Pediatric Wrist Pain Dr Leah Hillier MD CCFP
- Slides: 29
Pediatric Wrist Pain Dr. Leah Hillier MD CCFP (SEM) May 26 th, 2017 DAVID L. MACINTOSH SPORT MEDICINE CLINIC FACULTY of KINESIOLOGY and PHYSICAL EDUCATION UNIVERSITY of TORONTO
Agenda ▪ Case ▪ Specific Paediatric Considerations ▪ Differential Diagnosis ▪ History ▪ Anatomy/Physical ▪ Imaging ▪ Questions
Wynonna Rist ▪ 10 year old female ▪ left-handed ▪ gymnast (6 hours per week of gymnastics) ▪ presenting with left radial-sided wrist pain ▪ insidious onset (no traumatic event), gradually worsening ▪ pain primarily when weight bearing on the wrist, though does also have some aching at rest after gymnastics ▪ no swelling, not keeping her up at night, not stopping her from participating in gymnastics, but bothering her at times when writing at school
PEDIATRIC CONSIDERATIONS
Pediatric considerations ▪ Children’s bones have more cartilage and collagen than adults’ ▪ The skeleton is relatively weaker, but has greater elasticity (Frost 2000, Davis 2010) ▪ Growth plates are still open ▪ The periosteum is more active and promotes rapid healing and remodelling (Dwek 2010) ▪ Children tend to have more injuries of epiphyses and apophyses
Pediatric considerations http: //bones. getthediagnosis. org
Normal pediatric bone development in the wrist Radiopaedia
Normal pediatric bone development in the wrist Age 6 Age 9 Age 11 Age 13 http: //bones. getthediagnosis. org
DIFFERENTIAL DIAGNOSIS
Pediatric wrist differential diagnosis TRAUMA ▪ Buckle, greenstick, complete, and physeal injuries ▪ Galeazzi-equivalent Fractures http: //pubs. rsna. org/doi/full/10. 1148/rg. 342135073
Salter-Harris Classification Buckle fractures
Differential diagnosis of wrist pain ▪ Bony ▪ Distal radius fracture ▪ Acute scaphoid fracture ▪ Scaphoid stress fracture ▪ Other carpal fractures ▪ Carpal dislocation ▪ Growth plate injury - distal radial physeal injury (Gymnast’s wrist) ▪ Bennett fractures (1 st metacarpal fractures) ▪ Scaphoid Impaction Syndrome ▪ Ulnar stress fracture ▪ Osteoarthritis
Differential diagnosis of wrist pain ▪ Soft Tissue ▪ De Quervain’s tenosynovitis (tenosynovitis of the tendons of the first extensor compartment of the wrist: the abductor pollicis longus and extensor pollicis brevis) ▪ UCL injury of the thumb ▪ Extensor carpi ulnaris (ECU) tendonitis (overuse injury of the ECU tendon in the wrist) ▪ Extensor carpi ulnaris subluxation (rupture to medial wall of the ECU tendon sheath secondary to sudden or repetitive flexion and ulnar deviation, causing subluxation of ECU. ) ▪ Intersection syndrome: inflammation at the crossing points of the tendons of the first dorsal compartment and the extensor radialis longus and brevis. This point is typically 2– 3 in. proximal to the radio-carpal joint. This entity is seen in sports involving repetitive wrist extension. ▪ Scapholunate injuries ▪ Lunotriquetral injuries ▪ Triangular fibrocartilage complex (TFCC) injuries ▪ Distal radioulnar joint injury ▪ Ganglion
Differential diagnosis of wrist pain ▪ Other ▪ Carpal tunnel syndrome ▪ Wartenberg’s syndrome (nerve entrapment of the cutaneus branch of the radial nerve) ▪ Infection/osteomyelitis ▪ Crystal arthropathy/gout ▪ Inflammatory conditions (RA, psoriatic arthritis, etc) ▪ Neoplasm ▪ Referred pain from c-spine, brachial plexus, shoulder
History ID: includes dominant hand (in writing? in sport? ) CC: Location of pain (could you point to where you feel your discomfort? ) HPI: Start of symptoms (acute versus insidious onset) ? trauma ? mechanism of injury ? change in training load Aggravating and relieving factors Allergies/Meds/PMHx/Surg. Hx/Injuries Activities: Level of training, hours per week, level of competition, plans for the future in sport, other hobbies that involve hand/wrist (? guitar ? piano ? art) Development: Menarche, Growth spurt (how much? over what time period? ) Soc. Hx: Work in adults (? manual labour ? jackhammers ? manual dexterity ? repetitive motions) Fam. Hx: ? rheum ? connective tissue, etc Symptoms: pain, swelling, paresthesias, clicking, stiffness, function
Physical ▪ Having the patient show you the location of pain as a first step can often help to take a more efficient history ▪ both hands on pillow exposed above the elbows ▪ always compare to the contralateral side
Dorsal anatomy
Volar anatomy
Volar anatomy
Soft tissue anatomy
Key wrist landmarks
Sensation of the hand/wrist
Physical exam inspection • Skin changes (psoriatic plaques, lacerations) • Muscle wasting (thenar wasting, interosseous wasting) • joint deformity (heberden’s nodes, bouchard’s nodes, CMC squaring, subluxation/ulnar deviation, gouty tophi) • Swelling (dactylitis, individual joints), warmth • Masses (ganglion)
Physical exam inspection
Physical exam inspection
Physical exam inspection
Physical exam inspection
Physical exam manœuvres • ROM • Power • Neuro • Palpation of anatomic snuff box, axial loading of thumb (scaphoid pathology) • Piano key sign (DRUJ) • Finkelstein’s, resisted thumb extension (De Quervain’s) • Phalen’s, Tinel’s (carpal tunnel) • TFCC grind, fovea test (TFCC tear) • Watson’s test, palpation of SL ligament (SL ligament instability) • UCL stress testing (Gamekeeper’s thumb)
Physical exam manœuvres
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