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Hand Viva II

 Viva-1 what do you find in Wrist PA view ? 


( We don't have X ray , 

Suppose you saw an undisplaced fracture of Scaphoid ) 


Viva 

 Schapoid View - hand and wrist in ulnar deviation along with 15 degrees of cephalad angulation of X ray tube. 


Indications of Internal Fixation of Scaphoid fractures 

1.Displacememt > 1 mm 


2. SL Angle > 15 degrees 


3. Lunocaoitate angle > 15 degrees


4. Interscaphoid angle >20° (dorsal humpback)


5.Proximal pole # , Periluante dislocation 


6.Delayed union



Operative fixation in acute non displaced fractures 

Non union Scaphoid fractures 

Better early outcome scores in grip strength , ROM with fixation but no difference after 12 to 16 weeks 


Rate of delayed union is less with early fixation .

Complications 


AVN of Proximal Pole 

Non union 



Mx of established non-union


Arthritic changes not present 


Fixation with bone graft 


       ( Distal radius ) 


"Bone graft based on 1, 2 intermateacarpal 


branch of radial artery


Success rate - 70%


Arthritic changes present


-Radial Stylbidectomy


-Proximal row carpectomy


-Scaphoid excision 


- Four Corner Fusion 


- Wrist Arthrodesis




Viva-2


Suppose you saw an X ray / MRI . 


Findings on MRI 


What do you see in MRI ? 


TI MRI


 low signal intensity in the lunate suggestive of kienbeok’s disease




Cause


AVN of lunate bone on wrist


Staging of this condition 


 Lichtmann classification 


 (I) Normal radiographs, praettepossible Stress #


 (II) Sclerosis of Iunate, no colapse


IIIA. fragmentation & early collapse


IIIB. Schapolunate dissociation & fixed rotation 

 of schapoid 

IV. Degenerative changes on lunate .





Other important findings we see in radiographs 


Negative ulnar variance on AP n radiograph taken with forearm in mid-prone position.


Mx.


options


Non-op.


Analgesia


Splintage


operative


Joint levelling -Radial Shortening


Wrist Denervation 


Wrist fusion - Partial/total


Proximal row carpectomy


Choice depends on disease stage, degree of symptoms and partial factors.




Viva 3


You get an X ray of a patient with wrist pain . 


AP. radiograph of wrist - shows ulnar positive Variance. 


Appearance is typical of Ulnar Abutment Syndome.


Which structure is involved in this ? 


 TFCC


Anatomy of this?


Pyramid shaped fibrocartilaginous structure found at distsl aspect of ulna. 



Comprises of disc ( meniscus like structure) and a sling of ligament and acts a s a key stabilizer of DRUJ and ulnocaroal joint . 



Mx option for this condition 


Non operative 


Splints


Analgessia


-Avoid aggravating activities


Operative 


Arthroscopic wafer resection 


Open ulnar Shortening

Osteotomy 






Viva


Dorsal Compartment of Wrist 


I- APL, EPB


II. ECRL , ECRB


III. EPL


IV. EI, EDC


V. EDM


VI. ECU




De Quervaines Syndrome



 painful condition affecting first compartment of wrist joint. Commonin female, espcially post partum. 





Tell clinical Signs of DeQuervan’s syndrome. .



Localized Swelling along radial aspect of wrist 


Tenderness 


Finkelstein test


→


Mx. options 


Non operative 


Splinting


Analgesia


Local Steroid


operative 


- Surgical Release


If non-operative measures fail. 


under GA / regional anaesthetics & arm tourniquet


Release transverse or a longitudinal incision .




→ Adverse effects of local Steroid injection 


- Infection 


Injury of Sup. branch Radial Nerve, Painful Neuroma


- Tendon rupture


→Pitfalls of Surgery


failure to recognize anatomical variation EPB-lies in a separate compartment 


Incomplete Relief of symptoms


Painful Nuroma-injury to superficial branch of Radial Nerve


Kienbock's Disease / Ulnar Abutment Syndrome/ De Quervain's Tenosynovitis /Scaphoid Fracture 


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