FAQ Category: Wrist

Wrist pain is a common problem among many athletes. Over training and competing places great demands on various body parts. Shot put throwers are especially at risk for symptoms in the upper extremity.

Pain across the wrist during hyperextension described could be from any number of problems. There could be a problem in the bone such as a fracture or bone impaction. Or the pain could be caused by something in the soft tissues. This could be a torn tendon, ligament, or cartilage.

A recent study of athletes with similar symptoms found a new condition causing wrist pain. This is called extensor retinaculum impingement. The retinaculum is a band of fibrous tissue that goes across the wrist. It provides a protective covering over the tendons of the wrist and hand.

But the retinaculum can become thickened from overuse. Repetitive motion causes inflammation of the lining around the tendons. When the wrist is extended fully, the edge of the band puts pressure on the swollen and tender tendons. This pinching causes the pain athletes describe.

A medical exam is needed in order to know for sure what’s causing your son’s painful symptoms. It could be impingement or something else. The physician will take a history and perform an exam. X-rays or other imaging studies may be needed. Treatment depends on the underlying cause.

Corticosteroid injection is a way to stop the painful symptoms and find out what’s causing them. The physician injects a small amount of lidocaine (an anesthetic) combined with a steroid. The practitioner tries to avoid using too much anesthetic, which can cause complete blockage of the nerve.

The injection serves two purposes. First it provides an antiinflammatory to the area. This helps reduce any swelling that might be putting pressure on the nerve. With a small amount of anesthetic, painful symptoms can also be stopped.

Injecting the nerve or tendon can cause an immediate increase in painful symptoms and should be avoided. Let your doctor know right away if the injection is painful or causes numbness. He or she will pull the needle back out and redirect it to a better spot.

If the injection works, your symptoms will go away. This tells you that the nerve is impaired. The exact cause of the nerve disturbance isn’t identified by using steroid injections. Other diagnostic tests may be needed to rule out conditions such as diabetes, tumors, or a thyroid condition.

Treatment for scaphoid bone wrist fractures varies from patient to patient and surgeon to surgeon. Sometimes all that’s needed is a short arm cast. You won’t have any wrist motion but you may be able to use your fingers.

In other cases, a long arm cast (includes the elbow) is needed. With either the short arm or the long arm cast, your thumb may have to be included. This is called a thumb spica cast. The scaphoid bone is close to the thumb so immobilizing the thumb joint may help stabilize the scaphoid.

If surgery is needed, there are many additional choices. The surgeon may have to use an open incision to repair damaged ligaments and bone. Cast immobilization is almost always needed after this type of operation.

Your best bet is to ask the surgeon about percutaneous fixation without immobilization. Percutaneous means through the skin. Fixation is with a headless screw. So the screw is inserted through the skin and inserted into the broken bone. A special X-ray imaging called fluoroscopy is used to do this.

With percutaneous fixation, no cast or other immobilization is used. The patient is free (and encouraged) to move the wrist and fingers right away. Early mobilization gives patients a faster recovery and shorter rehab time. Strength returns faster and the bones are protected from loss of bone mineral density from disuse.

Wrist fractures can be very difficult to treat. Just choosing the most appropriate treatment can be a challenge. The best treatment for acute scaphoid fractures remains unknown. Sometimes the wrist is immobilized in a short arm cast. Other times, a long arm cast (including the elbow) is used. The thumb may or may not be included in the casting.

Surgery can be open or closed. Open surgery means an incision is made and the skin and soft tissues are pulled apart. This way the surgeon can get down to the bone. In other cases, arthroscopic surgery is possible. The surgeon inserts a long thin needle with a tiny TV camera on the end. This gives him or her a clear picture of the wrist joint and bones.

More recently, screw fixation has been improved and used much more often. The procedure can be done percutaneously or through the skin. A specially designed screw is inserted fully into the bone.

In order to make the right decision about the best method of treatment, the surgeon must know which bone(s) are involved. The location and type of fracture are important in choosing wisely. Because the scaphoid is an odd shape with several angles, it can take multiple X-rays to get all the views needed.

If the radiologist suspects the bone is displaced, a CT scan may be ordered. A displaced fracture means the broken pieces of bone have shifted or moved. They may not line up correctly. Having this kind of information can be very helpful when planning surgery. The CT scan shows any loss of joint space, changes in bone alignment, and the exact amount of fracture displacement called step-off.

In some cases, after X-rays and CT scan, an MRI may be ordered. Again, this additional imaging method offers useful information in identifying the problem and planning the treatment. Choosing the right kind of surgery and method can make a difference in the final outcome. Wrist motion and function is important in daily function. Taking a few extra images is a wise investment in a successful result.

Before joint implants were developed, the only surgical choice for a problem like this was a wrist fusion. Another word for fusion is arthrodesis. Joint fusion usually takes care of the pain problem. But it does so at a price: loss of motion. Once the joint is fused, you can’t move it anymore.

Loss of motion usually means a loss of function, too. For example, without wrist rotation, it becomes difficult to button clothes or perform basic hygiene activities. For some patients, having less pain actually improves their function even with the loss of motion. They are completely satisfied with the results.

Joint replacement for the fingers has been around for almost 40 years. Wrist replacement is a little newer. Over time, gradual improvements have been made in the way the implants are made and inserted. But the long-term results can be disappointing.

Many patients get the pain relief they hoped for, but their motion isn’t much better. And if the joint was deformed before surgery, it’s likely to still look deformed even with the new implant. Other problems that can occur include the implant loosening, breaking, or sinking down into the bone.

The good side of joint replacement is that if it doesn’t work in the end or fails for any reason, you can still have a fusion. Many patients take the first step to have a joint replacement and go from there. Others just opt to have the joint fused.

The decision should be made knowing the risks and potential long-term results of both choices. You should take into consideration your job or lifestyle and what it is you want to do with your hands.

Doctors don’t know what causes Kienbock’s disease, but the pain, tenderness, and swelling of the wrist often makes people that they’ve hurt or sprained their wrist somehow. There are 4 stages to the disease:

• 1- symptoms that look like a sprained wrist
• 2- the small bone in the hand affected by the disease, the lunate, gets hard
• 3- the lunate starts to break
• 4- arthritis may set in the wrist

The diagnosis of Kienbock’s disease is a hard one to make precisely because it may seem like the wrist is sprained. If the doctor suspects it early enough, in Stage 1, a magnetic resonance imaging test (MRI) may be helpful. By the time the disease progresses to Stage 2, the damage may be seen on an x-ray because hardened bone looks different from healthy bone. The doctor may choose to do an MRI or a computed tomography (CT) scan. By the time the disease gets to Stage 3, the breaking bones will be obvious on an x-ray.

Treatment for the disease can be conservative, meaning no surgery, or surgery can be done. If the patient and doctor choose to go the conservative route, the wrist may have to be in a brace or cast, and pain medication may help relieve the discomfort. If surgery seems to be the best way to go, an orthopedic surgeon will decide on the best approach.

The location, size, and shape of the scaphoid bone in the wrist make it a prime area of problems. Depending on which end of the bone is broken, problems can occur with loss of blood supply.

Most experts advise surgery to correct the problem. Without treatment, the bone can collapse causing deformity and later, joint damage. If the blood supply is disrupted, the bone can also die.

Casting the wrist and arm is not recommended based on other research in this area. A long arm cast is needed to stabilize the bone for healing. Healing can take up to six months or more. During that time, you can lose wrist and elbow motion, which can affect your overall function and quality of life.

Even patients who are symptom-free are advised to have this operation. This is because there is plenty of evidence to show a link between nonunion fractures and osteoarthritis later on.

There are a few reasons why this operation is not recommended. If the patient is an older adult and/or smokes, surgery may be too risky for the benefit it would provide. Surgery to correct the problem may not be a good idea if the wrist has already collapsed. In such cases, the bone may be removed instead of repaired.

You should discuss your concerns with the surgeon. Surgery can have a major impact on your life. Anything that can help maintain or improve the quality of your life is worth mentioning. Cosmetic appearance is important and deserves attention.

The hand surgeon has three options for operating on the wrist. If an arthroscope is used, puncture holes are made where the scope enters the skin and pushes through the tissue into the joint. There may be only a tiny incision. The incision could be along the back of the wrist (dorsal), the front of the wrist (volar) or slightly between the two called dorsoradial.

Sometimes the location of the incision is determined based on the problem and the treatment for it. For example, when bone grafting is used, surgeons prefer the volar approach. Again, this refers to the inside of the wrist — the area you are asking about.

If the fracture is on the side of the bone towards the wrist, a dorsal approach is used. The scope is inserted along the backside of the wrist. This method is not used if there is any concern about loss of blood supply to the bone.

You may have nothing to worry about if the surgeon has planned surgery from the dorsal side. Ask him or her to describe the operation for you. It’s best to ask questions and express your concerns now before surgery.

Preiser’s disease was named for the physician who first described it in 1910. It is a condition of osteonecrosis 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.

The patient reports wrist pain at rest and with movement. Tenderness over the scaphoid bone is common. Decreased grip strength is often reported.

X-rays are used to diagnose the problem. Changes in the scaphoid bone are seen at first. Later, the bone may break, fall apart, and/or collapse. Surgery may be needed to correct the problem.

Avascular necrosis (AVN) of the bone is the loss of blood supply to the area and then death of the bone. It can be insidious, meaning the cause is unknown. Only rarely are spontaneous or insidious cases reported.

The most common risk factors for this condition are trauma, steroids, tobacco use, and chronic alcohol use. A careful history may help bring to light possible causes in your daughter’s case.

She may have injured her wrist or hand (even years ago) but doesn’t recall the incident. Has she ever been prescribed steroids for an inflammatory or other health condition such as asthma or arthritis? Usually a history of steroid use can be traced back to within a few years of the AVN starting.

There may be lifestyle behaviors such as smoking and drinking that you (or her doctor) are not aware of that can contribute to this problem. These two risk factors are independent of each other. In other words, a person doesn’t have to smoke AND drink to be at risk for AVN. Either behavior alone increases the risk of AVN.

Studies show that early repair is best. Results are unpredictable for patients who wait more than three months after the injury to have surgery.

Left untreated, pain and loss of strength can prevent even the simple tasks of everyday life. Over time the abnormal position of the two bones can cause degenerative and arthritic changes in the wrist. The bones may even start to collapse, a condition called scapholunate advanced collapse or SLAC wrist.

Even with treatment, normal motion and strength are not returned fully. Weakness and pain occurs anytime resistance is given to the wrist (called loading. You may have trouble returning full-time to your job as a bricklayer even with the operation. Without it, your chances of recovery are very slim.

You didn’t mention what kind of surgery you had done. This could make a difference in choosing future treatment approaches. In some cases of scapholunate (SL) tears, the torn ligament between the two bones is removed.

The process of cutting out the torn ligament and shaving away its attachment to the bone is called debridement. The idea is to cause bleeding and the formation of scar tissue to help stabilize the wrist joint.

If that’s what you had done and the results aren’t satisfactory, then you may need a second (revision) surgery. There are several options now. You can have a capsulodesis or an arthrodesis.

A capsulodesis can be done one of several ways. The basic idea is to take a piece of cartilage from the radius (bone above the scaphoid) and attach one end to the scaphoid. The other end stays in place at the radius. This reduces the gap between the bones and holds the
scaphoid in place. Arthrodesis is done by grafting bone to fuse the joint solid.

Wrist fusion will often eliminate the pain but it also reduces motion at the wrist. Your age and level of activity may be factors in this decision to trade motion for pain relief. Talk to your surgeon about your options. Seek a second or even third opinion. It may help you line up all the pros and cons of each option before deciding on your next step.

If you look at your own wrist, you’ll probably see a small bump on the outside of your wrist. This is the bottom of the ulnar bone in your forearm. The bump is called the ulnar styloid process.

For someone with wrist rheumatoid arthritis (RA) this bump starts to break down. The tendons around it thin out so the bump is more obvious. What you are seeing actually has a special name: caput ulnae syndrome.

Other changes in the wrist from RA can contribute to this syndrome. For example when the bones in the wrist are affected by the arthritis, they can start to shift position. This is called subluxation. They may rotate and even dislocate or collapse.

Anything that changes the alignment of the wrist or joints around the ulnar styloid process can make it appear more prominent. Sometimes a surgeon will remove the bony bump. This isn’t just for cosmetic reasons. Reconstruction of the bones, tendons, and joints can help relieve your grandmother’s pain and improve the use of her wrist and hand.

This would be a good question for your rheumatologist and your surgeon. Get both opinions and suggestions. Have you tried the new disease modifying antirheumatic drugs (DMARDs)? Usually a six-month trial of DMARDs and antiinflammatory drugs is tried before surgery.

Other conservative measures that help some patients include splinting and exercise. An occupational or physical therapist can supervise you in trying a home program. They can help you find ways to do painful or difficult tasks more easily. Special devices can be purchased to help you open doors, jars, or other assist with other similar activities.

A wrist fusion usually does work well to control pain. But as you noted it will limit your motion and reduce your function. For many RA patients the pain relief is worth the trade off.

Other treatment options include a partial fusion or even a joint replacement. Partial wrist fusion gives stability to the joint while saving some motion. And yes! Wrist joint replacement is possible now. It has the benefit of preserving motion. Wrist implants have improved over the last few years with better long-term results.

Cosmetic appearance is always one thing to consider. Function is another. Humpback deformity of the wrist can occur when the scaphoid bone is fractured. The scaphoid is located on the thumb side of the wrist next to the radius (forearm bone).

If the fracture doesn’t heal then the bone fragment can get displaced and move. When that happens all the other bones around the area also shift position. That’s how you end up with a deformity.

Long-term studies show that wrist degeneration and eventual arthritis will occur. You may not have pain and disability now but the chances are good you will in time. According to the latest research you would be best advised to have the corrective surgery now. There are no long-term studies to prove this makes a difference. The advice is based on what we know happens if you don’t correct the problem.

It could very well make a difference — now and later. If you have a fracture the doctor would be able to see if it has healed or not. Sometimes when a broken bone isn’t put in a cast or even when it is, it doesn’t always heal or heal properly. This is called a nonunion fracture.

If that’s the case, then the first step would be to get you on the road to real recovery. If the bone has healed in the wrong position then all the bones in that row of wrist bones may be out of line. The bones may start to collapse. They will wear unevenly causing arthritic changes.

Treatment to avoid such complications may be possible. A trip to an orthopedic surgeon or hand specialist is likely a very good idea for you.

X-rays are only two-dimensional views inside a very complex structure. The two rows of wrist bones are all odd shapes held together like a jigsaw puzzle. Some bones in the first row overlap the bones in the second row. In other words, they don’t line up underneath each other all the way across the wrist.

If the fracture is at an odd angle it’s difficult to see on an X-ray. Usually a standard CT scan is needed to show angles and change in position of the bones.

New 3-D technology may be on the horizon. Japanese researchers have found a way to use 3-D imaging combined with computer software to create a model of the bone structure. By using the patient’s normal side and comparing it to the injured side, they are able to see much more than 2-D images provide.

This kind of information helps the doctor diagnose quickly and accurately. Knowing exactly what’s wrong helps the physician decide the best treatment and reduces complications.

Risk factors for carpal tunnel syndrome (CTS) are broad ranging. It’s unclear if there’s one single cause such as genetics, work, age, obesity, or smoking. Whether or not CTS is caused by work conditions remains a hot topic.

Some studies show repetitive movement patterns is a big risk factor. Others say ‘no’ — the condition was present before work and work just made it worse. It’s clear that middle-aged women (40 to 60) are at greatest risk but we don’t know why exactly.

So if you and your sister are in this age bracket you fit the demographics quite well. Physical fitness (or the lack of fitness) combined with menopause, obesity, smoking, diabetes, and a small wrist size can bump up your chances of developing CTS during this time of life.

Work may be an additional factor but your own situation shows why this is still a bit fuzzy. Some people who do the same job as you and some folks who stay home can still get CTS.

The most common cause of a lump that disappears on the back of the wrist is a ganglion cyst. But it could be a tumor, bone spur, or even an infection. It’s always best to have a doctor check to make sure it’s not something more serious.

Sometimes, wrist ganglion cysts go away. In many cases they start to get bigger, not smaller. If it gets big enough, it can put pressure on the nearby tendons, ligaments,
blood vessels, and nerves. The result may be pain, loss of motion, numbness and tingling, and swelling.

The best treatment is removal of the entire cyst. This includes the fluid inside, the outside covering, and the place where it attaches to the joint capsule called the stalk.

You may not need treatment. Sometimes these types of cysts are absorbed by the body and go away. Most of the time they don’t go away and may even grow larger. Some cysts have a one-way valve that allows fluid from the wrist joint to enter the cyst. The valve only
allows fluid to move in one direction. So once fluid gets inside the cyst, it’s stuck and can’t get out.

If the ganglion cyst becomes large enough, it can put pressure on nearby soft tissue structures. This pressure can cause painful symptoms. That’s why many patients opt to have the cyst removed.

There are several ways to do this. The doctor can put a needle into the ganglion cyst to suck out the fluid. In some cases, the fluid becomes more like soft jello and doesn’t come through a needle very well. This method of cyst removal leaves the cyst lining
behind. The ganglion cyst will return about half of the time.

You may have heard about a less optimal approach. That’s to smash the wrist ganglion cyst with a hard object such as a book. This pops the cyst, and ruptures the lining of the cyst. With the lining broken, the smashed ganglion cyst may not come back quite as often
as those drained by a needle. Most people are unable to do this to themselves (or allow someone else to do it).

The best treatment may be to remove the ganglion cyst with an operation. The wrist ganglion is completely removed including any connection it has to the joint or tendon sheath. There’s less chance the cyst will return after complete removal.