Years ago I received dire warnings that my wrist fracture and a triangle ligament tear would probably cause arthritis. I had the wrist in a cast but they didn’t fix the torn ligaments. So far, I haven’t had any problems like that. I know my grip isn’t as strong on that side but I have learned how to get around that. What happens to other people with this kind of problem who don’t have surgery to fix the torn ligaments?

You will probably be interested in the results of a study done by several hand surgeons from Sweden. They took a look at what happened to a group of patients with a displaced distal radial fracture that also caused a triangular fibrocartilage complex (TFCC) tear. The fracture was treated but the damaged soft tissue was not. These patients were treated for the fracture 10 to 15 years ago when the treatment protocol at that time did not call for TFCC repair or reconstruction.

Wrist pain at rest and with activities along with loss of strength and decreased function are disabling problems associated with triangular fibrocartilage complex (TFCC) tears. The triangular fibrocartilage complex (TFCC) suspends the ends of the radius and ulna 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). It stabilizes the distal radioulnar joint while improving the range of motion and gliding action within the wrist.

The question they asked (like yours) was, “What happens to untreated TFCC injuries?” This is called the natural history of a condition. Certainly, there is always a concern for arthritis developing after a traumatic injury. But does it? Are patients with untreated TFCC tears still unstable years later? To find out, they contacted a group of patients who met this criteria. Through telephone interviews, examinations, and X-rays, they were able to see some important trends.

First, there did not appear to be any direct link between wrist joint laxity present from the lack of the TFCC tension and subsequent arthritis. There were some patients who developed wrist arthritis but not any more than the general adult population who don’t have wrist injuries. The group as a whole did have some weakness in grip strength but this was not disabling.

About half the group had joint laxity (looseness) but not instability (joint slippage). Only one patient was unstable enough to have surgery. The others seemed to manage and adapt without further problems (again, very much like your report of yourself). Patients who only had a partial tear did have better overall results compared with those who had a complete TFCC tear.

The authors concluded from this study there was not enough evidence to suggest aggressive surgical treatment of TFCC tears when this type of associated soft tissue injury occurs along with a distal radius (wrist) fracture. However, the number of patients in the study was small (38) so they do advise further (larger) studies need to be conducted in order to further confirm or clarify their own findings.

I’m scheduled to have both of my wrists replaced with implants that are now available. I know there can be potential problems with any surgery. Fill me in on the most likely complications so I can be mentally prepared.

Yes, there are hip, knee, shoulder, elbow, finger, and now wrist joint replacements! Wrist replacement is also known as total wrist arthroplasty or TWA. As with any surgical procedure, there can be intraoperative (during surgery) and postoperative (after surgery) problems that develop. These might include blood clot formation, heart attack, complications from the anesthesia, infection, and damage to blood vessels or nerves. The risk of these things is fairly low, but it can still happen and does affect some patients.

In the specific case of total wrist arthroplasty (TWA), the most common problems or complications are infection, failure of the wound to heal, loosening of the hardware, wrist dislocation, tendon rupture, and impingement. One of the biggest reasons complications develop is from implant malpositioning. Implant loosening tends to be another major cause of problems.

As with any new surgical procedure, one of the first things surgeons look for are those patients who can benefit the most from the new treatment. This is one way to reduce or even avoid complications. In the case of wrist joint replacement, patients with wrist rheumatoid arthritis were the only candidates at first. Total wrist arthroplasty (TWA) makes it possible for these patients to avoid a wrist fusion or wrist bone removal (sometimes the only other surgical options).

Even so, anyone with severe bone loss, infection, bone subluxation (partial dislocation), or who uses a walking aid (cane, walker) is still not considered a “good” candidate for this procedure. When present, any of these factors is a contraindication to surgery. In other words, these problems keep the patient from having this procedure.

Over time and with improvements in implant design, fixation, and surgical techniques, more patients have been included in the list of potential or good candidates for total wrist arthroplasty (TWA). And fewer intraoperative and postoperative problems are developing. For example, stiffness after TWA can be prevented with the use of a postoperative wrist splint that holds the wrist in 30-degrees of extension.

Implant systems that have a locking screw option may decrease the risk of implant loosening. TWA should not be used in young adults (younger than 50 years old) or for anyone who is unable to follow directions for activity restrictions. Don’t hesitate to talk with your surgeon if you have any questions about these precautions as they might apply to you. And good luck!

Can you tell me the status of wrist replacement surgery these days? I know I’ll need a wrist replacement at some point. I’m just waiting for the technology to improve enough to ensure a good result. So far from what I’ve seen in blogs and chat rooms, lots of people who get them aren’t happy.

You are right — there are wrist replacements also known as total wrist arthroplasty or TWA available now. As with any new surgical procedure, one of the first things surgeons looked for were those patients who could benefit the most from this new treatment.

In the case of wrist joint replacement, patients with wrist rheumatoid arthritis were the only candidates at first. Total wrist arthroplasty (TWA) makes it possible for these patients to avoid a wrist fusion or wrist bone removal (sometimes the only other surgical options). Even so, anyone with severe bone loss, infection, bone subluxation (partial dislocation), or who uses a walking aid (cane, walker) are still not considered a “good” candidate for this procedure.

Over time and with improvements in implant design, fixation, and surgical techniques, more patients have been included in the list of potential or good candidates for total wrist arthroplasty (TWA). For example, additional diagnoses considered for this procedure now include post-traumatic arthritis, Kienböck disease, gout, and osteoarthritis.

And today, with more than one type of wrist joint replacement on the market, studies are being done to determine which implant(s) work the best. In a recent study, surgeons from the Florida Orthopaedic Institute and the Foundation for Orthopaedic Research and Education evaluated the results of using the Maestro Total Wrist System.

They followed 22 patients for a total of 23 wrist implants over a period that ranged from four to 55 months (almost five years). Using measures of pain, motion, and grip strength, they evaluated the outcomes.

They also took X-rays and made note of any complications to help them track results. Other studies have reported complications like infection, failure of the wound to heal, loosening of the hardware, wrist dislocation, tendon rupture, and impingement. One of the biggest reasons complications develop is from implant malpositioning. Implant loosening tends to be another major cause of problems.

In this group, seven of the 23 wrists developed problems. That’s almost one-third of the group and is a fairly high rate of complications. Taking a closer look at the problems that developed in this group, there were wrist contractures (most common problem), deep (joint) infection, synovitis (inflammation of the synovium or fluid inside the joint), and loose screws. In one case, a patient had fallen causing wrist dislocation. Three patients with active rheumatoid arthritis inflammation had failed surgeries.

More long-term studies are needed before all aspects of TWA (and especially individual implant designs) are known. For now, it looks like TWAs can be used successfully with people who have rheumatoid arthritis as well as patients with other diagnoses. In fact, patients who don’t have rheumatoid arthritis often have better bone and better alignment making it possible to successfully treat with TWA.

About a year ago, I fell while skateboarding with my 10-year-old granddaughter. At age 67, I know it was a stupid thing to do but I don’t regret it. What I do regret is the fact that the wrist I broke in the fall still clunks and hurts. And I don’t have the strength I need in that hand to pull weeds or lift a bag of dirt for my garden. What do you advise?

It sounds like there may be some instability in the wrist. That means some of the soft tissues (ligaments, cartilage) might have been injured at the same time as the bone fracture. There is one ligament in particular that could cause the kind of symptoms you have described if and when it is partially (or more likely) completely ruptured.

The triangular fibrocartilage complex (TFCC) suspends the ends of the radius and ulna 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).

Wrist fractures with associated soft tissue injuries can result in decreased grip strength, pain at rest, pain with activities, loss of wrist and hand function, and so on. Some patients report a feeling of instability, like the wrist is going to give out on them. You may feel as if something is catching inside the joint. There is usually tenderness along the ulnar (little finger) side of the wrist.

You will need a medical examination and diagnosis before the most appropriate treatment can be prescribed. Exactly what is damaged and how severe the damage is should be assessed. A hand surgeon will make the diagnosis through a series of steps starting with an interview about what happened and what symptoms you are experiencing now.

Special tests such as stress testing of the wrist 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. X-rays with a dye injected is called a wrist arthrography can be used to look for specific soft tissue tears. 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.

If the dye moves from one joint compartment to another, a tear of the soft tissues is suspected. But studies show that almost half the patients with a true triangular fibrocartilage complex tear have normal arthrograms. So other tests may be needed such as wrist arthroscopy.

Wrist arthroscopy is really the best way to accurately assess the severity of damage. A tiny TV camera on the end of the instrument allows the surgeon to look directly at the ligaments. The surgeon can perform a special of the integrity of the soft tissues by inserting a long thin needle into the joint.

A special trampoline test can be done to see if the fibrocartilage disk is okay. The surgeon presses the center of the disk with the probe. Good tension and an ability to bounce back show that the disk is attached normally and is not torn or damaged. If the probe sinks as if on a feather bed, the test is positive (indicates a tear). One advantage of an arthroscopic exam is that treatment can be done at the same time.

You may be a good candidate for conservative (nonoperative) care. This usually involves spending some time with a hand therapist who will direct and guide you through a rehab program. Or you may be advised to have surgery to repair or reconstruct the soft tissue damage, especially if there is a complete rupture of the ligaments and joint instability. The specific surgical procedure recommended will depend on the damage present. So that brings us back to our original advice to see an orthopedic (hand) surgeon and get a proper diagnosis so that the appropriate treatment can be started.

I dislocated a bone in my wrist (the lunate) when I fell off my bike and hit the pavement with my wrists. When I looked on-line I saw how this bone is protected by the other bones around it. Nothing else was dislocated so how or why did this one pop out?

The lunate carpal (wrist) bone is neatly tucked in between the two bones of the forearm, the two other carpal bones on either side, and another row of carpal bones next to the fingers.

It doesn’t dislocate easily and usually only after significant high-energy trauma. Falling off a bike and hitting the pavement could certainly cause this type of injury. Car accidents and sports injuries account for the majority of lunate injuries.

Dislocation of this bone usually means the soft tissues around the bone have been disrupted. The injury is technically referred to as a perilunate injury, meaning “around the lunate.” There are four steps or “stages of injury” that occur to force the lunate out of place. It’s a bit like dominoes — once the first one goes, a whole series of events takes place.

In stage one, the carpal bones next to the fingers are forced into a position of extreme extension. The ligaments around those bones pull the scaphoid bone of the wrist (the bone next to the lunate on the thumb side) into a position of extension. The ligament between the scaphoid and lunate tears. The force of the injury continues to transfer through the wrist to the ligaments around the lunate. That is stage two of the sequence.

In stage three, the lunate dislocates and pulls with it the ligament between the lunate bone and the triquetrum (bone on the little finger side of the lunate). And then in stage four, the ligament between the radius bone of the forearm and the lunate tears allowing the lunate to rotate or twist and dislocate.

Of course, all of these events occur in a matter of seconds starting at the moment of impact. The loss of the ligament stability and shift in bone alignment changes the whole structure and dynamics of the wrist. The natural “arcs” or archways formed by the two rows of carpal (wrist) bones is affected. This can put pressure on the nerves that travel through the arcs. And in a perilunate injury, any of the bones around the lunate can be fractured, dislocated, or both.

I am a construction worker just getting back to work part-time after a wrist injury that dislocated my lunate bone and tore the ligaments around it. Can I expect to get full recovery? No one seems to be willing to say “yes,” “no,” or even “maybe.”

The lunate carpal (wrist) bone doesn’t dislocate easily and usually only after significant high-energy trauma. The lunate is well-stabilized because it is neatly tucked in between the two bones of the forearm, the two other carpal bones on either side, and another row of carpal bones next to the fingers. It takes a high-energy trauma to cause this type of injury.

Dislocation of this bone usually means the soft tissues around the lunate have been disrupted. There are a series of events or “stages of injury” that occur to force the lunate out of place. It’s a bit like dominoes — once the first one goes, a whole series of events takes place.

The prognosis (what you can expect after treatment) depends on a couple of factors. These include: 1) timing of treatment (how soon surgery is done after the injury) and 2) quality of the reduction (how well the bones are lined up and stabilized). A delay of more than a month can mean worse results than with early treatment. Even with the best treatment early on, patients can expect some loss of grip strength and motion.

Severe injuries with less than ideal alignment can mean early arthritic changes. But most of these injuries do heal. Patients are able to resume daily activities and even return to work. Manual laborers have greater difficulty with return to full work activities and often report worse outcomes. Patients who are treated surgically using both the front (volar) and back (dorsal) wrist incisions tend to have decreased results as well.

Returning to work part-time is a good way to ease back into full employment. Depending on the type of work you do, it may also be necessary to modify work activities so that you aren’t putting full force on the wrist right away. If your rehabilitation program included hand therapy, your therapist can help guide you — both in preparing to return-to-work and also in planning and performing the actual work load.

What is ulnocarpal impaction syndrome?

To understand ulnocarpal impaction syndrome, picture where the ulnar bone of the forearm meets the wrist. This will be on the little finger side of the wrist. The two bones are jammed together (ulna against the wrist). The condition usually causes pain along that side of the wrist.

The constant force of the ulna against the ligament (triangular fibrocartilage complex or TFCC) between the two bones causes injury to this area of soft tissue. There are several possible causes of this problem. The first is called a congenital ulna-positive variance. That just means the person was born with a slightly longer ulnar bone (or shorter radius — the other bone in the forearm) than normal.

Sometimes this problem develops after there has been a wrist or elbow fracture of the radius. Shortening of the radius leaves the ulnar bone longer than the radius with the same end-result: impaction.

Ulnar impaction syndrome is rare without one of these traumatic anatomic changes. But there are some cases that occur when there is repeated loading of the ulna against the wrist bone. This could be a daily work activity such as gripping, a twisting motion of the forearm, and/or tilting the wrist toward the little finger.

Treatment begins with conservative (nonoperative) care. This is usually avoidance of movements that aggravate the symptoms, the use of nonsteroidal antiinflammatory drugs, and the use of a splint. If following a carefully prescribed program with these principals does not change the symptoms in three to six months, then surgery might be advised.

I am a hand therapist looking for information on the Regan Shuck test. I’ve heard about this for checking the wrist but have never seen it described or performed. Can you help me out?

The Regan “shuck” test is used to test for wrist instability in someone complaining of pain along the ulnar border (little finger side) of the wrist. The examiner moves the lunate wrist bone up and down while moving the rest of the wrist in the opposite direction.

To do this, place your thumb and index finger of one hand on the triquetrum and pisiform bones located at the distal end (bottom) of the ulna bone at the wrist. Now use the thumb and index finger of the other hand on either side of the lunate (in the middle of the wrist) between the triquetrum and the scaphoid bones.

By moving your two hands in opposite directions, you are creating stress across the lunotriquetral (LT) joint. Any excess motion here may be an indication of instability from injury and damage to the lunotriquetral ligament holding these bones together.

This test is considered a “provocative” maneuver because it will reproduce the patient’s painful symptoms when there is a problem at the LT joint. The diagnosis is usually made based on the patient’s history, clinical presentation, results of special tests like the Regan shuck test, and imaging studies.

Magnetic resonance arthrography (MRA)may provide the most accurate information. MRA involves injection of a dye into the joint(s) to look for any place where the dye leaks out (a sign of ligamentous tear). MRI, multidetector CT, and ultrasound are also available for some situations.

I know there are always possible complications after any kind of surgery. What kinds of problems can develop after surgery to repair a torn triangle wrist ligament?

Triangular fibrocartilage complex (TFCC) injuries of the wrist affect the ulnar (little finger) side of the wrist. Mild injuries of the TFCC may be referred to as a wrist sprain. As the name suggests, the soft tissues of the wrist are complex. The triangular fibrocartilage complex (TFCC) suspends the ends of the radius and ulna 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). They work together to stabilize the very mobile wrist joint. Disruption of this area through injury or degeneration can cause more than just a wrist sprain requiring surgical repair.

Arthroscopic debridement (smoothing or shaving) of the damaged tissue is then required. The surgeon debrides any tears of the tissue that might catch against other joint surfaces. Then the surgeon looks for any problems with the nearby soft tissues and 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 require 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.

Complications following surgery for TFCC tears can be broad-ranging and depend on the location and severity of the tear as well as the type of surgery required. For example, there are higher complication rates when instrumentation is used or if there is a shortening of one of the bones of the forearm. Delayed union, nonunion, infection, and persistent wrist pain and stiffness are the more serious problems that can develop.

Nerve injury during the surgery can leave behind persistent numbness, weakness, and deterioration of hand function. Further surgery may be needed to revise the first operation. Some patients need another surgery to remove any hardware used to stabilize the joint. The bottom of the ulna called the styloid may have to be removed. In rare cases, the procedure fails to provide the desired results. A wrist fusion may be the next step.

Most of the time the procedure goes well and provides the intended and desired results of pain free motion, restored function, and full strength. It’s good to be mentally prepared for all possible outcomes but even better to expect a perfect result right from the start!

How long does it take to recover from surgery for a torn triangular cartilage in the wrist? It took six months before I finally realized it wasn’t going to heal without surgery. Is this going to take another six months? I can’t believe how much time I’ve wasted trying everything from herbs and acupuncture to exercises and rehab. I need a break!

The triangular fibrocartilage complex (TFCC) is an important feature of the wrist. It suspends the ends of the radius and ulna bones of the forearm over the wrist. As the name suggests, 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).

Mild injuries of the TFCC may be referred to as a wrist sprain. As the name suggests, the soft tissues of the wrist are complex. They work together to stabilize the very mobile wrist joint. Disruption of this area through injury or degeneration can cause more than just a wrist sprain. Mild injuries often do respond well to hand therapy. But more severe injuries or radial-sided TFCC tears have a more difficult time healing because of a natural (anatomic) lack of blood supply.

In cases like yours where conservative (nonoperative) care does not yield the desired results, surgery may be necessary. But as you have discovered, it can take quite a while to reach this conclusion. The follow-up plan after surgery may vary depending on the type of procedure used by your surgeon. Newer and improved methods have made it possible for some patients to return to full, unrestricted activity as early as six weeks post-op.

At first, your wrist will be immobilized in a bulky dressing or cast. The type of immobilizing device used and the position your wrist is placed in depends on the type of surgery you had. Motion exercises for the fingers are usually started soon after the operation. Cast or brace removal is followed by physical therapy for six to eight weeks.

Physical therapy may be needed to help you regain full joint motion, strength, and normal movement patterns. Some patients have difficulty regaining pinch and grip strength. The therapist will help you get back specific motions lost such as ulnar deviation (moving hand at the wrist away from the thumb and toward the little finger) and supination (palm up motion) or pronation (palm down motion). The therapist will help make sure you do not use compensatory shoulder motions to make up the difference.

The goal is to restore full motion, strength, and function. The rehab program will be geared toward your needs at home, work, and play. Many patients are able to return to work with no restrictions. A small number may require some work restrictions or changes in work tasks. If there are no complications, you can expect anywhere from a six-week recovery up to six month period of time to return to normal.

I fell and broke my left wrist about seven weeks ago. Doctor slapped a cast on that baby and I thought I was good to go. Then I discovered last week that a tendon to my thumb ruptured. How can that happen with a cast on? I don’t get it.

Wrist fractures involving the radius bone of the forearm has a well-known complication associated with it. And you have just experienced that — rupture of the extensor pollicis longus (EPL) tendon of the thumb. This tendon helps move both the tip of the thumb and the wrist, so damage to it can impair function of the hand.

There are reports of how often this tendon rupture occurs after radial wrist fractures. The incidence ranges between 0.3 and two per cent. In a recent study, surgeons from Brigham and Women’s Hospital in Boston reported a five per cent incidence. This is much higher than previously thought and bears mention as well as closer study.

EPL tendon ruptures are more common with nondisplaced radial fractures. Nondisplaced means the bones did not separate or shift after the break occurred. What’s the connection between these two events (bone fracture and tendon rupture)?

When the force that breaks a bone is not enough to rip or tear the soft tissues around the bone, complications like the tendon rupture can occur later. This is because the tendon is held tightly against the bone. The fracture results in swelling, bleeding into the area, and the formation of a bone callus as healing takes place.

All of these events decrease the space around the tendon and put pressure on the tendon. The EPL tendon in particular doesn’t have a very good blood supply to its own tendon sheath (outer protective covering). Anything that disrupts this area can reduce blood flow and nutrition causing avascular necrosis. Avascular necrosis means death of the tissue due to loss of blood. The end result is rupture of the tendon.

Some surgeons have suggested other possible mechanisms for the EPL tendon rupture. There may be a bone spike that forms as a part of the healing process that cuts into the tendon. Or the tendon might have been injured if the fracture was displaced (separated) requiring a procedure called reduction to reset the bone alignment.

Any injury to the blood vessels in the area, blood clots, or even scar tissue can contribute to a tendon rupture. It’s not always clear what caused the problem. Your surgeon may be able to answer this question more specifically to your situation based on X-rays or CT scans.

Do you think if I have surgery to cut the nerves to my wrist, I’ll lose the sense of where my hands are? I am a musician in need of pain relief but not at the expense of not feeling my wrists and hands.

Wrist pain can be very chronic and very debilitating sometimes. When conservative (nonoperative) care isn’t successful in changing the clinical picture, then wrist denervation may be advised. This procedure has been done many many times with reliable results. Pain relief without loss of motion is the goal.

Cutting the sensory nerves that relay pain messages to the brain (not the motor nerves that control movement) is helpful in up to 90 per cent of all cases reported. However, your concern about feeling the position of the joints (something called proprioception) and sense of movement of the wrist and hands (called kinesthesia) is important.

A recent study at Mayo Clinic in Rochester, Minnesota took a look at this very phenomenon. They tested and measured the potential effect of denervating two nerves in the wrist on active and passive wrist motion. In the real surgical procedure, the nerves causing chronic pain would be cut. The purpose of the procedure is to eliminate wrist pain. This may be what you are referring to.

In this study, the subjects’ wrists were injected with a specific solution. The idea was to mimic denervation but without actually killing or permanently altering the sensory nerves responsible for transmitting information.

Two groups of normal adults between the ages of 20 and 54 were included in the study. A total of 80 people participated. One group received a real anesthetic to block the anterior and posterior interosseous nerves. The second (control) group received an injection of a saline (salt) solution to the same nerves.

After the injection, they measured the accuracy (or alternately, the error) in active and passive wrist motion. They did this by placing the wrist in one position and asking the patients to (as accurately as possible) reposition the joint to match the first position. Positions used included 10, 20, and 30-degrees of both wrist flexion and extension. The difference between the actual position and the place the volunteer moved the wrist to was calculated.

Two trials were completed (performed randomly) in each position with a rest of 30 seconds between. The wrist was fully relaxed between trials. They found there were no differences between the groups in ability to reproduce the test position. This indicates that even with nerve anesthetization (mimicking denervation), it is possible to accurately detect active and passive wrist motion. In other words, kinesthetic sense was not impaired or altered by blocking the nerves.

The authors suggest these results infer that effective partial denervation procedures are safe. The accessory nerves are still able to transmit important information about propriocetpion even with the sensory nerves blocked.

When I saw the hand therapist for my wrist pain, she did some interesting tests on me. She would put my wrist and hand in one position and tell me to remember how that felt. I wasn’t allowed to look during the test. Then she shook my wrist and hand out and asked me to go back to the position I was in before she shook me out. I was surprised how accurate I was. What’s the mechanism behind this?

When you move your wrist up and down and back and forth, you are able to sense just how much movement is occurring. The sense of joint position and movement makes up what we call proprioception and kinesthesia.

For a long time, we thought the information about proprioception and kinesthesia that was sent to the brain via the sensory nerves all came from the joint itself. But over the years with scientific investigation, researchers have been able to show that there are kinesthetic and proprioceptive sensory receptors located in many places in the joint and soft tissues.

Knowing that transmission of information about joint proprioception can come from the ligaments, tendons, muscles, joint surface, and skin is important. Surgery cutting into any of these structures can destroy them. Then the joint’s ability to detect motion and position could potentially be altered.

There is evidence that joints aren’t the only ones involved in producing proprioceptive messages. In fact, if anything, sensory receptors in the articular surface of joints don’t send messages until the joint is at its extreme ends of motion (full flexion or full extension).

The sensory receptors in the joint surfaces appear to have more of a protective role. There may be reflexes at the ligament-muscle interface that help regulate muscle contraction and regulate load on the joints. Evidence to support this idea point to the role of ligaments in joint stability AND motion.

The complete package of joint proprioception and kinesthesia is quite complex. Besides recognizing sense of joint position and movement through space, each joint also transmits to the brain any sensation of force and heaviness during muscle contraction, timing of motor control, and sensation of body orientation. All of these mechanisms are behind your skill as demonstrated during the test you were given by the hand therapist.

I have a painful wrist problem called impaction syndrome. The X-rays showed that the tip of my ulnar bone is too long so it’s smacking up against the bones in the wrist. The first surgeon I saw says she can shave down the tip of that bone or remove part of it or all of it. The second surgeon I went to said, no he would just remove a piece of the bone and collapse it down so it would be more natural. Do you think it matters how it is done?

It sounds like you have a condition called ulnar styloid impaction syndrome by its full name. This refers to a condition causing wrist pain because there is a short ulna (one of the two bones of the forearm) and a long styloid.

The styloid is a piece of bone at the end of the ulna that makes the ulna look longer on one side compared to the other. The styloid is a normal feature of the ulnar bone but when it is too long, it presses against the bones of the wrist. In particular, the triquetrum bone in the wrist gets compressed.

The contact point between the too-long tip of the ulnar styloid and the triquetrum (wrist) bone starts to get inflamed and swell up. There can be bone bruising and bone edema as well. Pain along the ulnar side of the wrist is a hallmark finding. But the diagnosis can be difficult to make. Imaging studies such as MRIs and CT arthrography may be needed to see if there is any soft tissue damage that could cause the same or similar symptoms.

Treatment ranges from conservative (nonoperative) care with antiinflammatories and hand therapy to surgery. There are several different types of surgical procedures that can be used.

As the first surgeon mentioned, the surgeon can shave down (decompress) or remove the styloid tip (stylectomy) altogether. Whether a partial or complete stylectomy is done, the surgeon makes every effort to save the ligaments holding everything together.

Surgeons may try other approaches such as the osteotomy procedure suggested by the second surgeon you saw. In any osteotomy procedure, the surgeon cuts out a wedge- or pie-shaped piece of bone from the styloid side of a bone.

Removing this piece of bone allows the surgeon to collapse the remaining pieces of the bone together, effectively shortening the bone while still preserving the natural shape of the bone. With ulnar impaction syndrome, an oblique osteotomy may be preferred. An oblique osteotomy procedure is done at an angle (on the diagonal) rather than straight across. After the piece of bone is removed, a pin is used to hold everything together until healing occurs.

A recent series study of five patients who had an oblique ulnar styloid osteotomy (OUSO) for the treatment of ulnar styloid impaction syndrome showed that this can be a successful and effective approach. Patients must be selected carefully to make sure the diagnosis is accurate.

If there is soft tissue damage from ligamentous instability, an osteotomy may not be the best choice. For those individuals with intact ligament attachments, the oblique osteotomy does not disrupt but rather preserves the soft tissues and maintains joint stability. That is a unique and important feature of this particular procedure.

Whichever surgeon you choose to go with just make sure you are a good candidate for the procedure recommended. Don’t hesitate to ask what makes the proposed surgery the best choice for you. You can also ask how many of these procedures the surgeon has performed, the success and failure rates, and any complications you might experience. Comparing the information about these two proposed procedures may help you solve the question of which one is best for you.

I’m having some mild pain along the little finger side of the wrist. The hand surgeon I saw last week thinks it is something called ulnar styloid impaction syndrome. I looked that up on the internet so I think I have a pretty good understanding of what it is. What I didn’t find was what will happen if I don’t have the recommended surgery? Can you help answer that question?

Just to be clear on what this problem is, ulnar styloid impaction refers to a condition causing ulnar-sided wrist pain because there is a short ulna (one of the two bones of the forearm) and a long styloid.

The styloid is a piece of bone at the end of the ulna that makes the ulna look longer on one side compared to the other. The styloid is a normal feature of the ulnar bone but when it is too long, it presses against the bones of the wrist. In particular, the triquetrum bone in the wrist gets compressed.

The contact point between the too-long tip of the ulnar styloid and the triquetrum (wrist) bone starts to get inflamed and swell up. There can be bone bruising and bone edema as well. Pain along the ulnar side of the wrist is a hallmark finding. But the diagnosis can be difficult to make. Imaging studies such as MRIs and CT arthrography may be needed to see if there is any soft tissue damage that could cause the same or similar symptoms.

The natural history of ulnar styloid impaction (i.e., what happens without treatment) is as follows. At first, the impingement just causes pain. But after a while, pressure builds up from the styloid process (tip) pressing against the triangular fibrocartilage complex or TFCC ligament. The TFCC ligament holds several bony structures of the wrist together including the ulna and the triquetrum.

With continued chronic pressure, the TFCC starts to tear and the contact surfaces of the two bones start to wear unevenly. Bone-on-bone friction can lead to painful synovitis (inflammation of the synovial fluid inside the joint).

If the impaction is allowed to continue without treatment, the wrist can lose its stability. Ligaments holding the bones together in perfect alignment start to break down. Bones start to shift and sublux (partially dislocate) or fully dislocate. Pain, decreased wrist motion, and loss of wrist and hand function can create significant disability.

What can be done about this problem? Treatment ranges from conservative (nonoperative) care with antiinflammatories and hand therapy to surgery. There are several different types of surgical procedures that can be used. If you don’t want to have surgery, you can try the conservative care route for a few months. If with your best efforts to follow the hand therapist’s guidelines you don’t get significant improvement, then it may be time to review again with the surgeon just what the surgical options are.

Many patients who are treated surgically experience good-to-excellent results. But there can be some mild persistent wrist pain that comes and goes. For the most part, patients get back to their former level of activity (including sports). Their satisfaction level is high enough they say they would have the same surgery over again if faced with the same decision again.

I’ve been hobbling along for months now with wrist pain — mostly along the pinky side but the whole wrist hurts. Sometimes it swells up and starts to click. It’s starting to affect my bowling score so I guess it’s time to do something about it. The question is what? Would an X-ray help? I know it’s not broken but I don’t know what’s wrong.

Wrist pain along the ulnar side is the main symptom of a condition called a triangular fibrocartilage complex tear (TFCC). 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). It stabilizes the distal radioulnar joint while improving the range of motion and gliding action within the wrist.

This is a simple explanation of a very complex injury. Mild injuries of the TFCC may be referred to as a wrist sprain. As the name suggests, the soft tissues of the wrist are complex. They work together to stabilize the very mobile wrist joint. Disruption of this area through injury or degeneration can cause more than just a wrist sprain. A TFCC injury can be a very disabling wrist condition.

The pain is made worse by any activity or position that requires forearm rotation and movement in the ulnar direction (toward the little finger). This includes simple activities like turning a doorknob or key in the door, using a can opener, or lifting a heavy pan or gallon of milk with one hand. Certainly lifting and throwing a bowling ball forward would trigger similar symptoms.

Other symptoms include swelling; clicking, snapping, or crackling called crepitus; and weakness, which may translate into a lower bowling score. Some patients report a feeling of instability, like the wrist is going to give out on them. You may feel as if something is catching inside the joint. There is usually tenderness along the ulnar side of the wrist.

TFCC injuries can be difficult to accurately diagnose. X-rays may show a difference in length between the two forearm bones (called variance). When one of these two bones is longer (or shorter) than the other, it is considered a risk factor for wrist pain and disruption of the triangular fibrocartilage complex. The surgeon may also be able to see something called the sag sign on X-rays. One of the carpal bones has shifted in position (sagged); this is an indication of instability.

In addition to X-rays, imaging with magnetic resonance arthrography (MRA) may be needed. A special dye is injected into the joint to show areas of damage and especially disruption of the joint. The most accurate way to diagnose TFCC is with arthroscopic examination.

Treatment for wrist problems like yours requires accurate diagnosis first. Make an appointment with a hand surgeon or other available orthopedic surgeon and get the process started. The sooner treatment is started, the sooner healing can begin. Until you know for sure what’s going on, you may want to stop bowling or any repetitive tasks that aggravate the problem.

I am frustrated and very anxious. I have a torn TFCC in my right wrist (I am right handed). I’ve spent the last three months in a splint with no change in my pain. If it was going to heal on its own, would it have happened by now? The surgeon is recommending an arthroscopic exam before trying something different. What do you think?

As the name suggests, triangular fibrocartilage complex (TFCC) is triangular in shape and made up of several ligaments and cartilage. It stabilizes the distal radioulnar joint (where the two bones of the forearm meet at the wrist) while improving the range of motion and gliding action within the wrist. The TFCC makes it possible for the wrist to move in six different directions (bending, straightening, twisting, side-to-side).

As the name suggests, the soft tissues of the wrist are complex. They work together to stabilize the very mobile wrist joint. Mild injuries of the TFCC may be referred to as a wrist sprain. Disruption of this area through injury or degeneration can cause more than just a wrist sprain. A TFCC injury can be a very disabling wrist condition. For a more detailed description and understanding of this wrist problem, see A Patient Guide to Triangular Fibrocartilage Complex (TFCC) Injuries.

The natural history of TFCC injuries is unknown. Natural history refers to what happens over time. Can these injuries heal on their own? If so, is it possible to predict who will heal and who won’t? Is there a timeline for how long to wait for healing to occur? These are questions we don’t have answers for just yet.

Clearly, there are some patients who do recover with conservative (nonoperative) care. The location and severity of damage, age of the patient, activity level, and cause of the original injury (e.g., trauma versus degeneration) may be important factors determining results.

Surgery is often a consideration when conservative care with cortisone injections, splinting, and hand therapy don’t change the patient’s symptoms. But there isn’t enough evidence to show that surgery gives any better results than the nonoperative approach.

Even with a complete diagnosis, treatment decisions aren’t easy. Each case of TFCC injury must be examined one-by-one. The presence of other associated injuries (e.g., torn ligaments, bone fractures) can influence both the treatment and results.

If your wrist is stable and the surgeon thinks there is potential for healing, it is reasonable to try waiting a bit longer to see if recovery without surgery is possible. If there’s no improvement, further evaluation with diagnostic arthroscopy as suggested by your surgeon is the next step. Any further treatment decisions would have to wait pending the results of these first two steps.

I have a wrist problem called Kienböck Disease. I’ve seen two surgeons who both want to do surgery. One suggested grafting a piece of bone to that area to help restore the blood supply. The other wants to shorten one of the bones in my forearm. Neither one of these appeals to me. Is there some other way to handle this problem?

Treatment of Kienböck Disease is usually directed toward taking pressure off the affected carpal (wrist) bone (the lunate). Preventing collapse of the lunate and helping to restore blood flow to the area are the two main goals of treatment.

Transplantation of a bone graft with an intact blood supply is one way to accomplish this. But the graft doesn’t always “take” and further surgery may be needed. A second common approach is joint-leveling. Here’s a brief explanation of why joint-leveling is used.

Some experts think that a difference in length between the two bones of the forearm (radius and ulna) adds stress and pressure on the lunate. 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 Kienböck disease. Chronic repetitive trauma can lead to damage of the arteries supplying blood to the lunate.

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. But this procedure has come under question because of the many complications associated with it and also because the problem has been successfully treated in other ways.

One of those other simpler yet still effective treatment techniques may be of interest to you. It’s called lunate core decompression. This procedure doesn’t involve bone graft or removing bone. Instead, a small hole is drilled into the center of the bone.

After surgery, the drill hole gradually fills with tissue. Sometimes, new bone forms within this area. The procedure may help increase the blood flow to the diseased area of bone and allow new blood vessels to form. Core decompression appears to slow down the disease process. It may even stop the progression of disease.

Studies show that lunate core decompression has good long-term (five-year) results for the majority of patients. Occasionally, tenderness over the lunate persists but the majority of pain and disability are gone. Some patients do end up needing further surgery if the lunate fails to recover. Ask your surgeon if you qualify for a core decompression procedure. It may be something that would work for you.

Dad was just diagnosed with Kienböck Disease of the wrist. Like the stubborn man he is, he is refusing any treatment. What will happen without the surgery the doctor is recommending? Can he heal on his own?

Kienböck 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. 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.

    In most cases, the disease does get worse without treatment. 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.

    There are several simple ways to treat this problem. Your father might be willing to try one of these. 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 (loss of blood to the bone) rather than true Kienbock’s disease, the condition may also clear up during this time. Transient osteonecrosis sometimes develops briefly after an injury.

    Surgery may be needed if conservative (nonoperative) care does not produce the desired results (return of blood supply to the bone). And it sounds like the surgeon is advising this step. Although there are many different surgical procedures that can be done, one that is simple and effective is called lunate core decompression.

    The lunate bone in the wrist is the usual target of Kienböck Disease. Decompression is a surgical technique used to take pressure and load off the bone. The best result is a restoration of blood flow to the area called revascularization.

    During the lunate decompression surgery, a small hole is drilled into the center of the bone. After surgery, the drill hole gradually fills with tissue. Sometimes, new bone forms within this area. The procedure may help increase the blood flow to the diseased area of bone and allow new blood vessels to form. Core decompression appears to slow down the disease process. It may even stop the progression of disease.

  • My brother crash landed while hang gliding and broke his wrist into many tiny pieces. The surgeon spent hours putting it all back together. We watched the video together last night but there wasn’t any real narration. When things are that busted up, how does the surgeon even know where to start?

    When trauma causes bones to fracture, split and explode apart, the surgeon is faced with some complex challenges. This is especially true in the wrist and hand where there are many bones intricately fitted together like a jig saw puzzle. One of the biggest challenges is how to separate the broken pieces when they are jammed together and then realign all the fragments.

    Traction is often used (suspending the forearm in a vertical position) to pull the bones apart. The surgeon suspends the patient’s forearm in a vertical traction unit. The first part of the procedure may have to be done with the hand suspended in mid-air. The position is definitely awkward for the surgeon.

    Once the impacted pieces of bone are pulled apart, the next step is to temporarily place the pieces together. To help guide him (or her), the surgeon uses fluoroscopic (real-time) X-rays. Fluoroscopy allows the surgeon to see inside the joint while performing the procedure.

    A special locking plate and wires will do the trick to hold the fracture together. Later the wires will be backed out and more secure, permanent fixation replaces the wires. The surgeon must take the time to fine-tune the reduction by lining each fragment up one at a time. Then it is necessary to go back and firmly attach everything together. And finally, the surgeon takes a look inside the joint for any other soft tissue damage that needs to be repaired.

    This may not describe exactly what was done to repair or reconstruct your brother’s wrist but it gives a general idea. The severity of the fracture and specific bones affected dictate how the surgeon approaches each case. Many hours and years of training go into complicated cases like this. They start by working on cadavers (human bodies preserved after death for study) in a laboratory with close supervision.

    When they are ready, they observe and assist other more experienced hand surgeons before attempting simple steps (always with guidance and supervision). Even fully trained hand surgeons perform as many wrist fracture fixation procedures (simple and complex) possible arthroscopically. By doing so with the simple surgeries, the more complex become a matter of completing several simple steps one at a time toward the final goal of restoring anatomy, alignment, and function.