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Ulnar Sided Wrist Pain for Postgraduate Orthopaedic Exams
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Ulnar Sided Wrist Pain for Postgraduate Orthopaedic Exams
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Language: EN.
Segment:0 .
Good evening, everyone, and welcome to this meeting, which is combined with the epochs mentors group and orthopedic Research UK. So our topic tonight is on the cided wrist pain and we are proud to welcome Mr. Lorenzo gurnani, who's a consultant and research unit guys and St Thomas trust and also a clinical lecturer in medicine at King's College London.
He's the current joint hand unit lead and lead to undergraduate medical education in orthopedics at guy's and St Thomas Hospital. Mr gurnani has a broad adult and pediatric hand and wrist surgery practice and is author of many peer reviewed publications. He's currently president of the pediatric and International Society of surgeons and Secretary General of the Italian Medical Society of Great Britain.
He's an examiner for the European diploma in hand surgery and a tutor for the British diploma in hand surgery. So I'm sure he'll have lots to teach us this evening. So just before I pass you over to Mr gurnani, I'll just quickly run through. We're going to have a lecture to start with. And if you have any questions, we ask you to write them in the chat box.
We'll keep a record of them and we'll ask them at the end. At the end of the lecture, we will do a short mq poll and we'd like you to answer that. It's all anonymous, so you don't need to worry. And then we'll go through the answers to those questions following the invited questions. We will then move on to a case discussion with top tips for the POCUS exam. And then following that, we'll move on to our ever popular vyver session.
We think we can accommodate six candidates today, so if you can make yourself known to Hanna from our UK and also in the chat, you can also raise your hands, but double check that we've confirmed with you and we'll get that organized. So before we move on, I'd just like to say anyone that wants to do a vyver, we understand that it's quite intimidating in this scenario, but it's the best way to learn and we've all done it.
And with usual, we recommend the textbooks at the bottom by our UK. And our concise orthopedic notes run written by the farke's mentor. So without any further ado, I will pass you over to Mr. Gurianov. Thank you. Thank you very much, KneeKG.
Good evening, everyone, and welcome to this session on city, Brisbane, I would like to thank orac and dfacs mentor group for the kind invitation and the amazing introductions they made. These will be quite a broad topic, as you may imagine, and Brisbane is one of the challenging topics in breast assessment, as we all know. First of all, we need to differentiate between what type of patients would come to our clinic.
We have patients with almost every strain of unknown origin and it can be a repetitive strain. It's quite common nowadays because of the occupational requirements of office workers, for instance, to see patients with repetitive strain injuries after working long hours at a desk or using a computer. But you can have patients with subclinical instability of the wrist, especially of the distal regional joint, or meet carpal joints that can be affected by other side of this pain.
And this is not easy to diagnose or inflammation, psychogenic causes or functional reasons. So associated with specific tasks. Other types of pain are associated with identifiable origin, and these are the cases of trauma fractures, for instance, dislocations or soft tissue damage. In general, the FCC disorders more the specific portion of these wrist issue instability and tenotomy of itis disorders of the lunatic medial ligament of the piscataquis joint instability and arthritis of the drug Allen carpal abutment, vascular neuropathy and other disorders.
So we have a real broad range of disorders. We will focus on the commonest ones and the ones that are most relevant to dfacs of exam. First of all, we need to refresh with the anatomy of the task. It's not just the cartilage, it's not just the triangular structure, it's a complex and as a complex, it is characterized by a number of structures that compose it. And you can see in this diagram that you have the central disk, but also you have a number of attachments onto the radius regularly, clearly and on to the ulna, both to the fovea of the ulnar nerve, which is the proximal most portion as the base of the ulnar nerve style and to the tip of the style of the main and most relevant from a functional point of view.
Attachment of the TCC to the Allen is the OVLT attachment, the 1 to the base of the style? And then you have, of course, the meniscus and you have the collateral ligament and you have the dorsal and vaulx radial ulnar ligaments that contribute to the stability of the carcass and of the WJZ. These very nice diagrams by Mr Donald sammut explain it all, and you see how complex, especially on the left one is the FCC.
We need also to remember that the extensive carpal ulnar nerve is tendon species is regarded as a component of the FCC, although it's partial external to it. And we have the Palmer own carpal ligament complex, which are the ulnar claw ulnar claw and ulnar claw pitted ligaments, which are also relevant in case of an injury. And on the right side, you see the volar and the doors already the ligaments.
If we assess the owner apartments in particular of the FCC, as I previously mentioned, the most relevant one from a functional point of view in terms of stability is the deep attachment also called the proximal component, or PC of the FCC. The distal component DC highlighted in yellow, it's the less relevant one. However, an injury to this attachment still causes trouble because it causes pain.
It can cause minor instability, and it cannot. Sometimes it can be not compatible with activities carried out by the patient. Therefore, you need to treat it if needed. Remember also the iceberg concept that was highlighted by a day about and look at it about the shock absorber portion of the SCC, which is the distal portion and the proximal most, which is the stabilizing portion of the carcass and of the Droege corresponding to the volar and dorsal ulnar ligaments.
So it's a real complex, not just a little ligament. When you have a doctor and you assess a patient with this type of injury, you need to assess patients for pain and instability. Pain can be elicited when you put pressure directly on the phobia, which is here on the ulnar nerve side of the wrist, just distal to the ulnar head. And if you put pressure on that, you may have a positive ulnar nerve of your sign, which is a pain as the site of injury.
However, you can test the patient in ulnar deviation, also applying some pressure as it is shown in the picture, and that can also elicit pain. If there is a tear or even a small one, you test the forearm in insubordination to see whether this elicits pain and you perform the compression test, which is again the one shown in the picture. However, you should also deviate the risk not just ulnar worse, but also dorsally in order to perform it in the best manner instability of the drug.
You can assess clinically, sometimes subclinical. As we mentioned previously, some patients have an obvious clunk in the information instapay nation and some others don't. So you need to test it and you test the stability, both in ulnar and radial deviation of the wrist in neutral deviation of the wrist. You should compare always to the other side to check whether there is a congenital instability or laxity, which is not pathological and that is best in both wrists.
However, if only one wrist is affected, then when you ulnarly deviate the hand, you would detencion further the TCC and the instability is expected to increase. When you readily deviate the hand whilst testing the drug, you should increase the stability of the test to see if it's intact or only partially damaged. If that doesn't happen, then the damage is more significant, of course.
And you can perform the piano key test, you see it on the bottom picture on the right side of the screen. You ask the patient to hold the forearm on the desk or table and press, and you see whether there is a piano key sign of the district ulnar nerve joint in case of more significant instability that may be difficult to appreciate and always remember. Whichever test you you're performing, you always need to compare the wrist with the injured wrist with the contralateral one.
In terms of imaging, X-rays will clearly show a dissociation, as it's shown in the X-rays in the center of the screen or almost eyelid fractures. Also, ulnar claw peel-back can be seen on x-rays, especially if you see a footprint either in the unit or in the room resulting from the apartment or in the ulnar nerve sometimes. However, there may be subtle. So you may want to request an MRI scan for that.
In terms of dissociation, when you have a clear dissociation of the district, the ulnar nerve joint, especially post traumatic, you should suspect a massive terrorist attack and there is something to bear in mind and not to misdiagnosed or underestimate. MRI scans would show the occult factors, the small ones, but also the large ones for confirmation of your diagnosis, of course, and they will show back to the ulnar claw apartment they show like the one in the center of the screen.
There is an effusion in the Droege, which you also see on the picture on the right side. And they also can show the extent of the damage. However, if you want to have a better assessment, you should consider an copy in these cases, especially if you are in doubt on what specific treatment you would suggest to the patient. In terms of arthroscopic assessment, these are the portals, the dorsal portals to the wrist.
I'm not mentioning volleyball traject because they are not relevant. However, the ones we commonly use are dorsal and the ones on the right side of the screen also include the dirigé portal and the foveal portal to see the attachment to the FCC, which are the proximal ones on the screen. This part are quite advanced, but they are very difficult to gain access to, and you may cause damage yourself when you gain access to them.
If you don't know exactly where to put the instruments. Therefore, I would recommend to use them only once you master the arthroscopy skills appropriately. So the main purpose we use are the three four, which is the initial portal, usually for a camera insertion in the radio, carpal joint and the SIG Sauer and 6U for insertion of the instruments. The mid, carpal radial and ulnar portals are located about centimeter distal to the proximal ones.
Also useful for carpal joint assessment, especially if you want to assess the capitated and the scaffold unit, a lunatic brittle instability through the scaffold and not electrical intervals. In case of a detachment of the distal component, which means the least relevant, however still important, component of the TCC on the ulnar satellite, with the camera in the portal three 4 and the hook in six side, you can perform the hook test.
You can try and basically push the FCC towards you if you see the FCC lifted up as a wave in the sea, as you see on the right side of the screen. That's a positive hook test, and it means that there is a detached attachment to the FCC, but this would mean that the detachment is actually massive. Therefore, you need to consider if you have a positive hook test, that there could be most likely an injury also to the proximal component of the FCC, not just to the distal.
In this case, mastering the technique of visualizing the proximal component through the four VL portal would become useful. However, this test already gives you a lot of information. It is not just distal. It is also proximal to if, like the picture on the left side, you only see a detached FCC from the ulnar hospitals of the wrist, and the hook test does not lift the CC as a wave in the C. As I said, that's a negative hook test, and that's definitely just a distal third of the FCC, which you can address.
Otherwise, you will see later that you can either divide them or attach them as required. Another important test is the trampoline test. You need to just apply gentle pressure with the hook to the FCC and see whether it bounces back. It's quite confusing to call it positive or negative, because what does it really mean? The trampoline test should elicit the bouncing of the task if it doesn't bounce back and it doesn't bounce back.
And it's detention. That means that there is a detached part for the task, so it has lost tension. However, if you elicit the trampoline test and it's therefore intensity is present, it means that the disk is healthy. So it's very difficult to define it as positive or negative, I would say, whether it's a present or not present.
In terms of proximal, FCC visualization has explained that later on, you can put the camera in the Droege and you can also use your prober or shave only. However, that is quite difficult and intricate to do. Remember, the parliament classifications, it is very important for your exercise or exam. It's the universally recognized classification of sectors. You have type one, which are the traumatic tests and typekit two, the degenerative tires.
And depending on which type you are seeing, then there are specific treatments. The commonest traumatic test as class 1 B. Therefore, this has led to a lot of literature being created on this topic, especially in terms of treatment. And an important treatment oriented classification, you should remember, is the one buy at, say, the us, the European Research society, one which classifies as the one A/B test based also on not only of the characteristics, but also on the repairability or not of the terms.
This is a paper that they would recommend to read because it's a review of this classification with a treatment algorithm based on the severity and/or the repeatability of the test, so it could be useful for their exam. It is also, excuse me, from the same paper it explains, as you can see, it looks quite intricate. However, it's quite simple. It's really based on what you see.
How old is the injury, how repair it is, and then you decide what treatment is more appropriate. You can repair the arthroscopic or by means of an open technique arthroscopy. You can insert your sutures through a needle. PDS is one of the commonest sutures that are used. However, you can use other materials, of course, depending on your practice, and then you can pull the suture out using a double loop or a mosquito or a retriever and not it around the wrist capsule.
Remember, if you are asked about these techniques, it's extremely important to protect the dorsal branches of the ulnar nerve and the issue tendon when you perform it, so you need to make a mini approach. Although it's arthroscopic, you have to open the skin to visualize the structures lying on the capsule because you don't want to entrap the ulnar nerve branches or the ICU in your suture when you tie the knot. There are also all techniques to repair ties that you can perform arthroscopic.
When you have a structure like this with the evolution, that's something you need to consider that it also causes an evolution of the ulnar nerve style because whenever I fracture, the displacement of the radius, dorsally pulls the TCC so strongly and acutely that it usually doesn't tend to come off the bone, but it tends to cause a bony aversion.
As you can see, here is a high energy injury with severe convention in particular involvement that required a double plating to stabilize due to its extreme instability. And in this case, the ulnar nerve style was reattached. However, when you read as the ulnar nerve style, it is an important consideration, and that's an important question you may be asked. You started when the evolution of the style.
It causes a complete convulsion with subsequent instability, which means you first should fix the radius and give stability to the wrist. Once the race is fixed, you should assess the Droege for instability. Intra operatively and then you make your mind up. And this is based on a number of criteria, not just as instability also on the patient general conditions, on the functional requirements, on prognostic factors, of course, and you need to make your decisions there.
Therefore, it's always worth discussing these the option of detaching the steroid or not with the patient prior to performing open reduction internal fixation surgery on the wrist in these cases, and you can make a plan with the patient accordingly, of course, explaining according to the principles of the informed consent. In this case, the decision was made to fix the style because there was gross instability of the drug after fixation of the ladies.
And when you have an ulnar nerve style it like in this case, you need to consider the anatomy of the style, as you can see in the central X-ray. Also, the fovea was reversed in this case, and that caused the detachment of the proximal component of the TCC. In order to reattach the personal component, one is a world without an ulnar nerve style with Bonnie avulsion, you can do it either by using an anchor like it is shown on the bottom part of this slide.
Or you can create interesting tunnels with choirs and sutures that will allow you to reattach the proximal component back onto the fovea. Remember, immobilization postoperatively of the forearm to avoid permission and separation is important wherever, whenever it is possible to, you should start rehabilitation of the elbow in flexion, extension, and does the wrist infection and extension the sugar.
Tongue splints are very useful for these patients post-operatively. Remember also the degenerative terms and the central perforations of the FCC, the designs that either non-repayable or do not require repair because don't cause instability unless they affect the peripheral portions of the FCC. Therefore, you would consider a debridement in these ones. One, you have irreparable terrors that caused growth and stability of the Droege.
You may want to consider a stabilization to stabilize it when the is when the test is no longer repairable, you need to use the tendon graft. There is a beautiful technique that was described by Bryan Adams with Berger, and this technique uses a long standing graft tunneling into the distal radius transversely and obliquely into the fovea of the ulnar. And you can see here that then the tendon as it comes out on the metastasis of the ulnar, can then be fixed back to itself or the other.
Now, bear in mind, when we have this technique that the palmar is long standing is not always very long, and it may not be possible to loop it back onto itself at the metaphysical. Therefore, we would have to fix it by other means, and you can use bone anchors or you can use interference screws. As you can see here, you have on the left while visible on X-ray distribution of joint dissociation.
Also shown on the MRI scan. And there was an irreparable tear both of the ulnar and of the radial components of the FCC. So it was a bifocal tear in this case. And Adam's technique with its long standing graft and fixation to the Allen with bone anchors allowed to restore true stability. Post-operatively, you need to remember what I mentioned earlier on.
It's paramount to protect the FCC, either whether you have repaired it or reconstructed it. So in above elbow plaster slap with neutral forearm rotation and/or multi-nation can be applied for two weeks. However, remember to use sugar tong splints because this allows the patient to flex and extend the elbow in order to avoid elbow stiffness without permitting and supine in the forearm. You can also ask the therapists and the patient to consider some wrist flexion and extension out of the splint.
However, you need to be absolutely sure that the patient would not permit and supine the forearm. So this is a bit risky. It really depends on the case, on the compliance and on the fact of whether the patient is regularly followed up by the hand therapist or not. And then you have, of course, the option of postoperative rehabilitation with below elbows, splinting and return to activities later on.
This takes quite some time to recover. When you have the usual practice, which is another potential cause of ulnar nerve, said Brisbane, then you have a lot of options. You have non operative options like splinting occupational therapy with activity, modification and posture adaptations, and you can consider injection of steroids in the Droege. They're also surgical options.
There is a full range of options. One of them, probably the old fashioned one, was the vacancy option, which you can also use for other indications. It can still be used in certain cases. However, you need to bear in mind that the owner stump would become quite unstable and you may face instability and associated pain problems, so this is something to bear in mind.
However, if you have a stable ligament structures, you can consider an ulnar nerve replacement. They are also partial ulnar nerve replacements available or if you have a very severe arthritis with very severe instability of the Droege as well. So no ligament stability that therefore does not allow you to use a normal ulnar nerve head replacement. You can consider the total gross replacement. There is this implant on the right bottom part of your screen that was developed a few years ago, and it has this specific indication.
Another cause for unnecessary pain. We move on with the safety issues. Now is the issue of cellulitis. It's quite common. You will come across. It is not always associated with instability. It may be caused by overuse of the wrist and you need to remember that also, this one can be treated either non-operated or surgically.
You may see some swelling over the ICU, but sometimes the swelling is very mild, so it it may not be present. However, you will definitely have tenderness on palpation over the tendon, especially over the ulnar area and the distal portion of the tendon. And you can refer the patient for splinting or occupational therapy again with activity, modification or adaptations and the injection of steroids.
And you can consider also surgical options if the non operative treatment fails, as you would do for any other sinusitis if it doesn't subside following non operative management or issue stabilization if you have some instability. Let's talk about instability. Instability can be severe and lead to subluxation, all the and as you can see here, remember that the patients with a shallow groove of on the and head for the ICU are more susceptible to develop this type of disorder.
However, it can occur to anyone after even lifting an heavy object and donating or supine forcibly the forearm. And this can lead to a disruption of the fibrous tunnel that holds the issue in place in its grove, and these may lead to subluxation that becomes painful. Patients complain of the painful clicking of the wrist during pronation and superannuation, but sometimes this can be quite subtle, so you may want to investigate it further with ultrasound scan if you are not sure based on clinical assessment information and superannuation alone.
Again, you have no known operative and surgical options don't. Operatively, you can use an available cast and sugar splint, but again, it should be an acute injury to the size of the ICU for this to work. Otherwise, it wouldn't work chronically just for symptom relief purposes. You can consider again splinting, even with the wrist extended to detention, the ICU, occupational therapy and steroid injections.
However, if you want to treat the chronic subluxation that causes chronic pain to the patient, you need to consider surgical options. And this use stabilization can be performed by means of a reconstruction of the tunnel. You can use a slap of extensive retina to reconstruct it, or if you are in an acute setting and you are treating acutely an injury that occurred recently, you can just repair the tunnel as required.
Pediatric critical days are these orders, so we move to the other side of the side. However, we remain on the ulnar aspect of the rest. These are also common clearly. Arthritis has the lion's share because arthritis is quite common because of aging process, because of the way the hand is used for specific occupational reasons or hobbies.
And it's quite painful because every time the patient applies pressure to the equitel region, the pain is elicited and it's quite a difficult pain, to cope with because there are a number of activities that we do when we require power grip or to apply pressure to the ball or ulnar nerve of our wrist. Therefore, it is quite a problem and definitely requires to be identified and treated in terms of investigations.
You you would request x-rays in 30 degrees of separation in order to be able to visualize the pediatric critical joint. And in terms of MRI scan, of course, as you can see, that becomes even clearer if you have arthritis or ganglia or effusion because they've become very obvious on the MRI scan. Remember that they can also cause compression to the enabling structures like the ulnar nerve, as we will see later on in the presentation.
The joint arthritis, the diagnosis is clinical, really based on the presence of pain on palpation and the right pressure on the area. There can be swelling, but swelling can be subtle as well, depending on the size of the hand as well and as the subcutaneous tissues of the patient are assessing. X-rays will require the piscataquis review, which is a lateral view with 30 degrees of separation, and you can request, as explained, that an MRI scan that shows it all, including the presence of effusion or ganglia treatment can be conservative or surgical.
Conservative is splinting or application of a soft padding to the area that the patient can use whenever they work or perform their hobbies that would cause pain otherwise or steroid injections into the medial joint. I would recommend to do them either X-ray guided or ultrasound guided because it's quite difficult to have access to these tiny joints, especially when the space is very narrow.
Surgically speaking, you can propose either a PC for Mac to me. So excision of the epimysium or esoteric mitral fusion, the indication for fusion usually easing in patients who are manual laborers or very sporty. Definitely the younger patients, because by means of not removing the passive form you preserve, somehow to some extent, really, the strength of the FCU removal of the passive form is not a big problem in terms of tissue strength reduction, or whether it has been demonstrated that there is some strength reduction.
Therefore, you wouldn't want to consider probably a PS4 McNamee in a younger patient with high functional demand and performing sports. No, not required selling stability is another potential cause of illness, pain. Sometimes is not a quitter. Ligament disruption is associated with an FCC tear, especially if post-traumatic for arthroscopy once again becomes quite important because you will be able to see whether there is a step off in the wrong track, little joint not seen on x-ray, or whether there is the presence of growth instability that allows you to insert your hook in the interval and see whether these dissociates remember.
Also that in the later stages of dissociation, you may also see that the so-called Veasey deformity, which is the opposite of the DC so you see the lunate tilted towards instead of dorsal. This is something we all see in clinic every so often is a congenital difference. It's called remote equitable coalition. There is a classification for it.
There are three types you can have so-called champagne flute pattern, which is the top one on the right side. And you see a partial collagen is a sin can draw this mostly in the case, but it can cause pain because of the stiffness of the neutral interface in type 2. You see a partial collision, partial bone infusion, type three, you see the total bone effusion. I mention this because this is again congenital, as I mentioned.
And over time, it causes arthritic changes. We see patients in the 50s, usually or 60s, coming to our clinics with this kind of disorder. This is quite severe. In this specific case. I've chosen for this presentation. However, you can see milder types of arthritis and abutment in the air, as it is clearly ulnar sided abutment in the wrist that causes ulnar nerve sided pain, sometimes a bit more central sided because it is affected.
However, it can be a cause of ulnar nerve celebrates pain. Treatment is quite difficult here because you don't have a room, not acquittal interval, so you need to consider initially non operative management, including splinting and steroid injections. But if you then have to consider surgical treatment, it becomes more and more intricate and also because the lunate fossa of the rages leg in this case appears damaged.
So you need to consider carefully your options, because these patients usually have quite a good range of motion, so any bony surgery needs to be carefully discussed with the patient. Discussing the balance of pros and cons very, very carefully, these ones are more subtle types with type 1. For instance, as I showed you earlier on today, you may not be able to identify it initially the first time you see it, but over time, with practice and as you see more of these coalitions, you will get used to it and you can see the champagne flute configuration.
Let's look at a abatement is also fairly common in patients with positive ulnar nerve variants, which means a longer owner than the radius is one of the normal variations of the length. So it's not a pathological finding per say, whether it causes ulnar claw pain because of the abutment either on the unit or on the ricketson. And if that happens, of course, the task becomes chronically damaged and the patient would come and seek your expert advice for pain.
In these cases, you need to consider again non operative options like splinting injection of steroids and occupational therapy. But should they fail? You need to consider surgery and surgery. You have two options. You have either the wafer procedure, which is a partial rejection of the distant her in the head. You just remove a little portion of the distal.
Learn only a couple of millimeters, really, you can't remove more than that. Otherwise, you end up performing a drugs procedure, which is what you don't want to perform, which is an ulnar nerve head reduction that may cause the instability of the ulnar nerve stump. And it's a completely different procedure that you use in other cases, rheumatoid or other cases, and also very rarely.
So you need to remove really only a couple of millimeters, and you can do that for topically using a bomberger. And as you can see in that arthroscopy picture, you see the helmet head underneath the broadly damaged TCC central disk. And when you perform, it arthroscopic, it's very time-consuming. And remember, you need to continue to alternate and supine in the forearm as you shave the hole in the head because the ulnar nerve head is broader than you would expect.
And what you see in this picture is only a tiny portion of the other hand. So by means of continuing continued inflammation and superannuation during the procedure, you would be able to create a flat surface on the distal edge of the ulnar had. It is a bit simpler and safer to perform the procedure open, and that will show you with the next slides. So this one is a case that was treated arthroscopic.
And you can see the owner head has been brought down to the same length of the radius, thus reducing the abutment on the learned post-operative care. It's a plucky application of a plaster slab, followed by a splint and hand therapy. This procedure does not change the stability, so it doesn't really affect it. This is another case where it could be useful to consider this type of procedure because it's unfortunate.
The margin of error areas in this case is not an ulnar nerve disorder. And this occurred in childhood. Therefore, it led to a length discrepancy, which is significant in this case, you may be tempted to perform an ulnar shortening was osteotomy, so I will show you later how it works, whether reducing the length of the ulna at the official level with the plate and screw insertion.
However, as you can see on the left, the sigmoid notch of the radius is also anomalous. So reducing drastically the length of the Allen in this case would cause more trouble than be helpful because it would create an interface between the head and the sigmoid notch that has ever has never had on the head. And this is an anomalous shape. So in this case, because of the injury of the fact that the injury occurred in childhood, there was no indication to an ulnar nerve short interest tenotomy and you can perform a wastrel procedure.
And interestingly enough, in arthroscopic assessment shows the dorsal method required trim as a bare bone because of the ulnar carpal severe abutment. And this is the open procedure performed that you can do more easily through an approach through the fifth compartment, the tandem that you see pulled away is the Eden tendon. Post-operatively after you have reduced the abutment, you can again apply a splint and then consider hand therapy.
Madeleine deformities, it is also another cause of wrist pain on the ulnar nerve side. Usually the onset is in during the late childhood and teenage years because of the increased functional requirements. And in these cases, the Allen is definitely very long and on the buttoning the corpus dorsally the corpus is also partially and proximal is a blood test.
So it's not just a normal carpal abutment in these cases. In order to achieve the extent of shortening you would like to achieve, in these cases, you need to consider a formal osteotomy, not just a wafer procedure. So you need to shorten the ulna as much as you can, depending on the system you use for the ulnar. Shortening osteotomy may be able to shorten even up to 8 millimeters or sometimes to 1 centimeter.
So it's quite a significant shortening you can achieve by. This means, remember that there is also the option of correcting the radius by means of corrective osteotomy that increases improves not only the tilt of the legs in both planes, but also the length because of the improvement of the tilt to some extent. And you can do either of these procedures or decide to perform them in a sequence.
And these are cases treated with the ulnar nerve shortening osteotomy, as I mentioned. Million of the distal radius is another problem. When the Millennium is significant, so you have a significant dorsal tilt of the radius, then you would consider correcting the Millennium first.
However, in cases where the Melungeon did not lead to a very severe dorsal angulation of the radius or in cases like this one in which addressing the Millennium, the radius very distally wouldn't change things much because the model is quite proximal. As you can see, then you can consider an ulnar shortening osteotomy as an option.
And this was done in this case, leading to resolution of the pain. Remember that were not only here to discuss about bone disorders of or tenodesis disorders, but we're talking about ulnar nerve side of Brisbane, another potential cause, which is not that common. However, not even that uncommon is the hypothetical hammer syndrome.
Remember, this is usually associated with manual activities of the patient, especially repetitive trauma to the or micro trauma to the Allen aspect of the wrist and palm of the hand, and is a true ulnar artery aneurysm that you should treat. As such, it can be resected and the ulnar artery ends can be either joined together or in case they don't reach, which is not common. However, you can use a vein graft to reconstruct them, so this is something you should also mention as a potential cause of unnecessary pain.
As well as nerve injuries, you can have injuries to the ulnar nerve on the ulnar nerve side of the hand caused by compression caused by tumors or caused by trauma that would lead to symptoms on the other side of the wrist. The anatomy of the ulnar nerve is paramount, especially in terms of animal anatomy. You need to know that there are three zones in zone 1.
Both the mod, which is the proximal most, you've got both the motor and the sensory components of the nerve in zone two, the motor ones and in zone three, the sensory distal to the bifurcation. Remember that anything arising from the pediatric mitral joint like a ganglion, for instance, can compress the ulnar nerve in zone 1. And remember that a fracture of the arm, especially if a shell of the base of the hook of the hamate can cause a compression of the ulnar nerve in zone 2 or even zone 3 if it is badly displaced and there is a local effusion and bleeding as well.
So you need to remember. Also, there is a need to remember the anatomy of the ulnar nerve and the symptoms that make different. Egoyan's can eye compression from an iron compression of the ulnar nerve. Thank you very much for your attention. Thank you very much, Mr gurnani. Yeah, that was very interesting.
Yeah, I certainly learned a lot. It's one of those things that I think we sometimes forget when we're treating this, the radius fractures and they have ongoing pain. We sometimes forget to think about this already with joint arthritis or GFC injuries. So it's really useful. I'm sure the candidates will appreciate it. I got this already on a joint osteoarthritis in one of my short cases in my exams as well, and I think I also got a medal.
And so very important. So what I'm going to do now is I'm going to ask Joe to unmute himself and ask some questions that the candidates have been putting in the chat box, if that's OK. Well, we should go. Thank you, Nick. Hello, Mr guy. Very, very nice talk and very important actually and especially in the short cases.
So the first? Actually, it's a very popular topic. So the first question was, is it the MRI or an MRI gram better to look at the fcc? Yeah this is actually a very good question because there are Graham. I was also trained that when I did my training in Allen based and but it's actually something we don't use that much because nowadays they can show perforations so that the SEC that are not really significant from a pathological point of view, we may have at the FCC perforation at birth and we are not aware of it.
So the outcome is lost a bit grounds compared with traditional MRI scans, which would be perfectly reasonable to do nowadays for see bearing in mind that nowadays we can also do an arthroscopy. So whenever we are in doubt, we can actually assess it better by means of direct visualization. So I would say MRI and arthroscopy is now the gold standard.
Yeah, thank you. Ideal implant for fixation of the ulnar nerve satellite. As there are implants in the case, I showed you a screw was used, however, you can use key wires for fixing it. Use a figure of eight suture as well as even links to a K wire or took wires. So a tension band constructs. You can even use tension band wiring if you have very fine tension, barbed wire available, or there are also when you have fractures of the head of the ulna, including the style of there are also little plates available that allow you to hook the ulnar styloid down back on its base and for the Galeazzi fracture.
Of course, with the structure of the 3D ulnar nerve joint, how many key wires. Do you use to use one or to put them to use to KYC in those cases to give better stability? Yes and to leave it for how long? Usually six weeks for the soft tissue healing. But clearly you need to bear in mind that they are very difficult. This this case, those cases because key wiring of this ulnar nerve joint leads to significant stiffness and also may cause other very austere reactions that can cause pain as well.
So you need to be a bit careful and do you breathe them or not? Personally, I tend to bury all wires in the wrist because I'm well aware of the risk of septic arthritis and osteomyelitis, which is a disaster in the wrist. Good and is there any preference for selection for the patient to decide direct's as versus to sooryavanshi or fusion or arthroplasty barracks? I would tend to use only extremely selected cases.
I'm talking about elderly patients with very low functional demand and extreme changes of the risk. Talking about rheumatoid cases. And in that case, drugs could do the job, of course, of improving the symptoms. However, it's not my first choice ever. I don't think that is anyone's first choice nowadays. So the company has also very limited indications and this again, something that is more historical nowadays rather than currently used much.
So we tend to use more replacement surgery when required. However, it's not always required because there are also no, not perfect treatments available. Yeah thank you. And is there any specific test to do on table under GAAP to test the stability of the distribution joint? Yeah, it's very important to test it just the same way. Test testing clinic, really?
Yeah so you need to test it with the rest in this position in ulnar deviation test is there is some instability. We should be presenting on the deviation neutral and radial deviation. In radial deviation, you should tighten up so that the SEC should be able to increase the stability in radial deviation of the wrist when you test it.
Another way of testing it is to test by means of moving the radius instead of moving the ulna. Because actually, if you think about it, the ulna doesn't move in dorsal and the dorsal and Palmer plane is the radius that does it. So you could hold the ulnar nerve stable and move the radius. It doesn't really matter as long as you test the stability of the joint.
Thank you. And there is a question from a physiotherapy point of view. Why do you prohibit slap lesion permission after reconstruction and for how long? Yeah, yeah, that's a very good question, because it really depends on what type of reconstruction is done. I would say if it's a minor peripheral tear that you have this distal component of the test that you repaired, you can actually safely start mobilizing sooner rather than later.
So in that case, I would not immobilize permission explanation for six weeks. I would do it for a limited period of time, just two weeks, probably. And then I would start with gentle exercise. But that really depends on the stability that you have achieved. If you perform a reconstruction of the TCC, then I would wait a bit longer because although the risk becomes stiff, it's actually the name of the procedure to create some stiffness.
We will overcome the stiffness with rehabilitation later on. So it depends on the severity of the injury and on the repair you made. So if it's a stable repair with a small injury, you can move sooner. Information suspension if it's an unstable, very unstable TCC, badly torn and the repair is significant or a reconstruction is being performed, then you would be a bit more careful. However, the sugar splints allows you to mobilize the elbow and also you can ask the patient, as I said, to flex and extend with Operation and supine waiting.
Yeah, after four weeks, so they start mobilizing the rest. Thank you. And in type III coalition with a change in the unit proximal rocker back to me, is it an option? I would actually like to ask this question to everyone in the audience because these are really good questions for the exam, it's not an option if you have a need for such changes.
So whenever you have learned for changes, unfortunately you'll lose a lot of options because you lose the option of performing a proximal rocker back to me. You lose an option of a four corner fusion because there's no way it would work. It would keep the arthritis that it just make more stiffness. So in that case, then you need to consider more significant procedures talking about arthroplasty or total joint fusion or a more benign one, which is the innervation of the wrist.
The innovation could allow you, unfortunately not in all cases, but often it works to reduce the symptoms or significantly improve them and buy time. Yeah thank you so well. This is more or less three questions in one. So how much on the variance can be corrected by wafer? And how much ulnar variance needed to be treated? Is and can we do a regular lengthening and instead?
So first question answer does not correct more than two, maximum three. I wouldn't do more than that otherwise. As I mentioned, it becomes a drugs. The onread is not very long, so you end up removing a lot of head if you do more than that. If you need to shorten by more than two or three mm, I would recommend that you perform and ulnar nerve shortening osteotomy, which you can perform front anything between 5 to eight or even centimeter.
With some systems, it depends on the system on the plate that you choose, really, because each company makes it slightly different in terms of when you need to do it, you need to do it only if the patient is symptomatic. So is the ulnar claw peel-back and is present but not symptomatic. There's clearly no indication we treat pain. We do not treat the X-ray. So if there is, there are symptoms and they are unfortunately present.
Despite non operative treatment, then you consider a shortening and you discuss the extent of shortening based on the length of the ulna. An important point. You don't make doing the presentation, but will make now is how to request the X-rays. To assess the ulnar length. You need to ask the radiographer to put the arm in this position with 90 degrees shoulder abduction and 90 degrees elbow flexion is the only way for the posture of interior.
X-ray view is the only way to see the actual length of the Allen in relation to the radius, and then you can measure the extent of ulnar positive variance. But again, you want to operate. If the patient is symptomatic, don't operate on an asymptomatic. One last question was about can you do radial lengthening? Radial lengthening?
I would not really recommend because it's a very intricate procedure. It requires bone grafting, most likely, and it's an extensive approach and is not as benign as a wafer or as an ulnar shortening, so it is possible. However, we only use radial lengthening when we have a significant discrepancy when we would not be able to achieve an appropriate shortening the compression of the carpal region with only shortening alone so we can do a radial lengthening.
And if it's not sufficient, you also do ulnar nerve shortening of those cases. But usually we are talking about reduce Maloney in this case. Thank you very much. Thank you. OK, that's great, thank you, Joe. So what we'll do now is if Ruth is available, we will share the mic questions.
And if you can all answer them as soon as you can, as I've said before, it's all anonymous. We don't know what answer you've put, but the sooner we do the mics, then we can move on to the survivors. Thank you. So question number one was about is you subluxation? It doesn't really lead to an increase the motivation of the rest.
So I'm afraid that's not correct. It is not the commonest cause of unnecessary pain. It is one of the potential causes. It can definitely be treated by means of osta fibrosis reconstruction, which is I see what most people have correctly confirmed, especially when it's either acute. You can do a repair or chronic. You can do a formal reconstruction. And the thing that about the instability is also very important because the ICU, just like the pq operators, are extrinsic stabilizers of the drug.
Therefore, a subluxation or a disruption of the fibrosis of the ICU does increase the risk of the instability, and as such, it is important to treat these injury. In fact, even in patients with very, very mild dietary instability would do not wish to undergo surgical treatment, and it is also another key point for our exam. You may want to mention that you can refer the patient to the therapist for strengthening of the PCU and of the ICU as external, extrinsic stabilizers of the drug in the first instance, to see whether you achieve an improvement in stability and the decrease in the symptoms before considering surgical procedures.
Question number two palmar type 2 factors type 2/3 are the degenerative terms, and they are indeed associated with control changes, either, on the other hand, or on the other side of the TCC on the carpal bones. They require most debridement. They don't require repair. It's not true that they do not usually require any treatment because they can be painful. So the Brodmann's injection of steroids can be considered.
However, they do not require significant treatment, so this one is partially correct. They are not caused by trauma because they are degenerative and are not typically radial sided. Question number 3 is about pediatric fetal ganglia. They are not often obvious on physical examination. Unfortunately, it would be nice if they were. Some of them are relatively big, so you may be able to see them. However, they are mostly ganglia arising from the FCU, rather than is the fetal joint that you see superficially.
They cannot be easily per patient. What you do when you perform palpation there is to try to elicit the pain of the peel-back joint. So what you do is to apply pressure on the position born and test whether there are symptoms caused by the pediatric arthritic changes. And effusion like you would do for the patella when you examine the knee. It may cause ulnar nerve compression.
As you as we clearly stated during the presentation, it does not always. Of course, it depends on the size and location of the ganglion, but it does cause a risk of compressing the ulnar nerve and they are usually associated with degenerative changes. So the last one is also incorrect because they are often associated with changes that there is always the ganglia arise, although changes may be very mild.
Hey, that's great. Everyone, thank you very much, I think Joe's just got one more question that popped up and then we'll stop recording and start the IVUS Joe. Hello, Mr Gurianov again. So in your practice, what are the indications to fix the owners taillight and distal radius fractures? Mm-hmm Is it the every unstable district ulnar nerve joint or there is other indications?
So that's also a very interesting question because I mentioned, but perhaps because of the length of these presentation, it may be missed that it also depends on the patients conditions, really. So it really depends on a number of factors. Clearly, if you have a young patient with high functional demands who has a grossly unstable deluge caused by abortion with bony style diversion, and you are fixing the radios and you realize after fixation that the area is unstable, then there is an indication for fixing it, and I would fix 100% of those ones.
However, if you have a patient who is a low functional demand, as are some arthritic changes of the distal regional joint or a very severely disrupted sigmoid notch, as it may occur in very high energy injuries with severe medial column disruption of the radius, then I would consider probably not stabilizing it intraoperatively. I would prefer to treat the radius to the rehabilitation for the patient and see whether symptoms are present later on.
That may need my attention because the risk is if you stabilize the drug in an arthritic joint or in a severely disrupted notch situation, then you may cause pain yourself by means of stabilizing the drug, so you need to be quite careful with that. Thank you. What are the indications for arthroscopy and undecided pain, and is there a portal proximal to three or four portal and using for what the proximity for portal?
There is, unfortunately, no portal because there is the radius, so you don't really want to enter the radius with the scope. There is the portal they showed is the proximal. Most ones are the district ulnar nerve joint portal and the proximal four wheel portal of the Allen, which is underneath the TCC. Because you look at the disk as a deep attachment, one of the TCC.
So these are the proximal most, but as I said, are very difficult ones and they are quite dangerous because if you don't place the instruments perfectly in the space you want to assess, you may cause control, damage or damage to the deep attachment to the FCC yourself. You need to be extremely, extremely careful in terms of indications for arthroscopy. Arthroscopy is indicated when you have a suspicion that there is something you can look for with an arthroscopy.
Clearly, it's quite obvious the response. I'm afraid, however, it's because you are suspecting it's there or you want to assess the extent of damage caused by ulnar claw abutment, or you want to assess the intricate ligament stability or the metacarpal portion, including the capitated head talking about ulnar nerve side of this pain. There are, of course, also radial sided indications for arthroscopy for scaffold onate scaffold ligament injuries, scaffold nonunion snack and lack of rest staging and so on.
There are a number. I also perform arthroscopy in terms of indication to fix particularly comminuted distal radial fractures, including the fighting vertical surface, so you can perform a first topically assisted distal radius fixation. Thank you very much. I just have one little thing to add. When talking about the world's ulnar nerve Deloitte, I just want to make it a clear point for everyone that this timely diversion that causes instability is only the one that includes the proximal portion of the stylesheet.
So the phobia, because the entire TCC is attached to the stylin in that case, which is from there now. But if the proximal attachment of the FCC, which is the four wheel attachment, is still attached to the ulna and you only have a tip of the ulna style avulsion, that doesn't mean that you need to fix it. Because in that case, I would not fix it.
I would see whether the patient is symptomatic later on and then addressed the problem of the distal component of the disk later on. Thank you very much. That's great, thank you very much. Sorry, I forgot the bit that we're going to move on to top tips for the Fox and case based discussion with Mr Gagliardi. Thank you.
We have a case, we may be presenting with a case of high energy injury to the wrist. This is a case of right hand, dominant young and healthy patient semi-professional slider that fell off the horse. Seven months before seeing you in clinic and was treated elsewhere, so you see these patients seven months later with a wrist fracture already treated elsewhere in a cast, and she comes to see you because of right wrist pain, clearly unassisted because it's the topic of tonight's discussion and weakness.
First of all, key points, when you ask something about administrative restraint after high energy trauma, you need to consider any potential previous injuries or so before the injury that is reported to you. You need to ensure that you are assessing whether the patient has comorbidities because you are suspecting that there is something relating to the trauma that may need surgical treatment.
Therefore, you want to know whether the patient is a smoker or not, because that may affect the prognosis of what you perform. You need to consider the type of trauma in this case high energy. So remember always to perform a thorough clinical history collection. When you do these, these type of assessment, the timing and the type of treatment received, the patient was treated elsewhere in a cast.
But when was it just after the injury? Was it two months later? Was it a timely treatment? Was the fracture reduced? Was the cast a full cast or just a back slap? Was it about elbow or below elbow? May, as this caused any other stiffness issues that you are not aware of, so you need to be able to gather all this information when you see the patients, it is very relevant to your exercise of exam.
You need to demonstrate that not only you have the knowledge, but you have the capacity to apply it in clinical settings. So you need to know not only what you are talking about, but also why you are talking about. What you're saying. So it's very important to start from the beginning. So talk about patient assessment, clinical history and then clinical examination. What symptoms in this case?
OK, we know it's unnecessary pain, but what tests would you consider? Would you consider a dirigé stability test? Definitely, Yes. After a distal radius microfracture or a wrist fracture in general, because you don't know whether the SEC has been disrupted. You don't even know if the drug has been overlooked or not. You need to check if there is a deformity of the wrist.
You may see it or you may not see it if there is any swelling. DCU inflammation after the trauma subluxation caused by disruption of the fibrous tunnel, you need to assess that as well. You need to assess the range of motion. Was physiotherapy carried out after casting? What is the current range of motion? Is there a mechanical limitation?
Is there pain associated with motion and the stability of all the key players, not only on the other side, but also on the radio side? So I put us the scaffold and ligaments that are never forget to mention the scaffold ligament. It's one of the most important ligaments. We have in our wrist because we are talking about unnecessary pain, meet carpal joint stability and destroy the ulnar joint.
The patient undergoes investigations, you get an X-ray and the X-ray shows a healed fracture, but it shows an overlooked ulnar nerve style. So you can then decide what you want to do. You want a CT scan to assess if there is a union, you want an MRI scan, like in this case, to assess the TCC and not just the thyroid. And the MRI scanner is very instructional in this case, because it shows clearly what I was explaining a few minutes ago, which is that when the ulnar nerve started is completely reversed in this case, including its base, which is that thin lip of bone you see radial tuberosity the ulnar nerve style it.
Clearly, you can see on the MRI scans that the whole of the SEC has come off with the. So you see the FCC and the ulnar nerve style is attached to it. So there is nothing left on the island in terms of the FCC attachments. It is a complete evolution of the FCC that clearly causes an instability. So this patient is coming to you complaining of pain on the underside of the wrist and of weakness.
Remember that instability of the WJZ can be a reason for the weakness, but can also be a consequence of the lack of supportive musculature. What about the icu? Is the ICU strong enough to help and try and stabilize these grossly unstable droege? What about the peak muscle? So that's the reason why you need to have asked the patient about physiotherapy.
You need to check also the muscle and mass of the forearm in the patient and compare it with the other limb. So it's all connected. Remember, it's not just the wrist they're assessing. You're assessing a person with an injury and you are assessing the patient as a whole, not just an X-ray or an MRI scan image. So extremely important to do everything appropriately and show confidence in your clinical examination and not just in your knowledge.
In this case, of course, now you know that there is a growth instability. You know that the ulnar nerve style is not United. There is nothing really visible here in terms of bridging, not even fibrous bridging. You don't see any changes in signal, so it's completely non United. So you need to consider other things. So we already discussed about how to test the stability in ulnar deviation neutral and radial deviation of the wrist by means of either moving the ulna or the radius if you prefer, which makes more sense to test the stability to compare it with the contralateral wrist to assess the muscular masses of the forearm, in particular, the extreme stabilizers, ICU and q is there working and if they can be improved, so you should refer this patient for hand therapy if the muscle masses are very, very small or wasted classification of the injuries you need to mention.
The classification mentions the parliament classification and also mentions that say, us treatment oriented classification, because that also is very relevant in terms of decision making for these type of injuries. This one is a type 1B injury, so the commonest injury you have, which means it's a completed version, is an earlier version of the TCC in this case, complete, of course.
So what do you do for it? Clearly, in a young patient, you need to fix it to reattach it if you want to restore stability, so you need to check the options you have. If you are asked about non operative options again, remember to mention the extrinsic stabilizes the muscles. Remember to mention splinting. Remember to mention that this patient could have been treated, but you do not know what happened because you didn't see the patient beforehand could have been treated with a sugar tong splint for six weeks after the injury in order to try and achieve healing of the Allen axilo.
Remember, it takes a long time for the taillight fractures and diversions healing to occur. But it may occur especially in young patients, and it may take even several months, sometimes to see some bridging either fibrous or bony across the nonunion site. In these cases, it's not uncommon to see that certainly is not happening old times. So that's also another problem you need to be very aware of and discuss with the patient.
So again, you have the full range of options there you need to have in front of you. When you talk to the examiner, the patient. So pretends the patient is there with you is not just an image. And think about the conversation, you would have with the patient about non operative operative timing of your treatment. If you want to try with muscular, strengthening first and splinting again is perfectly reasonable.
However, in a non-union setting like this one, it may not work. It's likely would not work, so you would ask them to consider surgical options. However, again, you need to show that you are confident with all the options and when they can be performed. So this is extremely important. Should we move on with the next case?
OK another case I would like to present you as it is something that may be asked to during the first self-exam and again, it's not the easiest type of cases, you may be asked about. Is this one you have a 19-year-old patient come into your clinic? Is a manual worker otherwise healthy complaining of unnecessary pain, especially when riding a bike or using a drill or screwdrivers?
The patient cannot recall any specific trauma. Certainly nothing relevant to the wrist and the complaints of spontaneous onset of pain. Three years ago, it was never investigated, so the first time they come to the hospital for this problem. Remember, there is no trauma here, so again, take a good history, especially in terms of past medical history, comorbidities that may have caused this pain onset occupation.
So OK, the manual worker, so this may cause tendonitis. Definitely, you need to think about either ICU or ICU patients, and why it is. You can think about pediatric fetal ganglia or wear and tear, although the patient is just 19. So you need to think in terms of differential diagnosis. However, you need us to consider that there are disorders that are not just caused by the occupation of the patient, that they are caused by genetic factors.
So we need also to take the family history in patients who do not report trauma and they start complaining of onset of pain. So consider really anything and everything because you don't have any imaging yet. You don't know anything about The patient, so you need to perform a thorough history and clinical examination. Symptoms wise patient complains of unnecessary pain in the ulnar claw region, you check if there is a deformity or some swelling and you check the range of motion.
You also check again the stability of the key players in the wrist. Careful, you might not like neutral ligaments. Meet carpal and joint if you can elicit any clunks or any instability in comparison with the contralateral wrist. So you examine this patient and you see the ulnar nerve head is quite prominent in both wrists on the doors of the wrist, which is not that uncommon.
Many people have prominent ulnar claw, especially those with the positive ulnar nerve variants. However, this patient is quite a prominent one, so you start thinking about it and you again remember the family story mentioned. You can ask the patient whether anyone else in the family has the same. And then you take an X-ray and you see that there is a reason why this is occurring, the Allen is definitely prominent, is definitely dorsally prominent.
However, remember very rarely can be also permanently prominent and the metacarpals, but that's very rare. So I wouldn't expect the examiners to asked you this during the first year, or it would be a very difficult question. Talking about the Communist pattern is this one I'm showing you today? You see the dorsally prominent in the head, and clearly you see that there is a radial anomaly.
This case is a magalong deformity of the wrist, with the typical features of the carpal bones shaped like a pyramid. With the inverted latex on the unit, you see the radial tilt completely subverted. Some of them have very significant radial Boeing. In this case, you don't have much going, but however, it is still in Maryland, and then you need to start describing this type of deformity to the examiner.
Extremely important to remember that there are also differential diagnosis. Mother deformity. First of all, is usually bilateral. By definition, we define model the true model of deformity, a bilateral one because it's congenital and it's often determined by genetic anomalies. However, it can also be syndromic or idiopathic. But the true modeling is 99% of cases bilateral.
We define pseudo model as those that are unilateral as a consequence of trauma or infection in childhood. That has led to a growth arrest of the radius and an anomalous shape. So those are pseudo mother in the form, which is not the true mother one deformity. So you need to explain this to the examiner unilateral or bilateral, you need to check maybe the other wrist as well.
Take an X-ray and see whether it looks the same in the case would be a mudroom like in this case, and you consider further investigations what you want to see to confirm the model on the form. It is also the Curtis ligament, which is an anomalous radiocarbon ligament that is present in the patients with model deformity on the volar side of the wrist, and that can be seen on an MRI scan.
So again, remember that the contralateral wrist x-rays in this case show similar deformities. So you call it Madeleine and remember the features of mother. There are some features that are typical of this deformity. There is a lot of literature on then I made a summary here of the typical ones. Also, the paper quoted underneath this is quite interesting because it explains how processes quantitatively on x-rays again shortening and blowing of the radius, increased water and ulnar claw of the distal radius articular surface.
Because of the lack of growth in length of the radius, the ulna continues to grow and dislocates dorsally due to the length discrepancy with the radius, and this causes ulnar nerve carpal abutment dorsally prominent Allen and ulnar claw pelvic pain, which is the reason why the patient came to see you a wide, estradiol ulnar nerve joint. There is, in fact, no distribution of joints. There is no single notch.
The carpal bones form an inverted pyramid with the proximal apex on the loopnet, as you can see in the x-rays, and the corpus is usually approximately involved in the blood. There are several degrees of subluxation. Some of them are more than are more aggressive than the others. And remember the famous viscous ligament, which is anomalous between the radius and the carcass that you can see on mri?
I've taken this MRI image here to show you the ligament is a thick band of dark tissue from arising from the radius and attaching to the lunate in this case, although it could be attached to the equator as well. Remember, the treatment depends on the age and on the symptoms of the patient. You can teach them no operatively surgical treatment is often not required, really, and you can treat them with occupational therapy activity, modification use of modified tools that do not elicit the ulnar nerve carpal pain post reputations.
I wouldn't really consider the role of the steroid injections here because the deformity is such that I doubt that the steroid injection would improve much unless you have ICU tendonitis caused by the deformity in the case, you may want to inject the ICU sheath, but not. Not really. The ulnar claw provision is badly deformed or surgical treatment and treatment depends on whether this is a child or an adult. In a child, you can release the ligament.
You can perform a lysis of the anomalous portion, the medial portion of the radius. So if they ask you, you need to be aware that when the child is young, you still have the potential to modify things by means of using the child's own growth as the key factor. So what you do is to perform a visualizes of the anomalous portion of the facts, which is the medial. So the ulnar nerve side of the radius with interposition of fat or soft tissue in order to prevent again the visualizes heals itself again.
And then you can see if over time these leads to an improvement in the shape of the radius, length and symptoms. However, if the deformity is very severe like the one I showed you, even in a child, you may consider the radial osteotomy when the child is old enough because you need to bear in mind that the radial tenotomy may damage the growth plate.
And in that case, you end up with the more significant problem. So I will use this in older children or early adolescents. And again, you can release the viscous ligament because it's a fibrous band of tissue that you will find when you approach the wall early for the osteotomy in order to shorten the ulna without shortening it. You can again use the growth potential for your perusal, really, and you can perform an ulnar nerve physiology.
You just have to use a choir or a little drill bit to to, Uh, damage the growth plate of the ulna and then let it fuse. So you basically cause the growth the rest of the disk to learn. However, don't do it too soon. There is no rule about the age this. I have discussed extensively with a number of colleagues from around the world and also reviews the literature on this topic.
And there is really no one who can say exactly the age where they were when they would do this, but they would all do it towards the end of the childhood and early adolescence. Because what you want to avoid also is to create another link. This length discrepancy yourself by means of shortening the ulnar nerve too soon in life. So again, if you this is something you consider towards a later ages, and when you are seeing an adult with these problems again, you can consider a radical tenotomy in order to increase the tilt of the radius and make it more anatomical.
And those are the length and you can consider an ulnar shortening. And this is a case in which you can really do either of them or both of them as required. Thank you very much, Mr Lorenzo, I think KneeKG is muted for some reason. That was an excellent talk and you covered this topic inside out. I think you had enriched us with a lot of information and we are going now.
We're going to start the fiber.
Segment:0 .
Good evening, everyone, and welcome to this meeting, which is combined with the epochs mentors group and orthopedic Research UK. So our topic tonight is on the cided wrist pain and we are proud to welcome Mr. Lorenzo gurnani, who's a consultant and research unit guys and St Thomas trust and also a clinical lecturer in medicine at King's College London.
He's the current joint hand unit lead and lead to undergraduate medical education in orthopedics at guy's and St Thomas Hospital. Mr gurnani has a broad adult and pediatric hand and wrist surgery practice and is author of many peer reviewed publications. He's currently president of the pediatric and International Society of surgeons and Secretary General of the Italian Medical Society of Great Britain.
He's an examiner for the European diploma in hand surgery and a tutor for the British diploma in hand surgery. So I'm sure he'll have lots to teach us this evening. So just before I pass you over to Mr gurnani, I'll just quickly run through. We're going to have a lecture to start with. And if you have any questions, we ask you to write them in the chat box.
We'll keep a record of them and we'll ask them at the end. At the end of the lecture, we will do a short mq poll and we'd like you to answer that. It's all anonymous, so you don't need to worry. And then we'll go through the answers to those questions following the invited questions. We will then move on to a case discussion with top tips for the POCUS exam. And then following that, we'll move on to our ever popular vyver session.
We think we can accommodate six candidates today, so if you can make yourself known to Hanna from our UK and also in the chat, you can also raise your hands, but double check that we've confirmed with you and we'll get that organized. So before we move on, I'd just like to say anyone that wants to do a vyver, we understand that it's quite intimidating in this scenario, but it's the best way to learn and we've all done it.
And with usual, we recommend the textbooks at the bottom by our UK. And our concise orthopedic notes run written by the farke's mentor. So without any further ado, I will pass you over to Mr. Gurianov. Thank you. Thank you very much, KneeKG.
Good evening, everyone, and welcome to this session on city, Brisbane, I would like to thank orac and dfacs mentor group for the kind invitation and the amazing introductions they made. These will be quite a broad topic, as you may imagine, and Brisbane is one of the challenging topics in breast assessment, as we all know. First of all, we need to differentiate between what type of patients would come to our clinic.
We have patients with almost every strain of unknown origin and it can be a repetitive strain. It's quite common nowadays because of the occupational requirements of office workers, for instance, to see patients with repetitive strain injuries after working long hours at a desk or using a computer. But you can have patients with subclinical instability of the wrist, especially of the distal regional joint, or meet carpal joints that can be affected by other side of this pain.
And this is not easy to diagnose or inflammation, psychogenic causes or functional reasons. So associated with specific tasks. Other types of pain are associated with identifiable origin, and these are the cases of trauma fractures, for instance, dislocations or soft tissue damage. In general, the FCC disorders more the specific portion of these wrist issue instability and tenotomy of itis disorders of the lunatic medial ligament of the piscataquis joint instability and arthritis of the drug Allen carpal abutment, vascular neuropathy and other disorders.
So we have a real broad range of disorders. We will focus on the commonest ones and the ones that are most relevant to dfacs of exam. First of all, we need to refresh with the anatomy of the task. It's not just the cartilage, it's not just the triangular structure, it's a complex and as a complex, it is characterized by a number of structures that compose it. And you can see in this diagram that you have the central disk, but also you have a number of attachments onto the radius regularly, clearly and on to the ulna, both to the fovea of the ulnar nerve, which is the proximal most portion as the base of the ulnar nerve style and to the tip of the style of the main and most relevant from a functional point of view.
Attachment of the TCC to the Allen is the OVLT attachment, the 1 to the base of the style? And then you have, of course, the meniscus and you have the collateral ligament and you have the dorsal and vaulx radial ulnar ligaments that contribute to the stability of the carcass and of the WJZ. These very nice diagrams by Mr Donald sammut explain it all, and you see how complex, especially on the left one is the FCC.
We need also to remember that the extensive carpal ulnar nerve is tendon species is regarded as a component of the FCC, although it's partial external to it. And we have the Palmer own carpal ligament complex, which are the ulnar claw ulnar claw and ulnar claw pitted ligaments, which are also relevant in case of an injury. And on the right side, you see the volar and the doors already the ligaments.
If we assess the owner apartments in particular of the FCC, as I previously mentioned, the most relevant one from a functional point of view in terms of stability is the deep attachment also called the proximal component, or PC of the FCC. The distal component DC highlighted in yellow, it's the less relevant one. However, an injury to this attachment still causes trouble because it causes pain.
It can cause minor instability, and it cannot. Sometimes it can be not compatible with activities carried out by the patient. Therefore, you need to treat it if needed. Remember also the iceberg concept that was highlighted by a day about and look at it about the shock absorber portion of the SCC, which is the distal portion and the proximal most, which is the stabilizing portion of the carcass and of the Droege corresponding to the volar and dorsal ulnar ligaments.
So it's a real complex, not just a little ligament. When you have a doctor and you assess a patient with this type of injury, you need to assess patients for pain and instability. Pain can be elicited when you put pressure directly on the phobia, which is here on the ulnar nerve side of the wrist, just distal to the ulnar head. And if you put pressure on that, you may have a positive ulnar nerve of your sign, which is a pain as the site of injury.
However, you can test the patient in ulnar deviation, also applying some pressure as it is shown in the picture, and that can also elicit pain. If there is a tear or even a small one, you test the forearm in insubordination to see whether this elicits pain and you perform the compression test, which is again the one shown in the picture. However, you should also deviate the risk not just ulnar worse, but also dorsally in order to perform it in the best manner instability of the drug.
You can assess clinically, sometimes subclinical. As we mentioned previously, some patients have an obvious clunk in the information instapay nation and some others don't. So you need to test it and you test the stability, both in ulnar and radial deviation of the wrist in neutral deviation of the wrist. You should compare always to the other side to check whether there is a congenital instability or laxity, which is not pathological and that is best in both wrists.
However, if only one wrist is affected, then when you ulnarly deviate the hand, you would detencion further the TCC and the instability is expected to increase. When you readily deviate the hand whilst testing the drug, you should increase the stability of the test to see if it's intact or only partially damaged. If that doesn't happen, then the damage is more significant, of course.
And you can perform the piano key test, you see it on the bottom picture on the right side of the screen. You ask the patient to hold the forearm on the desk or table and press, and you see whether there is a piano key sign of the district ulnar nerve joint in case of more significant instability that may be difficult to appreciate and always remember. Whichever test you you're performing, you always need to compare the wrist with the injured wrist with the contralateral one.
In terms of imaging, X-rays will clearly show a dissociation, as it's shown in the X-rays in the center of the screen or almost eyelid fractures. Also, ulnar claw peel-back can be seen on x-rays, especially if you see a footprint either in the unit or in the room resulting from the apartment or in the ulnar nerve sometimes. However, there may be subtle. So you may want to request an MRI scan for that.
In terms of dissociation, when you have a clear dissociation of the district, the ulnar nerve joint, especially post traumatic, you should suspect a massive terrorist attack and there is something to bear in mind and not to misdiagnosed or underestimate. MRI scans would show the occult factors, the small ones, but also the large ones for confirmation of your diagnosis, of course, and they will show back to the ulnar claw apartment they show like the one in the center of the screen.
There is an effusion in the Droege, which you also see on the picture on the right side. And they also can show the extent of the damage. However, if you want to have a better assessment, you should consider an copy in these cases, especially if you are in doubt on what specific treatment you would suggest to the patient. In terms of arthroscopic assessment, these are the portals, the dorsal portals to the wrist.
I'm not mentioning volleyball traject because they are not relevant. However, the ones we commonly use are dorsal and the ones on the right side of the screen also include the dirigé portal and the foveal portal to see the attachment to the FCC, which are the proximal ones on the screen. This part are quite advanced, but they are very difficult to gain access to, and you may cause damage yourself when you gain access to them.
If you don't know exactly where to put the instruments. Therefore, I would recommend to use them only once you master the arthroscopy skills appropriately. So the main purpose we use are the three four, which is the initial portal, usually for a camera insertion in the radio, carpal joint and the SIG Sauer and 6U for insertion of the instruments. The mid, carpal radial and ulnar portals are located about centimeter distal to the proximal ones.
Also useful for carpal joint assessment, especially if you want to assess the capitated and the scaffold unit, a lunatic brittle instability through the scaffold and not electrical intervals. In case of a detachment of the distal component, which means the least relevant, however still important, component of the TCC on the ulnar satellite, with the camera in the portal three 4 and the hook in six side, you can perform the hook test.
You can try and basically push the FCC towards you if you see the FCC lifted up as a wave in the sea, as you see on the right side of the screen. That's a positive hook test, and it means that there is a detached attachment to the FCC, but this would mean that the detachment is actually massive. Therefore, you need to consider if you have a positive hook test, that there could be most likely an injury also to the proximal component of the FCC, not just to the distal.
In this case, mastering the technique of visualizing the proximal component through the four VL portal would become useful. However, this test already gives you a lot of information. It is not just distal. It is also proximal to if, like the picture on the left side, you only see a detached FCC from the ulnar hospitals of the wrist, and the hook test does not lift the CC as a wave in the C. As I said, that's a negative hook test, and that's definitely just a distal third of the FCC, which you can address.
Otherwise, you will see later that you can either divide them or attach them as required. Another important test is the trampoline test. You need to just apply gentle pressure with the hook to the FCC and see whether it bounces back. It's quite confusing to call it positive or negative, because what does it really mean? The trampoline test should elicit the bouncing of the task if it doesn't bounce back and it doesn't bounce back.
And it's detention. That means that there is a detached part for the task, so it has lost tension. However, if you elicit the trampoline test and it's therefore intensity is present, it means that the disk is healthy. So it's very difficult to define it as positive or negative, I would say, whether it's a present or not present.
In terms of proximal, FCC visualization has explained that later on, you can put the camera in the Droege and you can also use your prober or shave only. However, that is quite difficult and intricate to do. Remember, the parliament classifications, it is very important for your exercise or exam. It's the universally recognized classification of sectors. You have type one, which are the traumatic tests and typekit two, the degenerative tires.
And depending on which type you are seeing, then there are specific treatments. The commonest traumatic test as class 1 B. Therefore, this has led to a lot of literature being created on this topic, especially in terms of treatment. And an important treatment oriented classification, you should remember, is the one buy at, say, the us, the European Research society, one which classifies as the one A/B test based also on not only of the characteristics, but also on the repairability or not of the terms.
This is a paper that they would recommend to read because it's a review of this classification with a treatment algorithm based on the severity and/or the repeatability of the test, so it could be useful for their exam. It is also, excuse me, from the same paper it explains, as you can see, it looks quite intricate. However, it's quite simple. It's really based on what you see.
How old is the injury, how repair it is, and then you decide what treatment is more appropriate. You can repair the arthroscopic or by means of an open technique arthroscopy. You can insert your sutures through a needle. PDS is one of the commonest sutures that are used. However, you can use other materials, of course, depending on your practice, and then you can pull the suture out using a double loop or a mosquito or a retriever and not it around the wrist capsule.
Remember, if you are asked about these techniques, it's extremely important to protect the dorsal branches of the ulnar nerve and the issue tendon when you perform it, so you need to make a mini approach. Although it's arthroscopic, you have to open the skin to visualize the structures lying on the capsule because you don't want to entrap the ulnar nerve branches or the ICU in your suture when you tie the knot. There are also all techniques to repair ties that you can perform arthroscopic.
When you have a structure like this with the evolution, that's something you need to consider that it also causes an evolution of the ulnar nerve style because whenever I fracture, the displacement of the radius, dorsally pulls the TCC so strongly and acutely that it usually doesn't tend to come off the bone, but it tends to cause a bony aversion.
As you can see, here is a high energy injury with severe convention in particular involvement that required a double plating to stabilize due to its extreme instability. And in this case, the ulnar nerve style was reattached. However, when you read as the ulnar nerve style, it is an important consideration, and that's an important question you may be asked. You started when the evolution of the style.
It causes a complete convulsion with subsequent instability, which means you first should fix the radius and give stability to the wrist. Once the race is fixed, you should assess the Droege for instability. Intra operatively and then you make your mind up. And this is based on a number of criteria, not just as instability also on the patient general conditions, on the functional requirements, on prognostic factors, of course, and you need to make your decisions there.
Therefore, it's always worth discussing these the option of detaching the steroid or not with the patient prior to performing open reduction internal fixation surgery on the wrist in these cases, and you can make a plan with the patient accordingly, of course, explaining according to the principles of the informed consent. In this case, the decision was made to fix the style because there was gross instability of the drug after fixation of the ladies.
And when you have an ulnar nerve style it like in this case, you need to consider the anatomy of the style, as you can see in the central X-ray. Also, the fovea was reversed in this case, and that caused the detachment of the proximal component of the TCC. In order to reattach the personal component, one is a world without an ulnar nerve style with Bonnie avulsion, you can do it either by using an anchor like it is shown on the bottom part of this slide.
Or you can create interesting tunnels with choirs and sutures that will allow you to reattach the proximal component back onto the fovea. Remember, immobilization postoperatively of the forearm to avoid permission and separation is important wherever, whenever it is possible to, you should start rehabilitation of the elbow in flexion, extension, and does the wrist infection and extension the sugar.
Tongue splints are very useful for these patients post-operatively. Remember also the degenerative terms and the central perforations of the FCC, the designs that either non-repayable or do not require repair because don't cause instability unless they affect the peripheral portions of the FCC. Therefore, you would consider a debridement in these ones. One, you have irreparable terrors that caused growth and stability of the Droege.
You may want to consider a stabilization to stabilize it when the is when the test is no longer repairable, you need to use the tendon graft. There is a beautiful technique that was described by Bryan Adams with Berger, and this technique uses a long standing graft tunneling into the distal radius transversely and obliquely into the fovea of the ulnar. And you can see here that then the tendon as it comes out on the metastasis of the ulnar, can then be fixed back to itself or the other.
Now, bear in mind, when we have this technique that the palmar is long standing is not always very long, and it may not be possible to loop it back onto itself at the metaphysical. Therefore, we would have to fix it by other means, and you can use bone anchors or you can use interference screws. As you can see here, you have on the left while visible on X-ray distribution of joint dissociation.
Also shown on the MRI scan. And there was an irreparable tear both of the ulnar and of the radial components of the FCC. So it was a bifocal tear in this case. And Adam's technique with its long standing graft and fixation to the Allen with bone anchors allowed to restore true stability. Post-operatively, you need to remember what I mentioned earlier on.
It's paramount to protect the FCC, either whether you have repaired it or reconstructed it. So in above elbow plaster slap with neutral forearm rotation and/or multi-nation can be applied for two weeks. However, remember to use sugar tong splints because this allows the patient to flex and extend the elbow in order to avoid elbow stiffness without permitting and supine in the forearm. You can also ask the therapists and the patient to consider some wrist flexion and extension out of the splint.
However, you need to be absolutely sure that the patient would not permit and supine the forearm. So this is a bit risky. It really depends on the case, on the compliance and on the fact of whether the patient is regularly followed up by the hand therapist or not. And then you have, of course, the option of postoperative rehabilitation with below elbows, splinting and return to activities later on.
This takes quite some time to recover. When you have the usual practice, which is another potential cause of ulnar nerve, said Brisbane, then you have a lot of options. You have non operative options like splinting occupational therapy with activity, modification and posture adaptations, and you can consider injection of steroids in the Droege. They're also surgical options.
There is a full range of options. One of them, probably the old fashioned one, was the vacancy option, which you can also use for other indications. It can still be used in certain cases. However, you need to bear in mind that the owner stump would become quite unstable and you may face instability and associated pain problems, so this is something to bear in mind.
However, if you have a stable ligament structures, you can consider an ulnar nerve replacement. They are also partial ulnar nerve replacements available or if you have a very severe arthritis with very severe instability of the Droege as well. So no ligament stability that therefore does not allow you to use a normal ulnar nerve head replacement. You can consider the total gross replacement. There is this implant on the right bottom part of your screen that was developed a few years ago, and it has this specific indication.
Another cause for unnecessary pain. We move on with the safety issues. Now is the issue of cellulitis. It's quite common. You will come across. It is not always associated with instability. It may be caused by overuse of the wrist and you need to remember that also, this one can be treated either non-operated or surgically.
You may see some swelling over the ICU, but sometimes the swelling is very mild, so it it may not be present. However, you will definitely have tenderness on palpation over the tendon, especially over the ulnar area and the distal portion of the tendon. And you can refer the patient for splinting or occupational therapy again with activity, modification or adaptations and the injection of steroids.
And you can consider also surgical options if the non operative treatment fails, as you would do for any other sinusitis if it doesn't subside following non operative management or issue stabilization if you have some instability. Let's talk about instability. Instability can be severe and lead to subluxation, all the and as you can see here, remember that the patients with a shallow groove of on the and head for the ICU are more susceptible to develop this type of disorder.
However, it can occur to anyone after even lifting an heavy object and donating or supine forcibly the forearm. And this can lead to a disruption of the fibrous tunnel that holds the issue in place in its grove, and these may lead to subluxation that becomes painful. Patients complain of the painful clicking of the wrist during pronation and superannuation, but sometimes this can be quite subtle, so you may want to investigate it further with ultrasound scan if you are not sure based on clinical assessment information and superannuation alone.
Again, you have no known operative and surgical options don't. Operatively, you can use an available cast and sugar splint, but again, it should be an acute injury to the size of the ICU for this to work. Otherwise, it wouldn't work chronically just for symptom relief purposes. You can consider again splinting, even with the wrist extended to detention, the ICU, occupational therapy and steroid injections.
However, if you want to treat the chronic subluxation that causes chronic pain to the patient, you need to consider surgical options. And this use stabilization can be performed by means of a reconstruction of the tunnel. You can use a slap of extensive retina to reconstruct it, or if you are in an acute setting and you are treating acutely an injury that occurred recently, you can just repair the tunnel as required.
Pediatric critical days are these orders, so we move to the other side of the side. However, we remain on the ulnar aspect of the rest. These are also common clearly. Arthritis has the lion's share because arthritis is quite common because of aging process, because of the way the hand is used for specific occupational reasons or hobbies.
And it's quite painful because every time the patient applies pressure to the equitel region, the pain is elicited and it's quite a difficult pain, to cope with because there are a number of activities that we do when we require power grip or to apply pressure to the ball or ulnar nerve of our wrist. Therefore, it is quite a problem and definitely requires to be identified and treated in terms of investigations.
You you would request x-rays in 30 degrees of separation in order to be able to visualize the pediatric critical joint. And in terms of MRI scan, of course, as you can see, that becomes even clearer if you have arthritis or ganglia or effusion because they've become very obvious on the MRI scan. Remember that they can also cause compression to the enabling structures like the ulnar nerve, as we will see later on in the presentation.
The joint arthritis, the diagnosis is clinical, really based on the presence of pain on palpation and the right pressure on the area. There can be swelling, but swelling can be subtle as well, depending on the size of the hand as well and as the subcutaneous tissues of the patient are assessing. X-rays will require the piscataquis review, which is a lateral view with 30 degrees of separation, and you can request, as explained, that an MRI scan that shows it all, including the presence of effusion or ganglia treatment can be conservative or surgical.
Conservative is splinting or application of a soft padding to the area that the patient can use whenever they work or perform their hobbies that would cause pain otherwise or steroid injections into the medial joint. I would recommend to do them either X-ray guided or ultrasound guided because it's quite difficult to have access to these tiny joints, especially when the space is very narrow.
Surgically speaking, you can propose either a PC for Mac to me. So excision of the epimysium or esoteric mitral fusion, the indication for fusion usually easing in patients who are manual laborers or very sporty. Definitely the younger patients, because by means of not removing the passive form you preserve, somehow to some extent, really, the strength of the FCU removal of the passive form is not a big problem in terms of tissue strength reduction, or whether it has been demonstrated that there is some strength reduction.
Therefore, you wouldn't want to consider probably a PS4 McNamee in a younger patient with high functional demand and performing sports. No, not required selling stability is another potential cause of illness, pain. Sometimes is not a quitter. Ligament disruption is associated with an FCC tear, especially if post-traumatic for arthroscopy once again becomes quite important because you will be able to see whether there is a step off in the wrong track, little joint not seen on x-ray, or whether there is the presence of growth instability that allows you to insert your hook in the interval and see whether these dissociates remember.
Also that in the later stages of dissociation, you may also see that the so-called Veasey deformity, which is the opposite of the DC so you see the lunate tilted towards instead of dorsal. This is something we all see in clinic every so often is a congenital difference. It's called remote equitable coalition. There is a classification for it.
There are three types you can have so-called champagne flute pattern, which is the top one on the right side. And you see a partial collagen is a sin can draw this mostly in the case, but it can cause pain because of the stiffness of the neutral interface in type 2. You see a partial collision, partial bone infusion, type three, you see the total bone effusion. I mention this because this is again congenital, as I mentioned.
And over time, it causes arthritic changes. We see patients in the 50s, usually or 60s, coming to our clinics with this kind of disorder. This is quite severe. In this specific case. I've chosen for this presentation. However, you can see milder types of arthritis and abutment in the air, as it is clearly ulnar sided abutment in the wrist that causes ulnar nerve sided pain, sometimes a bit more central sided because it is affected.
However, it can be a cause of ulnar nerve celebrates pain. Treatment is quite difficult here because you don't have a room, not acquittal interval, so you need to consider initially non operative management, including splinting and steroid injections. But if you then have to consider surgical treatment, it becomes more and more intricate and also because the lunate fossa of the rages leg in this case appears damaged.
So you need to consider carefully your options, because these patients usually have quite a good range of motion, so any bony surgery needs to be carefully discussed with the patient. Discussing the balance of pros and cons very, very carefully, these ones are more subtle types with type 1. For instance, as I showed you earlier on today, you may not be able to identify it initially the first time you see it, but over time, with practice and as you see more of these coalitions, you will get used to it and you can see the champagne flute configuration.
Let's look at a abatement is also fairly common in patients with positive ulnar nerve variants, which means a longer owner than the radius is one of the normal variations of the length. So it's not a pathological finding per say, whether it causes ulnar claw pain because of the abutment either on the unit or on the ricketson. And if that happens, of course, the task becomes chronically damaged and the patient would come and seek your expert advice for pain.
In these cases, you need to consider again non operative options like splinting injection of steroids and occupational therapy. But should they fail? You need to consider surgery and surgery. You have two options. You have either the wafer procedure, which is a partial rejection of the distant her in the head. You just remove a little portion of the distal.
Learn only a couple of millimeters, really, you can't remove more than that. Otherwise, you end up performing a drugs procedure, which is what you don't want to perform, which is an ulnar nerve head reduction that may cause the instability of the ulnar nerve stump. And it's a completely different procedure that you use in other cases, rheumatoid or other cases, and also very rarely.
So you need to remove really only a couple of millimeters, and you can do that for topically using a bomberger. And as you can see in that arthroscopy picture, you see the helmet head underneath the broadly damaged TCC central disk. And when you perform, it arthroscopic, it's very time-consuming. And remember, you need to continue to alternate and supine in the forearm as you shave the hole in the head because the ulnar nerve head is broader than you would expect.
And what you see in this picture is only a tiny portion of the other hand. So by means of continuing continued inflammation and superannuation during the procedure, you would be able to create a flat surface on the distal edge of the ulnar had. It is a bit simpler and safer to perform the procedure open, and that will show you with the next slides. So this one is a case that was treated arthroscopic.
And you can see the owner head has been brought down to the same length of the radius, thus reducing the abutment on the learned post-operative care. It's a plucky application of a plaster slab, followed by a splint and hand therapy. This procedure does not change the stability, so it doesn't really affect it. This is another case where it could be useful to consider this type of procedure because it's unfortunate.
The margin of error areas in this case is not an ulnar nerve disorder. And this occurred in childhood. Therefore, it led to a length discrepancy, which is significant in this case, you may be tempted to perform an ulnar shortening was osteotomy, so I will show you later how it works, whether reducing the length of the ulna at the official level with the plate and screw insertion.
However, as you can see on the left, the sigmoid notch of the radius is also anomalous. So reducing drastically the length of the Allen in this case would cause more trouble than be helpful because it would create an interface between the head and the sigmoid notch that has ever has never had on the head. And this is an anomalous shape. So in this case, because of the injury of the fact that the injury occurred in childhood, there was no indication to an ulnar nerve short interest tenotomy and you can perform a wastrel procedure.
And interestingly enough, in arthroscopic assessment shows the dorsal method required trim as a bare bone because of the ulnar carpal severe abutment. And this is the open procedure performed that you can do more easily through an approach through the fifth compartment, the tandem that you see pulled away is the Eden tendon. Post-operatively after you have reduced the abutment, you can again apply a splint and then consider hand therapy.
Madeleine deformities, it is also another cause of wrist pain on the ulnar nerve side. Usually the onset is in during the late childhood and teenage years because of the increased functional requirements. And in these cases, the Allen is definitely very long and on the buttoning the corpus dorsally the corpus is also partially and proximal is a blood test.
So it's not just a normal carpal abutment in these cases. In order to achieve the extent of shortening you would like to achieve, in these cases, you need to consider a formal osteotomy, not just a wafer procedure. So you need to shorten the ulna as much as you can, depending on the system you use for the ulnar. Shortening osteotomy may be able to shorten even up to 8 millimeters or sometimes to 1 centimeter.
So it's quite a significant shortening you can achieve by. This means, remember that there is also the option of correcting the radius by means of corrective osteotomy that increases improves not only the tilt of the legs in both planes, but also the length because of the improvement of the tilt to some extent. And you can do either of these procedures or decide to perform them in a sequence.
And these are cases treated with the ulnar nerve shortening osteotomy, as I mentioned. Million of the distal radius is another problem. When the Millennium is significant, so you have a significant dorsal tilt of the radius, then you would consider correcting the Millennium first.
However, in cases where the Melungeon did not lead to a very severe dorsal angulation of the radius or in cases like this one in which addressing the Millennium, the radius very distally wouldn't change things much because the model is quite proximal. As you can see, then you can consider an ulnar shortening osteotomy as an option.
And this was done in this case, leading to resolution of the pain. Remember that were not only here to discuss about bone disorders of or tenodesis disorders, but we're talking about ulnar nerve side of Brisbane, another potential cause, which is not that common. However, not even that uncommon is the hypothetical hammer syndrome.
Remember, this is usually associated with manual activities of the patient, especially repetitive trauma to the or micro trauma to the Allen aspect of the wrist and palm of the hand, and is a true ulnar artery aneurysm that you should treat. As such, it can be resected and the ulnar artery ends can be either joined together or in case they don't reach, which is not common. However, you can use a vein graft to reconstruct them, so this is something you should also mention as a potential cause of unnecessary pain.
As well as nerve injuries, you can have injuries to the ulnar nerve on the ulnar nerve side of the hand caused by compression caused by tumors or caused by trauma that would lead to symptoms on the other side of the wrist. The anatomy of the ulnar nerve is paramount, especially in terms of animal anatomy. You need to know that there are three zones in zone 1.
Both the mod, which is the proximal most, you've got both the motor and the sensory components of the nerve in zone two, the motor ones and in zone three, the sensory distal to the bifurcation. Remember that anything arising from the pediatric mitral joint like a ganglion, for instance, can compress the ulnar nerve in zone 1. And remember that a fracture of the arm, especially if a shell of the base of the hook of the hamate can cause a compression of the ulnar nerve in zone 2 or even zone 3 if it is badly displaced and there is a local effusion and bleeding as well.
So you need to remember. Also, there is a need to remember the anatomy of the ulnar nerve and the symptoms that make different. Egoyan's can eye compression from an iron compression of the ulnar nerve. Thank you very much for your attention. Thank you very much, Mr gurnani. Yeah, that was very interesting.
Yeah, I certainly learned a lot. It's one of those things that I think we sometimes forget when we're treating this, the radius fractures and they have ongoing pain. We sometimes forget to think about this already with joint arthritis or GFC injuries. So it's really useful. I'm sure the candidates will appreciate it. I got this already on a joint osteoarthritis in one of my short cases in my exams as well, and I think I also got a medal.
And so very important. So what I'm going to do now is I'm going to ask Joe to unmute himself and ask some questions that the candidates have been putting in the chat box, if that's OK. Well, we should go. Thank you, Nick. Hello, Mr guy. Very, very nice talk and very important actually and especially in the short cases.
So the first? Actually, it's a very popular topic. So the first question was, is it the MRI or an MRI gram better to look at the fcc? Yeah this is actually a very good question because there are Graham. I was also trained that when I did my training in Allen based and but it's actually something we don't use that much because nowadays they can show perforations so that the SEC that are not really significant from a pathological point of view, we may have at the FCC perforation at birth and we are not aware of it.
So the outcome is lost a bit grounds compared with traditional MRI scans, which would be perfectly reasonable to do nowadays for see bearing in mind that nowadays we can also do an arthroscopy. So whenever we are in doubt, we can actually assess it better by means of direct visualization. So I would say MRI and arthroscopy is now the gold standard.
Yeah, thank you. Ideal implant for fixation of the ulnar nerve satellite. As there are implants in the case, I showed you a screw was used, however, you can use key wires for fixing it. Use a figure of eight suture as well as even links to a K wire or took wires. So a tension band constructs. You can even use tension band wiring if you have very fine tension, barbed wire available, or there are also when you have fractures of the head of the ulna, including the style of there are also little plates available that allow you to hook the ulnar styloid down back on its base and for the Galeazzi fracture.
Of course, with the structure of the 3D ulnar nerve joint, how many key wires. Do you use to use one or to put them to use to KYC in those cases to give better stability? Yes and to leave it for how long? Usually six weeks for the soft tissue healing. But clearly you need to bear in mind that they are very difficult. This this case, those cases because key wiring of this ulnar nerve joint leads to significant stiffness and also may cause other very austere reactions that can cause pain as well.
So you need to be a bit careful and do you breathe them or not? Personally, I tend to bury all wires in the wrist because I'm well aware of the risk of septic arthritis and osteomyelitis, which is a disaster in the wrist. Good and is there any preference for selection for the patient to decide direct's as versus to sooryavanshi or fusion or arthroplasty barracks? I would tend to use only extremely selected cases.
I'm talking about elderly patients with very low functional demand and extreme changes of the risk. Talking about rheumatoid cases. And in that case, drugs could do the job, of course, of improving the symptoms. However, it's not my first choice ever. I don't think that is anyone's first choice nowadays. So the company has also very limited indications and this again, something that is more historical nowadays rather than currently used much.
So we tend to use more replacement surgery when required. However, it's not always required because there are also no, not perfect treatments available. Yeah thank you. And is there any specific test to do on table under GAAP to test the stability of the distribution joint? Yeah, it's very important to test it just the same way. Test testing clinic, really?
Yeah so you need to test it with the rest in this position in ulnar deviation test is there is some instability. We should be presenting on the deviation neutral and radial deviation. In radial deviation, you should tighten up so that the SEC should be able to increase the stability in radial deviation of the wrist when you test it.
Another way of testing it is to test by means of moving the radius instead of moving the ulna. Because actually, if you think about it, the ulna doesn't move in dorsal and the dorsal and Palmer plane is the radius that does it. So you could hold the ulnar nerve stable and move the radius. It doesn't really matter as long as you test the stability of the joint.
Thank you. And there is a question from a physiotherapy point of view. Why do you prohibit slap lesion permission after reconstruction and for how long? Yeah, yeah, that's a very good question, because it really depends on what type of reconstruction is done. I would say if it's a minor peripheral tear that you have this distal component of the test that you repaired, you can actually safely start mobilizing sooner rather than later.
So in that case, I would not immobilize permission explanation for six weeks. I would do it for a limited period of time, just two weeks, probably. And then I would start with gentle exercise. But that really depends on the stability that you have achieved. If you perform a reconstruction of the TCC, then I would wait a bit longer because although the risk becomes stiff, it's actually the name of the procedure to create some stiffness.
We will overcome the stiffness with rehabilitation later on. So it depends on the severity of the injury and on the repair you made. So if it's a stable repair with a small injury, you can move sooner. Information suspension if it's an unstable, very unstable TCC, badly torn and the repair is significant or a reconstruction is being performed, then you would be a bit more careful. However, the sugar splints allows you to mobilize the elbow and also you can ask the patient, as I said, to flex and extend with Operation and supine waiting.
Yeah, after four weeks, so they start mobilizing the rest. Thank you. And in type III coalition with a change in the unit proximal rocker back to me, is it an option? I would actually like to ask this question to everyone in the audience because these are really good questions for the exam, it's not an option if you have a need for such changes.
So whenever you have learned for changes, unfortunately you'll lose a lot of options because you lose the option of performing a proximal rocker back to me. You lose an option of a four corner fusion because there's no way it would work. It would keep the arthritis that it just make more stiffness. So in that case, then you need to consider more significant procedures talking about arthroplasty or total joint fusion or a more benign one, which is the innervation of the wrist.
The innovation could allow you, unfortunately not in all cases, but often it works to reduce the symptoms or significantly improve them and buy time. Yeah thank you so well. This is more or less three questions in one. So how much on the variance can be corrected by wafer? And how much ulnar variance needed to be treated? Is and can we do a regular lengthening and instead?
So first question answer does not correct more than two, maximum three. I wouldn't do more than that otherwise. As I mentioned, it becomes a drugs. The onread is not very long, so you end up removing a lot of head if you do more than that. If you need to shorten by more than two or three mm, I would recommend that you perform and ulnar nerve shortening osteotomy, which you can perform front anything between 5 to eight or even centimeter.
With some systems, it depends on the system on the plate that you choose, really, because each company makes it slightly different in terms of when you need to do it, you need to do it only if the patient is symptomatic. So is the ulnar claw peel-back and is present but not symptomatic. There's clearly no indication we treat pain. We do not treat the X-ray. So if there is, there are symptoms and they are unfortunately present.
Despite non operative treatment, then you consider a shortening and you discuss the extent of shortening based on the length of the ulna. An important point. You don't make doing the presentation, but will make now is how to request the X-rays. To assess the ulnar length. You need to ask the radiographer to put the arm in this position with 90 degrees shoulder abduction and 90 degrees elbow flexion is the only way for the posture of interior.
X-ray view is the only way to see the actual length of the Allen in relation to the radius, and then you can measure the extent of ulnar positive variance. But again, you want to operate. If the patient is symptomatic, don't operate on an asymptomatic. One last question was about can you do radial lengthening? Radial lengthening?
I would not really recommend because it's a very intricate procedure. It requires bone grafting, most likely, and it's an extensive approach and is not as benign as a wafer or as an ulnar shortening, so it is possible. However, we only use radial lengthening when we have a significant discrepancy when we would not be able to achieve an appropriate shortening the compression of the carpal region with only shortening alone so we can do a radial lengthening.
And if it's not sufficient, you also do ulnar nerve shortening of those cases. But usually we are talking about reduce Maloney in this case. Thank you very much. Thank you. OK, that's great, thank you, Joe. So what we'll do now is if Ruth is available, we will share the mic questions.
And if you can all answer them as soon as you can, as I've said before, it's all anonymous. We don't know what answer you've put, but the sooner we do the mics, then we can move on to the survivors. Thank you. So question number one was about is you subluxation? It doesn't really lead to an increase the motivation of the rest.
So I'm afraid that's not correct. It is not the commonest cause of unnecessary pain. It is one of the potential causes. It can definitely be treated by means of osta fibrosis reconstruction, which is I see what most people have correctly confirmed, especially when it's either acute. You can do a repair or chronic. You can do a formal reconstruction. And the thing that about the instability is also very important because the ICU, just like the pq operators, are extrinsic stabilizers of the drug.
Therefore, a subluxation or a disruption of the fibrosis of the ICU does increase the risk of the instability, and as such, it is important to treat these injury. In fact, even in patients with very, very mild dietary instability would do not wish to undergo surgical treatment, and it is also another key point for our exam. You may want to mention that you can refer the patient to the therapist for strengthening of the PCU and of the ICU as external, extrinsic stabilizers of the drug in the first instance, to see whether you achieve an improvement in stability and the decrease in the symptoms before considering surgical procedures.
Question number two palmar type 2 factors type 2/3 are the degenerative terms, and they are indeed associated with control changes, either, on the other hand, or on the other side of the TCC on the carpal bones. They require most debridement. They don't require repair. It's not true that they do not usually require any treatment because they can be painful. So the Brodmann's injection of steroids can be considered.
However, they do not require significant treatment, so this one is partially correct. They are not caused by trauma because they are degenerative and are not typically radial sided. Question number 3 is about pediatric fetal ganglia. They are not often obvious on physical examination. Unfortunately, it would be nice if they were. Some of them are relatively big, so you may be able to see them. However, they are mostly ganglia arising from the FCU, rather than is the fetal joint that you see superficially.
They cannot be easily per patient. What you do when you perform palpation there is to try to elicit the pain of the peel-back joint. So what you do is to apply pressure on the position born and test whether there are symptoms caused by the pediatric arthritic changes. And effusion like you would do for the patella when you examine the knee. It may cause ulnar nerve compression.
As you as we clearly stated during the presentation, it does not always. Of course, it depends on the size and location of the ganglion, but it does cause a risk of compressing the ulnar nerve and they are usually associated with degenerative changes. So the last one is also incorrect because they are often associated with changes that there is always the ganglia arise, although changes may be very mild.
Hey, that's great. Everyone, thank you very much, I think Joe's just got one more question that popped up and then we'll stop recording and start the IVUS Joe. Hello, Mr Gurianov again. So in your practice, what are the indications to fix the owners taillight and distal radius fractures? Mm-hmm Is it the every unstable district ulnar nerve joint or there is other indications?
So that's also a very interesting question because I mentioned, but perhaps because of the length of these presentation, it may be missed that it also depends on the patients conditions, really. So it really depends on a number of factors. Clearly, if you have a young patient with high functional demands who has a grossly unstable deluge caused by abortion with bony style diversion, and you are fixing the radios and you realize after fixation that the area is unstable, then there is an indication for fixing it, and I would fix 100% of those ones.
However, if you have a patient who is a low functional demand, as are some arthritic changes of the distal regional joint or a very severely disrupted sigmoid notch, as it may occur in very high energy injuries with severe medial column disruption of the radius, then I would consider probably not stabilizing it intraoperatively. I would prefer to treat the radius to the rehabilitation for the patient and see whether symptoms are present later on.
That may need my attention because the risk is if you stabilize the drug in an arthritic joint or in a severely disrupted notch situation, then you may cause pain yourself by means of stabilizing the drug, so you need to be quite careful with that. Thank you. What are the indications for arthroscopy and undecided pain, and is there a portal proximal to three or four portal and using for what the proximity for portal?
There is, unfortunately, no portal because there is the radius, so you don't really want to enter the radius with the scope. There is the portal they showed is the proximal. Most ones are the district ulnar nerve joint portal and the proximal four wheel portal of the Allen, which is underneath the TCC. Because you look at the disk as a deep attachment, one of the TCC.
So these are the proximal most, but as I said, are very difficult ones and they are quite dangerous because if you don't place the instruments perfectly in the space you want to assess, you may cause control, damage or damage to the deep attachment to the FCC yourself. You need to be extremely, extremely careful in terms of indications for arthroscopy. Arthroscopy is indicated when you have a suspicion that there is something you can look for with an arthroscopy.
Clearly, it's quite obvious the response. I'm afraid, however, it's because you are suspecting it's there or you want to assess the extent of damage caused by ulnar claw abutment, or you want to assess the intricate ligament stability or the metacarpal portion, including the capitated head talking about ulnar nerve side of this pain. There are, of course, also radial sided indications for arthroscopy for scaffold onate scaffold ligament injuries, scaffold nonunion snack and lack of rest staging and so on.
There are a number. I also perform arthroscopy in terms of indication to fix particularly comminuted distal radial fractures, including the fighting vertical surface, so you can perform a first topically assisted distal radius fixation. Thank you very much. I just have one little thing to add. When talking about the world's ulnar nerve Deloitte, I just want to make it a clear point for everyone that this timely diversion that causes instability is only the one that includes the proximal portion of the stylesheet.
So the phobia, because the entire TCC is attached to the stylin in that case, which is from there now. But if the proximal attachment of the FCC, which is the four wheel attachment, is still attached to the ulna and you only have a tip of the ulna style avulsion, that doesn't mean that you need to fix it. Because in that case, I would not fix it.
I would see whether the patient is symptomatic later on and then addressed the problem of the distal component of the disk later on. Thank you very much. That's great, thank you very much. Sorry, I forgot the bit that we're going to move on to top tips for the Fox and case based discussion with Mr Gagliardi. Thank you.
We have a case, we may be presenting with a case of high energy injury to the wrist. This is a case of right hand, dominant young and healthy patient semi-professional slider that fell off the horse. Seven months before seeing you in clinic and was treated elsewhere, so you see these patients seven months later with a wrist fracture already treated elsewhere in a cast, and she comes to see you because of right wrist pain, clearly unassisted because it's the topic of tonight's discussion and weakness.
First of all, key points, when you ask something about administrative restraint after high energy trauma, you need to consider any potential previous injuries or so before the injury that is reported to you. You need to ensure that you are assessing whether the patient has comorbidities because you are suspecting that there is something relating to the trauma that may need surgical treatment.
Therefore, you want to know whether the patient is a smoker or not, because that may affect the prognosis of what you perform. You need to consider the type of trauma in this case high energy. So remember always to perform a thorough clinical history collection. When you do these, these type of assessment, the timing and the type of treatment received, the patient was treated elsewhere in a cast.
But when was it just after the injury? Was it two months later? Was it a timely treatment? Was the fracture reduced? Was the cast a full cast or just a back slap? Was it about elbow or below elbow? May, as this caused any other stiffness issues that you are not aware of, so you need to be able to gather all this information when you see the patients, it is very relevant to your exercise of exam.
You need to demonstrate that not only you have the knowledge, but you have the capacity to apply it in clinical settings. So you need to know not only what you are talking about, but also why you are talking about. What you're saying. So it's very important to start from the beginning. So talk about patient assessment, clinical history and then clinical examination. What symptoms in this case?
OK, we know it's unnecessary pain, but what tests would you consider? Would you consider a dirigé stability test? Definitely, Yes. After a distal radius microfracture or a wrist fracture in general, because you don't know whether the SEC has been disrupted. You don't even know if the drug has been overlooked or not. You need to check if there is a deformity of the wrist.
You may see it or you may not see it if there is any swelling. DCU inflammation after the trauma subluxation caused by disruption of the fibrous tunnel, you need to assess that as well. You need to assess the range of motion. Was physiotherapy carried out after casting? What is the current range of motion? Is there a mechanical limitation?
Is there pain associated with motion and the stability of all the key players, not only on the other side, but also on the radio side? So I put us the scaffold and ligaments that are never forget to mention the scaffold ligament. It's one of the most important ligaments. We have in our wrist because we are talking about unnecessary pain, meet carpal joint stability and destroy the ulnar joint.
The patient undergoes investigations, you get an X-ray and the X-ray shows a healed fracture, but it shows an overlooked ulnar nerve style. So you can then decide what you want to do. You want a CT scan to assess if there is a union, you want an MRI scan, like in this case, to assess the TCC and not just the thyroid. And the MRI scanner is very instructional in this case, because it shows clearly what I was explaining a few minutes ago, which is that when the ulnar nerve started is completely reversed in this case, including its base, which is that thin lip of bone you see radial tuberosity the ulnar nerve style it.
Clearly, you can see on the MRI scans that the whole of the SEC has come off with the. So you see the FCC and the ulnar nerve style is attached to it. So there is nothing left on the island in terms of the FCC attachments. It is a complete evolution of the FCC that clearly causes an instability. So this patient is coming to you complaining of pain on the underside of the wrist and of weakness.
Remember that instability of the WJZ can be a reason for the weakness, but can also be a consequence of the lack of supportive musculature. What about the icu? Is the ICU strong enough to help and try and stabilize these grossly unstable droege? What about the peak muscle? So that's the reason why you need to have asked the patient about physiotherapy.
You need to check also the muscle and mass of the forearm in the patient and compare it with the other limb. So it's all connected. Remember, it's not just the wrist they're assessing. You're assessing a person with an injury and you are assessing the patient as a whole, not just an X-ray or an MRI scan image. So extremely important to do everything appropriately and show confidence in your clinical examination and not just in your knowledge.
In this case, of course, now you know that there is a growth instability. You know that the ulnar nerve style is not United. There is nothing really visible here in terms of bridging, not even fibrous bridging. You don't see any changes in signal, so it's completely non United. So you need to consider other things. So we already discussed about how to test the stability in ulnar deviation neutral and radial deviation of the wrist by means of either moving the ulna or the radius if you prefer, which makes more sense to test the stability to compare it with the contralateral wrist to assess the muscular masses of the forearm, in particular, the extreme stabilizers, ICU and q is there working and if they can be improved, so you should refer this patient for hand therapy if the muscle masses are very, very small or wasted classification of the injuries you need to mention.
The classification mentions the parliament classification and also mentions that say, us treatment oriented classification, because that also is very relevant in terms of decision making for these type of injuries. This one is a type 1B injury, so the commonest injury you have, which means it's a completed version, is an earlier version of the TCC in this case, complete, of course.
So what do you do for it? Clearly, in a young patient, you need to fix it to reattach it if you want to restore stability, so you need to check the options you have. If you are asked about non operative options again, remember to mention the extrinsic stabilizes the muscles. Remember to mention splinting. Remember to mention that this patient could have been treated, but you do not know what happened because you didn't see the patient beforehand could have been treated with a sugar tong splint for six weeks after the injury in order to try and achieve healing of the Allen axilo.
Remember, it takes a long time for the taillight fractures and diversions healing to occur. But it may occur especially in young patients, and it may take even several months, sometimes to see some bridging either fibrous or bony across the nonunion site. In these cases, it's not uncommon to see that certainly is not happening old times. So that's also another problem you need to be very aware of and discuss with the patient.
So again, you have the full range of options there you need to have in front of you. When you talk to the examiner, the patient. So pretends the patient is there with you is not just an image. And think about the conversation, you would have with the patient about non operative operative timing of your treatment. If you want to try with muscular, strengthening first and splinting again is perfectly reasonable.
However, in a non-union setting like this one, it may not work. It's likely would not work, so you would ask them to consider surgical options. However, again, you need to show that you are confident with all the options and when they can be performed. So this is extremely important. Should we move on with the next case?
OK another case I would like to present you as it is something that may be asked to during the first self-exam and again, it's not the easiest type of cases, you may be asked about. Is this one you have a 19-year-old patient come into your clinic? Is a manual worker otherwise healthy complaining of unnecessary pain, especially when riding a bike or using a drill or screwdrivers?
The patient cannot recall any specific trauma. Certainly nothing relevant to the wrist and the complaints of spontaneous onset of pain. Three years ago, it was never investigated, so the first time they come to the hospital for this problem. Remember, there is no trauma here, so again, take a good history, especially in terms of past medical history, comorbidities that may have caused this pain onset occupation.
So OK, the manual worker, so this may cause tendonitis. Definitely, you need to think about either ICU or ICU patients, and why it is. You can think about pediatric fetal ganglia or wear and tear, although the patient is just 19. So you need to think in terms of differential diagnosis. However, you need us to consider that there are disorders that are not just caused by the occupation of the patient, that they are caused by genetic factors.
So we need also to take the family history in patients who do not report trauma and they start complaining of onset of pain. So consider really anything and everything because you don't have any imaging yet. You don't know anything about The patient, so you need to perform a thorough history and clinical examination. Symptoms wise patient complains of unnecessary pain in the ulnar claw region, you check if there is a deformity or some swelling and you check the range of motion.
You also check again the stability of the key players in the wrist. Careful, you might not like neutral ligaments. Meet carpal and joint if you can elicit any clunks or any instability in comparison with the contralateral wrist. So you examine this patient and you see the ulnar nerve head is quite prominent in both wrists on the doors of the wrist, which is not that uncommon.
Many people have prominent ulnar claw, especially those with the positive ulnar nerve variants. However, this patient is quite a prominent one, so you start thinking about it and you again remember the family story mentioned. You can ask the patient whether anyone else in the family has the same. And then you take an X-ray and you see that there is a reason why this is occurring, the Allen is definitely prominent, is definitely dorsally prominent.
However, remember very rarely can be also permanently prominent and the metacarpals, but that's very rare. So I wouldn't expect the examiners to asked you this during the first year, or it would be a very difficult question. Talking about the Communist pattern is this one I'm showing you today? You see the dorsally prominent in the head, and clearly you see that there is a radial anomaly.
This case is a magalong deformity of the wrist, with the typical features of the carpal bones shaped like a pyramid. With the inverted latex on the unit, you see the radial tilt completely subverted. Some of them have very significant radial Boeing. In this case, you don't have much going, but however, it is still in Maryland, and then you need to start describing this type of deformity to the examiner.
Extremely important to remember that there are also differential diagnosis. Mother deformity. First of all, is usually bilateral. By definition, we define model the true model of deformity, a bilateral one because it's congenital and it's often determined by genetic anomalies. However, it can also be syndromic or idiopathic. But the true modeling is 99% of cases bilateral.
We define pseudo model as those that are unilateral as a consequence of trauma or infection in childhood. That has led to a growth arrest of the radius and an anomalous shape. So those are pseudo mother in the form, which is not the true mother one deformity. So you need to explain this to the examiner unilateral or bilateral, you need to check maybe the other wrist as well.
Take an X-ray and see whether it looks the same in the case would be a mudroom like in this case, and you consider further investigations what you want to see to confirm the model on the form. It is also the Curtis ligament, which is an anomalous radiocarbon ligament that is present in the patients with model deformity on the volar side of the wrist, and that can be seen on an MRI scan.
So again, remember that the contralateral wrist x-rays in this case show similar deformities. So you call it Madeleine and remember the features of mother. There are some features that are typical of this deformity. There is a lot of literature on then I made a summary here of the typical ones. Also, the paper quoted underneath this is quite interesting because it explains how processes quantitatively on x-rays again shortening and blowing of the radius, increased water and ulnar claw of the distal radius articular surface.
Because of the lack of growth in length of the radius, the ulna continues to grow and dislocates dorsally due to the length discrepancy with the radius, and this causes ulnar nerve carpal abutment dorsally prominent Allen and ulnar claw pelvic pain, which is the reason why the patient came to see you a wide, estradiol ulnar nerve joint. There is, in fact, no distribution of joints. There is no single notch.
The carpal bones form an inverted pyramid with the proximal apex on the loopnet, as you can see in the x-rays, and the corpus is usually approximately involved in the blood. There are several degrees of subluxation. Some of them are more than are more aggressive than the others. And remember the famous viscous ligament, which is anomalous between the radius and the carcass that you can see on mri?
I've taken this MRI image here to show you the ligament is a thick band of dark tissue from arising from the radius and attaching to the lunate in this case, although it could be attached to the equator as well. Remember, the treatment depends on the age and on the symptoms of the patient. You can teach them no operatively surgical treatment is often not required, really, and you can treat them with occupational therapy activity, modification use of modified tools that do not elicit the ulnar nerve carpal pain post reputations.
I wouldn't really consider the role of the steroid injections here because the deformity is such that I doubt that the steroid injection would improve much unless you have ICU tendonitis caused by the deformity in the case, you may want to inject the ICU sheath, but not. Not really. The ulnar claw provision is badly deformed or surgical treatment and treatment depends on whether this is a child or an adult. In a child, you can release the ligament.
You can perform a lysis of the anomalous portion, the medial portion of the radius. So if they ask you, you need to be aware that when the child is young, you still have the potential to modify things by means of using the child's own growth as the key factor. So what you do is to perform a visualizes of the anomalous portion of the facts, which is the medial. So the ulnar nerve side of the radius with interposition of fat or soft tissue in order to prevent again the visualizes heals itself again.
And then you can see if over time these leads to an improvement in the shape of the radius, length and symptoms. However, if the deformity is very severe like the one I showed you, even in a child, you may consider the radial osteotomy when the child is old enough because you need to bear in mind that the radial tenotomy may damage the growth plate.
And in that case, you end up with the more significant problem. So I will use this in older children or early adolescents. And again, you can release the viscous ligament because it's a fibrous band of tissue that you will find when you approach the wall early for the osteotomy in order to shorten the ulna without shortening it. You can again use the growth potential for your perusal, really, and you can perform an ulnar nerve physiology.
You just have to use a choir or a little drill bit to to, Uh, damage the growth plate of the ulna and then let it fuse. So you basically cause the growth the rest of the disk to learn. However, don't do it too soon. There is no rule about the age this. I have discussed extensively with a number of colleagues from around the world and also reviews the literature on this topic.
And there is really no one who can say exactly the age where they were when they would do this, but they would all do it towards the end of the childhood and early adolescence. Because what you want to avoid also is to create another link. This length discrepancy yourself by means of shortening the ulnar nerve too soon in life. So again, if you this is something you consider towards a later ages, and when you are seeing an adult with these problems again, you can consider a radical tenotomy in order to increase the tilt of the radius and make it more anatomical.
And those are the length and you can consider an ulnar shortening. And this is a case in which you can really do either of them or both of them as required. Thank you very much, Mr Lorenzo, I think KneeKG is muted for some reason. That was an excellent talk and you covered this topic inside out. I think you had enriched us with a lot of information and we are going now.
We're going to start the fiber.
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