Wrist forms the final link of upper extremity. It combines stability with mobility and allows hand to adjust for finer movements of grip, hook and pinch. Wrist hence is important. Wrist pathologies are common and often treatable. Wrist is multiaxial complex ellipsoid type of joints between radius, ulna and carpal bones. It is complex joint having radio carpal, ulnocarpal and radioulnar components. Wrist is some what a stable joint due to bony restraints. It is bound by carpal ligaments and collateral ligaments. As a multiaxial joint wrist has following motion
1. Flexion up to 90 degrees.
2. Extension up to 80 degrees.
3. Radial abduction up to 20 degrees
4. Ulnar deviation up to 30 degrees
5. Pronation supination arc of 80 degrees each
Fractures around wrist
Fractures around wrist are common. Most of them are caused by fall on out stretched hand. It is important to understand fracture geometry to understand the mode of treatment.
Metaphyseal fractures of lower thirds of radius
These are most common in children caused by fall on supinated hand. As per degree of load, the fracture takes various forms. Taurus fracture is stable compression fracture of dorsal cortex. In Green stick fracture, the distal fragment is dorsally tilted and supinated. In bayonet fracture there is overriding of bones. Most of these can be treated conservatively.Torus fracture requires cast for 4 weeks. Green Stick fracture requires closed reduction for angulations more than 20 degrees. Complete bayonet fracture is treated by anatomical reduction under image intensifier and treatment in cast. Surgery is occasionally indicated for irreducible or open fracture. Complications of properly treated fractures are rare. Some of them are recurrent deformity, nerve injury, cross union and growth arrest.
Distal radial physeal injury
Most commonly physeal injury is Salter Harris type two. The injury occurs in children between 6-12 years caused by fall on outstretched hand. Radiograph reveals dorsal shift and tilt in displaced injury. Most of these are managed by manipulation and cast. Cast is put with flexed and ulnar deviated wrist. Some rare cases might require open reduction and internal fixation with K wires. Though complications are rare, an unlucky child may present later with growth arrest or Pseudo madelung deformity.
Colle’s fracture
It is most common fracture of wrist occurring around 2 cm proximal to joint. It is caused by fall on outstretched hand. The fracture is common in elderly ladies. (M: f is 1:4). Anatomy of fracture is marked by six components respectively dorsal shift and tilt, radial shift and tilt, communition, and lastly Supination. Often, there is fracture of ulnar styloid or injury to TFC (50%) and around 1 cm shortening. Radiograph shows the above mentioned components of fracture geometry. The fracture can be stable or unstable. Unstable fracture is one with dorsal angulation more than 20degrees, shortening of more than one cm and with dorsal communition
Stable fractures are managed by manipulation and cast. An irreducible, open, and or unstable Colle’s fractures should be treated surgically. Surgical options are ligamentotaxis for osteoporotic and comminuted fractures. Percutaneous pinning is done for intraarticular fractures and open reduction for irreducible fractures. A proper physical therapy is must for proper rehabilitation. Complications though not very disabling, are common. There may be malunion, nerve and tendon injuries and later stiff hand due to sympathetic dystrophy.
Malunited colle’s fracture
Due to common occurrence this needs special mention. Main cause of malunion is loss of reduction. Colle’s fracture usually unites or malunites by around 6 to 8 weeks. The patient presents with dinner fork deformity of wrist. There is pain and stiffness of hand. It can be managed conservative with analgesics and physiotherapy. Corrective osteotomy is done in a young person for malunion without arthritis, but with good range of motion.
Smith’s fracture
The fracture also termed as reverse colle’s fracture. It is distal radial fracture that occurs in relatively younger age group. It is caused by fall on dorsum of flexed wrist. Distal radial fracture fragment displaces volar, proximal and radially. Fracture can be manipulated with image intensifier. Due to relative instability, fracture requires open reduction with crossed K wires.
Intraarticular fractures
Volar Barton’s Fracture is volar oblique distal radial fracture. It is caused by shearing force. There is often volar subluxation of wrist. The fracture is quite unstable and requires open reduction with buttress plate.
Dorsal Barton’s Fracture is dorsal oblique distal radial fracture caused by shearing force in younger age group. There is often dorsal subluxation of wrist and even dislocation. Fracture is manipulated under image intensifier and immobilised in a cast. Stability for reduction is afforded by volar carpal ligament. However unstable fracture requires open reduction and internal fixation with crossed k wires.
Chauffeur’s fracture is fracture of radial styloid occurring in young adults. Classically described mechanisms is recoil of cal handle or fall on ball of thumb.Undisplaced fractures can be treated in cast. Displaced fractures require k wire fixation.
Madelungs deformity
It is bayonet shaped deformity of lower radius with volar subluxation of carpus and dorsal subluxation of ulna. It occurs due to partial closure of palmar ulnar physis of lower end of radius. Madelungs deformity is more common in girls and often bilateral. It manifest in late childhood with stiffness and progressive deformity. The disease can be idiopathic, dysplastic or posttraumatic. In earlier stages, management can be conservative by splinting. Closed wedge osteotomy is done for severe deformity and impingement of carpus.
Injuries of Distal radioulnar joint (DRUJ)
Two articular surfaces sigmoid notch of radius and seat of ulna are bound together by triangular fibrocartiliginous complex. Triangular fibrocartiliginous complex functions as shock absorber and stabilizer. DRUJ injuries can be subluxation or dislocation, post traumatic athrosis, triangular fibrocartiliginous complex injuries, ulnar styloid fractures. These injuries are treated by immobilisation and physical therapy. Rare patient especially a sportsman require surgery.
Ulnar tunnel Syndrome
Ulnar tunnel is bound by superficial and deep transverse carpal ligament on volar and dorsal sides are respectively. Pisohamate ligament forms medial boundary.Ulnar tunnel Syndrome is compression of ulnar nerve in ulnar tunnel causing paresthesia and pain in ulnar nerve distribution. It can be caused by space occupying tumor, aneurysm or thrombosis of ulnar artery, fracture of hook of hamate and arthritis. Ulnar tunnel Syndrome can be managed conservatively by splintage and analgesics. Surgical decompression is required for resistant cases.
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome is compression of median nerve in carpal tunnel characterized by paresthesia of radical three fingers and wasting of thenar muscles commonly occurring in middle aged women. It is caused by any condition whether local or systemic causing increase volume and pressure on median nerve. The median nerve gets compressed in canal bound by transverse carpal ligament and radius. With Carpal Tunnel Syndrome the pressure rises to 30 mm and with wrist flexion up to 90 mm Hg. Phalen’s test: Palmar flexing both wrists causes severe pain with paresthesia over affected wrist within one minute. Carpal Tunnel Syndrome is managed by splint in dosiflexion and analgesics. Cortisone injection in carpal tunnel can be tried. Surgical decompression is done for resistant cases and for acute carpal tunnel syndrome.
Ganglion
Perhaps commonest of wrist swelling is ganglion. A ganglion is a cystic swelling overlying a joint or tendon sheath. It originates from mucinous degeneration of connective tissue or defect in capsule or tendon sheath. Ganglion is unilocular or multilocular cyst with fibrous wall having jelly like fluid. It is common in women of 40 years. Swelling may appear gradually or suddenly diminish in size. It is a tense, cystic swelling not attached to skin. The swelling can be managed by aspiration and steroid injection .An excision is necessary for symptomatic and complicated cases.
Rheumatoid wrist
Rheumatism of wrist is common. It goes through stages of synovitis, arthritis and deformity. Synovitis and proliferation forms an hourglass swelling on volar side its called palmar compound ganglion. Disease causes destruction of joint with dorsal subluxation ulnar head and ulnar shifting of carpal bones. Finally there is volar subluxation. As disease runs its course, there is badly arthritic pronated and flexed wrist. On radiograph there is erosive arthropathy with its components of demineralization, marginal erosions, and joint space diminution. Initial management is with disease modifying drugs and immobilisation. The surgical management is synovectomy in initial stages and arthrodesis in later.
Tuberculosis of wrist
Tuberculosis of wrist is of rare occurrence. The disease may start in synovium, lower end radius or capitulam. Later, it involves full carpus, tendons and radioulnar joint. Radiograph might show lytic lesion. There is demineralization, marginal erosions, and joint space diminution. Most of patients come to surgeon in phase of arthritis. Tuberculosis is treated on principles of chemotherapy, splintage and correction of deformity.
Wrist is important for activities of daily leaving and hence should be functional. Along with the treatment of the disease, it is very important to get wrist rehabilitated early.
