Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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Wrist Arthritis

Bill Wagner, MDSeattle Hand

Supervising Faculty, Swedish Sports Medicine Fellowship

Associate Team Physician, Seattle University

Clinical Instructor, University of Washington Department of Orthopaedics and Sports Medicine

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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Traumatic Arthritis

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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SLAC and SNAC wrists

Scapho Lunate Advanced Collapse (SLAC)

Scaphoid Nonunion Advanced Collapse (SNAC)

Analysis 4000 wrist X-Rays: 95% degenerative wrist

arthritis involved the scaphoid

Tear in SL ligament

Non-Union Scaphoid

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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SLAC and SNAC wrists SNAC arthritis 5-10% scaphoid fractures

result in Non-union Degeneration seen 10-20

years after fracture non-union

SLAC arthritis Most common type of

wrist arthritis SL ligament tear alters

carpal bone alignment Results in degenerative

change 5-20 years later

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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History: Which of your patients have this problem…

More common in men than in women

More common in persons who perform(ed) manual labor

Most common in the dominant wrist

Age at presentation 50-70 years old

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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History: What your patients tell you..

Wrist injury or scaphoid fracture 10-20 years ago

Many patients with SLAC or SNAC wrist have minimal symptoms

Present because of a secondary problem Carpal tunnel syndrome

Ganglion cyst

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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History: What you and your patient discuss…

Symptoms History of wrist pain

during/after activity

ADL’s modified depending on severity

Pain with motion

NSAIDs for pain relief

Pain loading the wrist in an extended position

Yoga

Push-ups

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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Physical Exam

Swelling and tenderness on radial(thumb) side of wrist

Limited wrist ROM is typical Average wrist

flexion/extension arc of 80-90°

Usually lose more extension than flexion

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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Differential Diagnosis

Any condition that causes dorsal radial wrist pain!

Inflammatory Arthritis

Cellulitis/Septic Arthritis

(STT) joint arthritis

de Quervain tenosynovitis

Dorsal carpal ganglion

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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Non-operative treatment

Many patients have mild pain They just need to be

reassured that pain won’t worsen!

Some patients require treatment for secondary problems such as CTS

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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Non-operative treatment by Primary Care Providers

Activity Modification

Icing

Wrist Brace

Acetaminophen or NSAIDs

Hand Therapy Maintain ROM Brace Ergonomics

Steroid injections

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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When to refer to Hand Doctor

Increasing Pain Weakness Loss of motion

Failed Bracing Acetaminophen NSAIDs Cortisone shot

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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Distal Radioulnar Joint (DRUJ) arthritis

DRUJ OA: primary and secondary causes

Primary OA is more common in women

Secondary causes Usually post traumatic

Fracture distal radius or ulna head

DRUJ ligamentous laxity or TFCC injury

Inflammatory causes less common now (biologic meds)

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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History: What your patients tell you…

“My wrist hurts when I turn a doorknob”

Loss of motion of wrist

“Crunching” or “clunking” feeling in the wrist

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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Physical Exam DRUJ arthritis

Swelling

Loss of wrist ROM

Loss of forearm ROM Pronation Supination

Tender DRUJ

Crepitus at DRUJ

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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Differential Diagnosis DRUJ arthritis

Inflammatory Arthritis RA Gout/Pseudogout

DRUJ instability/TFCC tear (blue arrow)

Dorsal Wrist tendonitis (red arrow)

Overuse/RSI dorsal wrist and forearm pain

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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What you can do to treat DRUJ Arthritis Activity Modification

Icing

Wrist Brace

Acetaminophen or NSAIDs

Hand Therapy Maintain ROM Brace Ergonomics

Steroid injections

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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When to refer to Hand Doctor

Increasing Pain Weakness Loss of motion

Failed Bracing Acetaminophen NSAIDs Cortisone shot

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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Take Home Points: Wrist Arthritis

The most common type of wrist arthritis you will see in your patients is post-traumatic arthritis in older men

Patients will complain of pain in the wrist when weight bearing

On exam there will be swelling and tenderness on the radial (thumb) side of the wrist and loss of wrist extension

Many patients can be treated with reassurance, activity modification, Icing, Acetaminophen, NSAIDs

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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Thank You!