Correction to: A Clinical Approach to Diagnosing Trigger Wrist

BackgroundTrigger wrist is a relatively unusual condition, produced by wrist or finger motion. The various causes of trigger wrist can originate from flexor tendon, extensor tendon, bones, or tumour. A proper clinical approach is required to diagnose and manage patients with trigger wrist.MethodsA keyword search was performed across Google Scholar and PubMed. Articles describing trigger wrist conditions were analysed. Based on the information obtain from the articles, the clinical manifestations and approach to diagnosing the cause of trigger wrist is discussed.ResultsA detailed history alone may lead to a reasonably accurate diagnosis. Patients can present with trigger wrist occurring during movement of the fingers or with wrist movements. Presence of tenderness around A1 pulley suggest trigger finger. Absence of tenderness over the A1 pulley may suggest trigger wrist. The wrist should be examined for any swelling or malunion around the wrist joint. Palpate for any bony prominence, clicking, or crepitus with the movement of the wrist. Examination for the presence of carpal tunnel syndrome should be performed. A simple radiograph of the wrist joint is needed to see any possible bony pathology such as malunion, instability or arthritis of the carpal bone. For soft tissue assessment ultrasound would be a good choice and can be done during finger or wrist movement. MRI is useful for further assessment of space occupying lesion within the carpal tunnel and is useful for surgical planning. Nerve conduction study is indicated for patients with median nerve compression symptoms. During the initial stage, the patient should be advised for activity modification to reduce the wrist and finger movements. Surgical treatment will depend on the causative factor. Surgery done under local anaesthesia has the advantage of reconfirming with the patient, resolution of triggering during surgery by asking the patient to actively move the fingers or wrist. ConclusionsTrigger wrist is a relatively rare condition compared with trigger finger, which is the most common disorder of the hand. To avoid inadequate and ineffective treatment of patients with trigger wrist, careful examination and proper diagnosis are vital.     

Particularities of hand and wrist complex injuries in polytrauma management

Hand and wrist lesions are relatively common in polytraumatised patients. These subjects sustain a wide range of potential life-threatening conditions and hand and wrist injuries incurred are often not diagnosed or are insufficiently treated. Closed lesions are the most frequently missed diagnosis, but even severe open lesions may be incorrectly treated. Most of these hand and wrist injuries can have a strong negative impact on long-term quality of life, particularly when treatment of these injuries is poor or delayed. Orthopaedic and hand surgeons should be vigilant in their assessment and treatment of patients with multiple injuries and a global approach, based on the advanced trauma life support (ATLS)-protocol, must be applied. The very common association of head, chest, abdomen, bone and soft-tissue lesions in the polytraumatised patient requires a multidisciplinary team approach from the beginning. The energy of trauma in these patients often causes complex injuries to the wrist and hand; these require correct treatment in terms of both timing and techniques. It is not possible to create a practical, useful guideline with a “one lesion-one solution” approach, because every case is different; therefore, this paper describes a spectrum of indications and techniques that may be useful in managing hand and wrist injuries, particularly in polytraumatised patients.     

Ulnar-Side Wrist Pain Management Guidelines: All That Hurts is Not the TFCC!

BackgroundUlnar-sided wrist pain is a common clinical problem, most often misdiagnosed as triangular fibrocartilage complex (TFCC) injury. It may be frustrating to the patient, as one may end up wearing a wrist splint for an unusually long period, disrupting their routine.PurposeBecause of the dilemmas in the diagnosing the cause of ulnar-sided wrist pain, various algorithms have been suggested but it is an individual’s choice to do a systematic assessment and follow in their routine clinical practice. We propose the ‘storey concept’ for examining the ulnar side of the wrist, with ulnar styloid as the reference point. The lower storey identifies the pathologies of the DRUJ, the intermediate storey identifies the pathologies of the radiocarpal joint and the upper storey identifies the pathologies of midcarpal and carpometacarpal joint.ConclusionAlso, it is important to ramify the cause of pain into stable or unstable wrist, with or without arthritis, as this will guide us in managing the pain arising from distal radioulnar joint. In addition to methodical clinical examination, ideal radiographs and high-resolution MRI are critical to diagnose wrist pathologies. The role of wrist arthroscopy has consistently increased, and complements in both diagnosis and treatment of wrist pain especially in ambiguous situations.     

Range of motion required for Auslan: a biomechanical analysis

Background

Auslan is used by the Australian deaf community and relies heavily on hand, wrist, and elbow movement. Upper limb injury or dysfunction may require surgical intervention to alleviate pain and provide a stable skeleton for function, leading to partial or complete reduction in motion. The aim of this study was to assess the wrist, forearm, and elbow motion required to communicate via Auslan, to tailor optimal interventions in this population.

Methods

A biomechanical analysis was conducted on two native Auslan communicators, who signed 28 pre-selected and common Auslan words and phrases.

Results

Sagittal plane wrist and elbow motion was found to be of greater importance than axial plane forearm rotation. Relative elbow flexion and generous wrist motion was common for many of the words and phrases, while end-range elbow extension was not recorded.

Conclusion

The maintenance of wrist and elbow motion should be prioritized when selecting surgical interventions for patients who communicate using Auslan.     

Snowboard wrist guards--use, efficacy, and design. A systematic review

The popularity of snowboarding has brought awareness to injuries sustained during the sport. Wrist injuries are among the most common injuries, and there is an interest in using protective equipment to prevent these injuries. The purpose of this study was to review the literature on wrist guard use, injury prevention, the biomechanical effects of wrist guards, and the various types of wrist guards commercially available for consumers. A literature search was done using MEDLINE? Ovid (1950 to January 2009), MEDLINE? PubMed? (1966 to January 2009), and EMBASE? (1980 to January 2009) for studies on snowboard injuries and wrist guards. References from the studies found were also reviewed. Two randomized controlled studies (Level I), one meta-analysis (Level II), eight prospective case control studies (Level II), one cross-sectional study, and four biomechanical-cadaveric studies were found from the literature search. Based on the review of this literature, wrist injuries are among the most common injury type, and wrist guard use may provide a protective effect in preventing them. There is no consensus as to what type or design of wrist guard is the most effective and which wrist guards are available for use by the consumer.     

De quervain tenosynovitis of the wrist

De quervain disease, or stenosing tenosynovitis of the first dorsal compartment of the wrist, is a common wrist pathology. Pain results from resisted gliding of the abductor pollicis longus and the extensor pollicis brevis tendons in the fibro-osseus canal. de Quervain tenosynovitis of the wrist is more common in women than men. Diagnosis may be made on physical examination. Radiographs are helpful in ruling out offending bony pathology. Nonsurgical management, consisting of corticosteroid injections and supportive thumb spica splinting, is usually successful. In resistant cases, surgical release of the first dorsal compartment is done, taking care to protect the radial sensory nerve and identify all accessory compartments. Repair of the extensor retinaculum by step-cut lengthening or other techniques is rarely required.     

Ulnar nerve excursion and strain at the elbow and wrist associated with upper extremity motion

Significant excursion of the ulnar nerve is required for unimpeded upper extremity motion. This study evaluated the excursion necessary to accommodate common motions of daily living and associated strain on the ulnar nerve. The 2 most common sites of nerve entrapment, the cubital tunnel and the entrance of Guyon's canal, were studied. Five fresh-frozen, thawed transthoracic cadaver specimens (10 arms) were dissected and the nerve was exposed at the elbow and wrist only enough to be marked with a microsuture. Excursion was measured with a laser mounted on a Vernier caliper fixed to the bone and aligned in the direction of nerve motion. A Microstrain (Burlington, VT) DVRT strain device was applied to the nerve at both the elbow and wrist. Nerve excursion associated with motion of the shoulder, elbow, wrist, and fingers (measured by goniometer) was measured at the wrist and elbow. An average of 4.9 mm ulnar nerve excursion was required at the elbow to accommodate shoulder motion from 30 degrees to 110 degrees of abduction, and 5.1 mm was needed for elbow motion from 10 degrees to 90 degrees. When the wrist was moved from 60 degrees of extension to 65 degrees of flexion, 13.6 mm excursion of the ulnar nerve was required at the wrist. When all the motions of the wrist, fingers, elbow, and shoulder were combined, 21.9 mm of ulnar nerve excursion was required at the elbow and 23.2 mm at the wrist. Ulnar nerve strain of 15% or greater was experienced at the elbow with elbow flexion and at the wrist with wrist extension and radial deviation. Any factor that limits excursion at these sites could result in repetitive traction of the nerve and possibly play a role in the pathophysiology of cubital tunnel syndrome or ulnar neuropathy at Guyon's canal.     

Superficial radial neuropathy secondary to intravenous infusion at the wrist: a case report

Radial sensory neuropathy is a rare clinical entity. Only one other case attributed to intravenous infusion at the wrist has been reported in the literature. Also known as cheiralgia paresthetica or Wartenberg’s disease, this benign compression mononeuropathy is often mis-diagnosed as is revealed in this case report. Understanding of the anatomy of the wrist, common etiologic factors which may be gleaned from the patient’s history, as well as pertinent symptoms and physical findings, may help to arrive at the diagnosis. Conservative treatment is often beneficial and should be considered before more invasive measures.     

Different effects of age, adiposity and physical activity on the risk of ankle, wrist and hip fractures in postmenopausal women

While increasing age, decreasing body mass index (BMI), and physical inactivity are known to increase hip fracture risk, whether these factors have similar effects on other common fractures is not well established. We used prospectively-collected data from a large cohort to examine the role of these factors on the risk of incident ankle, wrist and hip fractures in postmenopausal women. 1,155,304 postmenopausal participants in the Million Women Study with a mean age of 56.0 (SD 4.8) years, provided information about lifestyle, anthropometric, and reproductive factors at recruitment in 1996-2001. All participants were linked to National Health Service cause-specific hospital records for day-case or overnight admissions. During follow-up for an average of 8.3 years per woman, 6807 women had an incident ankle fracture, 9733 an incident wrist fracture, and 5267 an incident hip fracture. Adjusted absolute and relative risks (RRs) for incident ankle, wrist, and hip fractures were calculated using Cox regression models. Age-specific rates for wrist and hip fractures increased sharply with age, whereas rates for ankle fracture did not. Cumulative absolute risks from ages 50 to 84 years per 100 women were 2.5 (95%CI 2.2-2.8) for ankle fracture, 5.0 (95%CI 4.4-5.5) for wrist fracture, and 6.2 (95%CI 5.5-7.0) for hip fracture. Compared with lean women (BMI<20 kg/m(2)), obese women (BMI≥30 kg/m(2)) had a three-fold increased risk of ankle fracture (RR=3.07; 95%CI 2.53-3.74), but a substantially reduced risk of wrist fracture and especially of hip fracture (RR=0.57; 0.51-0.64 and 0.23; 0.21-0.27, respectively). Physical activity was associated with a reduced risk of hip fracture but was not associated with ankle or wrist fracture risk. Ankle, wrist and hip fractures are extremely common in postmenopausal women, but the associations with age, adiposity, and physical activity differ substantially between the three fracture sites.     

Intra-articular Myxoma Arising from the Scapholunate Ligament: A Rare Cause of Dorsal Wrist Swelling

The differential diagnosis of a dorsal wrist swelling includes ganglion, lipoma, cutaneous tumors, and benign peripheral nerve sheath tumors, with ganglions being the most common. We present the case of a myxoma arising from the dorsal scapholunate ligament mimicking a dorsal wrist ganglion. Volar wrist joint myxomas have been previously reported, but this is the first report of a myxoma arising from the dorsal side of the wrist joint.     

Pediatric Ganglion Cysts of the Hand and Wrist: An Epidemiologic Analysis

We analyzed all hand and wrist ganglions in patients aged 12 years and younger that were treated at our institution during a 3-year period. Our patients were predominately female (1.8:1). Volar ganglions were more common (1.2:1), whereas dorsal ganglions have been reported to be more common in adults. Ganglions had a higher incidence of arising from tendon sheaths in our patients (33%) compared to what has been previously reported for ganglions in studies of all age groups (5% to 16%). While observation and/or splinting alone will likely be helpful in resolution of a majority of pediatric hand and wrist ganglions, surgical excision should be employed in those that are symptomatic and/or do not resolve with observation. This study was not supported by any grants or outside financial support.     

Perimenopausal wrist fracture--an opportunity for prevention and management of osteoporosis.

OBJECTIVE: Review of Medscheme's administrative databases to study the relationship between hip fracture and previous wrist fracture in peri- and postmenopausal women. DESIGN: Retrospective analysis of 1995-1998 data for women aged 50 and above hospitalised for management of wrist fracture. Those identified were subjected to further review to establish rates of osteoporosis and/or hip fracture. Osteoporosis and/or hip fracture rates were also determined for a control population. MAIN OUTCOME MEASURES: Osteoporosis investigation and management rates in controls v. subjects who had experienced a previous wrist fracture. RESULTS: A total of 701 subjects was admitted to hospital for management of a wrist fracture between 1995 and 1998; and compared with 1,385 similarly aged controls. Diagnosis of osteoporosis and admission for hip fracture were more common in women who had experienced a previous wrist fracture (relative risk (RR) 1.55; 95% confidence interval (CI) 1.19-2.03 for osteoporosis, and RR 3.32; 95% CI 1.16-9.69 for hip fracture). Of 10 hip fractures which occurred in the wrist fracture group, 9 were in women not diagnosed as having, or treated for, osteoporosis. CONCLUSION: While women with a history of wrist fracture are more likely than controls to be tested and treated for osteoporosis, it nevertheless appears that insufficient attention is being paid to this premonitory event.     

Persistent posttraumatic wrist pain: complex regional pain syndrome? Mycobacterium tuberculosis infection should be in the differential diagnosis

It is a common algorithm for hand surgeons to diagnose and treat persistent post-traumatic wrist pain as complex regional pain syndrome (CRPS). Although it works for many patients, some conditions that affect the wrist don’t fall in this category and worsen with this treatment practice. We present a single-handed patient who had had a non-displaced distal radius fracture and was treated as CRPS for the next three months. He was eventually diagnosed with late tuberculous tenosynovitis of the wrist and a total wrist arthrodesis was performed. We believe that Mycobacterium tuberculosis infection should be in the differential diagnosis of persistent post-traumatic joint pain. This is especially important as Mycobacterium infections are becoming more common due to an increase in patients with chronic immunosuppression and definitive diagnosis and treatment of tuberculous tenosynovitis needs a high index of clinical suspicion.     

Arthroscopic excision of dorsal carpal ganglion cysts

Ganglion cysts are the most common tumor in the wrist. Dorsal carpal ganglion cysts represent 60 to 70% of all ganglion cysts in the hand and wrist. Standard treatment has been limited to observation, rest, immobilization, aspiration with or without injection, and surgical excision. Arthroscopic resection of dorsal carpal ganglion cyst have been done since the late 1980s. It has the advantages of less scarring and stiffness, the ability to inspect the wrist for other pathology and wrist instability. To date, the success of arthroscopic ganglion cyst resection is at least as good (1% recurrence) as current open techniques (0 to 10% recurrence). Risks of the procedure are similar to open techniques. Patient satisfaction with the procedure is high. In the largest reported series, there have been no major complications. This technique, for those who are comfortable with wrist arthroscopy, is effective and safe in treating this common wrist mass. The technique for this procedure is described as well as a brief history of treatment for dorsal carpal ganglion cysts.     

Arthroskopische Therapie von Handgelenkganglien

Ganglion cysts are the most common of all benign tumors of the wrist. Women are affected 3 times more often than men. The diagnosis of this harmless disease is made from clinical symptoms and clinical history assisted by ultrasound and magnetic resonance tomography. The latter is obligatory especially in the planning of arthroscopic ganglion cyst resection in order to exclude intraosseous participation and tumors from other sources. Treatment of wrist ganglion cysts should be carried out with caution and therapeutic measures (aspiration, open or arthroscopic resection) are as a rule only indicated for complaints or appropriate size for aesthetic reasons.     

Trigger Wrist

Trigger wrist is a relatively rare disease compared to trigger finger, which is the most common disorder found in hands. Patients with trigger wrist usually complain about the following symptoms: snapping and clicking or triggering around carpal tunnel with or without mild to moderate median neuropathy. There are a total of five cases of trigger wrist: three cases of anomalous muscle belly of flexor digitorum superficialis and two cases of fibroma around flexor tendon sheath within carpal tunnel. This study reports on two of those cases: one with anomalous muscle and the other with fibroma of flexor tendon sheath. Accurate examination and proper diagnosis are mandatory to obviate improper and time-wasting treatment for patients with trigger wrist.     

Karpale Instabilit?t

Carpal instability can be understood as a disturbed anatomical alignment between bones articulating in the carpus. This disturbed balance occurs either only dynamically (with movement) under the effect of physiological force or even statically at rest. The most common cause of carpal instability is wrist trauma with rupture of the stabilizing ligaments and adaptive misalignment following fractures of the radius or carpus. Carpal collapse plays a special role in this mechanism due to non-healed fracture of the scaphoid bone. In addition degenerative inflammatory alterations, such as chondrocalcinosis or gout, more rarely aseptic bone necrosis of the lunate or scaphoid bones or misalignment due to deposition (Madelung deformity) can lead to wrist instability. Under increased pressure the misaligned joint surfaces lead to bone arrosion with secondary arthritis of the wrist. In order to arrest or slow down this irreversible process, diagnosis must occur as early as possible. Many surgical methods have been thought out to regain stability ranging from direct reconstruction of the damaged ligaments, through ligament replacement to partial stiffening of the wrist joint.     

Rheumatic lesions of the carpus

The wrist is frequently involved in rheumatoid arthritis. The areas where the synovial membrane is best developed are the best areas for the development of the pannus as well. Proliferation of the synovial membrane lining the joint capsules leads to loss of ligamentary support of the wrist. This is the basis for further deformation. The direction of the carpal deformation is determined by normal anatomical conditions. Destruction of the elements that are essential for the stabilization of the wrist is responsible for these deformations; these elements are described. The flexor and extensor tendons of the fingers and wrist joint are coated with synovial sheaths. These can also be infiltrated by a synovial pannus or rupture due to abrasion by osteophytes. The dislocation, elongation, or rupture of tendons also leads to deformation. In accordance with our conception of the longitudinal pillars of the carpus we classify the different possible types of rheumatic carpal deformation into three groups: deformities of the ulnar, central, and radial type. Combinations of these various types are also common in the course of the disease and lead to instability and ankylosis. Synovectomy represents the basic treatment for the rheumatic joint. It is initially performed by radiosynovectomy. If there is persistent pain and swelling, an operative synovectomy is required. The following surgical procedures are most frequently combined with synovectomy of the wrist joint: synovectomy of the extensor tendons, resection of the head of the ulna, axial realignment of the wrist joint, and reconstruction of ruptured tendons. The operative technique is described in detail. This operation is also most commonly performed in the advanced stages. This operation produces good functional results that are reliable for a prolonged period of time, so that arthrodesis or arthroplasty can be avoided. Deterioration of the radiological findings, however, is common.     

Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears

Ulnar-sided wrist pain is a common cause of upper extremity disability. Presentation can vary from acute traumatic injuries to chronic degenerative conditions. Because of its overlapping anatomy, complex differential diagnosis, and varied treatment outcomes, the ulnar side of the wrist has been referred to as the "black box" of the wrist, and its pathology has been compared with low back pain. Common causes of ulnar-sided wrist pain include triangular fibrocartilaginous complex injuries, lunotriquetrial ligament injuries, and ulnar impaction syndrome.     

Risk of injury through snowboarding

OBJECTIVE: Survey of a group of snowboarders and study of their injuries, as well as analysis of the risk of injury considering the time spent on the snowboard. MATERIALS AND METHODS: Of 7,221 students participating in winter sport programs organized by Austrian schools, 2,745 of those riding snowboards were asked to fill out questionnaires pertaining to demographics, their experience level, equipment, snowboard riding habits, and associated injuries. RESULTS: A total of 2,579 snowboarders (94%), who spent a total of 10,119 days snowboarding, filled out a questionnaire which could be evaluated. A total of 152 snowboarders had suffered a mean of 10.6 injuries per 1,000 days of snowboarding, which required medical care; 5.4/1,000 injuries were moderate or severe. The most common injuries were to the wrist (32%), the hand (20%), and the head (11%). The rate of injury was especially high during the first half-day (roughly 3 hours). Use of wrist protection devices reduced injuries to the wrist from 2 to 0.5% (p = 0.048). CONCLUSION: Risk of snowboard related injury was highest in beginners. Through the use of wrist protection devices, the incidence of the most common injuries was dramatically reduced.