקנה 44(2+3+4)] מסקנה: תפקודן התקין של האצבעות חשוב יותר מתפקודו של שורש היד !!!!!!! מה הם שני התפקידים העיקריים של היד ? 1.אחיזה (על כל צורותיה) 2.מגע

13 גבר בשנות ה-40 טופל עקב שבר ברדיוס רחיקני ע"י קיבוע חיצוני וגבס. תמונות רנטגן וטווחי תנועה בשורש יד "יפים...." פרונציהסופינציהכיפוףיישור

14 ויד פגועה קשה ?

15 TOPOGRAPHIC ANATOMY OF THE WRIST Radial border 1 st comp Ulnar border FCR Ulnar border FCU radialcentralulnar middle axis 4 th finger VOLAR

16 TOPOGRAPHIC ANATOMY OF THE WRIST Dorsal ulnarcentralradial Radial border 1 st comp Radial border 2nd comp Ulnar border 4 th comp Ulnar border FCU


18 COMMON CAUSES OF WRIST PAIN ACCORDING TO TOPOGRAPHIC AREAS - 2 Dorsal areasVolar areas Radial Central Ulnar Radial Central Ulnar

19 COMMON DIAGNOSTIC TESTS AND PROVOCATIVE MANEUVERS ACCORDING TO TOPOGRAPHIC AREAS - 1 UlnarCentralRadialArea Palpation of the Hook of the Hamate Piso -Triquetral Grind Test FCU Palpation Test Tinel’s sign over the Ulnar Nerve FDC Palpation Test Phalen’s Test Tinel’s sign over the Median Nerve 1CMC Grind Test Palpation of STT joint Finkelstein’s Test FRC Palpation Test Tinel’s sign over the Palmar Cutaneous Branch of Median Nerve Volar

20 COMMON DIAGNOSTIC TESTS AND PROVOCATIVE MANEUVERS ACCORDING TO TOPOGRAPHIC AREAS - 2 UlnarCentralRadialArea LT Shear Test Derby’s Method for LT dissociation Ballottement Test Triquetral Impingement Ligament Tear (TILT) test Ulnar Snuff Box Compression test Piano Key Test Press Test Ulno-Carpal impaction test Ulnar styloid impaction test EDM test ECU Palpation Test ECU Subluxation Provoc Test Tinel’s sign over the Dorsal Branch of Ulnar Nerve Finger Extension Test (FET) Scaphoid shift (Watson’s) test SL Shear Test “Catch-up clunk” (Lichtman’s Test) EPL Test EIP Test Radio-Carpal Subluxation Test Palpation of Extensor Digitorum Brevis Manus 1 CMC Grind Test 2-3 CMC Shear test Palpation of Anatomic snuffbox/ Articular-Nonarticular test Intersection Syndrome Tinel’s sign over the sensory branch of Radial Nerve (Wartenberg’s Neuralgia ) Dorsal

21 PROVOCATIVE TESTS א-בדיקת הצד הרדיאלי של שורש היד ב-בדיקת הצד האולנרי של שורש היד ג-בדיקת המפרקים הרדיוקרפלים ומידקרפלים ד-בדיקת המפרקים הקרפומטקרפלים ה-סיבות חוץ פרקיות לכאבים בשורש היד

22 א.בדיקת הצד הרדיאלי של שורש היד 1.Dorsal wrist (DWS) test 2.Finger extension (FET) test 3.Articular/nonarticular (ANA) test 4.Scaphotrapeziotrapezoid (STT) test 5.Scaphoid shift maneuver (SSM) 6.Ballotment test (shear) test for SL

23 1.Dorsal wrist (DWS) test לבדיקת פרק S-L : This joint is not painful to palpation. If painful, suspect:  S-L dissociation  Kienbock’s disease  Dorsal wrist syndrome (S-L joint overloading with wrist pain secondary to S-L ligament synovitis and/or tear preceding evidence of rotary subluxation of the scaphoid)

24 2.Finger extension (FET) test (wrist-flexion finger-extension maneuver) Usually not painful If painful:  Periscaphoid inflammation  Radiocarpal or midcarpal instability  Symptomatic rotary subluxation of scaphoid  Kienbock’s disease

25 3.Articular/nonarticular (ANA) test. Always compare to the other side If severe pain:  Periscaphoid synovitis  Scaphoid instability  SLAC changes

26 4.Scaphotrapeziotrapezoid (STT) test Palpation of this joint is not painful If painful, suspect:  Triscaphe synovitis  Triscaphe OA

27 5.Scaphoid shift maneuver (SSM) (Watson test, scaphoid shear test) If painful: rotary subluxation, periscaphoid arthritis

28 6. S- L shear test Pressure on the scaphoid tuberclePressure on dorsal aspect of the lunate Simultaneous pressure in opposite directions

29 7.Scapholunate ballottement test

30 ב.בדיקת הצד האולנרי של שורש היד Areas involved: 1.DRUJ 2.TFCC 3.Ulnar carpus

31 1.DRUJ Decreased and/or painful pronosupination:  Degenerative disease  Subluxation “Piano key” sign: exaggeration of normal ulna head prominance.  Dorsal subluxation  Articular effusion

32 Ulnar impingement or impaction syndrome Decreased and/or painful pronosupination while ulnar head is pressed volarward and the pisiformis pressed dorsally

33 2.TFCC Suspected when:  Loss of forearm prosupination and wrist motion  Tenderness over TFCC dorsally  Palpable and/or audible click with forearm rotation or radioulnar deviation ( Ulnar carpal abutment test ) Necessitates: Three compartment arthrography

34 3.ULNAR CARPUS LT compression test : direct pressure along ulnoradial axis by palpating within the ulnar snuffbox. (Linscheid’s test) If painful:  LT instability  Synovitis  Degenerative disease  Partial synchondrosis

35 LT instability: Reagan’s test (L-T ballottement, shuck, shear) Pressure on the lunate Pressure on the triquetrum

36 LT instability: Masquelet’s test

37 Pressure on pisiformisPressure on dorsal aspect of the lunate Simultaneous pressure in opposite directions

38 TH instability test 1.Grasping of the triquetrum 2.Stabilization of capitate and carpus with other hand 3.Volar and dorsal stressing of the triquetrum

39 TILT: Triquetral Impingement Ligament Tear syndrome Triad of:  Localized triquetral pain  History of hyperflexion injury  Normal radiographs Mechanism: cuff of fibrous tissue that has become detached from the ulnar sling mechanism and chronically impinges on the triquetrum, resulting in synovitis, bony eburnation and pain.

40 ג.בדיקת המפרקים הרדיוקרפלים ומידקרפלים Radiocarpal anteroposterior drawer test

41 The “pivot shift” of the mid-carpal joint 1.מרפק מכופף ל- 90 עם אמה בסופינציה מלאה 2.אחיזה יציבה של האמה 3.הטיה רדיאלית מקסימלית של שורש היד 4.סופינציה נוספת לכף היד ללא תנועה בשורש היד 5.העברת היד מהטיה רדיאלית לאולנרית

42 The “pivot shift” of the mid-carpal joint הסבר במנח שתואר לעיל ראש הקפיטטום "ננעל" בלונטום והמטום "ננעל" בטריקווטרום. העצמות הנ"ל אינן יכולות לנוע יותר וולרית משום שהן נעצרות ע"י קפסולה קידמית ורצועה LT. במידה וקיים קרע ברצועות הנ"ל (או רפיון מולד) הקפיטטום "יוצא" מתוך הלונטום ובזמן העברת היד מהטיה רדיאלית להטיה אולנרית, השורה הרחיקנית "קופצת" בחזרה למקומה מלווה בנקישה מכאיבה.

43 ג.בדיקת המפרקים הרדיוקרפלים ומידקרפלים Midcarpal anteroposterior drawer test

44 ד.בדיקת המפרקים הקרפומטקרפלים CMC1 tests:  Grind test  Stress test  Adduction test

45 Carpal boss

46 ה.סיבות חוץ פרקיות לכאבים בשורש היד Finkelstein’s test “Wet leather” sign ECU problems: synovitis, subluxation, stenosis, partial rupture Pisiformis problems: fractures, OA Hook of hamate FCR tendinitis intersection syndrome Substitution maneuvers

47 COMMON DIAGNOSTIC TESTS AND PROVOCATIVE MANEUVERS List of publications and suggested readings for download in:

48 Thank you !

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