RADIOCARPAL JOINT

From Big Medical Encyclopedia

RADIOCARPAL JOINT [articulatio radiocarpea (PNA, BNA); articulus radiocarpicus (JNA)] — the joint of the distal end of a beam bone of a forearm with a proximal number of bones of a wrist relating to joints of a brush. Hp can be considered separately only in purely anatomic plan. In fiziol, and a wedge, the relations it is one of components of a difficult wrist joint (art. manus) consisting of a radiocarpal joint (art. radiocarpea); srednezapyastny joint (art. mediocarpea) — between proximal and distal ranks of bones of a wrist; intercarpal joints (articulationes intercarpeae) — joints between separate bones of a wrist; carpal and metacarpal joints (articulationes carpometacarpeae) — joints between a distal number of bones of a wrist and the bases of metacarpal bones; intermetacarpal joints (articulationes intermetacarpeae) — joints between the bases of the II—V metacarpal bones; distal radioulnar joint (art. radioulnaris distalis) — a joint between a distal epiphysis of beam and elbow bones. All listed components of a wrist joint are in close anatomic and functional unity.

Anatomy

Fig. 1. Linking of the left brush (dorsum): 1 — an interosseous membrane of a forearm; 2 — an ulna; 3 — an awl-shaped shoot of an ulna; 4 — an elbow collateral ligament of a wrist; 5 — a trihedral bone; 6 — an uncinatum; 7 — a capitate bone; 8 — the fifth metacarpal bone; 9 — back metacarpal sheaves; 10 — back carpometacarpal sheaves; 11 — a polygonal bone; 12 — back intercarpal sheaves; 13 — a navicular; 14 — a beam collateral ligament of a wrist; 15 — a back radiocarpal sheaf; 16 — an awl-shaped shoot of a beam bone; 17 — a beam bone.
Fig. 2. Linking of the left brush (palmar surface): 1 — an interosseous membrane of a forearm; 2 — a beam bone; 3 — an awl-shaped shoot of a beam bone; 4 — a palmar radiocarpal sheaf; 5 — an uncinatum; 6 — a beam collateral ligament of a wrist; 7 — a hillock of a navicular; 8 — a radiant ligament of a wrist; 9 — a polygonal bone; 10 — a palmar metacarpal sheaf; 11 — the first metacarpal bone; 12 — a hook of an uncinatum; 13 — gorokhovidno - a metacarpal sheaf; 14 — a capitate bone; 15 — a pea-shaped and hook sheaf; 16 — a pea-shaped bone; 17 — an elbow collateral ligament of a wrist; 18 — an ulna.
Fig. 3. Joints and linking of the left brush (cut parallel to a back of the hand): 1 — a beam bone; 2 — a radiocarpal joint; 3 — a navicular; 4 — a beam collateral ligament of a wrist; 5 — a trapezoid bone; 6 — a polygonal bone; 7 — an uncinatum; 8 — a capitate bone; 9 — a trihedral bone; 10 — an elbow collateral ligament of a wrist; 11 — a semi-lunar bone; 12 — interosseous intercarpal sheaves; 13 — a joint disk; 14 — a distal radioulnar joint; 15 — an ulna; 16 — an interosseous membrane of a forearm.
Fig. 4. The opened radiocarpal joint: 1 — a joint disk; 2 — the joint capsule; 3 — a trihedral bone; 4 — a semi-lunar bone; 5 — a navicular; 6 — the carpal joint surface of a beam bone.

At the majority of mammals both bones of a forearm take part in formation of Hp and joint surfaces have the form of the block. Due to the development of ability to pronation and supination between beam and elbow bones the isolated radioulnar joint forms, and at the distal end of an ulna the cartilaginous disk which at the person reaches the highest development develops.

Development of Hp in ontogenesis begins since the beginning of the 3rd month of an antenatal life and is connected with development of bones of a forearm and a brush. By the time of the birth joint surfaces still flatly, the capsule of a joint is thin, sheaves are not clearly expressed. Further formation of a joint, as well as other joints, happens depending on volume and the nature of its function.

The socket of Hp is formed by the carpal joint surface of a beam bone (facies articularis carpea radii) added from the elbow party of triangular shape with a connective tissue cartilage — a joint disk (discus articularis) which is strengthened by the basis at bottom edge of elbow cutting of a beam bone, and a top — on an awl-shaped shoot of an ulna. In front and behind it is connected with palmar and back radiocarpal and palmar loktezapyastny sheaves. Thickness of a disk in different departments fluctuates from 2 to 5 mm. The carpal joint surface of a beam bone has two impressions divided among themselves by the roller for carinate and semi-lunar bones. Cross sectional dimension of a joint surface is equal to 4 — 5 cm, back and palmar — 1,5 — 2 cm. The articular head is made by a proximal number of bones of a wrist: carinate (os scaphoideum), semi-lunar (os lunatum) and trihedral (os triquetrum), connected among themselves by intercarpal sheaves. Thickness of a joint cartilage fluctuates from 0,2 to 1,1 mm.

The joint crack of Hp in the radioulnar direction is projected in the form of the arc-shaped line from an awl-shaped shoot of a beam bone to an awl-shaped shoot elbow (tsvetn. fig. 1 — 4).

Joint capsule of Hp wide and thin; its upper edge is densely attached to edges of a carpal joint surface of a beam bone and a joint disk, lower — to edge of a joint surface of the first row of bones of a wrist. The capsule is strengthened by the following sheaves: on a dorsum — a back radiocarpal sheaf (lig. radiocarpeum dorsale), going slantwise, distally towards an ulna and fixed on a dorsum of bones of a wrist; on a palmar surface two sheaves — palmar loktezapyastny (lig. ulnocarpeum palmare) and palmar radiocarpal (lig. radiocarpeum palmare). The last originates from an awl-shaped shoot of a beam bone and is attached to bones of a wrist, and the loktezapyastny sheaf begins from the basis of an awl-shaped shoot of an ulna, a joint disk and is attached to trihedral and semi-lunar bones. From sides of Hp it is strengthened by a beam collateral ligament of a wrist (lig. collaterale carpi radiale) and elbow collateral ligament of a wrist (lig. collaterale carpi ulnare).

The joint capsule of Hp from sides is tense stronger, than with palmar and the back. Between yarns of sheaves the capsule quite often forms folds and protrusions which can give rise to cysts or hygromas of a joint.

The form of joint surfaces of a srednezapyastny joint differs in complexity and allows to consider it blokovidny or consisting of two spherical joints. The capsule is attached on edge of joint surfaces and from the back is free, the synovial membrane forms it folds. Bones of a wrist are connected among themselves by intercarpal interosseous sheaves (ligg. intercarpea interossea) and intercarpal joints (artt. intercarpeae). Sheaves do not fill completely intervals between bones of a distal number of a wrist therefore between them the cracks reporting a cavity of a srednezapyastny joint with carpal and metacarpal are formed. Joint of a pea-shaped bone (art. ossis pisiformis) represents a separate joint, in Krom it is jointed with a trihedral bone. Two sheaves: pea-shaped and hook (lig. pisohamatum) and gorokhovidnopyastny (lig. pisometacarpeum), the sinews of an elbow sgibatel of a wrist which are continuation, strengthen this joint. From palmar side of a bone of a wrist and the basis of metacarpal bones are connected by numerous palmar intercarpal sheaves (ligg. intercarpea palmaria), from which distinguish the bunches dispersing from a head of a capitate bone to the next bones — a radiant ligament of a wrist (lig. carpi radiatum). Over a furrow of a wrist, between elbow and beam eminences of a wrist, will pull a retinaculum of sgibatel (retinaculum flexorum). Back intercarpal sheaves (ligg. intercarpea dorsalia) are developed more weakly, than palmar.

To a palmar surface of Hp prilezhat two synovial vaginas of sinews of sgibatel of the fingers located under a retinaculum of sgibatel (retinaculum flexorum). To the back of Hp prilezhat the sinews of razgibatel of a wrist and fingers lying in six synovial vaginas under a retinaculum of razgibatel (retinaculum extensorum). At an awl-shaped shoot of a beam bone the beam artery passes to a back of the hand. The elbow artery and veins together with the nerve of the same name pass in an elbow furrow.

Hp belongs to two-axis joints with an ellipsoidal form of joint surfaces. In it the movements are possible: 1) in the sagittal plane — bending and extension; 2) in the frontal plane — reduction and assignment (an elbow and beam deviation); 3) roundabout (circumductio) when the ends of fingers spin. Amplitude of flexion and extensive movements averages in the sum apprx. 140 — 150 °; from them a half is the share directly of Hp, and another — of a srednezapyastny joint. During the bending and extension, assignment and reduction of a brush there is a simultaneous movement in both joints.

Blood supply Hp is carried out by carpal palmar and back branches of beam and elbow arteries and final departments of front and back interosseous arteries. These branches create palmar and back arterial networks of a wrist (rete carpi palmare et rete carpi dorsale). Veins, of the same name with arteries, fall into deep and superficial veins of a forearm.

Limf, vessels from Hp go to elbow and axillary limf, to nodes, following on the course of arteries (deep) or on the course of superficial veins (superficial).

Innervation Hp comes at the expense of front and back interosseous nerves (from median and beam nerves) and a deep branch of an elbow nerve.

The main muscles bending a brush are the beam sgibatel of a wrist, an elbow sgibatel of a wrist and a long palmar muscle. Other muscles located on a front surface of a forearm have indirect effect on a joint. Extension of a brush is made long and short beam razgibatel of a wrist, an elbow razgibatel of a wrist. Other razgibatel act on Hp indirectly. Assignment happens due to action of short and long beam razgibatel of a wrist, a beam sgibatel of a wrist, the long muscle which is taking away a thumb and long and short razgibatel of a thumb. Reduction is carried out thanks to action of an elbow sgibatel and a razgibatel of a wrist at the same time.

The radioanatomy

the X-ray analysis in direct (palmar) and side (elbow) projections gives the optimum review of a wrist joint. The corresponding laying of a hand is necessary for obtaining standard and undistorted images. The patient is seated sideways to a table, the shoulder is taken away on 45 — 50 °, the forearm is bent at an angle 90 °. In a direct projection the hand is pronirut, the brush is stacked parallel to the plane of the cartridge by easy bending of fingers at an elbow deviation of a brush on 10 — 15 °. In a side projection the brush is established by elbow edge in the vertical plane (aweigh) that distal department beam and an ulna, and also metacarpal bones were imposed at each other at a neutral position of a brush. Brush have on the cartridge (13 X 18) it is central the image included a distal quarter of a forearm and metacarpal department; the tube is deleted from a joint on 70 — 90 cm; the central bunch of beams shall pass perpendicularly to a joint at the level of Hp. Quality and degree of structure of the image are reached by elimination of motive (dynamic) unsharpness, diaphragming of a bunch of beams, selection of the corresponding exposure. The simultaneous X-ray analysis of both wrist joints which is carried out for the purpose of comparison of a sore and healthy hand does not allow to receive the correct images; it is necessary to remove each joint in the set identical projections separately.

In direct pictures (fig. 1) almost all bones having equal contours, and joint cracks in the form of accurate strips of an enlightenment are separately visible; the exception is made a trapeze (a polygonal bone) with a trapezoid bone, pea-shaped with a trihedral bone which can be seen separately only in slanting projections. The vertical crack of a distal radioulnar joint has width to 2 — 2,5 mm, a horizontal arc-shaped crack of a radiocarpal joint — to 2 — 2,5 mm, a horizontal S-shaped crack of a carpal joint — 1,5 — 2 mm, the horizontal broken crack of carpometacarpal joints — 1,5 — 2 mm, vertical cracks between separate bones of a wrist and the bases of metacarpal bones — 1 — 1,5 mm.

All bones making a wrist joint have a spongy structure, cortical substance is expressed poorly, but is more distinct on epiphyseal edge of a beam bone.

Nek-raya irregularity of intensity of blackout of bones is caused by hl. obr. imposing of a hook of an uncinatum on her body, trapezes — on a trapezoid bone, a hillock of a trapeze — on her body, a pea-shaped bone — on trihedral and partly on an uncinatum. From edges of a joint awl-shaped shoots of beam and elbow bones will stand. In 75% of cases the distal ends of beam and elbow bones are at one level (0 option), in 20% the ulna acts distalny beam (plus option of an ulna or minus option beam), in 5% the ulna is shorter elbow (minus option of an ulna or plus option of a beam bone). Owing to an inclination of an epiphysis of a beam bone in the palmar party on 5-15 ° (in 80%) its joint platform is imposed on proximal departments of carinate and semi-lunar bones.

Fig. 1. (Above) and schemes (in the bottom of) a wrist joint it is normal of the roentgenogram (at the left — a direct projection, on the right — a side projection): 1 — a beam bone; 2 — an ulna; 3 — an awl-shaped shoot of an ulna; 4 — a navicular; 5 — a semi-lunar bone; 6 — a trihedral bone; 7 — a pea-shaped bone; 8 — a trapeze; 9 — a trapezoid bone; 10 — a capitate bone; 11 — an uncinatum; 12 — 16 — metacarpal bones.

In pictures in a side projection (fig. 1) there is an imposing of bones at all levels of a wrist joint, but its basic elements and their ratios are traced clearly. Metacarpal bones, capitate, semi-lunar and beam bones are located on the center axial line and as if implanted each other; joint cracks between them are well distinguishable. Carinate and semi-lunar and carinate and capitate corners make 45 — 50 °. Cracks of the trapetsiopyastny and trapetsioladyevidny joints (which are partially covered with a pea-shaped bone) are separately visible. Only the front department of a trapeze, hillock of a navicular and the end of a hook of an uncinatum are free from imposings; on the back the edge of a trihedral bone slightly acts. The wedge-shaped shadow of an awl-shaped shoot of a beam bone accumulates on proximal departments of carinate and semi-lunar bones, and the awl-shaped shoot of an ulna is projected on the rear edge beam or slightly acts in the distal direction. Average terms of emergence of points of ossification in the bones making a wrist joint: capitate and ankyroid bones — by 3 months, an epiphysis of a beam bone — by 12 — 14 months, an epiphysis of metacarpal bones — by 1 — 2 years, a trihedral bone — by 2 — 3 years, a semi-lunar bone — by 3 — 4 years, carinate, a trapeze and trapezoid bones — by 4 — 6 years, an epiphysis of an ulna — by 6 — 7 years.

Methods of a research

Inspection of a wrist joint should be run by comparison with a healthy hand. At survey, a palpation, measurements with a research of function of a joint it is necessary to use identification points which awl-shaped shoots of beam and elbow bones, Lister's hillock (an apophysis of the distal end of a beam bone), a head of an ulna, hillocks of a navicular and a trapeze, a pea-shaped bone and a hook of an uncinatum, basis of metacarpal bones, and also skin reference points — a back furrow, proximal and distal palmar furrows of a wrist are among.

Fig. 2. The diagrammatic representation of amplitude of movements in a wrist joint is normal (in degrees): 1 — bending and extension; 2 — a beam and elbow deviation.

Amplitude of movements in a wrist joint — bending, extension, beam and elbow deviations — determine by a goniometer, reckoning from the neutral, zero provision of a brush (fig. 2).

Rentgenol, researches figure prominently in recognition and treatment of defeats of a wrist joint. For the correct treatment found rentgenol, changes it is important to consider constitutional, age and professional variability of Hp and all wrist joint, their anatomic options. For the purpose of obtaining additional information and specification of nature of defeats of a wrist joint make a X-ray analysis with horizontal laying in I braids (semi-pronation) and the II braid (semi-supination) projections. Use vertical (axial) projections of a carpal tunnel less often (the palmar surface of a joint in a profile) and the carpal bridge (a dorsum of a joint in a profile).

According to special indications apply a X-ray analysis with direct blowup, a tomography, an artropnevmografiya (see. Artrografiya ), film X-ray analysis.

At pathology of a wrist joint it is possible to see with the broad range of a deviation from a normal X-ray anatomic picture — from hardly traceable changes and small cystic enlightenments before extensive destructions and full disorganization of a joint. There are narrowings, deformations of joint cracks, changes in a configuration of bones to their superpositions and disappearance of joint cracks; changes of contours of bones, their deformation and fragmentation, zones of a sclerosis or osteoporosis, the centers of destruction, regional growths, ossificates come to light.

Pathology

As Hp is only one of parts of a wrist joint, any pathology of Hp or the next joints leads to disorder of function of all wrist joint. The joints forming a wrist joint consider separately only at certain defeats or interventions.

Malformations

, as a rule, do not cause Many porsk of development of a wrist joint noticeable funkts, frustration and are found accidentally; at the same time they can be shown with age, to become the contributing or burdening factor at damages and diseases of a wrist joint.

Concrescenses (merge) of bones of a wrist joint find at 0,6 — 0,7% of people; they occur among inhabitants of Africa more often than at Europeans. Concrescense of bones in transverse direction — polulunno-trihedral and capitate and ankyroid is most frequent. At merge of several bones, especially in lengthwise direction, the movements in a joint are considerably limited.

The hypoplasia and an aplasia of a wrist joint meet seldom. The underdevelopment or lack of a navicular is the most typical that can be combined with an underdevelopment of the I finger. The hypoplasia of all wrist or lack of a proximal number of bones of a wrist is shown sometimes only by excessive mobility in a joint, but with age frustration amplify because of insolvency of the copular device and instability of a wrist joint. Among additional (non-constant) bones the greatest a wedge, the awl-shaped bone (os styloideum) which is located from beam edge between the bases of the III metacarpal and capitate bones matters. Occurs at 1 — 2% of people and can give rise to painful ledges on a back of the hand which sometimes need to be resected.

The doubled navicular (os scaphoideum bipartitum) which was considered long since inborn so-called is referred to category of posttraumatic states. This pathology according to indications it is necessary to treat as nearthrosis (see).

Congenital dislocations of a brush are extremely rare and usually caused by defects of a beam bone (see. Talipomanus ). Inborn flexion contractures of a brush develop in connection with disturbances of an embryogenesis or birth trauma.

At deformation of Madelunga developing owing to a growth disorder of a distal epiphysis of a beam bone there is spontaneous hron, an incomplete dislocation of a brush. The forming typical skoshennost of the joint platform of a beam bone in palmar and elbow side and delay of growth of a beam bone lead to gradual shift of a brush in the palmar party and a vystoyaniya of a head of an ulna in the distal and back direction (see. Madelunga disease ).

Damages

Damages of a wrist joint make 30 — 35% of all changes and dislocations of bones of a skeleton.

Diagnoses stretching and bruise it is necessary to put with care, only after an exception of injuries of bones, joints, interosseous sheaves, a joint cartilage of bones of a wrist at the level of Hp and copular and capsular structures of a wrist joint. Result from injuries of soft tissues of a wrist joint a hematoma, tenosinovit, a peritendinitis, an apophysitis, a ganglion. Treatment of damages of soft tissues and a joint cartilage generally conservative, including an immobilization during 2 — 5 weeks.

Damages of a joint disk (discus articularis) quite often accompany fractures of a beam bone in the typical place, but can be and isolated. At persistent pains, the phenomena of a zashchelkivaniye excision of a disk is shown.

Dislocations in the field of a wrist joint, the making 2% of all traumatic dislocations, include dislocations of bones of a wrist, metacarpal bones and a head of an ulna which meet in the ratio 14: 1: 0,5. Because of features of a structure and the mechanism of a wrist joint levels of shifts of bones of a wrist usually do not match levels of anatomic division. Therefore dislocations of a brush in the area of Hp and a carpal joint are very rare.

Fig. 3. Roentgenograms of wrist joints in a straight line.i side projections: 1 — at back perilunartsy dislocation of a brush; 2 — at palmar dislocation of a semi-lunar bone.

The so-called perilunarny dislocations making 90% of all dislocations of bones of a wrist have the greatest practical value. There are many types of such dislocations, the main — initially arising back perilunarny dislocation of a brush (the semi-lunar bone remains in the bed) and formed for the second time as a result of self-reposition of a brush — palmar dislocation of a semi-lunar bone (fig. 3). These dislocations together with chrezladyevidno-perilunarny dislocation of a brush (when the line of dislocation passes under a semi-lunar bone and through the broken navicular) are observed in 4 cases from 5 dislocations of a wrist joint. Are characteristic of perilunarny dislocations, in addition to deformation of a joint, its shortening, forced halfbent position of fingers, disorder of sensitivity in a zone of a median nerve, the spontaneous pains which are sharply amplifying at night within 4 — 7 days even at an immobilization.

The type of dislocation can be established precisely only according to roentgenograms in two standard projections.

Fig. 4. The diagrammatic representation of reposition of dislocation of a semi-lunar bone in the distraktsionno-rychagovy way (on schemes of a skeleton the semi-lunar bone is shaded; shooters showed the direction of movements at reposition): 1 — a type of a brush at dislocation of a semi-lunar bone (a smoothness of contours of a wrist joint, increase in its circle, the bent position of fingers); 2 — stretching of a wrist joint on length at the supinated forearm and a brush; 3 — extension of a brush at the proceeding stretching; 4 — reposition of a semi-lunar bone at simultaneous bending and stretching of a brush; 5 — a state after reposition of dislocation.

The closed reposition is feasible within 7 — 10 days from the moment of dislocation. The distraktsionno-rychagovy way of reposition (fig. 4) is most rational. Unsuccessfulness of 1 — 2 attempts of the closed elimination of shifts forces to make open reposition urgently.

Fig. 5. Diagrammatic representation of temporary stabilization of joints of a brush and their bones spokes (continuous straight lines): 1 — after reposition of dislocations of bones of a wrist and at partial artificial ankyloses; 2 — after reposition of vyvikhoperelom of bones of a wrist and at bone plastics of nearthroses of a navicular; 3 — after reposition of dislocations of metacarpal bones and at an artificial ankylosis of carpometacarpal joints; 4 — after reposition of dislocations in a distal radioulnar joint.

Dislocations of metacarpal bones arise preferential at direct violence. To 80 — 85% of shifts — back, back and elbow. I and V metacarpal bones holding regional position are exposed to the isolated shifts rather more often. Simultaneous dislocations of two-three metacarpal bones are most typical. In 25 — 30% of cases together with metacarpal bones separate bones of a distal number of a wrist are displaced. The closed reposition is rather easy. At instability of the set bones make transdermal fixing by spokes of carpometacarpal joints (fig. 5, 1—3).

The palmar and back isolated dislocations of a head of an ulna meet in a proportion 2:1. They arise at violent supination or pronation. The acute pain and a crash are characteristic during an injury, narrowing of the radioulnar size at palmar shift, vystupany heads of an ulna at back dislocation, disturbance of rotational movements of a brush and a forearm. Reposition of fresh dislocation does not present difficulty, but the immobilization during 6 weeks on average position of a forearm with fixing of an elbow joint is necessary for prevention of a recurrence. More reliable before imposing of a plaster bandage to make cross fixing by spokes of both bones of a forearm (fig. 5,4).

Changes

Changes of a distal epimetafiz of a beam bone are mostly presented by fractures of a beam bone in the typical place with shift or without it, combined quite often with a change of an awl-shaped shoot of an ulna, damage of a joint disk and an incomplete dislocation of a head of an ulna (see. Kollis change ). After reposition of changes, especially splintered and shattered, often there comes secondary shift in a plaster bandage with disturbance of proper correlations at the different levels of a wrist joint. Therefore at unstable changes after reposition it is necessary to make fixing by spokes, and in particularly complex cases to resort to fixing in the device (see. Distraktsionno-kompressionnye devices ).

The isolated changes of awl-shaped shoots of beam and elbow bones meet infrequently. The first are usually without noticeable shift and grow together well. After changes of an awl-shaped shoot of an ulna the nearthrosis is quite often formed, there can be pains and considerable funkts, frustration. In these cases removal of the torn-off fragment with simultaneous audit of a joint disk is shown.

Changes of a navicular make from 70 to 85% of all fractures of bones of a wrist and hl meet. obr. at men aged from 18 — 20 up to 30 years. Taking into account a role of a navicular as main stabilizer in the mechanism of a wrist joint attach to early recognition of its changes special significance. Quite often right after an injury the line of a change on roentgenograms is badly traced; therefore in diagnosis give a priority a wedge, to signs (a smoothness of an anatomic snuffbox, local morbidity at palpation, local pain at effleurage on heads of I and II metacarpal bones, and also at beam and elbow deviations of a brush). Shifts at fresh changes, as a rule, do not happen. On roentgenograms in a straight line and the I braid projections the crack between fragments becomes clearer 10 — 14 days later from the moment of an injury. At a continuous immobilization a circular plaster bandage during — 12 weeks (depending on level and the provision of the plane of a break, age of the patient) the union comes in 95 — 96% of cases. At nearthroses of a navicular (fig. 6) the sclerosed switching plates on the ends of fragments with accurately designated crack between them various width and a form come to light; in the subsequent the deforming arthrosis which usually is most expressed in the area of a ladyevidnoluchevy joint develops. At bezbolevy nearthroses of a navicular conservative treatment is shown. Operational treatment of uncomplicated nearthroses consists in different types of bone plastics with use of spongy autografts. In the presence of the accompanying deforming arthrosis of Hp, an aseptic necrosis of fragments of a navicular resort to partial artificial ankyloses of a wrist joint or endoprosthesis replacement of a navicular.

Fractures of a trihedral bone meet in 17 — 20% of cases of all fractures of bones of a wrist and most often happen detachable. Fractures of a semi-lunar bone have generally character compression (in addition to more frequent changes of a back horn), meet seldom and their recognition is complicated (see. Kinbeka disease ). Fractures of a capitate bone are rare and usually occur at the level of a waist (upon transition of a body to a head). Regarding cases there is a rotation of a head, to-ruyu it is possible to eliminate only quickly. At changes of a hook of an uncinatum quite often there comes the compression of a motive branch of an elbow nerve.

Open damages of a wrist joint (isolated) meet seldom; they can be put to hl. obr. the cutting or cutting tools. As a result of direct violence (a prelum the press of a pla details, at hit of a hand between the rotating parts of cars or shaft, at influence of the rotating tool) together with a wrist joint damages the next departments of a brush or a forearm. Fractures and dislocations in similar conditions usually happen atypical. Operations are performed by the principles of the technology of treatment of open damages of a brush (see. Brush ). Since at the massive getting wounds at the level of a wrist joint the structures relating to distal departments of a brush are damaged, any interventions shall be directed, first of all, to rescue of function of fingers with recovery of sinews, nerves, integuments. In these conditions sometimes it is necessary to endow a part of function of a wrist joint, making excisions of the injured bones, temporary or continuous stabilization of a joint. Repeated recovery operations are often necessary.

Diseases

Inflammatory processes in a wrist joint happen isolated (monoarthritises) or in the form of one of the centers of widespread defeat. Nonspecific purulent arthritises (see) a wrist joint arise after the getting or not getting wounds, at spread of an infection from a brush or a forearm (hl. obr. owing to a purulent tenobursitis of an elbow bag) and as metastatic defeat at a pyemia or sepsis.

In an initial phase of a disease it is necessary to carry out active antiinflammatory therapy with introduction of antibiotics, an immobilization. During the progressing of process and detection of pus by means of a puncture the arthrotomy with a section on the elbow party of a palmar surface of a wrist joint, washing of a cavity of a joint antiseptic agents, audit of bones is shown. Further through constant tubular drainages wash out a joint, enter antibiotics.

To hron, to nonspecific inflammations carry quite often found pseudorheumatisms of a wrist joint which sometimes are one of the first displays of rhematoid polyarthritis (see. Pseudorheumatism ).

Gonorrheal arthritises of a wrist joint occur among gonorrheal damages of joints quite often and are often shown in the form of mono-arthritis. The disease begins with acute, intolerable pains and quickly increasing hypostasis extending to fingers and a forearm in the absence of symptoms of the ascending infection in the form of a limfangiit; at palpation and attempts of the movement in a joint and fingers there is a sharp morbidity. Radiological note very bystry development of sharply expressed regional osteoporosis. Early the begun massive antibioticotherapia and an immobilization stop development of process. At overdue diagnosis defeat of all parartikulyarny fabrics, destruction of joint cartilages, a spayaniye of sinews is inevitable.

To hron, to specific inflammatory processes of a wrist joint tubercular, brucellous, syphilitic arthritises belong. Tubercular arthritises of a wrist joint occur at 2 — 3% of patients with active forms of bone and joint process, there are hl. obr. in the form of primary osteitis beginning usually in a beam half of a proximal number of a wrist with the subsequent accession of arthritis at the level of Hp. Most often find already widespread process taking at least a part of a wrist and distal epimetafiza of a forearm or bone of a wrist and the basis of metacarpal bones. In rare instances find the isolated centers — in an epiphysis of a beam bone, in carinate, semi-lunar bones. The closed forms of tuberculosis of a wrist joint (without fistulas and abscesses) meet in 50 — 60%, and monoarthritises — in 60 — 70% of cases of damage of a joint tuberculosis.

At tubercular defeat of a wrist joint on roentgenograms find diffusion uneven osteoporosis, deformation and destruction of bones with blurring of a bast layer and an izjedennost of edges, reduction and disappearance of joint cracks. At early stages of a disease rest in a combination to specific chemotherapy can be led to recovery. But at extensive destructions it is not necessary to count on recovery of function even at a zatikhaniye of process; in these cases the combined treatment is shown. The most reliable concerning process interrupt and improvement of function is the economical resection of the affected bones with a full or partial artificial ankylosis of a wrist joint.

Brucellous arthritis of a wrist joint at patients with complications of a brucellosis is noted in 10%, monoarthritises — almost in half of cases of damage of a joint by a brucellosis. Since arthritises develop usually 2 — 3 later and up to 10 — 11 years from the beginning inf. process, that crucial importance for differential diagnosis is gained by skin (allergic) reaction of Byurne (see. Brucellosis ). At bone and joint forms of defeat observe an uzurirovaniye of joint surfaces and even brucellous osteomyelitis, but without suppurations and fistulas. The main method of treatment — an immobilization and medicamentous therapy.

Syphilitic arthritis — extremely rare disease of a wrist joint. The specific osteochondritis preferential at the level of Hp is shown by the expressed deformation of a joint at insignificant dysfunction. Treatment — according to philosophy of treatment of syphilis.

Dystrophic diseases. From them parartikulyarny defeats in a type of a periarthritis, the stenosing tendovaginites (the I—VI channels of a back ligament of wrist, palmar and cross ligaments of a wrist), a tendovaginitis, tendoperiostit, paratenonites, a bursitis are most numerous. Kinbek's disease belongs to bone and joint dystrophic diseases of a wrist joint (see. Kinbeka disease ), Prayzer's disease (aseptic necrosis of a navicular), primary (not traumatic) deforming arthrosis (see), cysts (fibrocystic defects) and some other states. All these diseases arise hl. obr. as a result of the prof. or household hron, traumatizations. The vast majority of dystrophic diseases, especially myagkotkanny, at timely recognition recovers by conservative methods in out-patient conditions.

Frequent cystous educations in perisinovialny fabric of a wrist joint are ganglion (see), the brushes making up to 80 — 85% of all gangliyev; on the back they meet by 4 times more often than from the palmar party.

Fig. 6. The roentgenogram of a wrist joint in a direct projection: the nearthrosis of a navicular deforming arthrosis of a radiocarpal joint; an intra bone ganglion of a capitate bone (it is specified by an arrow).

A specific place is held intra bone a ganglion, found in semi-lunar and capitate bones (fig. 6), in a head of an ulna in the form of the roundish center of an enlightenment with accurate contours. Intensive, arching pains, are characteristic especially at night. Ekskokhleation of the center of defeat with filling of defect with bone shaving leads to treatment.

Deformations of a wrist joint form preferential after not eliminated dislocations and fractures and become externally noticeable only at the considerable shift or the vicious provision of a brush. Are shown in funkts, the relation by instability of a joint owing to injury of ligaments and changes in the ratio of bones. At dystrophic processes, nonspecific arthritises there can also be an instability of a wrist joint as a result of disturbance of copular attachments, destruction of joint surfaces and bones. Because of disorganization of a joint with disturbance of its mechanism in the subsequent it is necessary to expect various displays of the deforming arthrosis, Krom is accompanied by synovites, tenosinovita, a bursitis, patol, ruptures of sinews, a syndrome of a carpal tunnel (the peculiar symptom complex arising owing to relative or absolute narrowing of the carpal channel with a prelum of a median nerve).

Deformations of a wrist joint arise also in the absence of its local defeats — as a result of postponed, hl. obr. in the childhood and youth, damages and diseases of proximal segments of an upper extremity or a nervous system — an ischemic contracture of Folkmann (see. Contracture ), a traumatic plexitis (see. Plexitis ), poliomyelitis (see. Poliomyelitis ), an encephalomeningitis (see. Meningitis ). Operational treatment of contractures, paresis and paralyzes of a brush, and also local distortions of a wrist joint includes partial artificial ankyloses, wedge-shaped resections, karpektomiya, transpositions of sinews, full artificial ankyloses.

From neurogenic osteoarthropathies of a wrist joint rather more frequent are siringomiyelichesky (see. Arthropathy ). The deforming osteoarthrites of a wrist joint in the form of local defeat are described (see. Kashina-Beck disease ).

Tumors

New growths of bones of a wrist joint are observed considerably less than in distal departments of a brush, and in 96 — 97% of cases they have high-quality character. Metastasises of malignant tumors in a wrist joint are noted by 15 times less than in other departments of a brush.

Fig. 7. The roentgenogram of a wrist joint at an osteoid osteoma of an uncinatum with X-ray opaque «nest» — it is specified by an arrow; on the right below — the scheme.

The most frequent bone tumors are osteoid osteomas (see), found in all bones, excepting pea-shaped, is more often than others carinate, capitate and ankyroid bones are surprised. The wedge, a picture is brighter, than at osteoid osteomas of other localizations. The nest of a tumor on the roentgenogram is defined in the form of the center of blackout (fig. 7). Differential diagnosis is simple. The regional resection of a bone with a full oncotomy leads to treatment.

Osteoblastoclastomas (see) in the field of a wrist joint are rare. The diagnosis is established on the basis of typical a wedge, and rentgenol, a picture and data of a puncture biopsy. The resection of the center of defeat shall be made within healthy fabrics to prevent a possibility of a recurrence. At major defects make bone plastics with a partial or full artificial ankylosis of a wrist joint.

From cartilaginous tumors To. pages occasionally find enchondromas of carinate, semi-lunar bones, and also osteochondromas and periosteal a chondroma (see. Chondroma ); the last find preferential in the field of an anatomic snuffbox.

Operations

Due to the achievements of modern surgery, and in particular surgeries of a brush, the profile of operative measures in the field of a wrist joint significantly changed. At damages, effects of damages and diseases of method of the choice there were savings operations: open repositions and repositions, replantations of bones, partial artificial ankyloses, bone plastics, Endoprosthesis replacement, economical resections. Full (total) artificial ankyloses, excisions of bones, extensive resections apply restrictedly, hl. obr. at contraindications to other interventions.

The puncture of a wrist joint is made from diagnostic or to lay down. purpose. The point at the level of Hp, in the place of crossing of linea bistyloidea with an inner edge of a sinew of a long razgibatel of a thumb is most convenient for a puncture that also corresponds to a projection of a hillock of Lister to linea bistyloidea. The needle is entered a little slantwise in the proximal direction and get between a beam bone and a proximal number of bones of a wrist. At a significant amount of contents (a hematoma, transudate, exudate) the puncture can be made in the place of the greatest protrusion.

Arthrotomies (see) in connection with a variety of pathology of a wrist joint can be the following types: back (back and beam, tylnoloktevy), palmar (palmar and beam, palmar and elbow), beam and elbow. The most common, convenient and safe way of an exposure of a cavity of a joint is the back arthrotomy.

Fig. 8. The diagrammatic representation of the main lines of cuts at an arthrotomy of a wrist joint: 1 — back and palmar wavy cuts; 2 — back and palmar shtykoobrazny cuts.

Back access to a wrist joint is made a longitudinal wavy section 6 — 7 cm long or a shtykoobrazny section (fig. 8); cut a superficial fascia and a retinaculum of razgibatel, the sinew of a long razgibatel of the I finger and a knutra — a sinew of razgibatel of fingers displace knaruzh, it is crosswise or T-shapedly open the capsule of a joint. At palmar accesses it is median make a longitudinal wavy section 6 — 7 cm long, cut a fascia and a retinaculum of sgibatel, identified and take aside a median nerve. Sinews of sgibatel take to the elbow or beam party. Open the capsule of a joint.

Indications to an arthrotomy two accesses arise sometimes at purulent arthritises, at irregular shapes of damages.

Open repositions and repositions make by means of a back arthrotomy and are much more rare — palmar. For elimination of shift prescription of St. 3 — 4 weeks it is reasonable to use the distraktsionny device during operation (see. Distraktsionno-kompressionnye devices ), at prescription of St. 7 — 8 weeks mechanical distraction during operation is an indispensable condition of an atravmatichnost and success of reposition. At shifts of bigger prescription carry out two-stage treatment: skeletal traction before operation and an operative measure using the distraktsionny device. Apply temporary stabilization of a wrist joint to prevention of a recurrence of shift spokes (fig. 5).

Replantations (see) are required in special cases when separate bones of a wrist, their fragments and blocks are displaced out of limits of a joint or when owing to wrinkling of sheaves it is impossible to make reposition in the regular way. Operation is performed with the imposed operational distraktsionny device, using two accesses: through a palmar section take the displaced bones and skeletirut them, through back — replantirut them in a bed.

Partial artificial ankyloses (incomplete, limited) keep a part of movements in a wrist joint and are alternative interventions when other savings operations are not shown. Depending on a type of defeat and its localization artificial ankyloses (see) make at the level of radiocarpal, carpal, carpometacarpal joints or between separate bones and their blocks. Partial artificial ankyloses can be shown at Kinbek's disease, the complicated nearthroses of a navicular, at heavy damages of an epiphysis of a beam bone, at benign tumors and cysts, at various forms of arthroses and arthritises.

Bone plastics (see) make as independent operation at not accrete fractures and nearthroses of hl. obr. navicular; it is also a component of complex operations at various damages and diseases of a wrist joint. Use of spongy and spongy and cortical autografts from a crest of an ileal bone, a distal metaepiphysis of a beam bone or the proximal end of an ulna is essentially important.

Endoprosthesis replacement (see) apply to substitution of the deleted trapezes, semi-lunar, carinate bones plastic (silicone) implants. Endoprostheses are not recommended for persons manual physical. work.

Arthroplasty (see) wrist joint by interposition of a fascia at the level of Hp apply seldom, hl. obr. at pseudorheumatisms with multiple damage of joints of a brush and proximal departments of an upper extremity.

Excisions in the field of a wrist joint have limited indications. Removal of separate bones is made at their final fracture owing to tumoral, specific or dystrophic process.

At persistent dislocations and incomplete dislocations of a head of an ulna, and also at the expressed arthrosis of a distal radioulnar joint most often make subperiosteal or ekstraperiostalny resections of a head though at the same time rotation of a forearm is a little limited. The resection of an awl-shaped shoot of a beam bone at nearthroses of a navicular is often combined with bone plastics of a navicular. Regional resections and ekskokhleation widely use at benign tumors of bones and opukholepodobny processes. (Together with distal department of bones of a forearm and proximal department of metacarpal bones) resort to extensive ekstrakapsulyarny resections of a wrist joint extremely seldom.

Artificial ankyloses of a wrist joint can be shown at the widespread deforming arthrosis, far come specific and nonspecific arthritises, and also at the dangling brush owing to paralyzes and paresis of a different origin when there are no conditions for a transposition of sinews.

For providing grasping power with fingers and preservation of rotational movements of a forearm it is necessary to leave at an artrodezirovaniye intact carpometacarpal and distal radioulnar joints. At impossibility to keep function of a radioulnar joint make a resection of a head of an ulna. Artificial ankyloses make preferential by means of a back arthrotomy using supplementary or laid on transplants from a crest of an ileal bone or an epimetafiz beam.

At the level of a forearm resort to an exarticulation of a brush or amputation only in extreme cases — at heavy crushes of a brush, far come purulent processes, malignant tumors. The exarticulation of a brush which was considered before adverse at the level of Hp is not an obstacle for prosthetics. Preservation intact a radioulnar joint provides the full volume of rotational movements of a forearm.

Postoperative treatment and rehabilitation. For success of operations technically correct, rather long and continuous immobilization has crucial importance. The so-called U-shaped plaster splint is most rational. The splint is imposed on a dorsum from heads of metacarpal bones; it shall bend around an elbow joint and come to an end from the palmar party at the level of distal phalanxes. Back and palmar parts of a splint are fixed soft bandage. In 12 — 15 days after operation the splint is replaced with a circular plaster bandage from the proximal end of a forearm to heads of metacarpal bones. At interventions concerning pathology of a navicular include the main phalanx of the I finger in a plaster bandage. The term of an immobilization in a circular bandage of 10 — 15 days (at excisions, a resection of a head of an ulna) to 16 — 18 weeks (at bone plastics of a nearthrosis of a navicular, at full artificial ankyloses of a wrist joint). Each 3 — 5 weeks change a plaster bandage for new.

From the second day after operation begin the active movements with fingers and exercises for muscles of a hand. After the termination of an immobilization carry out LFK, heat baths, massage and work therapy. Dignity. - hens. treatment for the purpose of prevention of the deforming arthrosis of a wrist joint is carried out not earlier than 2 — 3 months from the beginning of rehabilitation. Depending on the nature of operation patients start work without restriction or the facilitated work in 5 — 8 weeks since the termination of an immobilization.



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A. I. Ashkenazi; 3. P. Nechayeva, E. A. Vorobyova (An.).

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