By

Dr. Mahmoud Yasser, MD

Alex University
Bony anatomy of the wrist
Wrist arthritis
• Causes
-Degenerative OA (primary)
-Post traumatic due to carpal
instability.
-inflammatory as Rh arthritis.
-secondary to congenital anomalis
- Idiopathic
Diagnosis
• Symptoms and signs • Investigations
Pain Plain x rays
Tenderness CT scan
Limitation of movement MRI
Deformity (in advanced) Wrist arthroscopy
Treatment
• Conservative (Mild to moderate)
Non steroidal anti inflammatory
Steroid injection
Wrist support
Work modification
Physical therapy
• surgical
Limited fusion
Wrist arthrodesis
kienbock’s disease
• Avascular necrosis of the lunate
bone leading to abnormal
carpal motion and wrist
osteoarthritis.
• Cause is unknown but history of
trauma may be a risk factor.
• Progressive and potentially
debilitating condition if
unrecognized and untreated.
• Symtoms
Pain in wrist
Tenderness
Limitation of movement
Joint effusion
Deformity in advanced arthritis
• Invistigation
-Plain x ray in advanced stage reveled collapse of
the lunate, carpal instability and arthritis.
-CT scan if collapse has already occured
-MRI in early stage
-bone scan in early stage (very sensitive).
Early stage
Untreated and advanced stages
 • Surgical management
Treatment Before collapse -----vascularized
bone grafting for revascularization
• Conservative in
-Old age
-Younger than 15y
-In very early stage and mostly will
need surgical intervention.
Non steroidal anti inflammatory
Steroid injection
Wrist support
Work modification
Physical therapy
After collapse and before advanced arthritis
• Proximal row carpectomy
-The best results
-Removal of 3 (scaphoid, lunate
triquetrum) bones of proximal row
- Articulation of capitate to radius
- Aims to delay wrist fusion
- Will end in the future by wrist
arthrodesis
In late and advanced arthritis
• Wrist fusion (standard) • Total wrist arthroplasty (very bad
results)
Carpal tunnel syndrome (CTS)
• The most common compressive neuropathy
• Pathologic inflamed synovium the most
common cause of idiopathic CTS.
• Risk factors
- Females
- Obesity
- Pregnancy
- Hypothyrodism
- Rheumatoid arthritis
- Smoking
- Alcoholism
- Advanced age
- Repetitive motion activities
Anatomy of the carpal tunnel
Clinical picture
Symptoms
- Numbness and tingling in radial
3and 1\2 fingers.
- Pain and paresthesias that
awaken the patient at night.
• Signs
-Inspection may show thenar muscle
atrophy.
- Carpal tunnel compression test (Durkan’s
test) is the most sensitive test to diagnose
CTS
- Performed by pressing thumbs over the
carpal tunnel and holding pressure for 30
seconds.
Onset of pain or paresthesia in the median
nerve distribution within 30 seconds is a
positive result.
Diagnosis is clinical
• Invistigations
-EMG and NCV to confirm the
diagnosis
-plain x rays and MRI in young
patients for diagnosis secondry
CTS (Mass, bony tumors.
treatment
• Conservative • Surgical
- Non steroidal - Carpal tunnel release
- Night splint opened or endoscopic release.
- Activity modification (avoid
aggravating activity
- Steroid injection (especially in
pregnancy)

Rheumatoid arthritis
• A chronic systemic autoimmune
disease with genetic
predisposition
• More in female
• Symptoms
- Morning stiffness and polyarthropathy.
- All joints of the hand affected except
distal interphalangeal joint (DIJ) usually
spared.
• Diagnostic criteria
-morning stiffness
-Swelling of more than 3 joints
-Rheumatoid nodules
- Radiological changes in hand
- Systemic arthritis
- + Rheumatoid factor
- Arthritis of the hand joints
- 4 criteria or more = Rh arthritis
Hand and wrist in Rheumatoid arthritis
• 1- Rheumatoid nodules in aggressive disease • Treatment
over the IP joints (never in the DIP joint).
• 2- arthritis in wrist and all joints of hand except • 1- medical
DIP joint.
• 3- ulnar deviation of the fingers at MCP joint
• 2- physical therapy early as
due to extensor tendons rupture at the wrist possible before deformities
• 4- mallet finger due to rupture of extensor long life
expansion
• 5- Swan neck deformity due to rupture of • 3- surgical according to
terminal tendon deformity and arthritis
• 6- Boutonniere deformity due to silding of
extensor tendon at the site of middle inter
phalangeal joint
• Carpal tunnel syndrome.
Deformities of the hand in Rh arthritis
De Quervain’s tenosynovitis
• A stenosing tenosynovial inflammation • Symptoms
of the 1st dorsal compartment which - Gradual onset of radial sided wrist pain
include
- Pain exacerbated by gripping and
-abductor pollicis longus
raising objects with wrist in neutral
- Extensor polishis brevis
• Physical examination
• Women more than men
-Tenderness over the 1st dorsal
• 30-50 y compartment at the level of the radial
• Thickening and swelling of the styloid.
retinaculum including 2 tendons causes - Pain with resisted radial deviation .
increase tendon friction
- Normal motion and neurological
• Most of the cases resolve with non
operative treatment.
examination
Management
• Diagnosis mainly clinical
• x ray to exclude mass or
calcification
• Treatment
• Conservative
NSAID
Physical therapy
Local injection
• Surgical
surgical release of 1st dorsal
compartment in severe and
resistant cases