Hand and wrist

Hand and Wrist Treatment

Triangular Ligament Injuries

The triangular fibrocartilage complex (TFCC) is formed by collagenous fibers (ligaments) implanted in a fibrocartilage matrix that extends to the extremity of the radius and ulna. This keeps the forearm bones stable when they rotate or when the hand is grasping. Triangular ligament injuries are a frequent cause of ulnar pain and can be caused by either traumatic or degenerative processes.

Treatment

  • Conservative - consisting of immobilization with orthosis for three to four weeks and physiotherapy. Traumatic injuries require between four to sixteen weeks for recovery.
  • Surgery - considered if conservative treatment does not alleviate the pain. It consists of arthroscopic debridement to remove loose components or to reinsert them.

WRIST IMPINGEMENT - Ulno-carpal Impaction Syndrome Síndrome de impactación cúbito-carpiana

This condition, also known as Ulnocarpal Abutment Syndrome, is a degenerative wrist condition where the ulnar head impacts the ulnar-sided carpus compressing the triangular ligament and damaging the TFCC. It causes ulnar-sided wrist pain. It is attributed to positive ulnar variance which can be congenital or have resulted from a distal radius fracture with malunion, a consequence of trauma to the radius junction or injury to the elbow.

The pain is insidious and progressive increasing with sports activity and with pronation and ulnar deviation.

Treatment

  • Conservative - consisting of orthosis for three to six weeks and physiotherapy.
  • Steroid infiltrations can also be of diagnostic and therapeutic use and recovery ranges from four to sixteen weeks.
  • Surgery - consisting of decompressing the ulnar border of the wrist, ulnar shortening osteotomy, or arthroscopic wafer procedure.

Ulnar Styloid Impaction

This condition is associated with wrist pain on the little finger side, caused by a short ulna and a long styloid. When the styloid is too long it presses against the bones of the wrist, particularly the triquetrum bone and can lead to synovitis.

Treatment

Treatment ranges from conservative methods such as hand therapy to surgery by resection of the ulnar styloid.

Chondral Wrist Injuries

Cartilage is the tissue that covers the joint surfaces, reducing friction and allowing for proper joint movement. Articular cartilage damage in the wrist produces pain, blockages and decreased mobility, leading to wear and arthritis.

Most chondral wrist injuries are secondary to distal radius joint fractures.

Treatment

  • Wrist arthroscopy is used both for diagnosis and removing free bodies. Several treatment options are possible:
  • Microperforations are bone perforations to increase the vascularization of the area and help with the possible regeneration of the cartilage.
  • Mosaicplasty consists of transplanting a piece of another joint of lesser load into the injured area.
  • Autologous chondrocyte implantation, having shown the best results, is a two-part procedure where a culture of the patient’s cells are processed in laboratory, and the resulting collagen matrix is implanted into the injured area.

Posterior Ulnar Pathology

This injury usually involves the tendon and sheath of the extensor carpi ulnaris and is often caused by repetitive movements that combine lifting, impact, twisting or throwing. It is usually a slow progressive injury common with tennis players, golf players and weight lifters.

Treatment

  • Conservative - selective infiltration accompanied by steroid injection in the fibro-osseous sheath.
  • Use of splints, physiotherapy and changes in activity are further options.
  • Surgery - consisting of compartmental release to relieve pressure on the nerve.

Carpal Tunnel

This injury is caused by compression of the median nerve that passes through the carpal tunnel and is characterized by numbness and tingling in the hand and pain that radiates up the arm especially at night.

It is the most frequent nervous compression of the upper extremity and most causes are unknown, although they can come from anatomical or physiological causes such as diabetic neuropathies, position and use of the wrist.

Treatment

  • Conservative - this can be tried early on and if the condition is mild; it can consist of wrist splint, exercises and corticosteroid infiltrations.
  • Surgery - performed by section of the annular ligament of the carpus. This can be done via endoscopy or by open carpal tunnel release.

Synovial Ganglions

These are benign cystic tumors - small sacs of fluid that form over a joint or tendon. They are usually asymptomatic although sometimes painful. Dorsal ganglions are the most frequent type of wrist ganglia followed by Volar ganglions.

Treatment

  • In 50% of cases they are reabsorbed without treatment.
  • Surgery - consists of a transverse incision, resecting the pedicle and capsule. This treatment has a high rate of recurrence.

De Quervain Syndrome

De Quervain’s tenosynovitis produces inflammation of the tendon and the sheath that covers it on the thumb side of the wrist. It can be due to chronic overuse of your wrist, repetitive hand or wrist movements and causes pain when you turn your wrist, grasp something or make a fist. It is common with golfers and tennis players and women aged thirty to fifty years.

Treatment

  • Conservative - with anti-inflammatories, immobilization of the first finger and corticoid infiltration guided by ultrasound.
  • Surgery - consists of tenolysis - release of the first compartment to release the two tendons.

Carpometacarpal Boss

Carpal Boss is an overgrowth of bone where your index finger meets the carpal bones, causing a firm bulge on the dorsal part of the hand. The cause is not clear but could be related to overuse and repetitive motions as it tends to occur on the dominant hand. It is usually asymptomatic.

Treatment

  • Conservative - with anti-inflammatories, intra-lesional corticosteroid injections, immobilization and physiotherapy.
  • Surgery - if pain persists, the lump will be removed surgically, with recovery taking between two to six weeks.

Distal Ulnar and Distal Radius Fractures

These fractures are usually due to low energy trauma when you fall on your outstretched hands. They are very common, with fractures to the distal end of the radius being the most frequent.

The fractures can be classified as:

Extra articular: Colles fracture, Smith fracture, Barthon fracture and Hutchinson fracture.

Intra-articular.

Intra and extra articular.

Treatment

Due to the complexity and possibility of associated injuries to the scapholunate ligament, triangular fibrocartilage and median nerve, treatment is determined on a case by case basis.

Surgery - options include immobilization with plaster, closed reduction, open reduction and osteosynthesis.

Lunate Fractures

Although quite rare, these are the second most frequent carpal fractures and are often associated with other carpal injuries. Most are recognized when they produce Kienböck's disease (avascular necrosis). They are also typically caused by falling on an outstretched hand.

Treatment

Treatment for avulsion injuries consists of immobilization with cast or orthosis for four weeks.

Trigger Finger

This condition occurs when the flexor tendon is hindered from sliding normally within its sheath usually in flexion. It produces a snapping sensation, making it difficult to bend the affected finger or thumb. It is more frequent with people who perform repetitive gripping motion. The stiffness is also more typical in the morning, with the thumb or finger becoming stuck in flexion.

Non-Prosthetic Surgical Treatment

  • Conservative - aims to eliminate the lock and can be done with anti-inflammatories or corticosteroid injections.
  • Surgery - If not resolved by conservative treatment then a surgical release of the first annular pulley or a synovectomy is performed.
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