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THE WRIST JOINT:THE WRIST JOINT:ATHLETIC INJURIESATHLETIC INJURIES

Gianni RigoniGianni RigoniFMH HandsurgeryFMH Handsurgery

SSMSSSMS

Wrist Wrist unityunity

““The wrist links the hand The wrist links the hand to the forearmto the forearm””

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AnatomyAnatomyBoneBone

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AnatomyAnatomyIntrinsicIntrinsic ligament ligament

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AnatomyAnatomyTriangularTriangular fibrocartilagefibrocartilage(TFC)(TFC)

AnatomyAnatomyVolar Volar capsularcapsular ligamentligament

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AnatomyAnatomyDorsalDorsal capsularcapsular ligamentligament

AnatomyAnatomydorsaldorsal capsularcapsular ligament ligament (extensor (extensor retinaculumretinaculum))

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Wrist injuriesWrist injuriesSprainSprain and and FractursFracturs

IndirectIndirect injuryinjuryinin

flexionflexion--extensionextensionulnoulno--radialradial duxionduxionpro pro -- supinationsupination

or or combinedcombinedwithwith strong strong velocityvelocity and powerand power

Wrist injuriesWrist injuriesDinamicDinamic: : sprainsprain--fracturfractur

Hyperextension injury

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Wrist injuriesWrist injuriesPhysicalPhysical examinationexamination

SwellingSwelling

EmatomiEmatomi

Compare Compare withwith the the wholewhole sideside

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Wrist injuriesWrist injuriesDiagnosticDiagnostic problemproblem

EasyEasyin in seriousserious and and obviousobvious

pathologyspathologys

DifficultDifficult

in in hiddenhidden pathologyspathologys

!

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Wrist injuriesWrist injuriesPhysicalPhysical examinationexamination

activactiv movementmovementFlexionFlexion and and extensionextension ulnoulno--radiale radiale duxionduxion

Wrist injuriesWrist injuriesPhysicalPhysical examinationexamination

activactiv movementmovementpronoprono--supinazionsupinazion

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Wrist injuriesWrist injuriesfindfind the the painfullpainfull pointpoint

RoentgenographicRoentgenographic approachapproach

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RoentgenographicRoentgenographic approachapproachStandard Standard posteroanteriorposteroanterior viewview (PA)(PA)

Linee di Gilula

RoentgenographicRoentgenographic approachapproachStandard Standard laterallateral viewview

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L

C

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FurtherFurther instrumentalinstrumental esaminationesamination

ArthrographyArthrography (mono, bi or (mono, bi or tricompartimentaltricompartimental))ConventionalConventional tomographytomography (CT) and (CT) and CTCT--arthrogaphyarthrogaphyMagneticMagnetic resonanceresonance imagingimaging (MRI)(MRI)UltrasoundUltrasoundArthroscopyArthroscopy

InstrumentalInstrumental examinationexamination specificspecificvorvor bone bone tissuetissue

RadiographyRadiography

CTCT

MRIMRI

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InstrumentalInstrumental examinationexamination specificspecificvorvor ligamentligament

IndirectIndirect

-- ArthrogrgaphyArthrogrgaphy-- ArthroArthro CTCT-- ArhtroArhtro MRIMRI

DirectDirect

-- MRI MRI

-- ArthroscopyArthroscopy

Most frequently Injuries of the WristMost frequently Injuries of the Wrist

Bone InjuriesBone Injuries

-- Carpal Scaphoid FractureCarpal Scaphoid Fracture-- Distal Radius FractureDistal Radius Fracture-- Hook of Hamate FractureHook of Hamate Fracture-- Lunate FractureLunate Fracture

Ligament InjuriesLigament Injuries

-- Scapho Lunate RuptureScapho Lunate Rupture-- Luno Triquetral RuptureLuno Triquetral Rupture-- Midcarpal InstabilityMidcarpal Instability-- Dislocation af the Dislocation af the carpuscarpus-- PerilunatePerilunate dislocationdislocation-- Distal Radioulnar Joint and Distal Radioulnar Joint and

TriangularTriangular FibroFibro--cartilage cartilage ComplexComplex

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Carpal Scaphoid Carpal Scaphoid FratureFrature (CSF)(CSF)

-- The most commonThe most common, 70% of , 70% of allall carpal carpal fracturesfractures

-- The most The most problematicproblematic--in the Diagnosisin the Diagnosis--in the in the TraetamentTraetament

Carpal Scaphoid Bone Carpal Scaphoid Bone FracturFracturBiomechanicBiomechanic

lunatum

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Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureBiomechanicBiomechanic

Trauma in more then 90 degrees of Hyperextensionand 10 d. of radial Deviation

Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureDiagnosis: Diagnosis: PhysicalPhysical ExaminationExamination

-- TendernessTenderness in the in the ““anatomicanatomic snuffboxsnuffbox””

-- DecreasedDecreased rangerange of of motionmotion

-- PainPain withwith dorsiflexiondorsiflexion-- ((SwellingSwelling))

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Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureDiagnosis: Diagnosis: conventionalconventional radiologyradiology

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Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureDiagnosis: Diagnosis: conventionalconventional radiologyradiology

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Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureDiagnosis: Diagnosis: ConventionalConventional radiologyradiology

MONTHS LATERMONTHS LATER

NON UNIONNON UNION

Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureDiganosisDiganosis: CT: CT

Scaphoid Bone Fractur: NON UNION (PSEUDOARTHROSIS)

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Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureClassificationClassification

Herbert’sclassification

Classic

HO = horizontal fractureT = transversal fractureVO = vertical frcture

Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureDiagnosisDiagnosis

AnyAny contactcontact--sport sport athleteathlete whowho asas radialradialwristwrist painpain shouldshould bebe consideredconsidered to to havehave a a

scaphoid fracturescaphoid fracture untiluntil provenproven otherweiseotherweise

In In casescases of of clinicalclinical suspicionsuspicionMRI MRI studiesstudies isis neceserynecesery

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Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureTreatmentTreatment

IfIf thethe fracturefracture are are stablestable-- Cast Cast untiluntil healedhealed : 3 : 3 monthmonth-- Cast plus Cast plus useuse of a of a playinplayin cast/cast/splintsplint-- OperationOperation withwith internalinternal fixationfixation

IfIf the the fracturefracture are are instableinstable-- OperationOperation withwith internalinternal fixetionfixetion

Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureTreatment Treatment vorvor profesionalprofesional athleteathlete

Open Open reductionreduction and and and and internalinternal fixationfixation

AdvantageAdvantageRiturnRiturn to sport after 6 to sport after 6 weeksweeks ((withwith cast 10cast 10--12 w)12 w)

LessLess rate of rate of nonunionnonunion

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Carpal Scaphoid Bone FractureCarpal Scaphoid Bone Fractureideal ideal treatementtreatement

After 8 weeks

Ligament Ligament injuryinjuryThe most common and mostThe most common and most

problematicproblematic

ScapholunateScapholunateinjuriesinjuries

LunotriquetralLunotriquetral injuries injuries ScafotriquetralScafotriquetral injuryinjuryMidcarpal instabilityMidcarpal instabilityDislocation of the carpusDislocation of the carpus

Distal radioulnar Distal radioulnar joint (DRG) and joint (DRG) and triangulartriangularfibrocartilagefibrocartilagecomplex injuriescomplex injuries(TFC)(TFC)

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ScapholunateScapholunate ruptureruptureDinamicDinamic

Hyperextension traumaand ulnoradial load

ScapholunateligamentScapholunateligament ruptureruptureDiagnosis: Diagnosis: PhysicalPhysical examinationexamination

-- TendernessTenderness of of scafolunatescafolunateareaarea

-- DecreasedDecreased rangerange of of motionmotion

-- ((SwellingSwelling))-- Positive Watson TestPositive Watson Test

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ScapholunateScapholunate ruptureruptureDiagnosis: Diagnosis: physicalphysical examinationexamination

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Verticalizzazione dell’osso navicolare Watson Test

SccapholunateSccapholunate rupture: rupture: DiagnosisDiagnosisconventionalconventional radiologyradiology

Distance > 6mm

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ScapholunateScapholunate rupture: rupture: Diagnosis Diagnosis ArthrographyArthrography ((indirectindirect evaluationevaluation))

ScapholunateScapholunate rupture: rupture: DiagnosisDiagnosisCTCT--arthrographyarthrography ((indirectindirect evaluationevaluation))

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ScapholunateScapholunate rupture: Diagnosisrupture: DiagnosisRMRM--artrhographieartrhographie

( ( indirectindirect and direct)and direct)

Ecogradiente (evidenzia il contrasto) T1 (dettagli anatomici)

ScapholunateScapholunate rupture: Diagnosisrupture: DiagnosisArthroscopyArthroscopy (direct (direct evaluationevaluation))

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acuteacute ScapholunateScapholunate rupture: rupture: TreatmentTreatment

CompleteCompleteopen open ripairripair withwithaugmentetionaugmentetion usingusing a a portionportion of of scafotriquetralscafotriquetralligamentligament

IncompleteIncompletearthroscopycarthroscopyc shrinkageshrinkage

ScafolunateScafolunate rupture acute rupture acute withwith bone bone detachdetach

TreatementTreatement: : operationoperation

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chronicchronic ScapholunateScapholunate rupturerupturetreatementtreatement

RecontructionRecontruction of Sof S--L ligamentL ligament-- bonebone--ligamentligament--bonebone ((oteoligamentoplasticoteoligamentoplastic))-- transosstransossäärere fiationfiation withwith ligament ligament augmentationaugmentation

BatBat: 1) long : 1) long athleticathletic activityactivity interruptioninterruption2) bad 2) bad prognosisprognosis3) 3) riskrisk to to interruptinterrupt the the athleticathletic activityactivity

CronicCronic scapholunatescapholunate rupture: rupture: BoneBone--ligamentligament--bonebone repairrepair

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CronicCronic scapholunatescapholunateLigament Ligament fixationfixation ((TaleisnikTaleisnik))

ScapholunateScapholunate repairrepair::RisultRisult

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TriangularTriangular fibrocartilagefibrocartilage (TFC)(TFC)

TFCTFCStabilizerStabilizer of distalof distal

radioulnar joint radioulnar joint (DRUJ)(DRUJ)

DRUJ

TFC TFC anatomyanatomyulnotriquetralulnotriquetral and and ulnoamateulnoamate ligamentligament

Ulnolunate ligament

Ulnotriquetral ligament

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TFC TFC anatomyanatomy: : dordsaldordsal and and palmarpalmar ligamentligament

Dorsal radioulnar ligament

Palmar radioulnar ligament

TFC TFC anatomyanatomy::ECU ECU compartementcompartement

ECU

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TFC TFC injuryinjury

Acute Acute traumatictraumatic eventsevents involveinvolve axialaxial loadload--bearingbearing withwith rotationalrotational stressstress

OveruseOveruse

RepetitiveRepetitive traumatrauma

TFC TFC injuryinjuryDiagnosisDiagnosis

AnamnesisAnamnesisDifferentilalDifferentilal diagnosisdiagnosisPhysicalPhysical examinationexaminationImagingImaging studiesstudiesArthroscopyArthroscopy

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TFC injuriesTFC injuriesDianosisDianosis: : physicalphysical examinationexamination

TendernessTenderness betweenbetween the the pisiformpisiform and and ulnarulnar stiloidstiloidon the on the ulnarborderulnarborder of the of the wristwristDistal radio Distal radio ulnarulnar joint joint instability (piano instability (piano keykeysignsign))

TFC injuriesTFC injuriesDiagnosis: Diagnosis: imagingimaging studiesstudies

TricompartimentTricompartiment Wrist Wrist arthrogramarthrogramMRI MRI arthrogramarthrogram (high (high resolutionresolution))CT CT scanscan in in neutralneutral and and pronationpronation and and supinationsupinationWrist Wrist arthroscopyarthroscopy

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TFC InjuriesTFC InjuriesDiagnosis: Diagnosis: arthroscopyarthroscopy

AdvantageAdvantage-- DiagnosticDiagnostic-- TherapeuticTherapeutic

TFC injuriesTFC injuriesDiagnosis andDiagnosis and TreatementTreatement

The The physicianphysician treatingtreating high high levellevel athletesathletes maymayconsiderconsider a a more more aggressivaggressiv approachapproach to the to the patientpatient withwith suspectedsuspected TFC/DRUJ TFC/DRUJ injuryinjury

1)1) IfIf DRUJ DRUJ intabilityintability isis demonstrateddemonstrated, , earlyearlyinterventionintervention withwith arthroscopyarthroscopy (TFC (TFC repairrepair))

2)2) IfIf DRUJ DRUJ isis stablestable and and symtomssymtoms are are presentpresentforfor 2 2 weeksweeks, , arthroscopyarthroscopy isis indicatedindicated

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TFC injuries TFC injuries acuteacuteArtrscopicArtrscopic diagnosis diagnosis

CLASSIFICATION OF TFCC TEARS (CLASSIFICATION OF TFCC TEARS (PalmerPalmer))

1A ( 1A ( traumatictraumatic tearstears of the of the centralcentral articulararticular disc)disc)1B (1B (peripheralperipheral TFC at the TFC at the ulnarulnar insertioninsertion) ) 1C (distal to 1C (distal to ulnolunateulnolunate--ulnotriquetralulnotriquetral liglig.).)

1D (1D (lesionlesion at the at the radialradial insertioninsertion))

TFC injuries acuteTFC injuries acutePalmerPalmer 1A1A

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TFC injuries acuteTFC injuries acutePalmerPalmer 1B1B

TFC injuries acuteTFC injuries acutePalmerPalmer 1C1C

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TFC injuries acuteTFC injuries acutePalmerPalmer 1D1D

TFC acute injuriesTFC acute injuriesTreatementTreatement

PalmerPalmer 1A: 1A: arthroscopicarthroscopic debridementdebridementPalmerPalmer 1B: 1B: artroscopicartroscopic repairrepairPalmerPalmer 1C: 1C: repairrepair of of ulnocarpalulnocarpal ligamentsligaments open open or or arthroscopicalyarthroscopicalyPalmerPalmer 1D: 1D: arthroscopicarthroscopic repairrepair (?)(?)

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LunotriquetralLunotriquetral injuriesinjuriesDinamicDinamic

Extension trauma and radial devation

Lunotriquetral ligament

PhysicalPhysical examinationexaminationlunoluno--triquetral instability(LT)triquetral instability(LT)

Lunotriquetral ballottement(Reagan’s)

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LunotriquetralLunotriquetral injuriesinjuriesDiagnosisDiagnosis

UlnarsidedUlnarsided wrist wrist painpainWeaknessWeaknessGiwingGiwing waywayClick Click soundsoundTendernessTenderness over the over the lunotriquetrallunotriquetral ligamentligamentLunotriquetralLunotriquetral shearshear test test positivpositiv

LunotriquetralLunotriquetral injuriesinjuriesDiagnosis Diagnosis

Arthrography (?)Arthrography (?)MagneticMagnetic resonanzresonanzMost Most definitivediagnosticdefinitivediagnostictooltool are the are the arthroscopyarthroscopy

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LunotriquetralLunotriquetral injuriesinjuriesTherapyTherapy

AcuteAcute

immobilisationimmobilisation((HealingHealing in 80% of in 80% of casescases) )

CronicCronic:: surgicalsurgical optionoption

-- arthroscopicarthroscopiclunotriquetrallunotriquetral ligament ligament debridementdebridement

-- lunotriquetrallunotriquetral ligament ligament augmentationaugmentation plasticplastic

-- lunotriquetrallunotriquetral arthrodesisarthrodesis

PerilunatePerilunate dislocationdislocation

-- SignificantSignificant traumatrauma-- SignificantSignificant swellingswelling and and

decreaseddecreased ragerage of of motionmotion

-- ExcessiveExcessive radiocarpalradiocarpalhyperextensionhyperextension and and ulnarulnarddeviationddeviation plus plus intercarpal intercarpal supinationsupination

Disruption of ligament:- Scapholunate- Lunotriquetral- Capitolunate volar

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PerilunatePerilunate dislocationdislocationDiagnosisDiagnosis

PerilunatePerilunate dislocationdislocationDiagnosisDiagnosis

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PerilunatePerilunate dislocationdislocationTreatementTreatement: : surgerysurgery

PerilunatePerilunate dislocationdislocationResultResult

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Hook of the HamateHook of the Hamate FracturreFracturre

IncidenceIncidence 2%2%--4% 4% aallaallccarpalccarpal fracturesfracturesDirect trauma (Direct trauma (bybyabutementabutement of the hook of the hook on on anan object )object )TendernessTenderness over the over the hookhookDiagnosis:Diagnosis:--conventionalconventional radiologyradiology--CT CT scanscan

Lunate FractureLunate Fracture

isis rarerareadequateadequate traumatraumatendernesstenderness of the lunateof the lunateIn In combinationcombination withwithavascularavascular necrosisnecrosis((KienbKienböökk))Diagnosis:Diagnosis:-- conventopnalconventopnal radiologyradiology-- CT CT

Dinamic with hyperextension traumaand ulnar load

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Lunate Lunate fracturesfracturesDiagnosisDiagnosis

Lunate fractureLunate fractureTreatementTreatement

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LunatumLunatum FractureFractureResultResult

Grazie mille perGrazie mille per ll’’ascoltoascolto

MD G. RigoniVia St. Anna cp 16CH-6924 Sorengo