Semiopatologia Quirúrgica UBA

Main ideas, concepts, and lessons

Origin and purpose of the “wrist chart” / assessment forms

• The wrist assessment form was created to standardize and improve evaluation of wrist-related conditions.
• It was developed after discussion of real clinical cases at a congress.
• Its goals include:
  • Ensuring consistent language among professionals
  • Improving communication and supporting teamwork
• The chart is explicitly presented as a guide/tool, not a replacement for clinical judgment.

Why forms exist (and what they do)

They help clinicians:

• Evaluate using shared criteria and scoring
• Document findings to objectify aspects of care and support professional accountability
• Avoid confusion caused by different terminology (e.g., scoring definitions for joint mobility/pain)

The forms are described as having low/working validity—emphasizing reliability more than validity—because they evolved as clinicians learned what worked in practice.

Methodological stance on using the chart

• The chart is not meant to be followed rigidly on day one.
• Clinicians select which items to apply based on:
  • Patient needs
  • Clinical context
• The forms function like a platform/tool: useful, but not sufficient on their own.

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Clinical and rehabilitation focus: wrist fractures

Conservative vs surgical pathways

A major clinical theme is that management should consider:

• Conservative vs surgical pathways, depending on fracture characteristics (e.g., intra-/extra-articular involvement)
• Fracture stability/instability criteria, because instability affects:
  • Healing time
  • Rehabilitation needs
• Radiographic monitoring, including discussion of how often clinicians check and what “frequent checks” implies clinically

Key fracture-related concepts emphasized

• Intra-articular involvement (radiocarpal surface and triangular ligament) increases complexity and pain, and can require longer/more careful management.
• Stability/instability depends on factors such as:
  • Dorsal angulation
  • Comminution
  • Radial shortening
  • Step-offs (intra-articular)
  • Associated ulnar fracture
  • Patient age
• Locked volar plates
  • “Locked” refers to screw/plate design that improves stability and supports earlier mobilization.
  • The multiaxial hole design allows screw placement tailored to fracture pattern (compared conceptually to joining small wood pieces with properly oriented screws).
• Triangular fibrocartilage / triangular ligament
  • Treated as mechanically important (load distribution, stability, vascular characteristics).
  • Injuries can contribute to persistent ulnar-sided pain and symptoms during movement.

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Rehabilitation measurement: hand/wrist function after fracture

Assess the hand—not only the wrist

The talk emphasizes evaluating hand function as well:

• Swelling/immobilization can limit function even if the hand was not directly injured.
• Core movements to assess include grip patterns:
  • Power/arrowhead grip
  • Fine pinch
  • Key pinch
• Always compare to the contralateral (unaffected) side.

Functional synergy principle

• If wrist extension is insufficient, finger flexors may not work effectively due to altered biomechanics/synergy.
• This affects grip quality.

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Assessment of swelling and sympathetic dystrophy risk

Chart focus and monitoring indicators

One section addresses risk factors for conditions like sympathetic dystrophy and capsulitis.

Suggested monitoring includes:

• Autonomic-related changes, such as:
  • Asymmetry in sweating
  • Coloration changes
• Imaging progression signs, including a warning reference to “honeycombing”

Potential early interventions (conceptual)

• Consider discussing chronotherapy/corticosteroids with the medical team to help prevent progression.
• Presented as a decision point for physicians, where physiotherapists/kinesiologists may provide clinical clues.

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Risk factor identification beyond the wrist

A wrist fracture as a “consequence” event

A major lesson is that wrist fractures often reflect upstream causes (e.g., falls plus osteopenia/osteoporosis). Assessment should include:

• Past medical conditions and relevant medications
• Frequency of falls
• Bone health testing history and timing
• Smoking and alcohol use (contributors to bone density loss and fall risk)

Falls and environment

• Many falls occur at home due to:
  • Confidence
  • Distraction
  • Reduced vigilance

Age and sedentary lifestyle

• After ~age 40, and more so in older age, fall risk may be influenced by:
  • Mobility changes
  • Proprioception
  • Reflex changes
  • Visual/vestibular issues

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Radiographic measurement concepts

Wrist radiographs are emphasized with measurement categories including:

• Angles in different planes (frontal and lateral/sagittal)
• Ulnar variance / relative positioning concepts
• A named sign related to distances between structures (referred to in subtitles as “Ushers sign”)

These measurements matter because they influence:

• Biomechanics of wrist extension and grip pressure
• Orientation and loading of carpal structures
• Likelihood of residual pain via ligament involvement

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Scales used in the chart

Pain/function scale

• Analog scale 0 to 10
• Notes on subjective pain reliability:
  • Patient perception varies
  • Personality and psychosocial context may affect responses
• Interviewing advice:
  • Avoid “leading” questions
  • Instead, guide the patient to describe pain/function naturally

Treatment evolution section

• Typical expected number of sessions is around 10–20
• 20 is used as a baseline/proposed number because resolution can take longer.

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Methodology / instructions (detailed bullet format)

How to use the wrist chart (step-by-step approach)

• View the chart as a guide, not a mandatory checklist that must be fully completed on day one.
• Select assessment items based on:
  • The patient’s specific presentation
  • Clinical priorities at that time point
  • Examiner experience (the chart supports but does not replace expertise)
• Use consistent scoring language:
  • Ensure all clinicians interpret score levels the same way
• Document objectively when possible:
  • Use the chart to record findings for teamwork and professional defensibility

Clinical decision framework for wrist fractures (conceptual workflow)

• Before surgery/management decisions:
  • Identify whether the fracture is intra-articular vs extra-articular
  • Evaluate stability vs instability using criteria such as:
    • Dorsal angulation
    • Comminution severity
    • Radial shortening
    • Intra-articular step-off
    • Associated ulnar fracture
    • Patient age
• If intra-articular or unstable:
  • Expect a more complex/more painful process and potentially longer rehabilitation
• Monitor radiographically:
  • Follow-up frequency reflects clinician concern about displacement/instability

Rehabilitation assessment workflow for function

• Assess the hand and wrist together:
  • Look for limitations from edema/immobilization and altered mechanics
• Compare bilaterally:
  • Always evaluate the unaffected side to contextualize impairment
• Evaluate key functional components:
  • Power grip + pinch variations (fine pinch, key pinch)
  • Wrist extension adequacy (affects finger flexor efficiency)
• Track objective/behavioral indicators:
  • Swelling pattern/diameter differences
  • Autonomic signs (e.g., asymmetrical sweating)
  • Quality changes affecting movement and pain during wrist/forearm motion

Risk factor inquiry (falls + bone health + medication)

Ask about and record:

• Medication use (including chronic psychotropic/sleep medications, diabetes meds, thyroid meds, etc.)
• Medical history and surgeries relevant to fracture risk and rehabilitation capacity
• Bone health history (evidence of osteopenia/osteoporosis and timing)
• Number of falls in the last ~6 months (treated as clinically meaningful)
• Smoking and alcohol consumption patterns

Interpret wrist fracture as part of a wider cause chain:

• Falls + low bone density + systemic factors → consequence fracture
• Treatment should address primary contributors with physician coordination

When to escalate concerns to the physician (examples mentioned)

• Prolonged hospitalization, ICU-level severity, or unusual clinical courses as warning flags
• Persistent or concerning imaging/clinical signs (e.g., honeycombing-like diffusion signals) should prompt doctor notification
• Suspected progression to dystrophy triggers consideration of medical interventions (timing/type decided by physicians)

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Speakers / sources featured (as identified in subtitles)

• Pablo (main presenter / author of the concept discussion)
• Rodrigo (mentioned; also referenced regarding referral patterns)
• Ignacio (named in an anecdote/case discussion)
• Andrés (mentioned regarding criteria/forms discussion)
• Arriente (named relating to experience/clinical practice statements)
• Diego (asked/answered regarding hospitalization implications)
• Germán (asked whether hospitalization days were in ward vs ICU)
• Luciano de la Rosa (referenced for osteoporosis content)
• Laura (referenced for a talk; age-related changes/proprioception discussed)
• Agustín (referenced in relation to a survey assignment)
• Marcelo (named when referring to someone’s review of slides/images)
• Rubén (named during radiographic/angle discussion and explanation)
• Gonzalo (named during triangular ligament explanation)
• Denario (named in discussion about thyroid medications and risk evaluation)
• “University students / seminarian” (group addressed; not a named individual)
• English Public Health System / literature (mentioned as basis for reliability/validity concepts and the idea lineage for forms)
• IBA/UBA-associated seminar content implied by the title (“Semiopatología Quirúrgica UBA”); no specific institutional author beyond the speakers above.