I had an ORIF with a volar fixed angle plate placed 2 days ago.  I am supposed to keep my wrist in a splint for 2 weeks before I am allowed to do anything.  Is this normal?  I would think that my muscles would waste away in that time.

The protocol that your surgeon gave you sounds like the standard protocol– no movement for two weeks and no strengthening until week six.  A recent article has found it to be more beneficial, however, to begin passive motion fairly immediately and strengthening as soon as two weeks. This would be a good discussion to have with your surgeon.

How long is the recovery for a radial fracture and what can I expect during my recovery time?  I recently fell while skiing and have to have an “ORIF with a fixed volar angle plate.” I am a golfer and want to get back to my game this summer.

Typical recovery from this type of injury does take awhile but you can expect near to full recovery with the proper rehabilitation. A recent study found quicker return to normal function and decrease in pain with early motion and strengthening following the surgery versus the standard protocol of waiting for motion until two weeks after surgery and waiting to strengthening until six weeks after surgery.  You might look into the accelerated rehabilitation program and a physical therapist that can guide you in your recovery.  Also, this is a good discussion to have with your surgeon since recovery does also depend on the extent of damage and how well the surgery goes.

I’ve been putting off having surgery for a wrist problem known as Madelung deformity. How long do you think I can wait before it’s too late with something like this?

Madelung deformity of the wrist is a congenital (present at birth) deformity that can cause wrist pain, stiffness, and loss of motion. But the cosmetic appearance is what most often brings the person in to see a surgeon. The natural history (what happens over time) of untreated Madelung deformity is relatively unknown. There hasn’t been much written about this problem.

We do know that people can be free of any symptoms up until late adult life. You didn’t mention your age but it sounds like you aren’t an older adult. Over time, the deformity can get worse resulting in break down of the joint and instability. Tendon rupture is possible in advanced cases. Usually, the affected person will develop symptoms long before that happens.

The best way to treat this problem is also unknown with many surgeons in disagreement, conflicting opinions, and a general lack of consensus. Younger patients are followed annually with examination, evaluation, and X-rays to document what’s happening.

Experts in this area suggest surgery should be done when there are limiting symptoms rather than just for cosmetic purposes. A growing child who has no symptoms should be watched and re-checked each year as suggested. Only when the deformity is getting worse, the wrist is unstable, and/or the wrist is jammed together should surgery be planned.

Type of surgery is still under debate and study. Factors that must be considered when planning a surgical procedure include age (whether the patient is still growing), the presence of a difference in bone length between the two bones of the forearm, and severity of the radial bone bowing.

Because there just isn’t enough evidence to guide management of this rare condition, more studies are needed to identify the best treatment approach. Finding successful nonsurgical ways to treat the problem is always preferred in the growing child. Early joint replacement is not advised because of the limited time the implant will last, thus requiring additional surgery later.

Surgery that does not improve wrist motion or relieve pain may not be the best way to treat Madelung deformity. Patient preferences and dissatisfaction with the appearance of the forearm and wrist are important considerations as well. Older adults who have experienced additional complications from this condition (e.g., tendon rupture, wrist subluxation or dislocation) may require surgical reconstruction of the wrist.

I’ve heard doctors say we shouldn’t rely on the Internet for medical information but sometimes it helps. I’ll tell you my situation. I fell and injured my wrist and had an X-ray that showed a “crack” and “slight” shift of the scaphoid wrist bone. Suddenly, I’m scheduled for surgery to pin the bone. A quick search of the internet and I found some information that suggested all I needed was a cast. Long story short: I took myself to another surgeon who confirmed what I found. No surgery. End of story. Sometimes the Internet does make a difference!

In the case of a scaphoid fracture (the “crack”) that may or may not be displaced (the slight “shift”), there are many gray areas making a true diagnosis difficult. The scaphoid bone of the wrist is located on the thumbside of the hand just below the radius bone of the forearm. Because the bones of the wrist are wedged together, any displacement or shift in the position of one bone changes the anatomic alignment of the wrist. Pain, loss of motion, and loss of function are common symptoms that must be addressed.

It is known that a scaphoid bone that is fractured and displaced will not heal without proper re-alignment. And there is consensus (general agreement) that the best way to accomplish this is through open surgery. The fracture is reduced (bone ends put back together) and the bone is replaced where it belongs anatomically. Fixation is used (e.g., screws) to hold it all together until healing occurs.

There is also consensus that a nondisplaced scaphoid fracture does not require surgery but can heal with cast immobilization. Screw fixation can also be helpful in these cases. But the real question is how to accurately diagnose scaphoid fracture displacement. This must be done in order to determine the best treatment approach.

There is no consensus on a definition of a nondisplaced scaphoid fracture. That may be why this patient received the first diagnosis of a “slightly” displaced scaphoid fracture. There can be a slight change in the angle of the scaphoid bone after fracture. Does that qualify for a diagnosis of displacement?

Some experts have defined scaphoid displacement by measuring the angle between the scaphoid and lunate bones. The lunate is another bone in the first row of wrist bones just below the forearm. It rests next to the scaphoid bone so a change in the angle or gap between these two bones would signal a true displacement. But once again, there is no common agreement as to the degree of angle or amount of gap that qualifies for displacement versus nondisplacement.

Some surgeons avoid the dilemma of labelling the problem as displaced or nondisplaced by using the terms stable and unstable to describe the fracture. In some studies, CT scans were added to traditional X-rays in hopes of increasing the accuracy of diagnosis. But cadaver studies showed diagnosis of scaphoid displacement using CT scans was inaccurate more often than not.

There is a need for future research to create a consensus definition of scaphoid fracture displacement. In a recent review of this problem, surgeons from Columbia University Medical Center in New York City suggested that a minimally displaced fracture is still displaced and should not be labelled as nondisplaced. They recommend conservative treatment with cast immobilization (based on current consensus) when there is a less than one millimeter separation with no translation and no angulation.

So yes, we agree with you! There is much available on the Internet to help educate us all. In the case of medical problems, it is always a good idea to confirm information found with your health care provider (e.g., primary care physician, orthopedic surgeon). This step is advised before making treatment decisions where there isn’t general agreement on all aspects of a specific condition or situation such as you described.

What’s the standard treatment for a wrist fracture involving the scaphoid bone? I’m asking because that’s what my 27-year-old son has been diagnosed with after taking a bad fall. He’s too old for me (his mother) to tell him what to do but that doesn’t mean I don’t check out what’s happening for my own piece of mind.

The scaphoid bone of the wrist is located on the thumbside of the hand just below the radius bone of the forearm. Because the bones of the wrist are wedged together, any displacement or shift in the position of one bone changes the anatomic alignment of the wrist. Pain, loss of motion, and loss of function are common symptoms that must be addressed.

It is known that a scaphoid bone that is fractured and displaced will not heal without proper re-alignment. And there is consensus (general agreement) that the best way to accomplish this is through open surgery. The fracture is reduced (bone ends put back together) and the bone is replaced where it belongs anatomically. Fixation is used (e.g., screws) to hold it all together until healing occurs.

There is also consensus that a nondisplaced scaphoid fracture does not require surgery but can heal with cast immobilization. Screw fixation can also be helpful in these cases. But the real question is how to accurately diagnose scaphoid fracture displacement. This must be done in order to determine the best treatment approach.

There is no consensus on a definition of a nondisplaced scaphoid fracture. That may be why this patient received the first diagnosis of a “slightly” displaced scaphoid fracture. There can be a slight change in the angle of the scaphoid bone after fracture. Does that qualify for a diagnosis of displacement?

Some experts have defined scaphoid displacement by measuring the angle between the scaphoid and lunate bones. The lunate is another bone in the first row of wrist bones just below the forearm. It rests next to the scaphoid bone so a change in the angle or gap between these two bones would signal a true displacement. But once again, there is no common agreement as to the degree of angle or amount of gap that qualifies for displacement versus nondisplacement.

Conservative treatment with cast immobilization is recommended (based on current consensus) when there is a less than one millimeter separation with no translation and no angulation. Surgical fixation is most likely advised in all other cases.

I am a lady weight-lifter with a serious problem. I tore the interosseous membrane of my left wrist and now the bones in there shift around. I never know when I’m going to have a pain free day for lifting. I can’t decide if I should go for a repair of the problem or just have the wrist fused. What do you advise?

Damage to the interosseous membrane of the wrist can result in a condition known as scapholunate instability. Without the tough soft tissue membrane to hold these two bones in place, the scapoid tips forward (flexes) and the lunate tips backwards (extension). The result can be a painful, unstable wrist — certainly a condition that will make bench pressing a challenge.

Treatment for this problem usually begins with anti-inflammatory and/or pain-relieving medications and activity modification. Activity modification would certainly include avoiding lifting heavy objects! Hand therapy might be advised. The goals of this type of conservative (nonoperative) care would be to reduce pain while maintaining wrist alignment until the area scarred over. Ligaments don’t really heal or recover their normal strength and durability. But for the average person, the body’s method of filling in with fibrous tissue may be enough to get by with daily activities.

For someone with heavy load requirements (manual laborers, weight-lifters), surgical options include repair of the tear, reconstruction of the wrist, or wrist fusion. Presently, studies comparing ways to treat this type of instability do not show one approach that has the best results. Short-term results two to five years after stabilizing surgery seems to have a good track record. Nearly all patients report very little pain and are able to get back to work.

But long-term studies (10 to 15 years later) don’t show an ability to maintain these good results. Wrist range-of-motion and grip strength deteriorate over time. X-rays show gapping between the bones and a progressive change in the angle between the scaphoid and lunate. The end-result is arthritis.

In one study, patients were given a bone-retinaculum-bone graft. In this procedure, the surgeon takes a piece of soft tissue called the retinaculum from the patient’s wrist and uses it to replace the torn ligament. Plugs of bone harvested from the back of the distal radius (forearm bone near the wrist) were inserted into the scaphoid and the lunate. The bone plugs were held in place with screws and wires to create a stable wrist unit.

Some of the patients had good results but others did not. Patients who were weight-lifters or manual laborers performing heavy loading had the worst results. It’s not clear yet whether the graft strength/stiffness or the lack of adequate blood supply to the healing graft was the problem. This problem and possible treatment remains under investigation.

Sometimes a patient is advised to have the reconstructive surgery and follow closely the recommendations of surgeon and hand therapist during recovery and rehabilitation. This would require a lengthy period of time away from weights. Failure of reconstructive surgery leaves the patient with two final choices: have the bones removed from the wrist or wrist fusion.

Your best bet is to work closely with your surgeon to find the best solution for your situation. Type of injury and extent of damage along with activity expectations will all be factored into the final decision. Scapholunate instability is a notoriously challenging problem that requires a long-range approach — not just for the immediate question about returning to weight-lifting but also for wrist and hand function for the rest of your life.

I just saw the X-rays that explain why my wrist hurts so much. One bone (the scaphoid) goes one way while the bone next to it goes another way. All I know is the wrist hurts all the time. My job requires heavy loading so I keep aggravating it. I know I’m headed for surgery but what can they really do? Will the surgery hold up at work?

It sounds like you may have a case of scapholunate instability. This refers to a condition in the wrist where the ligament holding the two bones (scaphoid and lunate) together is torn or ruptured. The scaphoid tips one direction (flexes forward) and the lunate tips in the opposite direction (extends).

This creates a painful, unstable wrist. Surgical treatment to prevent total collapse of the joint is necessary. Some of the surgical choices include repairing the injured ligament, using a screw to hold the bones together, or reconstruction of the soft tissue and bone.

Surgeons recognize the difficulty of treating a scapholunate interosseous ligament injury. Without surgical treatment, the resulting wrist instability can cause collapse and eventual arthritis. To quote a surgeon from the Department of Orthopedics at the Alpert Medical School of Brown University (Rhode Island) who did a study on this problem: Scapholunate instability remains an unsolved problem despite novel approaches to its treatment.

In the original study published in 1998, there were 14 patients treated with a bone-reticulum-bone autograft. Fifteen years later, long-term results for six of those 14 patients were reported. In this study series, the reconstructive surgery called bone-retinaculum-bone or BRB was chosen.

In this procedure, the surgeon takes a piece of soft tissue called the retinaculum from the patient’s wrist and uses it to replace the torn ligament. Plugs of bone harvested from the back of the distal radius (forearm bone near the wrist) were inserted into the scaphoid and the lunate. The bone plugs were held in place with screws and wires to create a stable wrist unit. The wires were removed after eight weeks when the patients started hand therapy.

When the original 14 patients were followed-up (two to five years after the procedure), they reported very little pain and all were back to work. Only six of the original 14 were examined directly and X-rayed for the follow-up study. Three others were contacted by phone; two patients were completely lost to follow-up.

For those patients who were able to return for evaluation, measurements included wrist range-of-motion, pain, and grip strength. X-rays were used to look for wrist arthritis and to measure the scapholunate gap and angle. There was a wide range of results reported.

Three of the six returning patients had complete failure of the graft requiring another surgery. Two had a carpectomy (removal of the wrist bones) and one had an arthrodesis (wrist fusion). Either of these procedures was considered an “endpoint” (nothing more could be done). The three patients contacted by phone did not want to come back for re-evaluation, said they were fine, and did not want any further treatment.

On the positive side, some of the patients did have durable results even while working as manual laborers requiring heavy lifting or participating in competitive weightlifting. Obviously for them, the graft was stiff enough and durable enough to make these activities possible. Why the graft was less successful for others remains under investigation. The surgeons are looking at ways to improve blood supply to the graft tissue as one possible way to improve results.

Repair, reconstruction, or fusion are the three basic surgical treatment choices for the problem you face but there is a wide range of options among them. Your surgeon is the best one to advise you. Your daily activities and work situation will be taken into consideration — along with the type and extent of damage present in the wrist.

What does it mean when they say the new wrist replacements are “fourth generation.” I think I understand it but I thought I’d better ask to know for sure.

Total wrist arthroplasty (TWA) (wrist replacement) has been around for over 100 years. Over the last 40 years, the implants (prostheses) have been changed and improved through four generations of products. The result is a prosthetic that is longer lasting with fewer surgical and postoperative complications.

When severe arthritis has destroyed the wrist joint, an artificial joint gives the joint a new surface, which lets it move smoothly without causing pain. Increased strength and improved motion makes it possible to once again perform daily activities of living with greater ease and ability.

But the early implants (first generation) were not as successful as hoped for. There were problems with the implants sinking down into the bone (called subsidence). The implants were made of one piece, so the force placed on them during movement caused them to crack and shift. And patients often developed reactions to the implants.

The second batch of implants (second-generation) were made in more of a ball and socket design with separate component parts (no longer one piece). At first, patients got good pain relief and they were very happy with the results. But over time, the implant started to loosen, the joint deformed, and dislocation was not uncommon.

That led to the third-generation implants. These implants attempted to balance the soft tissues around the joint and were therefore more stable. The design allowed surgeons to put the implant in place without removing so much of the old bone. Cement and screws were used to keep the prosthesis from loosening. The stem on the wrist side was longer, another feature aimed at reducing implant loosening. But component loosening was still a problem. Half of the patients ended up needing a second (revision) surgery. The implants that did survive only lasted five-to-seven years.

Today’s fourth generation implants have a porous surface to allow bone to grow in and around it. This is different from previous implants that always required cement to hold them in place. Cementless implants mean less bone destruction and improved durability of the implant. The newer systems are made of cobalt chrome, titanium, and polyethylene (plastic). Only two (titanium) screws are used to help stabilize the implant.

Until recently (third-generation wrist arthroplasty), the complication rate was still much higher for arthroplasty (21 per cent) than for fusion (13 per cent). Long-term studies of fourth-generation implants are not available yet. Early reports (after three to five years) show improvement in pain with good satisfaction rates (95 per cent or more of the patients were happy with results).

Complications such as infection, soft tissue imbalance, and implant loosening and dislocation are much improved with the new fourth-generation prostheses. There are still times when wrist fusion is considered a better treatment option but this determination is made on a case-by-case basis.

I can’t figure out what to do. I have pretty bad wrist arthritis in my good hand (right side). I’m only able to type with two fingers (hunt and peck method) but the worst is trying to do chores around the house or get dressed. I’m embarrassed to say I can’t even manage the bathroom very well. The surgeon I saw suggested either a wrist fusion or joint replacement. Which is better? I don’t know how to choose between them.

Your surgeon will likely help you make this decision but presented the two options for you to think about. We do have two patient guides that you might want to read: A Patient’s Guide to Artificial Joint Replacement of the Wrist and A Patient’s Guide to Wrist Fusion. After reading these materials, you may have a better idea what might be best for you and/or some additional questions for your surgeon to help you make the decision.

In the meantime, we can offer you some additional information based on a review recently published on wrist replacements. Hand surgeons from the Warren Alpert Medical School (Brown University, Rhode Island) summarized what we know about total wrist arthroplasty (replacement). Problems with prostheses (wrist implants) and resulting design changes are discussed. Outcomes are compared with arthrodesis (wrist fusion), the alternative to wrist replacement.

Arthrodesis can get rid of pain and restore strength in badly degenerated wrist joints. Fusion surgeries make the wrist strong again, but they greatly reduce the wrist’s range of motion. This makes fusion surgery a poor choice for some people.

Total wrist arthroplasty (another word for replacement) can also relieve the pain caused by wrist arthritis. When severe arthritis has destroyed the wrist joint, an artificial joint gives the joint a new surface, which lets it move smoothly without causing pain. Increased strength and improved motion makes it possible to once again perform daily activities of living with greater ease and ability.

Total wrist arthroplasty (TWA) has been around for over 100 years but the procedure is still done much less often than other joints in the body, such as the knee or the hip. Over the last 40 years, the implants (prostheses) have been changed and improved through four generations of products. The result is a prosthetic that is longer lasting with fewer surgical and postoperative complications.

Today’s fourth generation implant has a porous surface to allow bone to grow in and around it. This is different from previous implants that always required cement to hold them in place. Cementless implants mean less bone destruction and improved durability of the implant. The newer systems are made of cobalt chrome, titanium, and polyethylene (plastic). Two titanium screws are used to help stabilize the implant.

Surgeons must choose patients carefully for this procedure to ensure success. A low-activity lifestyle is important. Patients must agree to activity restrictions such as no heavy lifting, avoiding over extending the wrist, and no participation in vigorous sports activities. Younger, more active patients may be advised to have an arthrodesis (fusion) rather than a wrist replacement to reduce pain and disability associated with wrist arthritis.

There are other factors that might prevent a patient from being a good candidate for wrist replacement. The most common one is poor bone stock. Poor bone stock refers to brittle bones (osteoporosis), bone infection, and bone erosion or deformity. The need for crutches or cane to walk and/or the inability to stand up without using the arms to push off would also keep a patient from having a wrist replacement. Anyone who is not a good candidate for wrist replacement can still consider wrist fusion as a possible treatment solution to their painful symptoms.

The number of studies comparing results between wrist fusion and replacement are limited. Until recently (third-generation wrist arthroplasty), the complication rate was still much higher for arthroplasty (21 per cent) than for fusion (13 per cent). Long-term studies of fourth-generation implants are not available yet. Early reports (after three to five years) show improvement in pain with good satisfaction rates (95 per cent or more of the patients were happy with results).

Complications such as infection, soft tissue imbalance, and implant loosening and dislocation are much improved with the new fourth-generation prostheses. There are still times when wrist fusion is considered a better treatment option but this determination is made on a case-by-case basis. Since your surgeon mentioned both possibilities, you may be a good candidate for either procedure. With a little more information about each one from our patient guides, you will be better prepared to discuss your decision with the surgeon at your next appointment.

Years ago, I tore the triangle ligament in my wrist and had to put my bowling activities on hold. I never did get back to bowling but I’m interested in trying it again. The problem is: my wrist clunks and clicks and I’m worried I might reinjure myself. Do you think it’s safe to give it a try anyway?

Painful clicking or clunking of the wrist is a sign that the triangular fibrocartilage complex or TFCC has been torn. The triangular fibrocartilage complex (TFCC) suspends the ends of the radius and ulna (forearm) bones over the wrist. It is triangular in shape and made up of several ligaments and cartilage.

The TFCC makes it possible for the wrist to move in six different directions (bending, straightening, twisting, side-to-side).Without it, the wrist is not stable at the distal radioulnar joint (DRUJ) — that’s where the two bones of the forearm attach to the first row of wrist bones.

With the symptoms you described, an orthopedic evaluation may be a good idea before lifting a heavy bowling ball with that hand. Understanding exactly what’s going on in the wrist and providing treatment if necessary is your first step.

Your physician will take your history (how, when, and what happened), ask about your symptoms, and perform a physical examination to make the diagnosis. Tests of joint stability can be conducted. Special tests such as stress testing of the wrist radioulnar and ulnocarpal joints help define specific areas of injury.

An accurate diagnosis and grading of the injury (degree of severity) is important. Usually, the grade is based on how much disruption of the ligament has occurred (minimal, partial, or complete tear). There are two basic grades of triangular fibrocartilage complex injuries. Class 1 is for traumatic injuries. Class 2 is used to label or describe degenerative conditions.

Other tests may be done to provoke the symptoms and test for excess movement. These include hypersupination (overly rotating the forearm in a palm-up position) and loading the wrist in a position of ulnar deviation (moving hand away from the thumb) and wrist extension.

A new test called the fovea sign applies external pressure to the area of the fovea. The examiner compares the involved wrist with the wrist on the other side. Tenderness and pain during this test is a sign that there is a split-tear injury (down the middle length-wise).

Split tears are more common with lower energy, repetitive torque injuries such as from bowling or golf. This type of ligament injury was first discovered when a surgeon pushed on the area of pain while using an arthroscope to look inside the joint. The surgeon saw the ligament open up like a book.

X-rays may show disruption of the triangular fibrocartilage complex when there is a bone fracture present. Ligamentous instability without bone fracture appears normal on standard X-rays. X-rays with a dye injected is called a wrist arthrography. Arthrography is positive for a TFCC tear if the dye leaks into any of the joints. There are three specific joint areas tested, so this test is called a triple injection wrist arthrogram.

It’s possible you had all these tests done when you were first told you had a torn “triangle ligament” (most likely, a triangular fibrocartilage complex or TFCC) injury. Wrist arthroscopy is really the best way to accurately assess the severity of damage. At the same time, the surgeon looks for other associated injuries of ligaments and cartilage. The surgeon performs the test by inserting a long thin needle into the joint. A tiny TV camera on the end of the instrument allows the surgeon to look directly at the ligaments.

Treatment for you with a chronic (older) injury will depend on the results of the testing. Conservative (nonoperative) care with splinting, antiinflammatory drugs, physical therapy, and possibly steroid injections may be advised. If the wrist is unstable (and that clicking/clunking you mentioned is usually a sign of instability), then surgery may be needed. But see your physician before leaping from “can I go bowling?” to “do I need surgery?”

I’m looking for any information I can find on the latest in surgical treatment of a torn triangular complex ligament for the wrist. I would like to be fully informed before I go back to the doctor for the results of the tests I had. I’ve already been told I’m likely going to need surgery.

There are several repair techniques for triangular fibrocartilage complex (TFCC) tears of the wrist. Too much damage to the surrounding tissues and/or severe wrist instability may mean repair isn’t possible. In such cases, full reconstruction is required. But let’s take a look at repair procedures first.

The outside edges of the triangular fibrocartilage complex have a good blood supply. Tears in this area can be repaired. But there is no potential for healing when tears occur in the central area where there is no blood supply. Arthroscopic debridement (smoothing or shaving) of the damaged tissue is then required.

The surgeon debrides any tears of the nearby soft tissue structures that might catch against other joint surfaces. Then the surgeon looks for any problems with the ligaments. A probe is used to detect tension or laxity (looseness) of the ligaments. Laxity is a sign of injury.

Arthroscopic debridement works well for simple tears. Much of the damaged tissue can be removed while still keeping a stable wrist joint. The torn structures can be reattached with repair sutures. Some ligamentous ruptures with fracture can also be repaired arthroscopically with reattachment and instrumentation. Instrumentation refers to the use of hardware such as wires and screws to help hold the repaired tissue in place until healing occurs.

There are new surgical techniques being tried for triangular fibrocartilage complex (TFCC) tears. For example, in Japan surgeons have reported arthroscopical treatment for TFCC tears that were torn at the foveal insertion point.

The fovea is a groove that separates the ulnar styloid from the ulnar head. The styloid is a small bump on the edge of the wrist (on the side away from the thumb) where the ulna meets the wrist joint. The foveal groove is at the junction of the ulnar bone and wrist. The deep portion of the TFCC attaches at the fovea. Rupture or avulsion of the TFCC at this place of insertion or attachment leaves the distal radioulnar joint unstable.

Their arthroscopic technique called transosseous outside-in was used to reattach (repair) the torn TFCC. They tunneled through the bone to get to the fovea. This creates bleeding from inside the bone. The bleeding helps form adhesions to hold the triangular fibrocartilage complex (TFCC) to the ulnar insertion point. K-wires were used to reattach the ligament to the bone.

Some complex tears require open repair. Open repair means the surgeon makes an incision and opens the tissues to perform the operation. This gives the surgeon a better view and better access of the area. The specific procedure depends on the tissues injured and the extent of the injury. For example, detachment of the radioulnar ligaments usually requires open repair. Instability of the distal radioulnar joint may require the use of wires to hold the area together until healing occurs.

In other cases, surgery has been delayed long enough that the torn ligament has retracted (pulled back) so far that direct repair can’t be done. In these cases, a tendon graft may be needed to help strengthen the repair.

Chronic and degenerative TFCC may require a different surgical approach. Debridement is not as successful with this group as it is with acute TFCC injuries. Sometimes it is necessary to shorten the ulnar bone at the wrist to obtain pain relief. There are different ways to accomplish shortening of the ulna to unload the ulnocarpal joint.

It’s good to have in mind different ways your injury might be treated. Your surgeon will also explain what is recommended for you and why. You may not need details of how the repair or reconstruction is actually done but if you ask, the surgeon will likely be glad to give you more information.

Can you please explain something to me? I had a wrist fracture (the Colles type) that looked perfectly fine on the X-ray when they casted my arm. But when they took the cast off, it looks like my arm is still crooked. Why is that?

A Colles (pronounced “call-eez”) fracture is a break in the last inch or inch and a half of the radius bone. The radius is one of the two bones in the forearm that meets the small bones of the wrist to form the wrist joint. Dr. Abraham Colles, an Irish surgeon, first described this type of fracture in 1814.

Colles fractures are the most common break in adults over the age of 50. The wrist is a place where bones frequently get weak from osteoporosis. The typical Colles fracture occurs when a person slips or trips and lands on an open hand with the palm down. Other causes of this fracture include car accidents and sporting activities.

This particular type of fracture actually occurs in two different age groups: the young and old but with different causes. Children and teens are more likely to be involved in high-energy, traumatic (sports) injuries. Older adults can fall from a standing position and break their wrists.

Treatment can involve closed reduction and immobilization (sounds like this is what you had done) or surgery. Closed reduction means the fracture is reset (lined up) without an incision or open surgery. Immobilization, of course refers to the cast you wore until the bone healed.

Colles fractures are notorious for loss of reduction — meaning the bones shift apart again. This can happen no matter what type of treatment is applied. Dr. Colles explained almost 200 years ago that the deformity will not interfere with motion or function. And studies in the late 1990s and early 2000s support this statement. There just isn’t a straightforward link between poor alignment with wrist deformity and function.

But in cases where the reduction is not maintained, further X-rays are usually taken to establish the underlying cause of the deformity. Then treatment options can be discussed. This can range from do nothing to a short course of rehab to surgical correction to restore shape, form, and function. Don’t hesitate to check with the physician who treated you and ask this question. It is important to your peace of mind as well as direct you to further treatment is that is warranted.

Mother fell down during the holiday and broke her wrist (a Colles’ type fracture). I was amazed that the surgeon gave HER the choice of treatment: surgery or no-surgery. I guess I thought surgeons made all those decisions based on their training and experience. Why confuse an elderly widow with more on her plate than she can handle by asking her to decide what to do?

That is a very good question. Your mother’s situation represents a shift in thinking toward more patient participation in many different medical decisions (evaluation and treatment). Part of this has come about because of the Baby Boomers (adults born between 1946 and 1964) who have now reached senior citizen status. As a group, they are more independent, more involved, and more demanding of their rights in many areas, including medical.

Patient satisfaction has become an outcome measurement of results. That means the surgeon’s satisfaction with how something looks on X-ray after treatment is not the only way results are measured.

Treatment ideas for Colles’ wrist fractures (radial bone is broken and displaced — meaning the end of the bones have separated) have ranged from the early days of Dr. Colles (even if the break doesn’t heal perfectly, the arm will function fine) to efforts started during the 1950s to “fix” the deformity and make it look straight again. The 1950s through the early 1990s found surgeons reducing the fracture as much as possible thinking that would ensure a more functional outcome.

But today, after many trials of different surgical methods of repair and restoration, it looks like the evidence supports Dr. Colles’ ideas after all. The extra cost of surgery and risk of complications may not be worth it — studies are showing that surgery doesn’t always yield a better result.

It comes down to this one thing: having a perfectly placed wrist fracture (as seen on X-rays) isn’t necessary to regain full function and use of the wrist. And, in fact, this type of anatomic alignment isn’t linked with loss of wrist and hand function in the older adult.

Studies comparing results between surgical repair and nonoperative treatment show equal results six and 12 months after the injury. And, patients treated with surgery suffer more complications more often that are worse than in the nonoperative groups studied. Patients treated conservatively report high levels of satisfaction with nonoperative care.

So now, instead of performing surgery right away to reset the bones and hold the two ends together with a metal plate and screws or pins, surgeons discuss all the pros and cons of both treatment approaches (surgical versus nonsurgical). Patients are given full disclosure based on current evidence when making a treatment decision between surgery and conservative care for displaced distal radial wrist fractures.

It is still a joint decision between surgeon and patient. The surgeon will recognize when a patient is unable to participate fully and then help guide the patient toward the best choice for his or her own circumstances.

All factors and variables are taken into consideration including the patient’s age, general health, presence of other diseases or problems, severity of the fracture, and the patient’s activity level and personal goals. As a family, you have some opportunities to express your cares and concerns as well.

I am at the hospital with my father who fell and broke his wrist (radial bone). We are furiously looking for any information that might help us. They are offering surgery or a quick fix now and recheck in one week to see if it is holding. What’s the best route? He’s 81-years-old but hale and hearty.

Everyday orthopedic surgeons must advise patients about treatment for the various problems presented. Often the question comes up with wrist fractures: can I get by without surgery?

Two hand surgeons from two different medical facilities recently published an article that might offer you some helpful information. They used the case of a 52-year-old woman who fell and broke the radius (bone in the forearm) at the wrist (similar problem to your father but in a younger person).

She was treated in the emergency department with a procedure known as closed reduction. This is the nonoperative approach being suggested as one option for your father. Without an open incision to realign the bones and without pinning the fracture site, the physician would use a special splint to hold the wrist in place.

X-ray findings are key here in making the decision. Is there a shortening of the broken bone? Do the two ends of the broken bone meet in a straight line? If there is a slight buckle making a hump referred to as a dorsal angle that measures 15 degrees or more, then surgery might be needed.

One way to evaluate this patient’s chances for full recovery is to review the published literature. They did this looking for outcomes other patients have had with these kinds of problems (dorsal angulation, radial shortening). There were several studies with large numbers of patients who chose a nonsurgical approach and were then followed for several years to see what happened.

Some of the studies divided patients out by the degree of dorsal angulation (e.g., zero to 10 degrees, zero to 15 degrees, more than 10 degrees, more than 15 degrees). Patients were asked questions several years later about their experience and perceived problems. Some researchers took follow-up X-rays. Others tested their patients for grip strength and other functional skills.

They report that with a small amount of radial shortening (three millimeters or less difference between the radius and the ulna), patients did just fine. Most of them (96 per cent) had good to excellent function and reported little to no pain. With slightly more shortening (three to five millimeters), the results were less impressive. Three-fourths of the patients still reported good results. As the shortening increased (radius bone more than five millimeters shorter), the satisfaction with results decreased.

Likewise, the more deformity was present in the wrist, the more likely the patient would have some measurable loss of motion and function. But overall, the amount of deformity seen on an X-ray in patients who were treated nonoperatively was NOT directly linked with worse function or worse results.

Age of the patient was a predictive factor. Younger, more active adults regained motion and function faster. By the end of six months after the injury, they had gained as much strength and motion back as older adults who took longer (up to a year) to recover. And for older adults who put low demand on their wrist, results were more often considered “satisfactory” compared with younger adults with the same amount of residual deformity or shortening.

One thing to consider is your father’s activity level and specific activities he enjoys (e.g., golf, tennis, cooking, and gardening require more strength and function than typing on a computer, jogging, or singing). In other words, people with low physical activity have different expectations and goals than patients who are physically very active. At age 81, hale and hearty still means something different than for most 51-year old adults.

When talking with the surgeon you can discuss: how the fracture looks on X-rays before reduction, the severity of your father’s symptoms (pain, swelling, function), and his expectations for activity.

All evidence points to good results without surgical treatment when there is minimal damage, deformity, and/or shortening of the bone. With nonsurgical treatment, your father would be followed weekly with serial X-rays for three weeks to make sure everything stays in place.

When the angulation and shortening are small, if the fracture site shifts back (after nonoperative care) to the amount of angulation and/or radial shortening present at the time of the injury, it’s likely that your father would not experience any problems regaining motion, strength, or function. Surgery is always an option at that time if advised.

Hopefully this information along with an additional conversation with the surgeon will aid you in making the best choice for your loved one.

I broke my wrist about six weeks ago. Fell off a ladder (dumb! I know better). I opted to go with closed reduction. They did put me to sleep and then put the bones back in place. I wore a special sling called a sugar-tong splint (I think that’s the right name). Now that I’m back to “normal” (splint off, back to work), I notice a bump along the top of my wrist. I don’t have full motion or strength yet. Will this all correct itself in time?

Splints are often used in the emergency department to provide support and limit motion when there is a fracture or soft tissue damage. The type of splint you mentioned is meant to provide support and comfort through stabilization of the fracture.

A sugar-tong splint keeps the injury from causing further harm or getting worse until you can be evaluated by a consultant such as an orthopedic surgeon. At that time, the best course of treatment is decided. That may be to remove the splint and apply a cast or perhaps a surgical procedure.

Patients with injuries that are splinted are usually referred for a follow-up evaluation by an orthopedic surgeon. Patients are either advised to make an appointment or an appointment is made for them shortly after the emergency department visit. Depending on the severity of the injury, this can vary from 24 hours up to two weeks. You didn’t mention this step in your treatment.

The fact that you have a visible deformity may be the result of missing this step. Or if you did receive the necessary follow-up, perhaps the degree of deformity is minimal and the surgeon expects it will recover in time.

If you are not being followed by a specialist, now would be a good time for a consultation. If you do have a surgeon who has been working with you all along, it may be a good idea to schedule a follow-up visit. You can find out if this is something serious or likely to recover in time.

Studies show that the degree of deformity (called dorsal angulation (e.g., zero to 10 degrees, zero to 15 degrees, more than 10 degrees, more than 15 degrees) may dictate the results. As you might expect, the larger the angle, the more severe the injury, and the more chance that further treatment is needed. Likewise, the more deformity is present in the wrist, the more likely you would have some measurable loss of motion and function.

But this correlation between severity and function is not closely tied so it is possible to have bony disruption but good results. In other words, a bony deformity does not automatically mean worse results.

Can you please explain to me what is a Darrach procedure for the wrist? I have a friend who is going on and on about this being the best thing that happened to her since sliced bread. Really? What kind of surgery is this anyway? I didn’t want to hear any more about it from her but I admit, now I’m curious enough to ask.

As you might suspect, the name Darrach really refers to the physician who first described and used this operation on someone’s wrist. Dr. Darrach actually published an article on his approach back in 1913. He used it on a patient who had a chronically dislocating wrist.

It is basically the surgical removal (called excision) of the distal end of the ulna. The ulna is one of the two bones in the forearm. The distal end refers to the end of the ulna at the wrist. Since the two forearm bones meet at the elbow and at the wrist, distal is the term used to designate the wrist end of the bone.

The place where the two forearm bones meet at the wrist is referred to as the distal radioulnar joint or DRUJ. Disruption of this joint for any reason (e.g., trauma, congenital deformity, degenerative arthritis) can cause disabling pain and dislocation. The joint is meant to help the wrist bones slide, glide, and rotate. These motions make it possible to brush your teeth, hold a cup of coffee, push up from a chair, pick up a cat or dog, and many activities of daily living.

But changes in the joint for any reason can produce pain, tenderness, loss of motion, and eventually, loss of function. By removing a small portion of the damaged end of the bone, the joint can still work but without the rubbing that’s causing the painful symptoms.

Your friend’s enthusiasm for the positive results of this procedure is understandable. The pain of an unstable or degenerating distal radioulnar joint (DRUJ) can be very debilitating. Being able to move the wrist, hand, and forearm again freely and without pain from this simple procedure is better than sliced bread!

What is the DRUJ joint? I saw an interview with Erin Andrews and one of my favorite NFL players. She was trying to find out about his DRUJ injury. So what is that?

Erin Andrews has become one of the most forthright American sports broadcasters. Her interviews are directive and to the point! As a host for FOX College Football (Fox Sports) and ESPN Sports, she keeps up on all the plays, players, and injuries. So it’s no surprise she has enough savvy herself to ask about a DRUJ injury.

DRUJ stands for distal radioulnar joint. The DRUJ is located between the two bones of the forearm. Since these two bones (the radius and the ulna) meet up at the elbow and down at the wrist, the word “distal” (meaning at the far end) tells us we are talking about the connection point at the wrist end of the bones.

The place where these two bones meet is designed to allow for rotation and gliding motions. These movements make it possible to shake a bell, wring out a wet rag, turn your palm up to receive change, take care of personal toileting needs, and many more activities of daily living. There is an S-shaped notch on the ulnar bone where the head of the radius sets. It’s this special anatomy combined with the soft tissues that hold everything together that makes everything work together so well.

But sometimes, due to a traumatic injury, inflammation, aging (degeneration), or a congenital problem (present at birth), the DRUJ becomes painful and/or unstable. Wrist fracture is a common cause of post-traumatic arthritis at this joint. Improper healing and deformity at the DRUJ from any trauma can create this type of painful arthritis.

Pain, tenderness, and loss of wrist and forearm motion are the main symptoms. But crepitus (that crunching, crackling sound and feeling when moving the wrist) is reported by some patients. And “clunking” is possible when there is subluxation (partial dislocation) of the joint.

Any of these symptoms can be addressed with proper management and treatment. Conservative care is always advised first. A physical therapist guides the patient through ways to modify activities that aggravate the condition while addressing the pain and loss of motion. For a football player steroid injections and taping will probably also be used.

Surgery may be needed for the patient who does not respond well to nonoperative care or when there is significant, disabling instability and/or arthrosis (degenerative disease of the DRUJ). There are many different ways to approach this problem surgically.

Resection arthroplasty is one of the first approaches considered for this problem when conservative care isn’t enough. This involves removing a small portion of the bone to eliminate the painful anatomy. Most of the motion is preserved without all the pain.

Part or all of the joint can be removed and replaced. This is referred to as either a partial or total arthoplasty. A third surgical choice is referred to as a salvage option. Salvage means “to save” as much of the joint and surrounding soft tissues as possible.

This type of approach often means sacrificing forearm motion in order to preserve function and strength. Some examples of salvage procedures for DRUJ instability include creating a one-bone forearm (OBF). This is a fusion technique. Another salvage procedure is a wide excision of the distal ulna (removal of a large portion of the bottom of the ulnar bone).

Whatever happens to this player, you can be sure Erin Andrews will be following up and giving us the scoop. Stay tuned!

I can see now how dragging my feet and refusing surgery for an unstable wrist joint is catching up with me. About 10 years ago, I fell off a ladder and tore the ligament between the scaphoid and lunate bones in my wrist. Before that injury, I couldn’t have told you the name of even one bone in my body but now I feel like a wrist expert. Unfortunately, the bones twisted inside the wrist. There was a lot of pain and “clunking” that I chose to ignore. Now the joint is destroyed. What happens from here? I mean, what are my options? Do I even have any options?

There are almost always options. Even doing nothing is an option. But hopefully we can offer you some information that will help you make some decisions. The first step, of course, is to see a hand surgeon who can evaluate you and offer you some guidance based on the specifics of your situation.

Treatment is important to restore the delicate balance and stability of the scapholunate joint (at least as much as possible). An accurate understanding of the problem (diagnosis) is essential before planning a course of action. Patient history (what happened, how it happened) is linked with physical exam (signs and symptoms of scapholunate instability) to obtain the necessary clues to make the diagnosis. Radiographs comparing one wrist to the other are advised, including flexion stress and clenched pencil views.

The routine use of advanced imaging (e.g., CT scans, MRIs, arthrography) is not always needed. But in cases like yours with longstanding, chronic changes, extra care may be needed to take a careful, closer look inside. Arthroscopic exam of the wrist (sometimes combined with fluoroscopy, a type of real-time X-ray) is the best way to confirm the diagnosis. The surgeon will be looking for location of damage, severity (partial or complete tears) of injury, and the presence of other soft tissue involvement.

Treatment (or more likely management in the case of chronic injuries) are centered around five-key factors including 1) condition of the scapholunate interosseous ligament, 2) amount of tissue left for a repair, 3) position and angle of the scaphoid bone, 4) possibility of realigning the carpal bones, and 5) condition of the cartilage lining the involved wrist joints.

Treatment varies depending on whether there is a partial tear, complete tear, dislocations, or twisted bones.Ssurgical treatment for more minor, acute injuries usually consists of tissue repair. More extensive damage (whether acute or chronic) may require tissue reconstruction using donor tissue as a graft to replace the damaged ligaments.

Preserving motion by stabilizing the joint and restoring the delicate balance provided by the scapholunate joint are always the desired outcomes. In cases of chronic, long-term scapholunate injuries, joint replacement may be an option. This is a joint preserving treatment that works well for many patients. If joint replacement is not an option or if it fails for any reason, then joint fusion becomes the last resort. Fusion is usually the final treatment offered for irrepairable injuries and deformities.

But before you imagine yourself so far gone that the only thing left to do is fuse the wrist, see a specialist. In the skilled hands of a surgeon, you may find relief from your symptoms, improved strength, and preservation of motion and function.

How does a person decide when you need surgery? I have a torn ligament in my wrist (the one between the scaphoid bone and lunate bone — I’m learning a lot about anatomy). Can’t get a straight answer out of my doc. Says I can try going with a splint and give it time but surgery is always an option. What would you recommend?

To help answer your question, we turned to an extensive review of treatment for scapholunate injuries recently published by the Department of Hand and Upper Extremity Surgery at the Hospital for Special Surgery in New York City. In this article, orthopedic (hand) surgeons provide an extensive, detailed, and very thorough review of scapholunate instability. They discuss what happens and how to treat this problem.

A little bit of anatomy goes a long way in understanding the complexities of this injury and why treatment isn’t always a cut-and-dried decision. The scapholunate joint describes a place in the first row of carpal (wrist) bones where the scaphoid bone and the lunate bones meet and greet, so-to-speak. The scaphoid is a small bone on the thumb side of the wrist next to the radius bone of the forearm. The lunate is in the middle of the row of carpal bones sandwiched between the scaphoid and the triquetrum on the little finger side of the wrist.

These three bones move together as part of wrist motion. The scaphoid and lunate are held together by the scapholunate interosseous ligament (SLIL). Perhaps this is the area of your injury. This ligament is a tough, C-shaped piece of connective tissue.

When the SLIL is intact, the scaphoid and the lunate move as one unit. Damage or injury to the SLIL can result in these two bones moving separately and independently of each other — a situation referred to as scapholunate instability. Extra, unintended shifting and motion of these bones can cause excruciating wrist pain, weakness, and loss of function. Just lifting a cup of coffee or brushing the teeth can be an agony.

Treatment is important to reduce pain, restore normal wrist and hand motion, and prevent joint loading and degenerative changes that could lead to further disability from arthritis. Treatment ranges from conservative (nonoperative) care to surgery. The decision about what to do and when to do it depends on five key factors.

These factors include 1) condition of the scapholunate interosseous ligament, 2) amount of tissue left for a repair, 3) position and angle of the scaphoid bone, 4) possibility of realigning the carpal bones, and 5) condition of the cartilage lining the involved wrist joints.

It is generally agreed that nonoperative treatment is an acceptable choice for those patients who 1) don’t want surgery, 2) still have good grip strength, 3) activity level of the patient, and 4) level of pain. There’s no doubt that instability at the scapholunate joint will eventually result in degenerative arthritis. But the progression to this stage is unpredictable and could be years for some patients.

That’s why conservative care is offered to patients who could get by with a splint and activity modification. It’s entirely possible to choose nonoperative care for years — even decades and manage just fine. Starting with nonoperative care makes sense because delaying surgery doesn’t necessarily set you back and then surgery is always a next-step alternative.