CARPAL INJURIES

SCAPHOID FRACTURE

Fracture of the carpalscaphoid bone is the most common fracture of the carpus and frequently diagnosis is delayed

Incidence-Scaphoid fracture accounts for about 50-80% of'carpal injuries

Diagnosis Afld Investigations- Clinical evaluation +Xrays (PA Lateral, scaphoid & clenched fist view) MRI, CT, bone scan maybe used to diagnose occult fractures

Complications- Delayed union, non union, osteonecrosis, CRPS

Management-

Conservative : 6-8 weeks glass holding cast for undisplaced fractures. For displaced and nonunion fractures of scaphoid refer to higher centre-for operative procedures where facilities are available.

HAND FRACTURES

 Metacarpal and phalangeal fractures are common comprising 10% of all fractures. There is high incidence of variation of mechanism of injury accounting for broad spectrum of patterns of fractures in hand.

Incidence and Classification - Distal phalanx fracture are most common of all hand fractures (45%) followed by metacarpal fractures (30%), proximal phalanx (15%) and middle phalanx (10%).   -

Diagnosis and investigations - Clinical evaluation + X-rays (PA, Lateral & oblique radiographs). CT may be required to assess the intraarticular fractures

Complications - Delayed union, malunion, nonunion, CRPS, stiffness & loss of motion, Infection, post traumatic osfeoarthrifis etc.

Management -

Metacarpal fractures: Undisplaced stable fractures can be treated conservatively with MCP joint immobilized >70 degrees. Displaced fractures usually require ORIF with K-wires or mini-plates.

Proximal phalanx& middle phalanx:

•                          Intraarticular fractures-ORIF is preferred. For comminuted fractures, ligamentotaxis with external fixators or specialised reconstruction techniques can be used.

•                          Extra articular-Stable fractures: conservative

•                          Unstable-CRlF or ORIF (K wire or mini plate)

Distal phalanx:

•                          Intra-articular fracture (Mallet finger) - Extension block pinning for mallet finger. Extension splitting for soft mallet finger

•                          Extraarticular fractures - Usually treated as soft tissue injury. If displaced widely, CRlF is recommended.

Reasons- for referral to higher centre- Lack of expertise, lack of infrastructure, fracture dislocations.

Tendon injuries: Patient with tendon injuries should be referred to higher centres for surgical procedure where the facilities are available.

CARPAL TUNNEL SYNDROME

Introduction- It is a syndrome of compressive neuropathy of median nerve at wrist caused due to elevated pressure within carpal funnel. Carpal funnel is a fibrous tunnel formed by palmar hallow of the articulated carpal bones & roofed by flexor retinaculum.

Aetiology-

·       Rheumatoid inflammation of flexor tendon sheath

·       Compound palmargangliori

·       Anterior dislocation of lunate

·       Malunited Colle's fracture

·       Myxoedema

·       Amyloidosis

·       DM

·       Steroid use

·       Pregnancy causing edema of tissues

Clinical Features-

·       Pain

·       Paraesthesia over palmar aspect of hand

·       Hand numbness worsening at night

·       Weakness and wasting of thinner muscles and sensory deficit

Treatment-

•                          Non operative methods such as NSAIDs and steroid injections

•                          If specific cause present, treat the cause

If patient does not respond to the conservative treatment then refer to higher centre where all the facilities are available.