A Patient’s Guide to Scaphoid Fracture of the Wrist

Introduction

Doctors commonly diagnose a sprained wrist after a patient falls on an outstretched hand. However, if pain and swelling don’t go away, doctors become suspicious that the injury is actually more serious. A fall on an outstretched hand commonly breaks the scaphoid bone of the wrist. X-rays taken at the time of the injury may not clearly show the fracture. If the fracture is not recognized early, it may not heal properly. This can lead to problems later.

This guide will help you understand

• what causes fractures of the scaphoid bone
• what nonunion of the scaphoid bone is
• what you can do to treat each condition

Anatomy

Where is the scaphoid bone of the wrist?

The anatomy of the wrist joint is extremely complex, probably the most complex of all the joints in the body. The joint is actually a collection of many joints and many bones. These joints and bones let us use our hands in many ways. The wrist must be extremely mobile to give our hands a full range of motion. At the same time, the wrist must provide the strength for heavy gripping.

The wrist is made up of eight separate small bones, called the carpal bones. The scaphoid bone is a carpal bone near the base of the thumb. The carpal bones connect the two bones of the forearm, the radius and the ulna, to the bones of the hand. The metacarpal bones are the long bones that lie underneath the palm. The metacarpals attach to the phalanges, which are the bones in the fingers and thumb.

One reason that the wrist is so complicated is because every small bone forms a joint with the bone next to it. This means that what we call the wrist joint is actually made up of many small joints. Ligaments connect all the small bones to each other, and to the radius, ulna, and metacarpal bones.

The scaphoid bone is a small carpal bone on the thumb side (radial side) of the wrist. It is the most commonly fractured carpal bone. This is probably because it actually crosses two rows of carpal bones, forming a hinge. A fall on the outstretched hand puts heavy stress on the scaphoid bone. This stress can cause either a small crack through the middle of the bone or a complete separation of the bone into two pieces. A separation is called a displaced fracture.

Related Document: A Patient’s Guide to Wrist Anatomy

Causes

What causes a scaphoid fracture?

A scaphoid fracture is almost always caused by a fall on the outstretched hand. We commonly try to break a fall by putting our hands out for protection. Landing on an outstretched hand makes hand and wrist injuries, including a fracture of the scaphoid bone, fairly common.

When a scaphoid fracture is recognized on the first X-ray, treatment begins immediately. But patients often assume that the injury is just a sprain, and they wait for it to heal on its own. In some cases, the wrist gets better. In many cases the bone fails to heal. The scaphoid fracture then develops into what surgeons call a nonunion.

A nonunion can occur in two ways. In a simple nonunion, the two pieces of bone fail to heal together. The second type of nonunion is much more serious. The lower half of the fractured bone loses its blood supply and actually dies. This condition is called avascular necrosis (Avascular means no blood supply, and necrosis means dead.)

The scaphoid bone is at risk for avascular necrosis. Only one small artery enters the bone, at the end that is closest to the thumb. If the fracture tears the artery, the blood supply is lost. Avascular necrosis becomes easy to see on X-rays several months after the injury.

Symptoms

How will I know if I have a scaphoid fracture?

The symptoms of a fresh fracture of the scaphoid bone usually include pain in the wrist and tenderness in the area just below the thumb. You may also see swelling around the wrist. The swelling occurs because blood from the fractured bone fills the wrist joint. Thin people will see a bulging of the joint capsule. The joint capsule is the watertight sac that encloses the joint.

Symptoms of a nonunion of the scaphoid bone are more subtle. You may have pain when you use your wrist. However, the pain may be very minimal. It is fairly common for doctors to see a nonunion of the scaphoid bone on X-rays, but the patient can’t remember an injury. These people probably suffered a wrist injury years ago that they thought was a simple sprain. Still, the most common symptom of a nonunion is a gradual increase in pain. Over several years the nonunion can lead to degenerative arthritis in the wrist joint.

Diagnosis

What tests will my doctor run?

Your doctor will first take a medical history. You will be asked questions about your pain and about any injuries to your wrist. Your doctor will also do a physical exam. The prodding and moving may hurt your wrist a bit. But it is important that your doctor know exactly where your pain is coming from.

Doctors should assume that any patient who has fallen on an outstretched hand and has swelling or tenderness on the thumb side of the wrist has a scaphoid fracture. You should assume this until tests prove otherwise. X-rays taken immediately after the injury may not show a fracture. Still, most surgeons will put a cast on the wrist and get another X-ray in 10 days. This gives the edges of the fractured bone time to heal, and may prevent nonunion. By waiting 10 days, the fracture is easier to see on an X-ray.

If it is still not clear whether or not you have a fracture, your doctor may order other imaging tests. You may have a bone scan done. A bone scan involves injecting tracers into your blood stream. The tracers then show up on special X-rays of your wrist. The tracers build up in areas of extra stress to bone tissue, such as a fracture.

Your doctor may also order a magnetic resonance imaging (MRI) scan. An MRI scan is a special imaging test that uses magnetic waves to create pictures of your body in slices. The MRI scan shows tendons as well as bones. It is painless and requires no needles or injections.

Treatment

Can a fracture or nonunion be healed?

Nonsurgical Treatment

Fracture

If the fracture is identified immediately and is in good alignment, you will probably wear a cast for nine to 12 weeks. The cast will cover your forearm, wrist, and thumb. This is necessary to hold the scaphoid bone very still while it heals. Your doctor will take X-rays at least once a month to check the progress of the healing. Once your doctor is sure the fracture has healed, the cast will be removed. Even with this type of treatment, there is still a risk that the fracture may not heal well and will become a nonunion.

Nonunion

A fracture that doesn’t heal within several months is considered a nonunion. If the injury is fairly recent, your doctor might recommend more time in the cast. He or she might also prescribe an electrical stimulator. The electrical stimulator is a device that sends a small electrical current to your scaphoid bone. You wear it like a large bracelet for 10 to 12 hours a day. Electrical current has been shown to help the bones heal.

Surgery

Screw Fixation

Some surgeons report good results doing surgery right away when a patient has had a recent, nondisplaced scaphoid fracture. Studies have shown that this method can help people get back to activity faster than wearing a cast for up to 12 weeks. The procedure involves inserting a screw through the scaphoid. The screw holds the scaphoid firmly until it heals.

Scaphoid Debridement

In cases where a nonunion has occurred despite wearing a cast and using an electrical stimulator, surgery will likely be suggested. An incision is made in the wrist directly over the scaphoid bone. The surgeon finds the old fracture line on the scaphoid bone. All the scar tissue between the two halves of the bone must be removed (debrided). This creates a fresh bone surface to allow healing to begin again. In some cases, damaged bone tissue from the scaphoid is also removed.

Bone Graft Method

Your surgeon may use a bone graft. A bone graft involves taking bone tissue from another spot in your wrist and inserting it into the fracture. A bone graft can stimulate healing on the surface of the bones. The bone graft is usually taken through a second small incision just above the wrist. (It is sometimes taken from the pelvis, through an incision in the side of your hip.)

After the bone graft is placed between the parts of the scaphoid bone, some surgeons also insert a metal pin or screw across the bone. The goal is to hold the two pieces of bone tightly together, allowing them to fuse into one bone.

When the surgery is complete, the incision is stitched closed. The arm is placed in a large bandage or a splint. You are then awakened and taken to the recovery room.

Sometimes the bones still do not heal as planned. Surgeons call a fused bone that fails to heal a pseudarthrosis. If the nonunion continues to cause pain, you may need a second operation. Your surgeon will probably add more bone graft and check that the pins or screws are holding the bones together.

Rehabilitation

What will my recovery be like?

Nonsurgical Rehabilitation

If the bone is in good alignment, and there are no problems with the blood supply to the bone, you may be placed in a cast for nine to 12 weeks. Some doctors prefer to start with a long-arm cast. Others use a thumb-spica cast designed to keep the wrist and thumb from moving.

The amount of time you need to wear the cast depends on what part is fractured and whether the bones heal well. When your doctor is certain the bones have healed, your cast will be removed. Your wrist will probably be stiff and weak from being in the cast. You may need physical or occupational therapy to help improve wrist range of motion and strength.

After Surgery

Depending on the type of surgery you have, you may be placed in a splint for up to 12 weeks after surgery. Your surgeon will X-ray the wrist several times after surgery to make sure that the bones are healing properly. Once the two halves of the scaphoid bone have healed, you can safely begin a rehabilitation program.

You may need physical or occupational therapy sessions for six to eight weeks after surgery. The first few treatments will focus on controlling the pain and swelling. You will work into doing exercises to help strengthen and stabilize the muscles around the wrist joint. Other exercises are used to improve fine motor control and dexterity of your hand. You’ll be given tips on ways to do your activities while avoiding extra strain on the wrist joint.

A Patient’s Guide to Osteoarthritis of the Wrist Joint

Introduction

Degeneration in a joint means the joint surfaces are starting to break down over time. The term degenerative arthritis is used by doctors to describe a condition where a joint wears out, usually over a period of many years. Some medical professionals call the condition osteoarthritis. Others use the term degenerative arthrosis. They prefer arthrosis because the term arthritis means inflammation. Degeneration by itself doesn’t always cause inflammation in the tissues of the joint. Still, these terms are generally used to mean the same thing.

This document will help you understand

• how osteoarthritis of the wrist develops
• what your doctor will do to diagnose it
• what can be done to ease the pain and regain wrist movement

Anatomy

What changes does osteoarthritis cause in the wrist joint?

The anatomy of the wrist joint is extremely complex, probably the most complex of all the joints in the body. The wrist is actually a collection of many joints and many bones. These joints and bones let us use our hands in many ways. The wrist must be extremely mobile to give our hands a full range of motion. At the same time, the wrist must provide the strength for heavy gripping.

The wrist is made up of eight separate small bones, called the carpal bones. The carpal bones connect the two bones of the forearm, the radius and the ulna, to the bones of the hand. The metacarpal bones are the long bones that lie underneath the palm. The metacarpals attach to the phalanges, which are the bones in the fingers and thumb.

One reason that the wrist is so complicated is because every small bone forms a joint with the bone next to it. This means that what we call the wrist joint is actually made up of many small joints. Ligaments connect all the small bones to each other. Ligaments also connect the bones of the wrist with the radius, ulna, and metacarpal bones.

Articular cartilage is the smooth, rubbery material that covers the bone surfaces in most joints. It protects the bone ends from friction when they rub together as the joint moves. Articular cartilage also acts sort of like a shock absorber. Damage to the articular cartilage eventually leads to osteoarthritis.

Related Document: A Patient’s Guide to Wrist Anatomy

Causes

How did I develop arthritis in my wrist?

Many wrist injuries, such as fractures and sprains, heal fairly easily. However, they can lead to problems much later in life. The injury changes the anatomy of the wrist just enough so that the parts no longer work smoothly together. The changes from the injury cause a lot of wear and tear on the wrist joint. Over time, this wear and tear degenerates the tissues of the joint, leading to wrist osteoarthritis. Doctors may also call this type of degeneration posttraumatic arthritis.

A bad sprain or fracture can actually damage the articular cartilage. The cartilage can also be bruised when too much pressure is put on the cartilage surface. The cartilage surface may not look any different. The injury often doesn’t show up until months later.

Sometimes the damage to the cartilage is severe. Pieces of the cartilage can actually be ripped away from the bone. These pieces do not grow back. Usually they must be surgically removed. If the pieces aren’t removed, they may float around in the joint, causing it to catch. They an also cause a lot of pain and do more damage to the joint surfaces.

Your body does not do a good job of repairing these holes in the cartilage surface. The holes fill up with scar tissue. Scar tissue is not as slick or rubbery as the articular cartilage.

Any kind of injury to the wrist joint can alter how the joint works. After a wrist fracture, the bone fragments may heal slightly differently. Ligament damage results in an unstable joint. Any time an injury changes the way the joint moves, even if the change is very subtle, the forces on the articular cartilage increase. It’s just like a machine; if the mechanism is out of balance, it wears out faster.

Over many years, this imbalance in joint mechanics can damage the articular cartilage. Since articular cartilage cannot heal itself very well, the damage adds up. Finally, the joint can no longer compensate for the damage, and your wrist begins to hurt.

Related Document: A Patient’s Guide to Ligament Injuries of the Wrist

Symptoms

What problems does arthritis of the wrist cause?

Pain is the main symptom of osteoarthritis of any joint. At first, the pain comes only with activity. Most of the time the pain lessens while doing the activity, but after stopping the activity the pain and stiffness increase. As the condition worsens, you may feel pain even when resting. The pain may interfere with sleep.

The wrist joints may be swollen. Your wrist may fill with fluid and feel tight, especially after use. When all the articular cartilage is worn off the joint surface, you may notice a squeaking sound when you move your wrist. Doctors call this creaking crepitus.

Osteoarthritis eventually affects the wrist’s motion. The wrist joint becomes stiff. Certain motions become painful. You may not be able to trust the joint when you lift objects in certain positions. This is because a pain reflex freezes the muscles when a joint is put in a position that causes pain. This happens without warning, and you can end up dropping whatever is in your hand.

Diagnosis

What tests will my doctor do?

The diagnosis of wrist osteoarthritis begins with a medical history. Your doctor will ask questions about your pain, how it interferes with your daily life, and whether anyone in your family has had similar problems. It is especially important to tell your doctor the details of any wrist injuries you’ve had, even if they happened many years ago.

Your doctor will then physically examine your wrist joint, and possibly other joints in your body. It may hurt when your doctor moves or probes your sore wrist. But it is important that your doctor sees how your wrist moves, how it is aligned, and exactly where it hurts.

You will probably need to have X-rays taken. X-rays are usually the best way to see what is happening with your bones. X-rays can help your doctor assess the damage and track how your joint changes over time. X-rays can also help your doctor estimate how much articular cartilage is left.

Your doctor may order blood tests if there is any question about the cause of your arthritis. Blood tests can show certain systemic diseases, such as rheumatoid arthritis.

Treatment

What can be done to get rid of my pain?

Nonsurgical Treatment

In almost all cases, doctors try nonsurgical treatments first. Surgery is usually not considered until it has become impossible to control your symptoms.

The goal of nonsurgical treatment is to help you manage your pain and use your wrist without causing more harm. Your doctor may recommend nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, to help control swelling and pain. Other treatments, such as heat, may also be used to control your pain.

Rehabilitation services, such as physical and occupational therapy, have a critical role in the treatment plan for wrist joint arthritis. The main goal of therapy is to help you learn how to control symptoms and maximize the health of your wrist. You’ll learn ways to calm your pain and symptoms. You may use rest, heat, or topical rubs.

A special brace may help support the wrist and reduce your pain during activity. Range-of-motion and stretching exercises can improve your wrist motion. Strengthening exercises for the arm and hand help steady the wrist and protect the joint from shock and stress. Your therapist will give you tips on how to get your tasks done with less strain on the joint.

To get rid of your pain, you may also need to limit your activities. You may even need to change jobs, if your work requires heavy, repetitive motions with the hand and wrist.

An injection of cortisone (a powerful anti-inflammatory medication) into the joint can give temporary relief. It can very effectively relieve pain and swelling. Its effects are temporary, usually lasting several weeks to months. There is a small risk of infection with any injection into the joint, and cortisone injections are no exception.

Related Document: A Patient’s Guide to Joint Injections for Arthritis

Surgery

If the pain becomes unmanageable, you may need to consider surgery. There is no single surgery for arthritis of the wrist. The wrist is complex, and many different injuries can lead to arthritis. As a result, there are many possible surgical procedures for treating a painful wrist joint. Which one is right for you depends on your underlying problem, how much of the wrist joint is involved, and how you need to use your wrist.

In some cases, people with arthritis of the wrist have already had wrist surgery after an earlier injury. This past surgery may have repaired broken bones or stitched together torn ligaments. The surgery at least may have helped delay osteoarthritis in the wrist. A previous surgery can be a factor in deciding which procedure is best for you.

If the arthritis involves only one or two of the small carpal bones of the wrist, you may undergo a special procedure that focuses on only those bones. If you have advanced osteoarthritis that affects most of the wrist, your doctor will probably suggest a wrist fusion or an artificial wrist joint.

When the wrist joint becomes so painful that it is difficult to grip or move the wrist, your doctor may recommend fusing the wrist joint. A wrist fusion is sometimes called an arthrodesis of the wrist. The goal of a wrist fusion is to get the radius bone in the forearm to grow together, or fuse, into one long bone with the carpal bones of the wrist and the metacarpals of the hand. A wrist fusion is a challenging operation. A fusion of most other joints involves only two or three bones. Wrist fusion involves getting 12 or 13 bones to grow together. But wrist fusion is usually successful in relieving wrist pain.

Related Document: A Patient’s Guide to Wrist Fusion

A wrist fusion gets rid of pain in the wrist and restores strength, but it isn’t a great choice for someone who needs to move the wrist more freely. Patients who have arthritis in both wrists don’t usually get two wrist fusions. That would make it very difficult to do everyday activities such as turning door knobs and taking care of basic hygiene.

Patients who have wrist arthritis due to systemic diseases, such as rheumatoid arthritis, are much more likely to have arthritis in both wrists. These patients probably don’t need wrist strength as much as good range of motion. They would probably benefit from at least one wrist joint replacement. In some cases, surgeons fuse one wrist for strength and replace the other wrist with an artificial joint for motion.

Related Document: A Patient’s Guide to Artificial Joint Replacement of the Wrist

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

If you don’t need surgery, you will probably work with a physical or occupational therapist. Range-of-motion exercises for the wrist should be started as pain eases. A program of strengthening follows. Eventually you will be doing strength exercises for the arm and hand. Dexterity and fine motor exercises are used to get your hand moving smoothly. You’ll be given tips on keeping your symptoms under control. You will probably progress to a home program within four to six weeks.

After Surgery

Your hand and wrist will be bandaged with a well-padded dressing and a splint for support after surgery. Physical or occupational therapy sessions may be needed for up to three months after surgery. The first few treatment sessions will focus on controlling the pain and swelling after surgery. You will then begin to do exercises that help strengthen and stabilize the muscles around the wrist joint. You will do other exercises to improve the fine motor control and dexterity of your hand. Your therapist will give you tips on ways to do your activities without straining the wrist joint.

A Patient’s Guide to Ligament Injuries of the Wrist

Introduction

Wrist injuries are common. If a wrist injury causes significant damage to the ligaments, it can result in serious problems in the wrist. Such an injury typically continues to cause problems unless corrected.

This guide will help you understand

• how ligament injuries of the wrist occur
• what your doctor will do to diagnose serious ligament injuries
• what treatment options may be recommended

Anatomy

What structures are involved?

The front, or palm-side, of the wrist is referred to as the palmar side. The back of the wrist is called the dorsal side.

The wrist is made up of eight separate small bones, called the carpal bones.

The carpal bones connect the two bones of the forearm, the radius and the ulna, to the bones of the hand.The metacarpal bones are the long bones that lie underneath the palm. The metacarpals attach to the phalanges, the bones in the fingers and thumb.

The carpal bones are arranged in two rows: the proximal row of four bones sits next to the forearm (radius and ulna), and the distal row of four bones connects to the metacarpal bones.

These two rows of bones work together like the links in a chain to allow the hand to move up (dorsiflex) and down (palmarflex). The connections between each carpal bone also allow the bones to shift as the hand is moved sideways (radial deviation and ulnar deviation).

One reason that the wrist is so complicated is because every small bone forms a joint with the bone next to it. Articular cartilage covers the ends of bones where they meet in a joint. Articular cartilage is a smooth, slippery substance that lets the bones slide against one another without causing damage to either surface.

Ligaments connect all the small wrist bones to each other. Ligaments also connect the bones of the wrist with the radius, ulna, and metacarpal bones.

These ligaments are important in balancing the movement of all of the wrist bones.

When one or more of these ligaments is injured, the way the bones move together as a unit is changed. This can lead to problems in the wrist joint that cause pain. Eventually, arthritis may develop in the wrist joint.

Related Document: A Patient’s Guide to Wrist Anatomy

Causes

How do ligament injuries of the wrist occur?

By far the most common way the wrist is injured is a fall on an outstretched hand. (The same type of force can happen in other ways, such as when you brace your self on the dashboard before an automobile crash.) Whether the wrist is broken or ligaments are injured usually depends on many things, such as how strong your bones are, how the wrist is positioned during the injury, and how much force is involved.

Any kind of injury to the wrist joint can alter how the joint works. After a wrist injury, ligament damage may result in an unstable joint. Any time an injury changes the way the joint moves, even if the change is very subtle, the forces on the articular cartilage increase. It’s just like a machine; if the mechanism is out of balance, it wears out faster. Over many years, this imbalance in joint mechanics can damage the articular cartilage. Since articular cartilage cannot heal itself very well, the damage adds up. Finally, the joint can no longer compensate for the damage, and the wrist begins to hurt.

Symptoms

How do I know if I have a ligament injury of the wrist?

When an injury occurs, pain and swelling are the main symptoms. The wrist may become discolored and bruised. Doctors refer to this as ecchymosis. The wrist may remain painful for several weeks. There are no specific symptoms that allow your doctor to determine whether a wrist ligament injury has occurred.

Once the initial pain of the injury has subsided, the wrist may remain painful due to the instability of the ligaments. If the ligaments have been damaged and have not healed properly, the bones do not slide against one another correctly as the wrist is moved. This can result in pain and a clicking or snapping sensation as the wrist is used for gripping activities.

In the late stages, the abnormal motion may cause osteoarthritis of the wrist. This condition can cause pain with activity. During activity, the pain usually lessens, but when the activity stops, the pain and stiffness often increase. As the condition worsens, a person may feel pain even when resting. The ability to grip with the hand may be diminished. The pain may interfere with sleep.

Related Document: A Patient’s Guide to Osteoarthritis of the Wrist Joint

Diagnosis

What tests will my doctor do?

The diagnosis of ligament injuries of the wrist begins with a medical history. Your doctor will want to know about any injuries to the wrist, even if they were years ago and healed without much problem.

Your doctor will then physically examine your wrist joint. It may hurt when your doctor moves or probes your sore wrist. But it is important that your doctor sees how your wrist moves, how it is aligned, and exactly where it hurts.

You will need X-rays. X-rays are usually the best way to see what is happening with your bones. After a wrist injury, X-rays can help determine whether a wrist fracture has occurred. X-rays can also help your doctor determine whether certain types of ligament injuries have occurred by looking at how the bones of the wrist line up.

If X-rays do not show enough information, other tests may be ordered to view the ligaments better. In some cases, an arthrogram of the wrist is used. This test requires that dye be injected into one of the small joints of the wrist. Special X-rays are then taken to look for leakage of the dye out of the joint. This may help confirm that the ligaments are torn.

More recently, doctors are also using magnetic resonance imaging (MRI) to look at the wrist ligaments. The MRI machine uses magnetic waves to create pictures that look like slices of the wrist joint. Unlike X-rays, an MRI scan shows the soft tissues such as ligaments quite well and can sometimes confirm the presence of a torn ligament in the wrist.

Finally, for cases in which the diagnosis is still in question, arthroscopy of the wrist joint may be used to determine whether a ligament injury is causing the continued symptoms. The arthroscope is a miniature TV camera that is inserted into the wrist joint to allow the surgeon to see the ligaments that may be torn. In some cases, the arthroscope may also be used to assist with repair of the ligaments at the same time.

Treatment

What can be done for ligament injuries of the wrist?

The first challenge in treating a ligament injury of the wrist is recognizing that it exists. Many patients fall and injure their wrist and assume they have a sprain. They treat the sprain with rest for a few weeks, and then resume their activities. Many ligament injuries go unrecognized until much later when they cause problems.

The treatment of a ligament injury depends on whether it is an acute injury (just happened within weeks) or a chronic injury (something that happened months ago).

Nonsurgical Treatment

A wrist injury that causes a partial injury to a ligament, a true wrist sprain, may simply be treated with a cast or splint for three to six weeks to allow the ligament to heal.

Surgery

In cases where the ligaments are completely torn and the joints are no longer lined up, surgery may be suggested to either repair the ligaments or pin the bones together in the proper alignment to hold them in place while the ligaments heal.

There is no single operation that is used to fix ligament injuries of the wrist. Several surgical procedures are used depending on the problem.

Percutaneous Pinning and Repair of the Ligaments

If the ligament damage is recognized within a few weeks after the injury, the surgeon may be able to insert metal pins to hold the bones in place while the ligaments heal. This procedure is called a percutaneous pinning. (Percutaneous means through the skin; an incision is not required.) The surgeon uses a fluoroscope to watch as the pins are placed. The fluoroscope is a type of continuous X-ray machine that shows the X-ray image on a TV screen.

In some cases, getting the bones lined up properly is not possible, and an incision must be made to repair the ligaments. The longer the surgery is done after the initial injury, the less likely it is that the bones can be aligned properly. It is also less likely that torn ligaments will heal once scar tissue has developed over the ends. The metal pins are placed to hold the bones still while the ligaments heal. The pins are usually removed four to six weeks after the procedure.

Ligament Reconstruction

When the ligament damage is discovered six months or more after the initial injury, the ligament may need to be reconstructed. This procedure involves making an incision over the wrist joint and locating the torn ligament. Once this is done, a tendon graft is used to replace the ligaments that have been torn. The tendon graft is usually borrowed from the palmaris longus tendon of the same wrist. This tendon doesn’t do much and is commonly used as a tendon graft for surgical procedures around the hand and wrist. The tendon is removed from the underside of the wrist through one or two small incisions.

Again, metal pins are used to hold the bones stationary while the tendon graft heals. The pins are removed six to eight weeks after the surgery.

Fusion

When the ligament instability is discovered long after the injury and arthritis is present in the joints between the unstable bones, a fusion may be suggested. Two or more bones are fused by removing the cartilage surface between the bones. When the raw bone surfaces are placed together, the bone treats them as it would a fracture. The surfaces heal together. The bones fuse into one bone. This stabilizes the motion between the bones and reduces the pain that occurs when the arthritic joint surfaces rub together.

If the entire wrist has become arthritic from longstanding instability, a complete wrist fusion may be required.

Related Document: A Patient’s Guide to Wrist Fusion

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

After wearing a splint or cast for three to six weeks, your doctor may have you work with a physical or occupational therapist. Treatments are used to help you regain wrist range of motion, strength, and function.

After Surgery

If you have surgery, your hand and wrist will be bandaged with a well-padded dressing and a splint for support. Physical or occupational therapy sessions may be needed for up to three months after surgery. The first few treatment sessions focus on controlling the pain and swelling after surgery. Patients then begin to do exercises that help strengthen and stabilize the muscles around the wrist joint. Other exercises are also used to improve the fine motor control and dexterity of the hand. The therapist suggests ways to do activities without straining the wrist joint.

A Patient’s Guide to Kienbock’s Disease

Introduction

Kienbock’s disease is a condition in which one of the small bones of the wrist loses its blood supply and dies, causing pain and stiffness with wrist motion. In the late stages of the disease, the bone collapses, shifting the position of other bones in the wrist. This shifting eventually leads to degenerative changes and osteoarthritis in the joint. While the exact cause of this uncommon disease isn’t known, a number of treatment options are available.

This guide will help you understand

• how Kienbock’s disease develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

How does the wrist joint work?

The anatomy of the wrist joint is extremely complex, probably the most complex of all the joints in the body. The wrist is actually a collection of many joints and bones. These joints and bones let us use our hands in lots of different ways. The wrist must be extremely mobile to give our hands a full range of motion. At the same time, the wrist must provide the strength for heavy gripping.

The wrist is made of eight separate small bones, called the carpal bones. The lunate is one of these bones.

It is the bone that is affected in patients with Kienbock’s disease.

The carpal bones connect the two bones of the forearm, the radius and the ulna, to the bones of the hand. The metacarpal bones are the long bones that lie underneath the palm. The metacarpals attach to the phalanges, which are the bones in the fingers and thumb.

Related Document: A Patient’s Guide to Wrist Anatomy

Causes

Why do I have this condition?

Doctors have not determined exactly what causes Kienbock’s disease. A number of factors seem to be involved. Usually the patient has injured the wrist. The injury may be a single incident, such as a sprain, or a repetitive trauma. But the injury alone does not seem to cause the disease.

The way that blood vessels supply the lunate is thought to play a role in Kienbock’s disease. Some bones in the body simply have fewer blood vessels that bring in blood. The lunate is one of those bones. A bone with a limited blood supply may be more at risk of developing the disease after an injury. The reduced blood supply might be the result of a previous injury to the blood vessels.

Other bones around the lunate may play a role in the disease, too. The length of the ulna, the bone of the forearm on the opposite side of the thumb, may be a factor. When the ulna is shorter than the radius, an imbalance of pressure is created in the wrist joint. Normally, the ulna supports a portion of the force that needs to be transferred from the hand to the forearm. If the ulna is too short, this cannot occur. The lunate is caught between the capitate bone and the radius and must absorb more force when the hand is used for heavy gripping activities. Over time, this extra force may make it more likely for a person to develop Kienbock’s disease. Chronic repetitive trauma can lead to damage of the arteries supplying blood to the lunate.

Kienbock’s disease is also sometimes found in people with other medical conditions that are known to damage small blood vessels of the body. Whatever the cause, the lunate bone develops a condition called osteonecrosis. In osteonecrosis, the bone dies, usually because it’s not getting enough blood.

Symptoms

What does Kienbock’s disease feel like?

The primary symptoms of Kienbock’s disease are pain in the wrist and limited wrist motion. Pain may vary from slight discomfort to constant pain. In the early stages there may be pain only during or after heavy activity using the wrist. The pain usually gets slowly worse over many years. The wrist may swell. The area over the back of the wrist near the lunate bone may feel tender. You may not be able to move your wrist as much as normal or grip objects as well.

Patients often have the condition for months or years before seeking treatment. It rarely affects both wrists. Without treatment the bone may collapse. When the lunate bone is displaced or fragmented, it can rub on the tendons that slide along the back of the wrist – the extensor tendons. The abnormal bone may eventually wear through one or more of the extensor tendons along the back of the wrist. The wrist becomes unstable. The resulting misalignment causes even more uneven wear on the bones leading to osteoarthritis between the radius and the carpal bones.

Diagnosis

How do doctors identify the problem?

Your doctor will begin by taking a detailed history of the problem and examining the wrist.

X-rays and possibly a magnetic resonance imaging (MRI) scan will be ordered. The X-rays are useful to determine how far the disease has advanced. This helps your doctor plan treatment. The MRI machine uses magnetic waves instead of radiation to take a series of pictures that look like slices of the wrist. The MRI scan is most useful if your doctor is not sure whether the lunate bone has lost its blood supply. The MRI is extremely accurate at showing whether a bone has a blood supply or not. Changes in the lunate bone will usually appear on one of these tests. No other tests are usually required.

Treatment

What can be done for the condition?

Kienbock’s disease usually progresses slowly over many years. To help understand it and recommend what treatment is best, hand surgeons divide the progression of the disease into four stages.

• Stage one: The bone loses its blood supply, and a fracture of the lunate may occur.
• Stage two: The bone hardens (called sclerosis) because of the lack of blood supply.
• Stage three: The dead lunate bone collapses. It may break into several pieces and move out of its normal position.
• Stage four: The surfaces of the nearby wrist bones are damaged, resulting in arthritis of the wrist.

Related Document: A Patient’s Guide to Osteoarthritis of the Wrist Joint

The goal of treatment is to decrease the load across the lunate and/or bring a better blood supply to it. Treatment is determined by what stage the disease is in. Staging can be difficult since the degenerative changes occur slowly over a long period of time. Repeated imaging studies may be needed to confirm earlier suspicious findings.

There is no strong evidence at this time to suggest one treatment works better than another. The physician looks at all the factors and makes the best clinical judgment possible. Your age, occupation, activity level, and findings from the diagnostic process will all be taken into consideration.

Nonsurgical Treatment

Stage one Kienbock’s disease is usually treated using nonsurgical treatments. Doctors may suggest immobilizing the wrist in a cast for up to three months. It is possible that the blood supply to the lunate will return and the disease will clear up during this time. If the patient has what’s known as transient (meaning short-lived) osteonecrosis rather than true Kienbock’s disease, the condition may also clear up during this time. Transient osteonecrosis sometimes develops briefly after an injury.

Surgery

Operative treatment can be broken down into several major categories, including 1) revascularization 2) intercarpal fusion; 3) lunate excision; 4) lunate decompression and joint-leveling procedures; 5) proximal row carpectomy; and 6) wrist fusion.

Revascularization

Stage two and stage three Kienböck’s disease often require surgery when immobilizing the wrist doesn’t help. Attempts to restore the blood flow to the lunate are most likely to be successful when the disease is in the early stages. The procedure to restore blood flow is called revascularization. During the operation, the surgeon moves a small section of blood vessels (and also possibly bone) from elsewhere on the wrist. The segment is attached to the deteriorating lunate bone. This is done to restore blood flow to the lunate and halt its deterioration. This is a newer procedure to treat Kienböck’s disease and is not always successful. Vascularized bone graft does have the advantage of implanting live bone with a ready made blood supply.If this is successful, the bone heals and the blood supply in the transferred bone fragment grows into the rest of the lunate to restore the blood supply to the entire lunate.

Intercarpal Fusion

Using an arthroscope, a thin instrument with a TV camera on the end, surgeons are able to operate using a small incision over the lunate. The surgeon cleans the area around the lunate, and then fuses the lunate to the carpal bone next to it. This is called an intercarpal fusion. It’s not a complete or total fusion because not all of the wrist bones are fused together. Bringing an extra blood vessel to revascularize the lunate (described above) is not necessarily a part of the treatment.

Lunate Excision

One of the oldest methods for treating Kienbock’s disease is called a lunate excision. The abnormal bone was just removed, leaving an empty space in the wrist joint. The bones in the area collapsed into the empty space. This usually was not ideal and created problems later on. Other options include filling the empty space with a piece of tendon coiled up and stuffed into the hole. An artificial lunate bone may also be used to fill this space and maintain alignment of the bones.

Lunate Decompression and Joint Leveling

If you were born with an ulna that is too short, you have what is called an ulna minus wrist joint. As described above, this can lead to increased pressure on the lunate and may be contributing to the problem. Your surgeon may recommend a joint leveling procedure to reduce the pressure on the lunate. Doing this may allow the bone to heal and revascularize, or it may at least slow the progression of the arthritis in the joint. A joint leveling operation either shortens the bone that is too long ( the radius) or lengthens the bone that is too short (the ulna). Joint leveling operations include ulnar lengthening and radial shortening osteotomy.

Ulnar Lengthening

The operation for ulnar lengthening is done by making a small incision on the ulnar side of the wrist. The ulna bone is cut. Osteotomy is the term surgeons use to describe cutting a bone. The bone is not cut straight across, but like a stair step. This allows the surgeon to slide the two ends of the bone apart about 1/4 or 1/2 inch and still have the bone overlapping and connected. This type of cut prevents ending up with a large gap between the two segments of bone that can delay or prevent healing.

The surgeon will slide the two segments of ulna apart until X-rays show the joint is level and the radius and ulna are of equal length. The two segments of bone are held in place with a small metal plate and screws until they heal together. The plate may be removed once the bone heals.

Radial Shortening Osteotomy

If your surgeon suggests a radial shortening osteotomy, then the goal is to shorten the bone that is too long. A radial osteotomy is sometimes preferred because the bone just heals better. The distal end of the radius near the wrist joint is larger than the ulna with a better blood supply. This means that it heals faster and more reliably.

To perform the radial osteotomy, the surgeon makes a small incision though the skin over the end of the radius. Before the operation, the surgeon uses the X-rays and measures how much bone must be removed to make the joint level. The radius is cut completely in two pieces and a small section, or wedge, of the bone near the wrist is removed. The two segments of the shortened radius are aligned and held in place with a metal plate and screws until healed. Some studies show this method has a lower rate of complications and good outcomes. It is used more often than ulnar lengthening.

Stage two Kienbock’s disease and wrists in stage three that are stable can be treated with joint leveling procedures. Decreased pain with improved range of motion and strength are possible with joint leveling. But getting the exact length needed can be difficult.

Capitate Shortening

Some surgeons prefer a capitate shortening (known as the Almquist procedure), which shortens a carpal bone on the other side of the lunate. Lunate decompression and capitate shortening are both helpful for reducing the force on the lunate. This procedure does not level the joint.

Carpectomy

In stage four, also known as late-stage Kienbock’s disease, surgeons focus on treating the wrist osteoarthritis that results when the lunate collapses and dies. One surgical option at this stage is proximal-row carpectomy. Carpectomy means excision (removal) of one or more of the carpal bones. The wrist is made up of two rows of carpal bones, four in each row. The lunate is in the proximal row (the row closest to the forearm). When the lunate has collapsed, but the wrist joint is not terribly arthritic, the four carpal bones of the proximal row may simply be removed. This allows the distal row (the other four bones) to slide down a bit and to begin moving against the forearm bones instead.

The wrist joint seems to work pretty well after this procedure. The advantage is that you will still have a good deal of wrist motion, unlike wrist fusion (described below). A proximal row carpectomy is a good solution when you need a flexible wrist more than you need a strong one, such as in someone who plays piano for a living.

During this procedure, the surgeon can also take out a section of the nerve that supplies feeling to the wrist joint to reduce wrist pain. This will not affect the feeling in your hand, because it only affects the nerve that goes to the wrist joint itself, below the skin level.

Wrist Fusion

Finally, your surgeon may also suggest a wrist fusion when the entire wrist has become arthritic. (A wrist fusion is sometimes called an arthrodesis of the wrist). A fusion is an operation that allows all the bones of the wrist to grow together to form one bone. This makes the wrist stiff. You will not be able to bend the wrist after a fusion. You will be able to turn the wrist palm up and palm down. A fusion is a good solution when you need a strong wrist more than you need wrist movement, such as someone who does manual labor.

Related Document: A Patient’s Guide to Wrist Fusion

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

If the bone is in good alignment, you may be placed in a cast for up to 12 weeks. This amount of time is needed to allow the blood supply to return to the bone. When your doctor is certain the bones have healed, your cast will be removed. Your wrist will probably be stiff and weak from being in the cast. You may need physical or occupational therapy for four to six weeks to help improve wrist range of motion and strength.

After Surgery

You’ll be placed in a splint for about 12 weeks after surgery. Your surgeon will X-ray the wrist several times after surgery to make sure that the bones are healing properly. Once your wrist has begun to heal, you can safely begin a rehabilitation program.

After surgery, you may need physical or occupational therapy sessions for eight to 12 weeks. The first few treatments will focus on controlling the pain and swelling. You will work into doing exercises to help strengthen and stabilize the muscles around the wrist joint. Other exercises are used to improve fine motor control and dexterity of your hand. You’ll be given tips on ways to do your activities while avoiding extra strain on the wrist joint.

A Patient’s Guide to Intersection Syndrome

Introduction

Intersection syndrome is a painful condition of the forearm and wrist. It can affect people who do repeated wrist actions, such as weight lifters, downhill skiers, and canoeists. Heavy raking or shoveling can also cause intersection syndrome.

This guide will help you understand

• what part of your forearm is causing the problem
• what may have caused this condition
• what can be done to stop the pain

Anatomy

What part of the forearm is causing my pain?

The pain from intersection syndrome is usually felt on the top of the forearm, about three inches above the wrist. At this spot, two muscles that connect to the thumb cross over (or intersect) the two underlying wrist tendons (tendons connect muscles to bones).

The two muscles that cross over the wrist tendons control the thumb. They are the extensor pollicis brevis and the abductor pollicis longus. These two muscles start on the forearm, cross over the two wrist tendons,

and connect on the back part of the thumb. When these muscles work, they pull the thumb out and back.

The extensor carpi radialis brevis and the extensor carpi radialis longus muscles run lengthwise along the back of the forearm. The tendons of these two muscles attach on the back of the hand. The action of these two wrist tendons pulls the wrist back, into extension.

Most of the tendons around the wrist are covered with a thin tissue called tenosynovium. Tenosynovium is very slippery. It allows tendons to glide against one another and the surrounding muscles, fat, and skin with very little friction.

Related Document: A Patient’s Guide to Wrist Anatomy

Causes

What caused my condition?

If you overuse the wrist extensor tendons, the slippery tenosynovial lining may become inflamed from the constant rubbing against the two thumb muscles. As the tenosynovium becomes more irritated and inflamed, it swells and thickens. You feel pain when you move your wrist because the swollen tendons are rubbing against the thumb muscles.

Wrist extensor tendons work like the bow used by violin players. The wrist extensor tendons are like the bow, and the thumb muscles are like the strings. As the wrist curls down and in, the wrist tendons rub back and forth against the thumb muscles. The friction builds up, much like the effect of rubbing two sticks together. This leads to irritation and inflammation of the tenosynovium covering the wrist extensor tendons.

The wrist extensor tendons are strained by any activities that cause the wrist to curl down and in, toward the thumb. These wrist movements are especially common in downhill skiers when they plant their ski poles deeply in powder snow. The same movement is involved when pulling a rake against hard ground. Racket sports, weight lifting, canoeing, and rowing can also stress the wrist extensor tendons.

Symptoms

What does intersection syndrome feel like?

The friction on the wrist tendons causes pain and swelling in the tenosynovium that covers the tendons. The friction hampers the smooth gliding action. You may hear a squeaking sound and feel creaking as the tendons rub against the muscles. This is called crepitus. You may have swelling and redness at the intersection point. Pain can spread down to the thumb or up along the edge of the forearm.

Diagnosis

What tests will my doctor run?

Doctors usually make the diagnosis of intersection syndrome during a physical examination. Most of the time no special tests are required.

The main challenge is distinguishing intersection syndrome from de Quervain’s tenosynovitis. De Quervain’s tenosynovitis is a condition that is very similar to intersection syndrome.

Related Document: A Patient’s Guide to de Quervain’s Tenosynovitis

Both syndromes involve inflammation in the tendons of the wrist. However, the pain begins in different spots. Intersection syndrome causes pain at the intersection point, about three inches up the forearm. De Quervain’s tenosynovitis causes pain along the edge of the wrist, closer to the hand. Your doctor will examine your forearm and wrist carefully to locate exactly where your pain is coming from.

Treatment

What treatment options are available?

Nonsurgical Treatment

It is most important to stop or change activities that are causing your symptoms. Take frequent breaks when doing repeated hand and thumb movements. Avoid repetitive hand motions such as heavy grasping, wringing, or turning and twisting movements of the wrist. Downhill skiers may get relief by avoiding heavy planting and dragging of their ski poles and by getting a shorter pole with a smaller basket diameter.

Keep your wrist in a neutral alignment. In other words, keep it in a straight line with your arm, without bending it down and in. You may be issued a special forearm and thumb splint called a thumb-spica splint. It keeps the wrist and lower joints of the thumb from moving. By resting the wrist extensor tendons and the thumb muscles, it allows the area to begin healing.

Anti-inflammatory medications may help control the swelling of the tenosynovium and ease symptoms. These medications include common over-the-counter medications such as ibuprofen and aspirin. Ice treatments can also help decrease swelling and relieve pain.

If these simple measures fail to control your symptoms, your doctor may suggest an injection of cortisone. Cortisone is a very effective anti-inflammatory medication. Cortisone injections will usually control the inflammation in the early stages of the problem. However, cortisone’s effects are generally temporary, lasting from several weeks to months.

Related Document: A Patient’s Guide to Joint Injections for Arthritis

Your doctor may have you work with a physical or occupational therapist. The main focus of treatment is to reduce or eliminate the cause of the irritation to the thumb tendons. Your therapist may check your workstation and the way you do your work tasks. Your therapist may give you suggestions about healthy body alignment and wrist positions, helpful exercises, and tips on how to prevent future problems.

Surgery

Surgery is rarely necessary to treat intersection syndrome. In extremely difficult cases, a surgeon may remove some of the thickened tenosynovium around the tendons. The operation is called a tendon release.

The tendon release procedure can usually be done on an outpatient basis, which means that you won’t have to spend the night in the hospital. It can be done using a general anesthetic, which puts you to sleep, or a regional anesthetic. A regional anesthetic blocks the nerves going to only a certain part of the body. Injection of medications similar to lidocaine can block the nerves for several hours.

You may get an axillary block, which puts the arm to sleep, or a wrist block, which puts only the hand to sleep. It is even possible to perform the surgery by simply injecting lidocaine around the area of the incision.

The first step is to make a small incision over the spot where the two muscles cross over the two wrist tendons.

The surgeon identifies the irritated tendons, and then separates and removes the inflamed tenosynovium from the tendons.

The skin is then stitched together, and your hand is wrapped in a bulky dressing.

Rehabilitation

What can I expect after treatment?

Nonsurgical Rehabilitation

If nonsurgical treatment is successful, you may see improvement in four to six weeks. You may need to continue wearing your thumb splint to control symptoms. Try to do your activities using healthy body and wrist alignment. Limit activities that require repeated motions of the wrist and thumb.

After Surgery

A period of rehabilitation is needed after surgery. Pain and symptoms generally begin to improve after surgery, but you may have tenderness in the area of the incision for several months.

At first, take time during the day to support your arm with your hand elevated above the level of your heart. You should gently move your fingers and thumb from time to time during the day. Keep the dressing on your hand until you return to the doctor. Avoid getting the stitches wet. Your stitches will be removed 10 to 14 days after surgery.

You will probably need to attend occupational or physical therapy sessions for six to eight weeks, and you should expect full recovery to take several months. You’ll begin by doing active hand movements and range-of-motion exercises. Therapists also use ice packs, soft-tissue massage, and hands-on stretching to help with the range of motion. When the stitches are removed, you may start carefully strengthening your hand and thumb by squeezing and stretching special putty. Therapists also use a series of gentle stretches to encourage the wrist tendons to glide smoothly under the thumb muscles.

As you progress, your therapist will give you exercises to help strengthen and stabilize the muscles and joints in your wrist and thumb. Other exercises are used to improve fine motor control and dexterity. Some of the exercises you’ll do are designed to get your hand working in ways that are similar to your work tasks and sport activities.

Your therapist will help you find ways to do your tasks that don’t put too much stress on your thumb and wrist. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

A Patient’s Guide to Ganglions of the Wrist

Introduction

A ganglion is a small, harmless cyst, or sac of fluid, that sometimes develops in the wrist. Doctors don’t know exactly what causes ganglions, but a ganglion that isn’t painful and doesn’t interfere with activity can often be left untreated without harm to the patient. However, treatment options are available for painful ganglions or ones that cause problems.

This guide will help you understand

• what parts of the wrist are involved
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What parts of the wrist are involved?

The anatomy of the wrist joint is extremely complex, probably the most complex of all the joints in the body. The wrist is actually a collection of many joints and bones. These joints and bones let us use our hands in lots of different ways. The wrist must be extremely mobile to give our hands a full range of motion.

At the same time, the wrist must provide the strength for heavy gripping.

The wrist is made of eight separate small bones, called the carpal bones. The carpal bones connect the two bones of the forearm, the radius and the ulna, to the bones of the hand. The metacarpal bones are the long bones that lie underneath the palm.

Ligaments connect and hold all these wrist bones together. The ligaments allow the bones to move in all directions. These ligaments meld together to form the joint capsule of the wrist. The joint capsule is a watertight sac of tissue that surrounds the wrist bones. Inside the wrist capsule are the joints themselves. The joint capsule contains a small amount of lubricant, called synovial fluid, that allows the bones to move together easily. The many tendons required to move the fingers run just outside the joint capsule.

Ganglions are generally attached by a stalk of tissue to a nearby joint capsule, tendon, or tendon sheath (tissue covering the tendon). Wrist ganglions are attached to the wrist joint capsule. Typically only one ganglion appears, often in a location that is predictable to doctors. However, ganglions have been seen in almost every joint in the hand and wrist.

Sixty to 70 percent of wrist ganglions are dorsal wrist ganglions. A dorsal wrist ganglion is found on the back of the hand, often centered over the wrist, though it can appear in any number of areas along the back of the wrist. A dorsal wrist ganglion may be not be visible from the outside. Doctors refer to this hidden type of ganglion as occult, or concealed.

A volar wrist ganglion typically appears on the palm side of the wrist in the wrist crease just below the thumb. This is the second most common type of wrist ganglion.

Related Document: A Patient’s Guide to Wrist Anatomy

Causes

Why do I have this problem?

Doctors don’t know why ganglions develop. In some cases, the wrist has been injured previously. Repetitive injuries, such as those that can occur from playing tennis or golf frequently, seem to play a role in ganglion development as well.

One theory suggests that wrist ganglions are formed when connective tissue degenerates or is damaged by wear and tear. The damaged tissue forms a weakened spot in the joint capsule, just like a weak spot on a car tire that allows the inner tube to bulge through. The joint fluid may escape through this weakened area and begin to collect in a cyst outside the joint. Over time this cyst grows larger. The joint fluid seems to move out of the wrist joint into the ganglion, but not the other way. In the end, a clear, sticky fluid fills the cyst. The fluid is a mix of chemicals normally found in the joint.

Symptoms

What does a ganglion feel like?

A patient with a dorsal wrist ganglion may feel a bump or mass on the back of the wrist. With a volar wrist ganglion, the bump is felt on the wrist crease below the thumb. The mass may appear suddenly, or it may develop over time. The ganglion may occasionally increase or decrease in size.

The wrist may ache or feel tender. The ganglion may also interfere with activities. A volar wrist ganglion may compress the median or ulnar nerve, causing trouble with sensation and movement. An occult dorsal wrist ganglion may be quite painful and tender, even though it is smaller than other ganglions. Typically the symptoms from a ganglion are not harmful and generally do not grow worse. These cysts will not turn into cancer.

Diagnosis

How do doctors diagnose the problem?

Your doctor will ask for a history of the problem and examine your hand and wrist. Usually, this is all that’s required to diagnose a ganglion. An occult dorsal wrist ganglion, however, may be more difficult to locate because of its small size.

Treatment

What can be done to treat a ganglion?

Treatment for dorsal and volar wrist ganglions may be either surgical or nonsurgical. The relative risks and benefits of any ganglion treatment should be considered carefully.

Nonsurgical Treatment

Dorsal Wrist Ganglions

In the past, dorsal wrist ganglions were treated by breaking them without rupturing the skin. This was done with a mallet (or bible) or simply with firm pressure. However, because ganglions often reappeared after this type of treatment, it is no longer used.

Observation is often sufficient treatment for wrist ganglions. Ganglions typically are harmless and usually do not grow worse over time. Nor do they usually cause damage to the tendons, nerves, or the joint as a whole. As many as 50 percent of wrist ganglions may eventually go away by themselves.

Beyond observation, closed rupture with multiple needle punctures is another nonsurgical treatment option for dorsal wrist ganglions. In this procedure, the cyst wall is punctured with a needle, and anti-inflammatory and numbing drugs are injected into the cyst. This treatment can shrink the cyst and alleviate symptoms. However, the ganglion is likely to reappear.

Volar Wrist Ganglions

Observation is the most common nonsurgical treatment for volar wrist ganglions.

Surgery

Surgery is recommended when the patient feels significant pain or when the cyst interferes with activity. It is also recommended if the ganglion is compressing nerves in the wrist, since this can cause problems with movement and feeling in the hand. Surgery is usually done using regional anesthesia, which means only the arm is put to sleep, but it can also be done under a general anesthesia in which you go to sleep.

Dorsal Wrist Ganglion

Doctors have two options to surgically treat dorsal wrist ganglions. The first is cyst puncture and aspiration. (Aspiration means drawing the fluid out with suction.) However, this procedure has less than a 50 percent success rate.

Excision, or removal, of the cyst is the second option. Removing the cyst is usually effective if the stalk that connects the cyst to the joint capsule and a bit of the surrounding capsule are removed. Usually only a single incision is made, but depending on the location of the ganglion, a second incision may be necessary.

To remove a dorsal wrist ganglion, a small incision is made in the back of the wrist. The tendons that run across the back of the wrist and into the fingers are retracted (or moved) out of the way. This allows the surgeon to see the ganglion and follow it down to where it attaches to the wrist capsule. Once the surgeon locates this stalk, the entire ganglion is removed, including the area where it attaches to the joint capsule. The joint capsule may or may not need to be repaired with sutures. Finally, the skin incision is closed with sutures.

Volar Wrist Ganglion

Puncture and aspiration is not recommended for volar wrist ganglions located in certain areas because of the possibility of nerve and blood vessel damage. In other areas, needle puncture has a better success rate.

Excision is the most common surgery for a volar wrist ganglion. Removing the cyst is usually effective if the stalk that connects the cyst to the joint capsule and a bit of the surrounding capsule are removed. The surgical procedure is basically the same, except the volar ganglion is usually very close to the radial artery (the artery in the wrist used to feel someone’s pulse). In some cases, the volar ganglion even winds around the artery. This makes removing the ganglion a bit more difficult. The surgeon must be careful to protect the artery, while at the same time removing the cyst down to the joint capsule, just like with the dorsal ganglion.

Complications

Both of these procedures have risks. Even after excision surgery, a ganglion may reappear, though this is uncommon. There is a slight risk of infection with both procedures. Excision can sometimes result in decreased motion, instability, and nerve or blood vessel damage. Removing a volar ganglion has a greater risk of nerve and blood vessel damage. However, the vast majority of people have two arteries that travel into the hand. If one is injured, the other is sufficient to provide an adequate blood supply to the hand.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

You may simply be asked to observe the ganglion for changes. A splint may be issued to keep your wrist from moving and to allow the ganglion to shrink. You may be shown how to massage the area in order to move fluid out of the ganglion. If you find that the ganglion has gotten bigger, notify your doctor.

After Surgery

A bulky dressing is applied to the wrist and forearm. You will be encouraged to move your fingers and wrist soon after surgery. Stitches are removed after two weeks. Physical therapy exercises should be continued until you can move your wrist normally.

A Patient’s Guide to Wrist Fusion

Introduction

Arthritis of the wrist has many causes, and there are many ways of treating the pain. These treatments can be very successful, at least for awhile. But eventually the entire wrist can become so painful that nonsurgical treatments don’t work anymore. At this point, your surgeon may recommend a wrist fusion. Wrist fusion may also be necessary after severe trauma to the wrist. Fusion is sometimes called arthrodesis.

This guide will help you understand

• how a wrist fusion eases the pain of arthritis
• how surgeons perform the operation
• what the recovery process is like

Anatomy

What parts of the wrist are involved?

The anatomy of the wrist joint is extremely complex, probably the most complex of all the joints in the body. The wrist is actually a collection of many joints and many bones. These joints and bones let us use our hands in many ways. The wrist must be extremely mobile to give our hands a full range of motion. At the same time, the wrist must provide the strength for heavy gripping.

The wrist is made up of eight separate small bones, called the carpal bones. The carpal bones connect the two bones of the forearm, the radius and the ulna, to the bones of the hand. The metacarpal bones are the long bones that lie mostly within the palm. The metacarpals are in turn attached to the phalanges, the bones in the fingers and thumb.

One reason that the wrist is so complex is that every small bone forms a joint with the bone next to it. This means that what we call the wrist joint is actually many small joints. Ligaments connect all the small bones to each other, and to the radius, ulna, and metacarpal bones.

Articular cartilage is the smooth, rubbery material that covers the bone surfaces in most joints. It protects the bone ends from friction when they rub together as the joint moves. Articular cartilage also acts sort of like a shock absorber. Damage to the articular cartilage eventually leads to degenerative arthritis.

When the articular cartilage is worn away over time, the bones begin to rub against each other. This causes the pain of degenerative arthritis. Degenerative arthritis is also called osteoarthritis.

Related Document: A Patient’s Guide to Osteoarthritis of the Wrist Joint

Related Document: A Patient’s Guide to Wrist Anatomy

Rationale

Why do I need wrist fusion surgery?

Many of the small joints in the wrist can become arthritic. When this happens, the wrist joint can become extremely painful. Moving your wrist may become difficult because of the pain and stiffness. Your grip can also get weak from the pain. Whenever the hand grips or uses strength in any way, the wrist feels the force. This happens because the muscles running from the forearm to the hand contract, tightening the wrist bones together. This causes pain.

In advanced problems with arthritis, the alignment of the wrist can change, leading to deformity. Fusing the bones together is a way to improve the alignment and prevent further deformation. Fusion may also be needed to align the wrist after a severe wrist injury.

A fusion of any joint eliminates pain by making all the bones grow together into one solid bone. When the bone ends can no longer rub together, there is no more pain. Fusion surgeries are used in many joints. Fusion surgeries were very common before the invention of artificial joints.

A wrist fusion is somewhat different from fusion in other joints. Most joints are made up of only two bones. Wrist fusion involves getting 12 or 13 bones to grow together.

The goal of a wrist fusion is to get the radius in the forearm, the carpal bones of the wrist, and the metacarpals of the hand to fuse into one long bone. The ulna of the forearm is not included in the fusion. The joints between the ulna and the radius are what allow you to turn the palm of your hand up and down. By not fusing the ulna, you should still be able to rotate your hand. However, you will not be able to bend your wrist after the operation.

A wrist fusion is a trade-off. You will lose some motion, but you will regain a strong and pain-free wrist. Regaining strength is especially important to younger people who need to work with their hands. These patients need strength more than flexibility. Wrist fusion gives them a strong wrist that is good for gripping. Patients who need more movement than strength should consider another type of operation, such as an artificial wrist joint replacement.

Related Document: A Patient’s Guide to Artificial Joint Replacement of the Wrist

Preparations

What do I need to do before surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. The amount of time patients spend in the hospital varies.

Surgical Procedure

What happens during wrist fusion surgery?

Surgeons fuse wrists in many different ways. In the past, most of the procedures used a bone graft from your pelvis. Surgeons now try to take a small amount of bone from the end of the radius bone instead. A bone graft involves taking bone tissue from one area and transplanting it into another area. This encourages the ends of the bone to grow together. If your surgeon grafts bone from your pelvis, you will have two incisions, one on the back of your wrist, and another on the side of your hip. Your surgeon may also try to fuse the bones without a graft.

Surgery can last up to 90 minutes. Surgery may be done using a general anesthetic, which puts you to sleep during surgery. In some cases, surgery is done using a local anesthetic, which numbs just the wrist and hand. With a local anesthetic you may be awake during the surgery, but your surgeon will make sure you don’t see the operation.

Once you have anesthesia, your surgeon will make sure the skin of your wrist and hand are free of infection by cleaning the skin with a germ-killing solution. The surgeon then makes an incision down the back of the wrist. Since most of the blood vessels and nerves are on the other side of the wrist, going through the back helps prevent nerve and vessel damage.

Next, the tendons and ligaments are moved to the side. This allows the surgeon to see all the bones and joints of the wrist. The articular cartilage is then removed from each joint that will be fused. At this point, the wrist joint consists of many small bones with space between them where the cartilage is missing. If you are getting a bone graft, the graft is placed between each of the spaces in the wrist bones.

The surgeon places a metal plate with screw holes on the back of the wrist. The plate goes from the radius to the metacarpal bone of the middle finger. The plate is attached to the bone with metal screws. The plate keeps the bones from moving so that they stay in proper alignment while they grow together. The plate usually stays inside your hand permanently. It is not removed unless it causes problems.

At the end of the operation, the incisions are stitched together. Your arm is placed in a large, rigid splint or cast, and you are woken up and taken to the recovery room.

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following wrist fusion are

• infection
• nerve and blood vessel injury
• tendon irritation
• nonunion of the bones

Infection

Any surgery carries the risk of infection. You will probably be given antibiotics before the procedure to reduce the risk. If you get an infection, you will need more antibiotics. If the areas around the bone graft and metal plate become infected, you may need surgery to drain the infection.

Nerve and Blood Vessel Injury

All of the nerves and blood vessels that go to the hand travel across the wrist joint. Because the operation is performed so close to them, it is possible to injure either the nerves or the blood vessels during surgery. Retractors that hold the nerves and vessels out of the way during surgery may cause temporary damage. Permanent injury to the nerves or blood vessels rarely happens, but it is possible.

Tendon Irritation

The plate that is screwed into the back of the wrist can irritate the tendons that cross this part of the wrist. If this happens, you may need short-term treatment with medication, ice, or visits to a physical or occupational therapist. If pain and irritation still don’t go away after trying these treatments, your surgeon may have to remove the plate. Surgeons will try to wait to do this until they are certain the bones have fused together.

Nonunion

Sometimes the bones do not fuse as planned. This is called a nonunion, or pseudarthrosis (false joint). If the joint motion from a nonunion continues to cause pain, you may need a second operation. In the second procedure, the surgeon usually adds more bone graft and checks that the plates and pins are holding the bones still. The bones need to be completely immobilized for fusion to occur.

After Surgery

What can I expect after surgery?

After surgery, you will wear an elbow-length cast for about six weeks. This holds the wrist still while the ends of the bones fuse together. Your surgeon will want to check your hand within five to seven days. Stitches will be removed after 10 to 14 days, although most of them will have been absorbed by your body. You may have some discomfort after surgery. Your surgeon can give you pain medicine to control the discomfort.

You should keep your hand and wrist elevated above the level of your heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up.

Rehabilitation

What will my recovery be like?

A removable splint replaces the cast after six to eight weeks. You can then take the splint off to do your exercises during the day. The joints in the fingers may feel stiff or sore from the immobility caused by the cast.

If you still have pain, or if the stiffness in the joints above or below the wrist doesn’t improve, you may need a physical or occupational therapist to direct your recovery program. The first few therapy treatments will focus on controlling the pain and swelling from surgery. Your therapist may use gentle massage and other types of hands-on treatments to ease muscle spasm and pain. Then you’ll begin gentle range-of-motion exercises for the joints above and below the wrist.

Your surgeon will X-ray the wrist several times after surgery to make sure that the bones are healing properly. Once your surgeon is sure that fusion has occurred, you will begin a strengthening program. It will take some time to regain the strength in your hand and arm. As with any surgery, you need to avoid doing too much, too quickly.

Strengthening exercises give you added stability around the wrist joint. Some of the exercises you’ll do are designed to get your hand and wrist working in ways that are similar to your work tasks and daily activities. Your therapist will teach you ways to use your hand and arm so that you can do your tasks safely and with the least amount of stress on your wrist. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Your therapist’s goal is to help you keep your pain under control, improve strength, and to regain fine motor abilities with your wrist and hand. When you are well under way, your regular visits to the therapist’s office will end. Your therapist will continue to be a resource, but you’ll be in charge of doing your exercises as part of an ongoing home program.

A Patient’s Guide to de Quervain’s Tenosynovitis

Introduction

The condition called de Quervain’s tenosynovitis causes pain on the inside of the wrist and forearm just above the thumb. It is a common problem affecting the wrist and is usually easy to diagnose.

This guide will help you understand

• how this condition starts
• how to recognize the symptoms
• what can be done to stop the pain

Anatomy

What part of my thumb and wrist is causing problems?

De Quervain’s tenosynovitis affects two thumb tendons. These tendons are called the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB).

Tendons connect muscle to bone. Muscles pull on tendons for movement. The muscles connected to the APL and EPB tendons are on the back of the forearm. The muscles angle toward the thumb.

On their way to the thumb, the APL and EPB tendons travel side by side along the inside edge of the wrist. They pass through a tunnel near the end of the radius bone of the forearm. The tunnel helps hold the tendons in place, like the guide on a fishing pole.

This tunnel is lined with a slippery coating called tenosynovium. The tenosynovium is a slippery covering that allows the two tendons to glide easily back and forth as they move the thumb. Inflammation of the tenosynovium and tendon is called tenosynovitis. In de Quervain’s tenosynovitis, the inflammation constricts the movement of the tendons within the tunnel.

Related Document: A Patient’s Guide to Wrist Anatomy

Causes

How did this condition develop?

Repeatedly performing hand and thumb motions such as grasping, pinching, squeezing, or wringing may lead to the inflammation of tenosynovitis. This inflammation can lead to swelling, which hampers the smooth gliding action of the tendons within the tunnel. Arthritic diseases that affect the whole body, such as rheumatoid arthritis, can also cause tenosynovitis in the thumb. In other cases, scar tissue from an injury can make it difficult for the tendons to slide easily through the tunnel.

Symptoms

What problems does this condition cause?

At first, the only sign of trouble may be soreness on the thumb side of the forearm, near the wrist. If the problem isn’t treated, pain may spread up the forearm or further down into the wrist and thumb.

As the friction increases, the two tendons may actually begin to squeak as they move through the constricted tunnel. This noise is called crepitus. If the condition is especially bad, there may be swelling along the tunnel near the edge of the wrist. Grasping objects with the thumb and hand may become increasingly painful.

Diagnosis

What tests will my doctor want to do?

Doctors usually diagnose de Quervain’s tenosynovitis easily through a physical examination. Most of the time no special tests are required. The major problem can be distinguishing de Quervain’s tenosynovitis from intersection syndrome, which is a very similar condition.

Related Document: A Patient’s Guide to Intersection Syndrome

Careful attention must be paid to where the pain is located: over the de Quervain’s tunnel near the end of the radius bone, or over the intersection point on the wrist. The intersection point is about three inches up the forearm.

The Finklestein test is one of the best ways to make the diagnosis. You can do this test yourself. Bend your thumb into the palm and grasp the thumb with your fingers making a fist with the thumb inside. Now bend your wrist away from your thumb. If you feel pain over the tendons to the thumb, your problem may be de Quervain’s tenosynovitis.

Treatment

How can I make the pain go away?

Nonsurgical Treatment

If at all possible, you must change or stop all activities that cause your symptoms. Take frequent breaks when doing repeated hand and thumb actions. Avoid repetitive hand motions such as heavy grasping, wringing, or turning and twisting movements of the wrist. Keep the wrist in a neutral alignment. In other words, keep it in a straight line with your arm, without bending it forward or backward.

Your doctor may want you to wear a special forearm and thumb splint called a thumb-spica splint. This splint keeps the wrist and lower joints of the thumb from moving. The splint allows the APL and EPB tendons to rest, giving them a chance to begin to heal.

Anti-inflammatory medications may also help control the swelling of the tenosynovium and ease symptoms. These medications include common over-the-counter medications such as ibuprofen and aspirin.

If these simple measures fail to control your symptoms, your doctor may suggest an injection of cortisone into the irritated tunnel. Cortisone reduces the swelling of the tenosynovium and may temporarily relieve your symptoms. Cortisone injections will usually control the inflammation in the early stages of the problem.

Related Document: A Patient’s Guide to Joint Injections for Arthritis

Your doctor may have you work with a physical or occupational therapist. The main focus of therapy is to reduce or eliminate the cause of irritation of the thumb tendons. Your therapist may check your workstation and the way you do your work tasks. Suggestions may be given about the use of healthy body alignment and wrist positions, helpful exercises, and tips on how to prevent future problems.

Surgery

If all else fails, you may need surgery. The goal of surgery is to give the tendons more space so they no longer rub on the inside of the tunnel. To do this, the surgeon performs a surgical release of the roof of the tunnel.

This surgery can usually be done on an outpatient basis, which means that you won’t have to spend the night in the hospital. It can be done using a general anesthetic, which puts you to sleep, or a regional anesthetic. A regional anesthetic blocks the nerves going to only a certain part of the body. Injection of medications similar to novocaine can block the nerves for several hours.

In surgery for de Quervain’s tenosynovitis, you may get an axillary block, which puts the arm to sleep, or a wrist block, which puts only the hand to sleep. It is even possible to perform the surgery by simply injecting novocaine around the area of the incision.

Once you have anesthesia, your surgeon will make sure the skin of your forearm and wrist is free of infection by cleaning the skin with a germ-killing solution. The first step in the surgical release is to make a small incision along the thumb side of the wrist.

The surgeon moves aside other tissues and locates the tendons and the tunnel. An incision is made to split the roof, or top, of the tunnel. This allows the tunnel to open up, creating more space for the tendons. The tunnel will eventually heal closed, but it will be larger than before. Scar tissue will fill the gap where the tunnel was cut.

The skin is then stitched together, and your hand is wrapped in a bulky dressing.

Rehabilitation

What can I expect after treatment?

Nonsurgical Rehabilitation

If nonsurgical treatment is successful, you may see improvement in four to six weeks. You may need to continue wearing your thumb splint to control symptoms. Try to do your activities using healthy body and wrist alignment. Limit activities that require repeated motions of the wrist and thumb.

After Surgery

Rehabilitation is more involved after surgery. Full recovery could take several months. Pain and symptoms generally begin to improve after surgery, but you may have tenderness in the area of the incision for several months.

Take time during the day to support your arm with your hand elevated above the level of your heart. You should move your fingers and thumb occasionally during the day. Keep the dressing on your hand until you return to the surgeon. Avoid getting the stitches wet. Your stitches will be removed 10 to 14 days after surgery.

You will probably need to attend occupational or physical therapy sessions for six to eight weeks. You’ll begin doing active hand movements and range-of-motion exercises. Therapists also use ice packs, soft-tissue massage, and hands-on stretching to help with the range of motion. When the stitches are removed, you may start carefully strengthening your hand and thumb by squeezing and stretching putty. Therapists also use a series of gentle stretches to encourage the thumb tendons to glide easily within tunnel.

As you progress, your therapist will give you exercises to help strengthen and stabilize the muscles and joints in the hand and thumb. Other exercises are used to improve fine motor control and dexterity. Some of the exercises you’ll do are designed to get your hand working in ways that are similar to your work tasks and sport activities.

Your therapist will help you find ways to do your tasks that don’t put too much stress on your thumb and wrist. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.