FAQ Category: Wrist

Wrist fractures (or any fracture for that matter) can be comminuted and/or impacted requiring traction to pull the pieces apart. Comminuted means the bone has broken into several fragments (often there are many tiny pieces). Impacted tells us the bones have been jammed together.

Traction gives a distractive force needed to pull the impacted bones apart. This is a necessary step before the pieces can be lined back up and wired together. What you see in the photos that looks like a Chinese finger trap is used to suspend the hand allowing the weight of the arm to give the distractive force needed.

It’s a very handy technique called vertical distraction. It may sound simple to say the surgeon suspends the patient’s forearm in a vertical traction unit and in reality, it only takes about five minutes. But the process is a bit more complicated than that. And just try operating on a hand suspended in mid-air. The position is awkward for the surgeon.

Surgeon have to be very clever and make adaptations when necessary. For example, in a recent report, one hand surgeon from Spain described (and showed photos) of his use of carabiners to help suspend a patient’s hand who had a comminuted and impacted wrist fracture. In case you aren’t familiar with the term, carabiners are metal clips used by rock climbers to hold things. Everything down to how to maintain sterility had to be considered.

So if you like a good puzzle, you like to be challenged, and you are good with your hands — becoming a surgeon might be just the thing for you!

The scaphoid is the most common carpal bone to break. It is located on the thumbside of the wrist next to the radius (larger of the two forearm bones). And according to results of studies published in orthopedic journals, it’s also not uncommon for patients to be unaware of a fracture or the cause. In other words, having no recollection of an injury resulting in a scaphoid fracture is not unusual.

The question then arises: why does this particular bone fail to heal? Is there something that creates a nonhealing response? Is it age or sex (male versus female)? Does the medical care patients receive fail to treat the problem correctly? Having a better idea of how and why scaphoid fractures result in a nonunion may help surgeons manage these cases more effectively in the future.

Some studies have reported a nonunion rate as high as 40 per cent. This high rate occurred when the patients were not diagnosed or treated right away. To give you an idea how that 40 per cent rate compares, there’s a three per cent rate of nonunion when the problem is diagnosed and treated within 30 days of the injury. This finding supports the idea that timing of evaluation and treatment might be an important factor.

But it doesn’t answer the question of why you had no symptoms at first. The answer to that isn’t as clear. Some experts suggest the very fragile blood supply to the scaphoid area might be a factor. The location and severity of the fracture could also explain the lack of symptoms. A severe fracture of the scaphoid bone on the forearm side of the wrist is more prone to nonunion. Again, the reasons for this are not entirely clear.

The good news is that you have finally been diagnosed so that treatment can begin. Follow your physician’s treatment plan carefully. Patient noncompliance (failure to cooperate with treatment) is one reason why nonunion fractures fail to respond.

You aren’t the first parent to ask that question! Does anyone really know the mind of 18-year-olds? But to help you out as much as possible, here are several factors that might help explain your son’s situation.

First, the scaphoid is the most common carpal bone to break. It is located on the thumbside of the wrist next to the radius (larger of the two forearm bones). Studies have reported a nonunion rate as high as 40 per cent. This high rate occurs when the patients are not diagnosed or treated right away.

To give you an idea how that 40 per cent rate compares, there’s a three per cent rate of nonunion when the problem is diagnosed and treated within 30 days of the injury. This finding supports the idea that timing of evaluation and treatment might be an important factor. You have probably already figured that out with your son’s situation!

The real question is how do these young athletes keep on playing with a broken wrist? The truth is that quite a few of these fractures don’t cause painful symptoms at all. In a recent study from Canada, one-third of a group of 96 patients with scaphoid fractures did not seek medical attention.

They either didn’t think it was much of a problem or the painful symptoms got better without treatment. Pressure to return to sports participation in this age group may have led some to minimize their symptoms. In those patients who were evaluated, the diagnosis was missed because there is a high rate of false negative response when relying on X-rays. In other words, the X-rays don’t show the fracture.

Even with timely cast immobilization, scaphoid fractures don’t always heal. Surgery is required anyway. So although you can’t know how your son’s injury would have responded with early treatment, there’s a good chance he would have required surgery anyway. Hopefully, this will put him well on the road to recovery now.

The wrist with its double layer of bones and ability to turn and twist in all directions is a challenge to replace. For many years, anyone with severe wrist pain, deformity, loss of motion, and loss of hand function were offered only one treatment option: arthrodesis (fusion). But today, thanks to modern technology and improved surgical techniques, a total wrist replacement is possible.

As more and more studies are done involving wrist replacements, surgeons are getting a better idea of what works best.a Any age can be accepted. They must have good enough bone stock to support the implant. And patient compliance (doing what the surgeon tells you to do) is very important.

For example, usually after surgery, there is to be no carrying or lifting of anything heavier than 15 pounds for at least six weeks. After that there may be some other restrictions on heavy work like no lifting or moving heavy objects, gardening, or bowling.

Doing too much too soon can compromise the surgery. The joint implant might come loose or even break. Just one wrong move could really make a difference in a negative way. It takes time for the healing response to lay down new bone around the implant so that it remains firmly fitted and stable.

Patients are usually warned to be prepared for a few “less than perfect” results. For example, the implant does not allow enough wrist extension to push up from a chair with that hand. The wrist may be improved, but the fingers remain the same and that might be with pain and deformi

For the most part, the majority of patients who receive a total wrist replacement for rheumatoid arthritis are pleased with the results. Motion and function are improved such that patients rate their results as satisfactory or completely satisfactory.

Patients report it is possible to get used to doing things without full wrist motion but much better to have a wrist replacement that allows motion and function once again. They say the happiness of being able to fasten buttons, pick up loose change, and even walk the dog can’t be measured!

Of course, each patient must come to terms with the best way to treat their orthopedic problems. But on the flip side, the surgeon must educate the patients and provide the most realistic picture possible. A successful fusion is far better than a failed surgery to replace the joint.

Some information we gathered from recent studies might help put this into perspective for you. Surgeons are still reporting a pretty high complication and failure rate. In a study from the University of Iowa, the failure rate was 50 per cent. And those were early failures — not after the patient had the wrist implant for years and years.

You might think that was just one place but reviewing other similar studies, we found the same type of results. The biggest problem appears to be loosening of the implant on the hand side (as opposed to the component part on the forearm side).

The second most common problem was something called subsidence — the implant literally sinks down into the bone. Most of the patients who have complications or failures end up having another surgery. The surgeon either removes and replaces the implant or removes the implant and fuses the joint.

You may wonder what about the other half who had good results? Well, they gained enough motion to regain considerable function. And it didn’t take that much increased motion to be considered a success. Even a few degrees of wrist motion can position the fingers in such a way to allow patients to complete many previously impossible tasks.

The problem is surgeons don’t know yet how to predict who will have good results and who will be a failure from the outset. Those kind of predictive factors may be determined eventually — but we don’t have that information yet.

Much of treatment for painful wrist conditions depends on the underlying cause. Treatment may vary depending on the location and severity of symptoms or type of damage present (if there is any).

One of the most common causes of chronic wrist pain is osteoarthritis. This could be from a previous trauma or a progressive degenerative process associated with aging. There are other diagnoses such as rheumatoid arthritis or Kienböck disease (loss of blood supply to a wrist bone).

Depending on your diagnosis, there may be some other things you can try. The first thing is to go back to your primary care physician or orthopedic surgeon (whoever has been treating you) for a re-evaluation. It’s possible all you need is a revision of your medications or review of activity modifications.

Perhaps it’s time for an updated splint or even a more concentrated rehab program. A program of conservative (nonoperative) care is always advised for at least three to six months before considering surgery. And alternative approaches like acupuncture or relaxation techniques might be helpful.

Local injection of a numbing agent into the wrist might give you some temporary pain relief. This procedure is also a way to find out if surgery to cut the sensory (pain producing) nerves might be helpful.

So you see, there are options but in order to know which one is best for you, an examination is really the next step. It is often the case that specific treatment based on the underlying etiology (cause) is the most effective over the long-term.

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. In the late stages of the disease, the bone collapses, shifting the position of other bones in the wrist.

This shifting eventually leads to degenerative changes and osteoarthritis in the joint. While the exact cause of this uncommon disease isn’t known, a number of treatment options are available.

Early Kienböck 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 affected bone will return and the disease will clear up during this time. Splinting may be used to hold the wrist in a position of good alignment to help maximize blood flow that is present.

Surgery may be suggested as in your case. The least invasive procedure would be denervation (cutting the sensory nerves to end pain signals). Numerous small studies have shown good results with this approach. There are very few disadvantages and many advantages.

One of the positive features of a denervation procedure is the instant pain relief. Without the pain, many patients are finally able to move the wrist again. Grip strength improves as does the joint motion. Daily home and work activities become manageable.

As with any surgery, there are always risks of complications such as infection, blood clot formation, or nerve palsy. With the type of surgery you are considering, there might be some bleeding into the area causing a hematoma (small pocket of pooled blood). This is a minor problem that will resolve on its own with time.

The only real “down” side (if you can even call it that) is the fact that the underlying problem (in your case, the Kienböck disease) doesn’t go away or even get better. Denervation can buy you some time though before considering more extensive surgery.

People with severe wrist arthritis like yourself (usually from rheumatoid arthritis) find themselves in a bit of a bind — literally. With pain, swelling, and loss of wrist motion it becomes increasingly difficult to perform even the simplest task.

Most often both wrists are affected — not just one. Personal hygiene can become a huge problem. Whether in the bathroom, bedroom, or kitchen, even a few degrees of motion can indeed make a big difference in function.

Even a few degrees of wrist motion can position the fingers in such a way as to allow patients to complete many previously impossible tasks. And manufacturers of these implants are watching closely to the results. They have made slight changes in the shape of the implant surface. Even small changes have made significant differences in return of motion and function.

Studies comparing patient satisfaction after wrist fusion versus wrist replacement show much higher marks for the wrist implantation. Even though complication rates are almost double for wrist replacement compared to fusion, the improvements in function and motion were enough for patients to support wrist replacement as their preferred choice.

Implant manufacturers are continuing to improve the design of wrist implants. Efforts to mimic the normal anatomy of the wrist are paying off. Fewer wrist dislocations and improved wrist stability are reported with the newer, improved “second generation” implants.

Wrist fractures in older adults are both common and problematic. Selecting the best treatment for each individual isn’t always a cut-and-dry affair. Patient preferences, type of insurance coverage, severity of the fracture, quality of bone, and even geographical location can impact treatment methods.

If the fracture is stable (bone is broken but ends are not separated), then a cast or airsplint is often the treatment of choice. Osteoporosis (brittle) bones, displaced (separated) fractures, and fractures with several (or many) bone fragments may require some additional care.

In such cases, surgery to reduce (line the bones back up) the fracture and hold it in place may be required. This type of surgery is called open reduction and internal fixation (ORIF).

It sounds simple enough but there are many different ways to accomplish the task. Once again, the surgeon is back to deciding what will be best for that patient. Should the volar locking plate system be used? Or would an external fixation device provide a better outcome for this patient? There are multiple fixation systems to choose from including screws, wires, plates, and rods. And each of those can be placed in different ways.

Having said all that, let us throw one more thing into the mix. How the bone fracture heals (and looks on X-ray) or from the outside doesn’t always translate into poor motion, strength, or function. In other words, it could be just a visual deformity that doesn’t impair the use of that wrist or hand.

Your father can always seek the opinion of his surgeon about this situation. But if he is not distressed by how it looks and the hand works just fine, there may be nothing needed in the way of additional treatment.

Many people today want to make their own decisions about health care events. This is especially true with the Baby Boomers (people born between 1946 and 1964). The first of these folks are hitting the 65 year old mark and entering the “senior” status. This group is characterized by a strong consumer rights and activist approach to social, political, and even personal affairs.

Physicians (and other health care providers) are being encouraged to see patients as consumers. Given the right education, they want to make informed decisions for themselves. Sometimes that approach is just right.

For example, in the case of a broken wrist, there is no one best way to treat the problem of an unstable wrist fracture. Straightening the bones out and applying a cast may not look as perfect and pretty as doing open surgery but it reduces the risk of complications that older adults might face with surgery.

And there are quality of life issues to consider. Quality of life includes activity level and ability to complete daily tasks around the house or at work. Wrist pain, loss of wrist/hand motion, decreased strength, and impaired function can really put a damper on quality of life. Function (using that hand) may be more compromised with one type of surgery versus another. For a piano teacher that choice may be very important.

For your mother and her situation, letting the surgeon make the best choice was the right thing to do. When information overload muddies the waters, it’s best not to step in and wade around! But for others, more information is needed for them to weigh the risks against the benefits and make a choice that best suits their own personal needs.

Any manual laborer involved in repetitive tasks who reports wrist pain, tenderness, swelling, and/or weakness could be suffering the effects of joint damage, ligament tears, leasions of the cartilage, and/or any combination of these problems. The problem could be something as simple as tendinitis (inflammation of the tendon).

Another possibility is something called osteochondritis dissecans (OCD). OCD is a problem that usually affects the knee, but can also occur in other
joints such as the elbow, ankle, and wrist. It’s a localized problem, meaning it only affects one bone and doesn’t spread. The primary area involved is the joint articular surface (cartilage lining the joint surface).

A piece of the articular cartilage detaches or separates from the underlying layer called the subchondral bone. Basically, OCD is a separation of the joint lining from the first layer of bone underneath. When the subchondral bone just under the cartilage surface is injured, there is also damage of the blood vessels to the bone.

Without blood flow, the area of damaged bone actually dies. This area
of dead bone can be seen on an X-ray and is sometimes referred to as the osteochondritis lesion. A joint surface damaged by OCD doesn’t heal naturally.

Treatment involves surgery to replace the damaged bone with a healthy bone graft. One of the newer surgical approaches is the osteochondral autograft transplantation (OATS).

The surgeon takes out the damaged area, harvests a piece of donor bone (from the patient), and replaces the damaged bone with the graft. The piece of bone graft is held in place with a wire until full healing takes place. The patient is placed in a protective splint to limit motion that might disrupt the graft.

Studies show that manual laborers who have this particular problem and procedure are able to return to work. They are able to perform the job tasks once again without discomfort and with full return of wrist motion and strength. However, with continued repetitive motion, there is an increased risk for another episode of this problem.

All of these potential problems are just guesses at what might be causing your husband’s symptoms based on the history and symptoms you described. A clinical examination is really required before making any real diagnosis. Early treatment for problems like this often yield good results (better than waiting until the problem has progressed too far).

There are some experts who consider these two problems to be one and the same with just a few differences. You might say they are two conditions on a continuum. Others view them as separate entities.

Preiser’s disease was named for the physician who first described it in 1910. It is a condition of osteonecrosis (death of bone) of the scaphoid bone in the wrist. The scaphoid is the first bone in the wrist next to the radius (forearm bone on the thumb side).

Osteonecrosis refers to death of the bone caused by a loss of blood supply. Avascular necrosis (AVN) is a term used to refer to loss of blood to the bone with subsequent death of the bone.

Some experts say this is a spontaneous condition. In other words, it happens without any apparent reason. Others suggest a small fracture or other trauma is the main cause of Preiser’s disease.

With osteochondritis dissecans (OCD), there is a loss of blood supply to the scaphoid but that’s not how the problem got started — that’s a result of the main problem. A piece of the articular cartilage detaches or separates from the underlying layer called the subchondral bone.

Basically, OCD is a separation of the joint lining from the first layer of bone underneath. When the subchondral bone just under the cartilage surface is injured, there is also damage of the blood vessels to the bone. Without blood flow, the area of damaged bone actually dies. This area of dead bone can be seen on an X-ray and is sometimes referred to as the osteochondritis lesion.

Symptoms are pretty much the same for both conditions. There is wrist pain at rest and with movement. Tenderness over the scaphoid bone is common. Decreased grip strength is often reported.

Clinical tests can’t differentiate between the two problems. Imaging studies such as X-rays, CT scans, and MRIs are used to diagnose the problem. The main difference is that osteochondritis dissecans is a focal problem — meaning the damage is just located on one part of one bone. With Preiser’s, there are multiple places on the scaphoid where the bone has broken into pieces or fragments because of a loss of blood supply.

The final diagnosis may not be possible until the surgeon looks inside the joint arthroscopically. Seeing the whole scaphoid bone and examining the damage, location, and effects of the lesions aids in making a clear call on what is causing the patient’s symptoms.

The name scaphoid nonunion advanced collapse (SNAC) actually helps describe the condition. Scaphoid is a bone in the center of the wrist. It is a key player in providing flexible mobility of the wrist joint.

A fracture of the scaphoid bone that doesn’t heal is described as a nonunion. When the scaphoid is broken, it no longer stays in alignment. If one or both of the fractured pieces shifts (collapses), the joint becomes unstable. Trauma (like your drill press accident) is the main cause of this type of scaphoid collapse.

Any trauma, injury, or other disease process that affects the scaphoid can also potentially affect the other bones (capitate, lunate, triquetrum, hamate) and ligaments in contact with the scaphoid.

Damage (tears or ruptures) of the scapholunate ligament (between the scaphoid and lunate bones) puts the wrist at additional increased risk for uneven wear, joint degeneration, and wrist arthritis.

That doesn’t paint a very rosey picture for you. But the fact is that treatment for this condition can cause problems of its own. Studies have not been done to really nail down what’s the best treatment for this problem. Each patient is treated on a case-by-case basis.

Future studies comparing the results of each treatment method based on patient age, strength, activity level, and work requirements may help guide treatment decisions for this problem. With the information here, we hope you can go back to your surgeon and discuss what might be the best treatment approach for you.

The scaphoid is a key player in wrist movement because of its location. It sits in the center of the wrist. Any trauma, injury, or other disease process that affects the scaphoid can also potentially affect the other bones and ligaments in contact with the scaphoid.

Damage (tears or ruptures) of the scapholunate ligament (between the scaphoid and lunate bones) puts the wrist at risk for uneven wear, joint degeneration, and wrist arthritis. Fractures of the scaphoid bone that don’t heal (called a nonunion fracture) can result in the same process of joint destruction and arthritis.

Treatment may depend on what’s happening with the scaphoid. For example, has it collapsed and shifted out of alignment? Is the scapholunate ligament torn or ruptured? What other bones are affected? And finally, has the scaphoid fracture healed or is there a nonunion fracture still present?

The least invasive (nonoperative) method can be tried first. (splint, hand therapy). Medications may be added if pain is a problem. If you don’t improve or only have limited change in your pain, then injection therapy or nerve denervaton (sensory nerve sending pain messages is destroyed) can be tried.

Surgery is the last option when pain and weakness and loss of function persist or progress. Surgery can also be done in stages. Removal of the damaged scaphoid and a fusion of the remaining bones surrounding the (now missing) scaphoid allow for some wrist motion to be saved. Alternately, the affected row of carpal</i. (wrist) bones can be removed completely. Further treatment failure may lead to total fusion of the wrist joint.

The next step is to see your hand surgeon for an evaluation. Once your case has been reviewed and all clinical tests and measurements taken, then it becomes much clearer what are your treatment options.

A ganglion is a small, harmless cyst, or sac of fluid, that sometimes develops in the wrist. Doctors don’t know exactly what causes ganglions. But we know they can be very painful and disabling.

Many patients report pain increases whenever moving the wrist into extremes of wrist motion (flexion and especially extension). Wrist motion is very important with the kinds of activities you are engaged in. Aspirating or surgically removing it are two treatment options.

Aspiration involves placing a needle into the cyst and removing any fluid inside. Surgery can be done two ways: open incision or the less invasive arthroscopic approach. Most experts recommend leaving it alonge unless it is creating serious problems.

There are several reasons for the leave-it-alone advice. First, they don’t get much worse than what you are experiencing now. The medical term for that idea is limited morbidity of the lesion. Second, left alone, they often go away on their own. And third, if you have them surgically removed, they often come back.

Patients should keep in mind that surgery comes with its own set of risks. Infection, poor wound healing, and decreased wrist motion are possible complications. Other problems that can develop include damage to the blood vessels or nerves, injury to important wrist ligaments or bones, and poor cosmetic appearance.

Where does all that leave you? Each person must make his or her own decision about treatment. If the cyst doesn’t hurt and doesn’t limit activity or function, then the evidence supports leaving it alone.

Given your concern about your rodeo performance, you have the option of trying aspiration to see if reducing the cyst and altering the symptoms (even if only temporarily) affects your time.

If there’s no change in your activities and it comes back, then further treatment may not be needed. There’s always the possibility that aspiration will take care of the problem. There are many clinical factors to consider. Your surgeon is the best one to advise you on this.

A ganglion that isn’t painful and doesn’t interfere with activity can often be left untreated without harm to the patient. However, treatment options are available for painful ganglions or one like you have that causes problems. Altered sensation and loss of hand function can interfere with daily activities, self-care, and work or play.

Before treating it, there are three things to know about wrist ganglions. First, they don’t get much worse than what you are experiencing now. The medical term for that idea is limited morbidity of the lesion. Second, left alone, they often go away on their own. And third, even if you have them surgically removed, they often come back.

Treatment consists of reassurance that nothing needs to be done, aspiration, or surgical removal. Aspiration involves placing a needle into the cyst and removing any fluid inside. As you know, surgery can be done two ways: open incision or the less invasive arthroscopic approach.

Which treatment approach has better results? A review of studies done shows that even with equal results between doing nothing and having surgery or aspiration, patients who have the cyst removed or aspirated are happier (more satisfied) with the results than patients who accept reassurance alone.

The cyst comes back more often with aspiration compared with surgery. There’s some evidence that surgery works better because the surgeon can get all the way down to the stalk of the cyst. The stalk is where it connects into the tissue and draws synovial fluid from the joint. Recurrence rate after open versus arthroscopic surgery is fairly even (slightly more with arthroscopy).

Surgery (when it is done) may not be 100 per cent “successful” if success is defined by everything is perfect and the cyst never comes back. But the reality is that at least one out of every 10 patients who have a ganglion cyst surgically removed experience recurrence of the problem. Some studies report an even higher than 10 per cent incidence of recurrence after surgical removal (up to 39 per cent recurrence rate).

That doesn’t really answer your question because there isn’t enough evidence from high-quality studies to point to one approach as being superior to the other. Surgeons agree that more research into this problem is really needed.

It’s important to be able to sort through all the patient variables and find the right treatment for each person. Your surgeon may be able to shed some light on your situation that will guide you in this final decision.

It is possible to develop soft tissue and bone infections from contact with fish or contaminated water (fish tanks or aquariums, river water). There is a specific type of bacteria called mycobacterium that contribute to these kinds of problems.

Most of these bacteria are rare (e.g., M. kanasaii, M. leprae, M. abscessus, M. arupense). One of the more common causes of hand infections is one you have probably heard of: mycobacterium tuberculosis. But the one that is associated with fish is called mycobacterium marinum.

And there have been reported cases of sushi chefs developing finger, hand, and/or wrist infections from contact with fish contaminated with this bacterium.

Recognizing and diagnosing joint infections referred to as septic arthritis isn’t always easy. The patient may not have a known history, trauma, or other event they can link with the new symptoms of joint pain, redness, and swelling.

Many surgeons rely on their own clinical expertise for this one. Lab tests (blood work, joint fluid analysis) give some idea of what’s going on but are not accurate enough to be used as the only means of diagnosis. For example, some bacteria don’t show up in the joint fluid culture at all.

In fact, in the case of gonococcal bacteria, the culture is negative 50 per cent of the time when the patient really does have an infectious process going on. Elevated white blood cells and sed rate (erythrocyte sedimentation rate) suggest an inflammatory response but aren’t specific enough to say what for sure.

With aspiration (removal) of joint fluid, lab analysis will eventually be positive — but sometimes, not until significant damage has been done to the joint. The bacteria can spread beyond the joint and cause further systemic problems. It’s far better to find out quickly that there is a bacterial infection and nip it in the bud, so-to-speak.

But no one test is “definitive” — capable of diagnosing the problem accurately or immediately. The synovial fluid aspiration and analysis is really the best we have available right now. But this test misses almost as many cases of infection as it catches.

What physicians really need is an evidence-based Clinical Practice Guideline. Such a document would offer guidelines for evaluating, diagnosing, and treating a septic wrist joint. But much more research is going to have to be done before such a set of clinical guidelines can be written.

Usually, patients with this problem are put on a broad spectrum intravenous antibiotic. Broad spectrum means that until the specific “bug” (bacteria) is identified, an antibiotic is given that will kill them all (or as many as possible). As soon as the lab culture comes back with the exact bacteria present, the patient is switched to an oral antibiotic that will specifically target those bacteria.

The fluid can be aspirated (removed) as many times as needed. In some cases, one time is all that’s required. With the antibiotics, aspiration is followed by pain relief, decreased swelling, and improved joint motion. Surgery is recommended when needle aspiration doesn’t yield the expected results (i.e., the patient doesn’t get better quickly — usually within 12 hours).

In all cases, surgery is recommended if the infection has progressed to the point of erupting through the joint. The surgeon irrigates and debrides (cleans out) the joint. This procedure helps remove bacteria and infection (pus) and give the joint a chance to heal. Just like with the aspiration procedure, surgical drainage may be done more than once.

With persistent infection in the joint, there is a risk of severe joint damage that can spread to the bone and beyond. Other problems such as osteomyelitis (bone infection) can result in loss of bone, fracture, and deformity. The bacteria can also spread to other parts of the body and become systemic with equally serious complications.

Volkmann ischemic contracture is the sustained contraction of one or more muscles after a long period of time without blood. This usually occurs in association with another condition called acute compartment syndrome (ACS).

Acute compartment syndrome (ACS) is characterized by elevated pressure from increased fluid in one of the many separate compartments of the forearm, wrist, and hand. In fact, the forearm has three separate compartments. Each section is separated by connective tissue called fascia.

The hand has 10 of these compartments. There are a total of 15 compartments in the entire upper extremity (arm) from shoulder to hand. Any condition that changes the pressure in a compartment can reduce blood flow (called ischemia) and cause death of the tissues (necrosis).

The most common cause of ACS is a bone fracture. Repetitive exercise (muscle contractions over and over) is another potential cause. Other causes of ACS of the upper extremity include dressings, tourniquets, or casts that are too tight. Bleeding disorders and burns can also increase the amount of fluid (called fluid volume) inside a compartment. These compartments are tightly packed with very little room for extra fluid. In a smaller number of cases, swelling from a spider or snake bite can also lead to ACS.

Loss of blood to the soft tissues inside the affected compartment(s) can cause irreversible damage. The muscles go into full contraction and cannot let go or relax. The patient’s hand, forearm, and/or upper arm assume a telltale position that is called Volkmann contracture.

Patients who progress to the point of having a Volkmann contracture are not likely to regain full use of the affected area even with surgical treatment. Additional surgeries such as muscle or tendon transfers may be needed. The Parkinson disease may interfere with recovery. But with early recognition of the problem and adequate treatment, your brother will be assured of the best outcomes possible.