Magnetic Resonance Arthrography of the Wrist: The Impact on Operative Management of Wrist Injuries

Background There is no consensus on the utility of arthrography in the evaluation of wrist injuries. This study evaluates ordering trends of different types of magnetic resonance imaging (MRI) of the wrist and compares rates of surgery following these imaging modalities. Methods A national claims-based database was used to identify patients who underwent MRI within 90 days of a first-instance diagnosis of wrist injury from 2010 to 2018. The utilization of MRI without intravenous (IV) contrast, MRI with IV contrast, and MRI with arthrogram was investigated. The instances of operative procedures of the wrist within 1 year of MRI study were recorded. Patient demographics, comorbidities, type of operative procedure, and ordering physician specialty were obtained. Logistic regression analysis was used to evaluate the utilization of MRI and subsequent 1-year operative intervention rates as well as association of patient-related factors. Results Magnetic resonance arthrography use was associated with higher rates of subsequent operative treatment. Surgeons were more likely to order an arthrogram at the time of MRI. Younger patients were more likely to undergo MRI-based advanced imaging. Conclusion Surgeons may perceive MRA of the wrist to play an important role in operative decision-making following wrist injury. Level of Evidence This is a Level III, retrospective cohort study.

A Case Report of Volar Dislocation of Ulnar Head: A Very Rare Wrist Injury Easy to Overlook and Easy to Diagnose

Introduction: Ulnar volar dislocation (UVD) is a very rare entity. Due to rarity of condition, usually, it’s misdiagnosed at emergency departments and management of this clinical entity is not well studied. Here, we report a case of UVD impressing diagnostic challenge, indication of treatment, and follow-up. Case Report: A 29-year-old man presented to orthopedic outpatient service with complaining of the right wrist pain. He had an assault history 3 days before. In the emergency department, he had been diagnosed as wrist sprain. Splint and pain killers were prescribed. Due to increase of pain, he admitted to orthopedics. He was diagnosed UVD. Under general anesthesia, joint was reduced with forced pronation maneuver. After 3 weeks immobilization period, magnetic resonance images revealed partial injury of triangular fibrocartilage complex then splint removed and rehabilitation initiated. Over than 24 months, he is doing well without movement limitation and wrist strength impairment. Conclusion: For prevention misdiagnosis of UVD, physical examination is very important. Forearm rotation limitation with pain in the wrist should be indicative for distal radioulnar joint injury. Physical examination should be supported with proper evaluation of suitable radiographs. After reduction of joint, magnetic resonance images give clues about ligamentous injury. Our case supports the importance of rigorous physical examination and evaluation of radiographs for wrist injury. In the presence of partial injury of ligaments, the condition can be treated with shorter periods of immobilization and early rehabilitation. Keywords: Wrist pain, ulnar volar dislocation, distal radioulnar joint, forearm rotation.

Epidemiology and Long-Term Outcomes of Wrist Sprains in Military Academy Cadets

Background: The American Society for Surgery of the Hand advises patients that symptoms after wrist sprains resolve in 6 weeks and that recovery is usually excellent; however, there is scant supporting evidence for this reassurance. Purpose: To describe the epidemiology and report long-term outcomes of wrist sprains. Study Design: Descriptive epidemiology study. Methods: The US Department of Defense Military Health System Management Analysis and Reporting Tool was queried for wrist sprain International Classification of Diseases, Ninth Revision, codes between 2005 and 2008 among US Military Academy cadets. The electronic medical records were reviewed to obtain demographic information, mechanism of injury, and patient characteristics. A telephone survey was conducted to collect Single Assessment Numeric Evaluation (SANE) score, the shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and ability to return to full military duty. Results: Of the 90 patients identified, 49 patients (50 wrists) met the final inclusion criteria. The mean patient age was 21 years, the majority were male (86%), and most sprains occurred during athletics (65%) and military activities (20%). Most patients (61%) had radiographs taken after index wrist sprain, and few (14%) underwent magnetic resonance imaging (MRI). After a mean follow-up of 10.4 years, most patients (78%) had no further wrist injury. The average SANE and QuickDASH scores were 88 and 7.5, respectively. Two patients (4%) ultimately were treated with surgical repair. Most patients (96%) were on an upper extremity profile, limiting military duty for a median of 14 days. All patients ultimately returned to full military duty. Conclusion: Patients with a wrist sprain diagnosis were followed for an average of 10 years. Although the majority (96%) of patients required a median of 14 days with limited upper extremity function, MRI is rarely indicated in the acute setting and most patients will never have another wrist injury and can expect excellent wrist recovery outcomes.

Leading Wrist Injuries in a Golfing Population. Golf Swing Biomechanics a Significant Cause of Pathology

Golf participation has increased significantly over the past 50 years. Injury rates have mirrored this increase with amateur and elite golfers suffering a similar injury incidence to rugby players. The upper limb is the second most common anatomical site of injury in this population. Wrist injury and specifically the ulnar side of the leading wrist is the most prevalent. Leading wrist injuries affect the tendons, fibrocartilage, bones and neural structures that are located on the ulnar side of the wrist and hand as well as the soft tissue aponeurosis and bony and ligamentous canals that traverse the wrist joint. The most commonly injured lateral wrist structure is the Extensor Carpi Ulnaris tendon. This is particularly liable to injury due to the forces placed on it during the golf swing. Other structures on the medial side of the leading wrist associated with golf related injury and pathology include Triangular Fibro-cartilage, the hamate bone, the bony canals through which the nerves travel, as well as the flexor aponeurosis and Flexor Carpi Ulnaris tendon. Risk injury to the medial aspect of the leading wrist is increased by the newer golfing theories and techniques which endeavour to create increase golf club head speeds by storing greater energy by a phenomenon called “lag”. Lag results in greater speed as the club head releases at impact but results in injury to the medial wrist anatomical structures. Swing biomechanics, and their alteration and augmentation are a major factor in medial wrist injury. Diagnosis of these pathologies requires careful history and examination, as well as the use of radiology and electrodiagnostic medicine to confirm the pathology and degree. Treatment is targeted to the specific disability. Classical treatments are mostly employed and usually involve rest and anti-inflammatory treatments. Newer therapies such as Platelet Rich Plasma injection and Deep Oscillation therapy have proven beneficial. Splinting is often employed on return to play. Early diagnosis and cessation of the offending activity often allays the need for surgery. The rhyme that “minutes to diagnosis means weeks to recovery” is particularly apt for medial wrist golf injuries. Surgery will be required in long standing or chronic cases. Return to play, unlike many sports injuries, will require careful golf biomechanical assessment and alteration in swing dynamics. The objective of this chapter is to identify how the new biomechanical manipulation of the wrist and specifically the leading wrist has resulted in increased injuries to this anatomical structure. The type of injury, diagnosis and treatment is discussed in detail. Club head speed is generated through a combination of improved golf club equipment, golf payer fitness and manipulation of the golf club by the left wrist resulting in increased golf club lag and torque which all contribute to wrist injuries.

Capturing the costs of acute hand and wrist injuries: Lessons learnt from a prospective longitudinal burden of injury study

Introduction Given the high incidence of hand and wrist injuries, they are exceptionally costly to the economy. This prospective, longitudinal study aimed to establish methods for capturing the burden of acute hand and wrist injury from an individual and societal perspective. Methods A prospective longitudinal design with baseline measures of injury type and severity, and repeated measures of disability, cost, and activity limitations and participation restrictions at six weeks, three months, and six months was selected. Participants were recruited from two large urban Australian public health care services. We sought to establish methods for capturing the burden of acute hand and wrist injury from an individual and societal perspective and compare survey completion by the method of administration. Results A total of 206 patients consented to participate in this study, representing 54% of those invited to participate. The survey completion rates were 18% at six weeks, 2.4% at twelve weeks, and 0.004% at six months following injury. From the limited data collected at six weeks, it was noted that nearly half of the patients reported a decrease in usual financial income, 14% reported absenteeism, and 62% reported presenteeism. Participants who elected to have data collected via phone call had the highest survey completion rate ( n = 6/10; 30%) at six-week’s follow-up. Discussion The study findings highlight the difficulties of completing longitudinal survey research investigating individual and societal burden with this population. Future research should be carefully designed to encourage participation and retention by considering patient and public involvement in study design, the time burden placed on the participants within and across selected survey time points, providing participants with incentives to participate, and highlighting the relevance and real-world applications of the findings.