Traumatic injury of wrist and hand. FOREARM FRACTURES.

(The kind we have done with the teacher's notes and completed, in italics, with that seen in class.) OUTLINE OF THE CLASS: 1) Fractures and dislocations of the carpus: • • • Scaphoid fractures (pseudoarthrosis). Carpal fracture-dislocations. SLAC wrist SNAC wrist. 2) Fractures of the metacarpals and phalanges: • Fractures of the distal phalanx (> 50%). • middle and proximal phalanx fractur es. • triphalangeal finger metacarpal fractures. • 1st metacarpal fractures (Ben nett and Rolando). 3) Forearm Fractures INTRODUCTION The hand is the executive body and a region sensitive anatomical and functional complex as a functional unit that goes beyond the anatomical limits wrist markin g, involving the rest of the upper limb. His treatment involves a multidisciplin ary approach, that is, they involve several specialties, including orthopedic su rgeons, plastic and vascular, as well as rehabilitation and rheumatologists (the cosmetic surgery usually treated by a large soft tissue involvement, the trauma involved little). Lesions affecting this region are very frequent, accounting for socioeconomic co st (days lost, disability) and psychological (body is a presentation and relatio nship with others). The goal of surgery is to restore a helpful hand, sensitive and aesthetically acceptable, advances in microsurgical techniques have expanded treatment options, making possible reimplantation of members amputees, skin cov erage than previously thought impossible, injury or joint replacements degenerat ive or inflammatory. CARPAL INJURIES Excluding fractures of the tip of the radio frequency that are the subject of a separate issue include: 1 - scaphoid fracture: It is the most common fracture in volving the carpal bones. It is a little boat-shaped bone (scaphoid = ship or bo at), and anatomically there are three parts: body, neck and base (tuber). It is surrounded by 2 / 3 of articular cartilage, hindering blood supply, which comes from branches of the radial artery, a dorsal and proximal (70% of vascularizatio n), which penetrates the neck, and a penetrating flight and distal the scaphoid tubercle (30%) is also supposed to get a small blood supply to the proximal pole through escafosemilunares ligaments. In the left image, we see the scaphoid in a radiograph. In the right image, we s ee a specimen where we highlight the scaphoid with the scapholunate ligament. The causal mechanism is usually a fall on the hand with the wrist in hyperextens ion, producing a radial shock back on the neck of the scaphoid. Clinically there is pain and edema in the snuffbox and the scaphoid tubercle (palpable under the skin), and pain on pressure on the spine of the thumb. The simple Rx (AP, later al and oblique) is diagnostic in most displaced fractures, but sometimes it is d ifficult to identify the fracture line in the absence of displacement. CT scanni ng is more useful complementary, enabling you to identify fractures not visible on the Rx, and quantify the movement perfectly (this is the test of choice and s hould be performed in all scaphoid fractures). MRI does not provide too many det ails other than to CT or even can confuse us, and the scan can help rule out fra cture shows no uptake. In any case, if there is a high degree of clinical suspic ion (clinical positive) with negative radiology, lack of access to other complem entary examinations (for example, the emergency door) warrants the opening of an

orthopedic treatment to repeat radiological study to 15 to 20 days (in class sa id 8-10 days), in which changes will be visible by the phenomena Rx Reparative s imple, if there is fracture. Also useful are dynamic radiographs in ulnar deviat ion (left) and radial (right) forced displacement that can be made visible minim um unidentifiable at rest). Displaced fracture Rx dynamic: radial and ulnar inclination (The arrow indicates the ring sign: it is the most prominent of the scaphoid tubercle, seen in radial inclination) Undisplaced fracture The most widely used classification is that established by Herbert, which has th erapeutic value: A) stable fractures (capable of treating orthopedic): 1. Fractu re of the tuber. 2. Non-displaced fracture of the neck. B) Unstable fractures (u sually surgery): 1. Oblique fracture of distal 1 / 3. 2. Displaced fracture of t he neck. 3. Fracture of the proximal pole. 4. Fracture-dislocation of carpal sca phoid fracture (any). 5. Comminuted fracture. Fracture of the neck is not displaced from the displaced fracture (A2) neck (B2) ("complete with step") Fracture of the proximal pole (B3) Treatment: Orthopedic for fractures type A (stable) and the majority of fractures in childr en. Place a cast braquiopalmar 4 weeks, followed by plaster antebraquiopalmar ot her 4-8 weeks (8-12 weeks total immobilization, limited to six weeks in fractures of the tuber), the immobilization includes the first finger in opposition (ie, the first phalanx), leaving open the interphala ngeal, with the wrist in slight flexion and radial inclination. Gypsum Plaster braquiopalmar including antebraquiopalmar with thumb, thumb, as t t º finish initial consolidation For fractures type B and children in selected cases. We recommend open reduction and pin fixation or screw type Herbert. Is justified in selected patients percu taneous osteosynthesis for displaced fractures of the neck to shorten the period of immobilization (elite athletes, manual laborers, ...) and / or reduce the ri sk of nonunion. Fracture of the proximal pole (left) and tt º Qx with special screw (right) Complications: The pseudarthrosis is the most common complication and one of the most serious. There are certain conditions that predispose: inadequate initial treatment: sometimes, the cast does not restrict movement at all or may even be that the fracture itself does not impede the movement (it hurts but it works), so that the patient comes to the doctor 2-4 we eks and it's too late. Delayed diagnosis or early termination of the detention. Displacements of> 1 mm or instability of focus (or very oblique vertical strokes , comminution) Vascularization of focus: Fractures of the proximal pole, because of their precarious irrigation are predestined to undergo avascular necrosis, a nd nonunion. Most pseudoatrosis not hurt in its evolution, though they are on th

e radiograph. Left to their natural evolution, which generates instability in th e dynamics of carpal lead to the formation of degenerative changes (osteoarthrit is) in a predictable sequence, known as SNAC wrist (scaphoid non-union advanced collapse). To avoid this be achieved, in addition to the consolidation of pseudo arthrosis focus, restore the normal anatomy of the scaphoid. Thus, the usual seq uence in the evolution of the nonunion would be (see picture): 1 Osteoarthritis at the tip of the radial styloid. 2 Effect of the radial styloid and scaphoid (j oint). Allocation 3rd more advanced involvement of other joints. In this film we see a nonunion of the proximal pole of the scaphoid. Treatment Modalities: • In non-displaced fracture: bone graft and internal fixation (technique Matti-Russe). • Split with collapse fly (the anterior cortex of the neck is broken and scaphoid is flexed, appearing on the back a "hump" - humpted scaphoid): anterior cortical graft (trapezoidal) and fixation (Fisk technique). • vascularized bone grafts. • Rescue techniques: for cases with arthrosis or nec rosis of proximal pole: Partial fusion (intracarpianas between carpal bones). Resection of the 1st row o f carpal bones (proximal carpectomía for if painful, it is best not to remove an d reduce the pain.) Total wrist arthrodesis. Partial fusion: remove the scaphoid. Resection of the first row of carpal bones 2 - carpal fracture-dislocations are the most serious injuries, and often the re sult of very violent causal mechanisms (sports, accidents traffic ...). Usually, the lunate is in place or dislocated, so in case of dislo cation, one must know to be with him. Fracture patterns of distribution, therefo re, around the lunate (dislocations perilunares): Pure dislocation perilunar: rare, but very serious and demanding of cutting all the ligaments that anchor in the lunate, causing instabilities intracarpianas an d often avascular necrosis. If successful orthopedic reduction can be seen an im age of "false normal" (ligament injuries). Associated fractures: the most common are the neck of the scaphoid and the stylo id process, although any bone can fracture around the lunate (any carpal bone). Enucleation of the lunate: exceptional, but with an avascular necrosis rate clos e to 100%. Transescafosemilunares fracture-dislocations (they said in class.) When it breaks the unity of the carpal bones, ligaments always break. Ligament i njuries, especially the scapholunate ligament injury, often advise surgical trea

tment€almost always. Orthopedic treatment are subsidiaries of dislocations that involve non-displaced fracture of the scaphoid, where the ligament is intact (ie , fracture-dislocations transescafoperilunares completely cut). Fig.1 → RX side to observe the image of a crescent, which is the lunate. Fig.2 → This RX has broken the scaphoid and lunate and except the fragment of the scaph oid, everything else has gone out of your site. Fig.1 Fig.2 Complications: In the short term (emergency) is the compartment syndrome and acu te median nerve entrapment, which usually resolves after reduction. Long term: w e have a scapholunate instability (SLAC wrist) or avascular necrosis (Kienböck). 3 - Instabilities (SLAC wrist, SNAC-wrist) • SLAC wrist: scapholunate instability. • SNAC Wrist: scaphoid nonunion. SNAC wrist: Scaphoid nonunion. SLAC wrist: scapholunate instability. We see the "Terry-Thomas sign." It is known as carpal instabilities that generate the injury loss of anatomic re lationships between two bones or two groups of them there are: Static: Rx visible in the simple, such as scapholunate, which shows an increased space between the two bones (Terry-Thomas sign). Dynamics: identifiable only ci neradiología or arthroscopy. Rx dynamic in making moves, They could also be divided into: Dissociative: separation are expressed. Dissociative No: typical rheumatic impaired mobility between two groups of bone (midcarpal or radiocarpal). As already said in speaking of the scaphoid nonunion , instability between two carpal bones causes the medium to long term development of degenerat ive disorders in a predictable sequence, which in the case of scapholunate insta bility is known as SLAC wrist (scaphoid lunate Advanced Collapse), which is the most common instability. The sequence of injury is similar for both (SLAC and SN AC): - Osteoarthritis escaforradial. - Honing the radial styloid. - Midcarpal ar throsis. Radiosemilunar osteoarthritis. Treatment involves the repair of injuries (ligamentous repair or reconstruction) or if rescue techniques are already established degenerative lesions (arthrodes is, carpectomías). HAND FRACTURES The most common are those of the distal phalanx (> 50%), in association to crush ing and / or amputation of the finger pads. The objective in these injuries is e arly functional restoration and stabilization by reducing enough to allow mobili ty, reducing edema and the formation of joint stiffness (which are the most freq uent complications) and tendon adhesions (the longer fixed, then more problems f unctional). Reductions should be as anatomically possible, accepting small angle s in the sagittal plane, but not rotations. 85% of these injuries can be treated orthopedically. When you osteosynthesis surgery is preferable. The hand is very mobile. The metacarpals 2 and 3 are fixed (almost immobile) and

form the basis of the hand, while the rest of the metacarpals are mobile. The d igital channels are apparently large extent parallel, but bending the fingers po int towards the tubercle of the scaphoid, this allows to identify rotational def ormities of the metacarpals and that, if any, by flexing the fingers, fractured "hide" under the rest (when we flex fingers, normally, go to the center is wrong , lies elsewhere: the 3rd on the 4th and 5th). Fractures of the metacarpals norm ally flexes as flexors and interossei are stronger than the extensors, and end u p bending the distal fragment normal situation the fracture (and the interosseou s shorten the fracture). (See picture). → if finger PATTERNS OF DISPLACEMENT Fracture of the 1st metacarpal base (Bennett's fracture-dislocation) of the base fragment, the ulnar and palmar articular is in bed without moving, while the re st (dorso-radial) is attached to the shaft and undergoes a shift toward proximal and dorsal by the action of abductor pollicis longus. The reduction is performe d by maximum abduction with traction and direct pressure on the back of the base of the thumb is usually unstable and require surgical stabilization. (Rolando's fracture dislocation is a similar injury, but the dorsal and radial fragment is separated from the shaft, giving the line an appearance Y. Ideally, the plate f ixation). Reduction maneuver Bennet lux Left fx-fx-lux and right Rolando plate osteosynthesis Fracture base of 5th metacarpal: a movement is to proximal and dorsal ulnar frag ment in the posterior ulnar traction. Rest of fractures of the metacarpals 2 to 5: by the action of the interosseous and flexor flexes the distal fragment, appe aring on the back angulation. The proximal fragment does not move, and the inter osseous tend to shorten the break. NOTE: The 1st climb up and back MTC is constant in the fx-lux Bennet, similar de formity in the fx-lux at the base of the 5th MTC. Proximal phalanx: the interosseous flex the proximal fragment and the lateral sl ips of the extensor apparatus extend the distal (anterior angulation, "recurvatu m with dorsal sinus). The bottom arrow refers to the anterior angulation or recurvatum, "while the top points to the dorsal sinus. Middle phalanx: Fractures proximal to the insertion of the superficial flexor of the proximal fragment length suffer by the action of the central slip of the ex tensor apparatus, and flexion of the distal flexor (dorsal angulation) fractures distal to this insertion fragment suffer flexion proximal and distal extension (anterior angulation). In this picture we see a proximal fracture of the middle phalanx (distal phalanx can not see in the picture). The arrow refers to the dorsal angulation. This fi

gure presents the distal fracture of the middle phalanx. The arrow refers to the anterior angulation. Distal phalanx: avulsion roximal migration of the tendon avulsed (flexion nsion in the flexor, the fracture of the insertion of flexor or extensor cause p fragment and deformity in the opposite direction to the in avulsion of the extensor-finger hammer-and hyperexte latter is rare).

TREATMENT (teacher's notes) 1. In nondisplaced stable fractures syndactyly (band age from a broken toe and its neighbor, which serves as a splint) is the best dy namic orthosis; to opt for immobilization, splints are placed in a functional po sition (slight extension of the wrist, flexion 70 ° of metacarpophalangeal (MCP) and extension of proximal interphalangeal (PIP) and distal (DIP), which positio n is known as "intrinsic plus", and to cancel its action.). The consolidation is usually not visible radiographically until 6th 7th week, but should be allowed the mobilization protected from the 3rd week. Syndactyly Splinting 2. In unstable fractures opt for closed or open reduction and internal fixation (needles, plates bolted). In case of severe soft tissue injuries or open fractur es may opt for external fixation. Fracture of the 1st phalanx treated with screws. Fracture of the 1st phalanx tre ated with plate and screws. Fracture of the 1st phalanx treated with Kirschner wires. Open fracture treated with external fixation. Fractures of the 3rd, 4th and 5th MTC treated with plates bolted Fractures of the 3rd and 4th MTC treated with screws Fracture of the 4th MTC treated with Kirschner wires 3. Rotational deformities, and sometimes the lateral deviations, should be caref ully reduced and stabilized, surgically if there is a possibility of displacemen t after reduction. 4. Fractures of the 1st metacarpal base (Bennett and Rolando) tend to be unstable after reduction, so it is considered almost always surgical indication. Then we decided to also treat we gave in class, as it differs, in part, on their notes. According to the professor for review must be explored before, but just in case ... we both: a) Treatment of fractures of the phalanges 1 - Orthopedic t reatment: stable fractures, nondisplaced Syndactyly is the best dynamic orthosis . Immobilization splint in functional position is the most used method. It is us ed in stable, non-displaced fractures and those stable after reduction. Consolid ation is not apparent in RX until 6-7 weeks, this is not an obstacle to allow mo bilization of the finger protected from the 3rd week. 2 - Surgical Treatment: Pe rcutaneous Intramedullary. Open reduction and internal fixation (screws, plates) : intra-articular fractures. External fixation: open fractures or extensive soft tissue injury. b) Fractures of the metacarpals 1 - Orthopedic treatment: In non-displaced fract ure or stable after reduction: immobilization in a cast or brace 3-4 weeks with wrist in 40 ° of extension, MCF 60-80 ° of flexion and extension almost IF; or f unctional treatment. In fractures of the neck of the ERM is used JAHSS reduction

maneuver. Residual angulation can be accepted on April 30th and 5th MTC, but th e 2nd and 3rd MTC are fixed,€need to be more demanding. The lateral deviations o r rotations should be corrected accurately, surgically if necessary. 2 - Surgica l treatment: is performed in unstable fractures or deformities residual rotation or lateral deviation: percutaneous osteosynthesis: the most common. It requires careful technique. Open fixation and wire fixation, plates or interfragmentary screws. External fixation: open fractures or soft tissue injury. JAHSS maneuver 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 - Tendon Terminal 2 - 3 triangular ligament - oblique retinacular ligament 4 5 transverse retinacular ligament - lateral bands together 6 - extrinsic centra l slip 7 - 8 streak lateral extrinsic - intrinsic lateral streak 9 - intrinsic m edial streak 10 - Canopy interossei 11 - sagittal bundles 12 - 13 interossei - l umbrical muscle 14 - extrinsic extensor tendon Sprains and dislocations and sprains, dislocations of the interphalangeal and me tacarpophalangeal are subsidiaries of orthopedic treatment, except when there ar e avulsions of the attachments of the collateral ligaments, which often require surgical rehabilitation. The most frequent dislocation proximal interphalangeal, which is easily reducible, obviously under anesthesia. The most important injur y of the ulnar collateral ligament of the 1st MCP (skier's thumb or the woodcutt er), which is produced by forced abduction of the thumb. The problem is to estab lish the diagnosis of gravity, because at rest may be "normal" Rx, it is advisab le to stress (forced abduction). If displaced avulsion of the insertion or compl ete tear of the ligament (sprain grade III), surgery is recommended. The disloca tions are possible in all joints: IFD dislocation (rare, hammer toe). Dislocation IFP (the most frequent sports ac cidents). MCF dislocation (rare, difficult to reduce). Carpometacarpal dislocati ons (rare and usually associated with fractures of the metacarpal base. In fact, fractures are most common carpometacarpal dislocations). Carpal dislocations (perilunares). Radiocarpal dislocations (exceptional). FOREARM shaft fractures This chapter includes the diaphyseal fractures of radius and ulna, because the e nd corresponds to epiphyseal articular fractures of the elbow and wrist. The for earm positions the hand in space. As long bone shaft fractures, have a peculiar behavior because this anatomical segment consists of a pair of movable bones and parallel. Functional recovery required return of shortening, rotation and axial, preserve mobility of the elbo w, radioulnar and wrist joints and grip strength recovery. All this is achieved by reducing anatomical deformities and providing a stable fixation for early mob ilization. ETIOLOGY caused by falling on the hand or direct trauma to the forear m: in sports accidents, work, school or road, and the isolated fracture of the s haft of the ulna which is considered a defensive injury (FRACTURE OF THE STICK, is a fracture legal level is used: occurs when a person is protected against an attack by putting his forearm in front of her). Appears often associated with mu ltiple trauma. It has terrible consequences for the functional compartment syndr ome affecting → if flexors is difficult to recover; consequences for life. They are very common injuries in children. RANKING These lesions can be classified: • location: 1 / 3 proximal, middle or distal. • At the stroke and / or comminutio n: transverse, oblique, ...., Green stem. • For the displacement. • For related musculoskeletal injuries: Floating Elbow: diaphyseal forearm fracture of the humerus, the risk of

complications is higher (nonunion, malunion and infection), both by the associat ion of injury and the fact of being more frequent in trauma patients with other injuries. Monteggia fracture dislocation: Although initially described as association of a shaft fracture of the ulna with a dislocation of the radial hea d, now also includes all injuries that may occur in the proximal radioulnar join t (fractures of the head or neck of radio, pure dislocation or fracture-dislocat ions .) Galeazzi fracture dislocation: involving fracture of the diaphysis of the radi us and lesion of the distal radioulnar (distal epiphysis fracture or neck of the ulna, distal radioulnar dislocations or fracture-dislocations).€(QUESTION OF MIR) CLIN ICAL AND DIAGNOSTIC addition to the antecedent of the causal mechanism (or schoo l sports accident ...), where displaced fractures usually very conspicuous defor mity, which is variable depending on the pattern of displacement. On physical ex amination is very important to make an assessment of: • Musculoskeletal injuries associated (deformity) of humerus fractures (floating elbow), proximal radiouln ar joint (Monteggia) and distal (Galeazzi), wrist and hand, polytrauma ... • Inj uries neurovascular: median, ulnar and radial (n.interóseo posterior branch of n .radial and n.interóseo anterior branch of the median). Radial and ulnar arterie s. • Compartment syndrome: due to the potentially catastrophic consequences of t his syndrome in this location and its relative frequency, it should make a diagn osis and treatment. Remember that the loss of pulses is usually a late sign, and at first is characterized by severe pain in the forearm and the appearance of s ensory impairment. Typical position in the forearm fracture, especially in children. Are protected to avoid being touched. Forearm fracture with a clear deformity Forearm fracture deformity curve For diagnostic radiology is necessary, as in other locations, two orthogonal pro jections, preferably anteroposterior and lateral, including the elbow and wrist, to avoid missing movement or associated injuries. Fracture of forearm (ulna and radius) Green stick fracture (Greenstick) Ulna fracture "defensive" (nightstick). In the last two as we progressively RX i s formed callus consolidation. Fracturaluxación of Moteggia in children (left) and adult (right) Galeazzi Fracturaluxación in two different projections TREATMENT The goals are: - Reduction anatomic deformity (shortening, angulation, rotation). - Stable fracture fixation. - Early movements. The options are: - cast immobilization: is permitted in minimally or nondisplace d fractures of both bones in children or the shaft of the ulna in adults. The do wnside is that occasionally occur secondary to reduced travel edema into the cas t, and which requires a delayed mobilization of the elbow and wrist, and recover ed better tolerated in children than in adults. - External fixation: the forearm is reserved for grade III open fractures (a, b and c) the classification of Gus

tilo, or to any degree if it takes more than 24 hours development. In this mode, the control of the deformities is worse, and the associated soft tissue injurie s, early mobilization is constrained. - Intramedullary fixation: usually with Ki rschner wires (although there are specific key). They are used in children or se rious multiple injuries, as a fast and simple technique. The main drawback is th e poor control of rotational deformities. - Open reduction and internal fixation with plates bolted: currently the standard treatment. It is indicated in: o Dou ble or isolated fractures of the adult radio. or grade I open fracture Gustilo I I if <24h of evolution. or Injury or associated (floating elbow, Monteggia, Gale azzi, Sd compartment) refracture and nonunion. Orthopedic treatment (seen in a cast) Treatment with intramedullary needle Treatment with plate osteosynthesis Complications from surgical approaches (neurovascular injury, infection) have be en reduced in frequency with the development of anatomical approaches, careful s urgical technique and antibiotic prophylaxis. COMPLICATIONS • Infection: rare, except in open fractures. (Osteosíntesis. ..). • Compartment syndrome: after fractures of the tibia and fibula, is the most common. • neurological injuries: the most common is the radial nerve and its branches, b y or iatrogenic injury. • Pseudarthrosis: more frequent in cases of multiple trauma and associated injur ies. The Treatment consists of fixation with autologous graft and plating. • Consolidations vicious: it is a consolidation in a non-anatomic position. Usua lly occur in orthopedic treatments and intramedullary fixation (in this case rotatio nal deformity) and are well tolerated here than in other locations. The treatmen t consists of corrective osteotomy and fixation with plate and screws. • radioulnar synostosis: is the formation of a bony bridge between bone by ossification of the interosseous membrane, causing a blockage of supinat ion. It usually occurs in severe trauma€patients with prolonged mechanical venti lation with high concentrations of O2 or delay surgery. Its treatment is surgica l resection adding a prophylaxis for heterotopic ossification formation (indomet hacin with or without radiation therapy). • refracture it involves the fracture of a bone on another, and previous fractur e consolidated, with less than a year lapse between the two. The forearm is by far the most common and usually associated with green stick fractures treated ortho pedically or needles, or after removal of plate osteosynthesis. His treatment is the plating. Its importance is such medicolegal level in countr ies like USA, which currently shows rigid protective brace for six months after the fracture to reduce the possibility. (All this comes next, was not in class, but the teacher has included it in the n otes he has given us, we have looked at the committee last year and also did the same.)

APPENDIX Although the original agenda includes an item devoted exclusively to non-traumat ic pathology that affects this anatomical region, this section will include brie f notes on some important institutions for their frequency. (Miguel Angel Moltó Beautiful). Common digital deformity in some rheumatic diseases can also have a traumatic origin, or join various etiologies. The two most common are: • Boutonnière (or finger in eye): Rupture of the central slip of the extensor ap paratus fingers, this injury causes a shifting progressively to fly (above) of the later al bands at the proximal interphalangeal (PIP), which causes a deflection of it. In an attempt to return, the extensor apparatus is shortened causing hyperexten sion of the metacarpophalangeal (MCP) and distal interphalangeal (DIP). • Gooseneck: Rupture of the extensor digitorum insertion proximal to its inserti on in the dorsum of the distal phalanx, the DIF fell in flexion, and there is a hypere xtension in the IFP. When you have a traumatic origin can be found rupture of th e tendon proximal to its insertion, or even a bone-wrenching as he appears to st art bending the IFD, with inability to actively extend. This situation is known as hammer toe, and treatment is usually an orthopedic STACK splint, which keeps the IFD hyperextension (6 weeks full time, 6 only at n ight), leaving the IFP. Sometimes surgery is performed reintegration. Canalicula r SYNDROMES entrapment of a peripheral nerve in a tight anatomical most common i n the wrist and hand is Carpal Tunnel Syndrome (CTS, median nerve under the carp al anterior annular ligament), followed by ulnar nerve entrapment at the level o f Guyon's canal. The ulnar nerve is most often caught at epitrocleoolecraniano g roove at the elbow, but unlike the latter, in the carpus no sensory disturbances occur in the back of the hand, as the sensory branch to the back of the hand ne rve divides before entering the Guyon canal. • N.cubital elbow motor impairment (Wattemberg sign of separation of the five finger musc paresis. Hypothenar) with ulnar sensory deficits in the hand, 5th finger and ulnar ½ 4th finger). • N.cub ital Guyon: motor impairment and sensory deficits in the ulnar territory palmar (back free of symptoms). Radial nerve injury, which is exclusively sensitive to this level, often causes hypo / dysesthesias, and is known as meralgia paresthet ica, being less frequent than before. Kienbock's disease is avascular necrosis o f the carpal lunate bone and, like the rest of avascular bone necrosis, most do not respond to an identifiable cause. There are 2 current etiological: • Traumatic: is known about its relationship with carpal fractures, which could cause a temporary disturbance of blood supply to the lunate. It can also happen in dislocations of the carpus (the lunate or perilunares) as a result of repeate d microtrauma (manual workers) or as result of functional overload (Cerebral Pal sy). • Atraumatic: there are certain constitutional factors occur more frequently in these patients (people with iris blond clear, late-onset puberty, morphological variants of the lunate, ulna shorter in relation to radio-minus-cu be formula), but also identify causes associated with microvascular obstruction (treatment with corticosteroids , alcoholism, DCI-the bends, ...) or connective tissue diseases (SLE, scleroderma, vasculitis). The typical patient would be a m ale manual worker€in the 4th decade of life, in the dominant hand. Clinically ma nifested by pain with functional limitation variable, and loss of strength. Give n that so little specific symptoms, they often request additional examinations: plain films is not useful in the early stages, so it comes to CT, which shows th e progressive deformation of the lunate, the scan, used for early diagnosis but has lower specificity than MRI, useful in all developmental stages of the diseas e. The most widely used classification refers to the stages of the disease based

on diagnostic findings, and has therapeutic value and prognosis: • Stage 0: absence of demonstrations. • Stage 1 (prerradiológico): changes on MR I and scintigraphy. • Stage 2 (trabecular): appearance of hyperdense or cystic a reas in the simple Rx-in MRI shows the extent of the injury. • Stage 3 (strain) visible changes in Rx, but more precisely identified with CT and MRI. The deformity of the lunate conditions in the dynami c instability of the carpus. • Stage 4 (OA perilunar): enough with the Rx. Depending on the stage amending therapeutic approach: - Stages 0, 1 or 2 slight symptomatic: conservative (rest, NSAIDs, bracing rest), vascular grafts. - Stage s 0, 1 or 2 symptom: denervations carpal shortening radio, vascularized grafts. Stage 3: resection of the 1st row of carpal bones (proximal carpectomía) or part ial fusion (between carpal bones, keeping the wrist joint). Stage 4: total fusion of the wrist (including radiocarpal joint, intercarpal and carpometacarpal). Dupuytren's disease is a condition of the superficial palmar fascia, which is ch aracterized by the development of abnormal fibrous tissue (fibromatosis) in the form of nodules and cords that conditions over time digitopalmares contractures (flexion deformities of the fingers shortening of the palmar fibers). Usually un known cause, is more common in manual workers (repetitive microtrauma), diabetic s or patients with family history. It can occur in association with other fibrom atosis (plantar, knuckles, penis, mediastinum, retroperitoneum), and although ha ve been linked with the consumption of alcohol and snuff, this relationship is c learly demonstrated. Appears abnormal fibrous tissue in or around the fibers of the fascia longitudinally oriented, but not in transverse or in the perpendicula r. Are considered to have certain triggers that lead to tissue reaction, such as rupture of fibers of the fascia or the appearance of inflammatory episodes. Thi s entity affects 4-10% of the population, mostly males in the 5th decade. Initia lly detected palmar nodules and cords along the route of the flexor muscles in t he palm of the hand that progress to digital contractures. It is a benign, progr essive and recurrent, which can spontaneously stop temporarily or permanently, f or which there is no conservative. Surgical resection (fasciectomy) is not curat ive, because the disease can develop in the fingers neighbors or not resected ar eas of the superficial palmar fascia, and is recommended before the contracture exceeds 30 degrees. The aim is to restore or improve the hand function, associat ing arthrolysis (joint release) if there contractures joint set, and provide skin coverage if necessary (grafts or skin flaps). TUMORS The vast majority of bone tumors that can appear in the hand are benign, and ar e discussed further in the issue devoted to tumors. By their frequency in the ha nd must remember: aneurysmal bone cyst: metacarpals and proximal humerus in children. giant ce ll tumor: metaphyseal distal radius and proximal humerus adults> 40 years. Enchondroma: young adult short tubular bones of hands and feet. iple enchondromatosis. Ollier: mult

Mafucci: enchondromas + hemangiomas. Osteochondroma: a typical location, but rar

e is the tuft of distal phalanx of the fingers under the nail (subungual exostos is). Lorena & Juanjo "Experience is a comb they give you when you're bald." "Living in the clouds is not bad ... bad is down." "When you went hammer did not have mercy ... now that you are the anvil, have, have PATIENCE !!!".