Ulnar Nerve Compression Diagnosis and Treatment Options

The ulnar nerve runs to the pinky side of the hand where it is responsible for both muscle actions and sensations.  Because the nerve must travel through a small canal at the wrist, the nerve can become entrapped resulting in pinky and or ring finger numbness as well as difficulty pulling your thumb in towards your hand and using your pinky, depending on which portion of the nerve is compressed.

Ulnar nerve compression can be caused by numerous factors.  Soft tissue tumors can impinge on the nerve in the narrow space it has to travel into the palm.  Long-term trauma can also cause nerve damage, like vibrations (jackhammer use), prolonged pressure on the wrist (i.e. weight lifting and bike riding), which is often conservatively treated by rest and occupational adjustments. Acute trauma, like wrist bone fractures can also impinge on the ulnar nerve. Arthritis and metabolic conditions, such as alcoholism, hypothyroidism or diabetes can also play a role.

When diagnosing patients with ulnar nerve entrapment, doctors must consider multiple sites higher in the arm that could potentially be causing the problems at the hand and take a careful history including occupational use and length and duration of the hand numbness or muscle weakness. Examination should also include strength tests, sensation testing, ulnar nerve testing along its path through the arm, and a vascular examination.  All results should be compared to the uninvolved side.  MRI, x-rays, and nerve conduction tests can also help determine exactly why and where the nerve is being compressed.

Ulnar nerve compression is first treated by nonsurgical management, such as rest or physical therapy.  If symptoms do not resolve within two to four months surgery is recommended. Surgery involves either removal of the compressive tissue, wrist fracture repair, or open up the canal through which the ulnar nerve runs.  Evidence is sparse regarding surgical outcomes, however the existing studies show good results with surgery.

Early Motion and Strengthening Following a Radial Fracture Repair Leads to Decreased Pain and Earlier Return to Function

Lower arm bone fractures are fairly common and are often the result of falling.  When the radius, one of the forearm bones, is badly fractured it is often repaired by inserting a plate with screws to hold all of the bone fragments together. Following the surgery the wrist is placed in a cast for two weeks and strengthening and moving the wrist is not allowed until six to eight weeks after the surgery. However, this protocol for restoring a person’s normal wrist function has now been called into question with the results of a recent research study.

Authors of this study wondered whether or not it was necessary to place a wrist in the cast for two weeks and hold off on strengthening for so long or if it would lead to faster healing to start the wrist motion and strengthening immediately after surgery.  They took 81 people who under went the same surgery (open reduction and internal fixation with a volar fixed-angle plate) and divided them into two groups.  The first group consisted of 42 people who underwent the standard rehabilitation protocol following the surgery of waiting for two weeks before moving the wrist and another six weeks before beginning strengthening.  The second group was made up of 36 people and underwent an accelerated rehabilitation program which involved beginning gentle passive motion of the wrist and forearm three to five days after surgery with gentle strengthening and active motion beginning at the two week mark. The standard protocol involved all of the same activities of the accelerated four weeks after the accelerated program.

The authors followed the patient’s recovery for six months after their surgeries.  Results showed that the patients who underwent the accelerated rehabilitation program fared better initially, having less pain and an ability to do more than those undergoing the typical rehabilitation protocol.  At the six month follow up there was not much of a difference. Authors concluded that for a quicker return to normal function, it is recommended to use an accelerated protocol for rehabilitation following a radial head fracture surgery that involves movement immediately after surgery and starts strengthening two weeks after surgery.

Best Way to Treat Madelung Deformity

Madelung deformity of the wrist is a congenital (present at birth) deformity that can cause wrist pain, stiffness, and loss of motion. But the cosmetic appearance is what most often brings the child or teenager in to see a surgeon. The best way to treat this problem is unknown with many surgeons in disagreement, conflicting opinions, and a general lack of consensus.

In this article, two surgeons from the University of Washington (Seattle) Medical Center review this wrist deformity and offer their opinions and preferred treatment. Using X-rays of a 13-year-old patient, they show what the deformity looks like (e.g., pyramid shape of the wrist and bowing of the radius bone in the forearm). Females are affected four times more often than males and both wrists are usually involved.

Two distinct features of this problem include: 1) the presence of a ligament (Vickers ligament) that holds the lunate bone of the wrist to the bottom of the radius and 2) growth arrest at the growth plate (physis) where the radius joins the wrist. Vickers ligament is named after the physician who first identified this extra soft tissue structure. It is believed that the ligament may be the cause (or at least a contributing factor) to the deformity because of the pressure (compression) it places on the bones.

X-rays are also used to demonstrate changes made in several patients treated surgically for a significant Madelung deformity. The controversy over when to do surgery is a key feature of this discussion. The question comes up: should surgery be done to correct the appearance when there are no symptoms? If the patient does report pain and/or loss of motion, is surgery warranted if there is only mild loss of function? And what type of surgery should be done?

After describing various types of surgeries used by others (e.g., soft tissue releases, radial dome osteotomy and physiolysis, combined radial and ulnar osteotomies, isolated radial osteotomy, isolated ulnar osteotomy, arthroplasty), the authors offer their preferred treatment.

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

Type of surgery is still under debate and study. Factors that must be considered when planning a surgical procedure include age (whether the patient is still growing), the presence of a difference in bone length between the two bones of the forearm, and severity of the radial bowing. Three basic surgical approaches include: release/removal of the Vickers ligament with corrective osteotomy, wrist arthroplasty (joint replacement), or arthrodesis (wrist fusion).

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

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

End of the Road for Scapholunate Instability

This follow-up study from the Department of Orthopedics at the Alpert Medical School of Brown University (Rhode Island) gives us an idea of the long-term results for surgery to correct scapholunate (wrist) instability. In the original study published in 1998, there were 14 patients treated with a bone-reticulum-bone autograft. Now 15 years later, long-term results for six of those 14 patients are reported.

Scapholunate instability refers to a condition in the wrist where the ligament holding the two bones (scaphoid and lunate) together is torn or ruptured. The scaphoid tips one direction (flexes forward) and the lunate tips in the opposite direction (extends).

This creates a painful, unstable wrist. Surgical treatment to prevent total collapse of the joint is necessary. The surgical choices include repairing the injured ligament, using a screw to hold the bones together, or reconstruction of the soft tissue and bone. In this study series, the reconstructive surgery called bone-retinaculum-bone or BRB was chosen.

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

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

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

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

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

In summary, the authors of this study recognize the difficulty of treating a scapholunate interosseous ligament injury. Without surgical treatment, the resulting wrist instability can cause collapse and eventual arthritis. But of the many types of treatment approaches, none have a good track record for long-term results, including this bone-retinaculum-bone autograft. Their final statement sums it up quite well, Scapholunate instability remains an unsolved problem despite novel approaches to its treatment.

Wrist Replacement or Fusion?

Imagine trying to wash dishes, get dressed, or use the toilet with only one hand. That’s what happens to people with a painful arthritic wrist. For many people, arthritis of the wrist can cause pain, loss of function, and extreme disability.

If you have painful, disabling wrist arthritis, which is better for you: wrist fusion or replacement? In this article, hand surgeons from the Warren Alpert Medical School (Brown University, Rhode Island) help answer that question by reviewing what we know about total wrist arthroplasty. A historical summary with brief description of each of the four generations of implants is included. Problems with each generation of prostheses and resulting design changes are discussed. Outcomes are compared with wrist fusion or arthrodesis, the alternative to wrist replacement.

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

Today, the wrist joint can be replaced with an artificial joint (also called a prosthesis). Total wrist arthroplasty (another word for replacement) can also relieve the pain caused by wrist arthritis.

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

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

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

The authors provide photos of the three current fourth-generation total wrist implant systems available on the market. They reviewed considerations and techniques for surgeons, and included photos taken during open surgical procedures. They also provided X-rays showing implant alignment as soon as the prosthesis was in place.

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

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

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

In summary, anyone interested in the evolution of wrist arthroplasty (replacement) will find this article of interest. Complications such as infection, soft tissue imbalance, and implant loosening and dislocation are much improved with the new fourth-generation prostheses. There are still times when wrist fusion is considered a better treatment option but this determination is made on a case-by-case basis. And the authors say that all things being con

Case Series of Wrist TFCC Repair

A fall onto the extended hand and wrist can result in a significant tear of the triangular fibrocartilage complex or TFCC. Painful clicking or clunking of the wrist is a sign that this anatomic structure has been torn. Without it, the wrist is not stable at the distal radioulnar joint (DRUJ) — that’s where the two bones of the forearm attach to the first row of wrist bones.

In this study, hand surgeons from Japan report the results of 11 patients treated arthroscopically for TFCC tears at the foveal insertion point. The fovea is a place on the distal ulnar (forearm) bone where the deep portion of the TFCC attaches. Rupture or avulsion of the TFCC at this place of insertion or attachment leaves the distal radioulnar joint unstable.

Conservative (nonoperative) care consists of a wrist brace and steroid injections and may be the first treatment approach. But if the wrist remains painful, unstable, and limited in daily functions, then surgery may be needed. In the case of these 11 patients, a special arthroscopic technique (transosseous outside-in) was used to reattach (repair) the torn TFCC.

By tunneling through the bone to get to the fovea, the surgeons create bleeding from inside the bone. That bleeding helps form adhesions to hold the triangular fibrocartilage complex (TFCC) to the ulnar insertion point. K-wires were used to reattach the ligament to the bone. For those readers who are interested, the authors provided a written description, X-rays, and drawings to show how the procedure was done.

The real focus of the article was the results of this repair technique. They used two different tools to assess outcomes: the Upper Limb Disability Questionnaire and the Mayo Modified Wrist Score. The main information collected using these two tools included level of disability and function. Additional measurements used to assess results were grip strength, pain, range-of-motion, and joint instability.

All 11 patients did suffer a traumatic injury from a fall and had moderate distal radioulnar joint (DRUJ) instability. The arthroscopic exam showed complete rupture of the TFCC in everyone (no ligament fibers remained at the foveal insertion point). Four of the patients had some scar tissue at that site instead.

After surgery, the TFCC was tight enough to restore wrist stability, reduce pain, and improve grip strength and function. Four of the patients still reported mild pain with activity. Only two of the 11 patients still had some mild instability at follow-up (20 months later).

Although there are several open repair techniques for triangular fibrocartilage complex (TFCC) tears, the results of this study showed that the less invasive arthroscopic approach is effective. The authors say that before this technique can be widely adopted, some questions must still be answered.

For example, which patients can be best treated for this problem using the arthroscopic surgical approach described (transosseous outside-in sutures)? The patients in this study had a traumatic injury but not all TFCC tears are caused by an injury. Can those types of TFCC damage be repaired this way?

They know that anyone with severe degenerative changes of the TFCC must still be treated using an open surgery approach. And if there is a big shift in the position of the ulna (away from the wrist), it is too much to bridge the gap using the arthroscopic technique described in this study.

Patients who have severe distal radioulnar joint (DRUJ) instability likely have serious damage to the soft tissues around the TFCC. In such cases, it may not be possible to surgically repair the TFCC at all. Full reconstruction would be the treatment choice instead.

Other questions yet to be answered include: 1) How long after the injury can the arthroscopically-assisted foveal repair technique be successfully used? 2) How well will these results hold up five or even 10 years from now? 3) Can the results be repeated with a larger set of patients?

What to Tell Patients About Treatment for Wrist Fractures

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

Two hand surgeons from two different medical facilities join together in this article to discuss that decision. They use the case of a 52-year-old woman who falls and breaks the radius (bone in the forearm) at the wrist.

She is treated in the emergency department with a procedure known as closed reduction — in other words, without an open incision to realign the bones and pin the fracture site, the physician uses a special splint to hold the wrist in place. But a follow-up X-ray a week later shows some problems.

There is a shortening of the broken bone and the two ends of the broken bone don’t meet in a straight line. Instead, there is a slight buckle making a hump referred to as a dorsal angle that measures 15 degrees. She asks the age-old questions: do I really need surgery? Won’t this heal on its own?

Well, yes, it probally will heal but not in good alignment. The surgeon must then help the patient understand the possible risks and results. For example, it’s possible the slight deformity won’t have any negative effect. But it’s also possible that she will lose strength and function in that hand that won’t come back even with rehab without surgery to restore the normal alignment.

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

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

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

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

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

Where does all this good feedback and information leave the surgeon in advising this particular patient? Well, the first thing is to address her activity level and specific activities she enjoys (e.g., golf, tennis, cooking, and gardening require more strength and function than typing on a computer, jogging, or singing). In other words, people with low physical activity have different expectations and goals than patients who are physically very active.

Second, when advising this patient, the surgeon can compare four things: how the fracture looked on X-rays before reduction, how the fracture looks at the time of evaluation (in this case, one week later), the patient’s symptoms (pain, swelling, function), and the patient’s expectations for activity.

There is one other bit of information from previous studies that may guide the surgeon in advising this patient. And that is the fact that patients who have poor outcomes are usually the ones who have the worst fracture deformity and least reduction at the time of the accident.

In this patient’s case, there were two millimeters of radial shortening and 15 degrees of angulation before reduction. One week later, X-rays showed only one millimeter of difference and the wrist was in neutral alignment (no dorsal angulation).

All evidence points to good results in cases like this without surgical treatment. With nonsurgical treatment, she will be followed weekly with serial X-rays for three weeks to make sure everything stays in place. The surgeons make note of the fact that even if the fracture site shifts back to the amount of angulation and/or radial shortening present at the time of the injury, it’s likely that she would not experience any problems regaining motion, strength, or function.

Complete Review of Scapholunate (Wrist) Instability

Every bone, joint, and ligament in the wrist is important for a coordinated balance between movement and stability. Disruption of any one of these can create painful problems and loss of hand function. In this article, orthopedic (hand) surgeons provide an extensive, detailed, and very thorough review of scapholunate instability. They discuss what happens and how to treat this problem.

The scapholunate joint describes a place in the first row of carpal (wrist) bones where the scaphoid bone and the lunate bones meet and greet, so-to-speak. The scaphoid is a small bone on the thumb side of the wrist next to the radius bone of the forearm. The lunate is in the middle of the row of carpal bones sandwiched between the scaphoid and the triquetrum on the little finger side of the wrist.

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

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

What can be done to restore the delicate balance and stability of the scapholunate joint? Treatment is important to restore normal motion and prevent joint loading and degenerative changes that could lead to further disability from arthritis. First, the surgeon must have a very clear understanding of the anatomy and biomechanics of the entire wrist, including the scapholunate joint. The authors of this article provide a very complete review of these two areas.

An accurate diagnosis is essential before planning a course of action. Patient history (what happened, how it happened) is linked with physical exam (signs and symptoms of scapholunate instability) to obtain the necessary clues to make the diagnosis. Radiographs comparing one wrist to the other are advised, including flexion stress and clenched pencil views. Examples of these types of X-rays are provided.

The routine use of advanced imaging (e.g., CT scans, MRIs, arthrography) is not advised. Indications, pros, and cons for each test are discussed, along with research evidence for the sensitivity and specificity of these tests. Arthroscopic exam of the wrist (sometimes combined with fluoroscopy, a type of real-time X-ray) is the best way to confirm the diagnosis. The surgeon will be looking for location of damage, severity (partial or complete tears) of injury, and the presence of other soft tissue involvement.

In this article, principles of management are offered centered around five-key factors including 1) condition of the scapholunate interosseous ligament, 2) amount of tissue left for a repair, 3) position and angle of the scaphoid bone, 4) possibility of realigning the carpal bones, and 5) condition of the cartilage lining the involved wrist joints.

Step-by-step, the authors walk surgeons through various stages of scapholunate instability. They provide specific details of surgical procedures to perform and offer ideas about the expected outcomes (results).

Descriptions, drawings, and X-rays are included for partial tears, complete tears, dislocations, bone rotations, acute, and chronic injuries. Timing of surgery, type of sutures, and techniques preferred by these experienced surgeons are also discussed. The senior surgeon offers tips on what to do when the scapholunate interosseous membrane cannot be repaired or when tissue reconstruction with graft material is required.

The authors end by reviewing surgical goals and reminding surgeons to keep these goals in mind when formulating a plan of care. Reducing pain, restoring function, and delaying the start of degenerative changes that could lead to painful arthritis top the list of typical goals. Treatment ranges from conservative (nonoperative) care to surgery. The advantages of surgical treatment are offered for tissue repair, tissue reconstruction, joint replacement, and joint fusion. Preserving motion by stabilizing the joint and restoring the delicate balance provided by the scapholunate joint are always the desired outcomes.

Treatment of DRUJ (Wrist) Arthritis

The wrist is a complex joint with many bones, ligaments, and tendons to support it through all of the motions needed for daily activities. Damage to the distal radioulnar joint (DRUJ) portion of the wrist can be a challenge to treat. In this article, hand surgeons from Mass General Hospital in Boston bring us up-to-date on this problem and offer their advice about treatment.

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

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

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

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

Any of these symptoms can be addressed with proper management and treatment. Conservative care is always advised first. A physical therapist guides the patient through ways to modify activities that aggravate the condition while addressing the pain and loss of motion.

Surgery may be needed for the patient who does not respond well to nonoperative care or when there is significant, disabling instability and/or arthrosis (degenerative disease of the DRUJ). There are many different ways to approach this problem surgically. That’s one of the reasons the authors wrote this article. They present what they refer to as their preferred treatment algorithm.

An algorithm is a series of steps that help a surgeon make the final decision about what is best for each patient. With DRUJ problems, a careful history, examination, and imaging studies are necessary. The full extent of the injury and soft tissue involvement must be revealed before doing any surgery.

Once a decision has been made to operate, there are many choices. Resection arthroplasty is the first one discussed. This involves removing a portion of the bone to eliminate the painful anatomy.

The authors present three options for resection arthroplasty: the Darrach procedure, hemiresection procedures (there are several variations), and the Sauvé-Kapandji procedure. Indications for use, pros and cons, and outcomes for each approach are provided.

The second major category of surgical options for DRUJ problems is the implant arthroplasty. This is a type of joint replacement that includes partial ulnar head replacement, total ulnar head arthroplasty, or total DRUJ arthroplasty. Arthroplasty is another word for joint replacement.

The third and final surgical choice is listed as a salvage option. Salvage means “to save” as much of the joint and surrounding soft tissues as possible. This type of approach often means sacrificing forearm motion in order to preserve function and strength. Some examples of salvage procedures for DRUJ instability include creating a one-bone forearm (OBF). This is a fusion technique. Another salvage procedure is a wide excision of the distal ulna (removal of a large portion of the bottom of the ulnar bone).

In summary, the authors use descriptions, drawings, photos, MRI images, and X-rays to assist other surgeons in evaluating and managing painful, disabling arthritis of the distal radioulnar joint (DRUJ). This is an important joint needed for forearm rotation (turning hand up and down) and putting weight through the hand and wrist. It is a complex joint that presents many treatment challenges. The treatment algorithm offered comes from the many years of experience of these authors managing patients with this problem.

Understanding Ulnar-Sided Wrist Pain

Pain along the little finger (ulnar) side of the wrist has three major causes: 1) triangular fibrocartilage complex injuries, 2) lunotriquetrial ligament injuries, and 3) ulnar impaction syndrome. Any of these problems can also limit grip strength and hand function.

The surgeon treating any of these problems must understand the complex bony and ligamentous anatomy, circulation, and nerve supply when planning surgery. In this article, Dr. K. Sachar from Hand Surgery Associates of Denver, Colorado reviews the clinical and imaging diagnosis then discusses treatment for all three problems.

The patient’s history will help the surgeon decide if the injury is acute from trauma, chronic from overuse, or degenerative from the natural process of aging. Each of these causes is associated with specific symptoms referred to as the clinical presentation.

For example, a traumatic injury with a popping sound and visible deformity suggests joint dislocation. Pain that lasts a long time is often present with injuries to the ligaments that hold the bones together. Sometimes an old injury flares up with new activities or increased activity involving the wrist and hand.

The physical exam can offer helpful clues. The surgeon compares the painful wrist to the other uninured wrist. He or she will be looking for any differences in appearance, motion, stability, and/or strength. Swelling is more likely with bone fractures. Movements that cause or reproduce pain are called provocative maneuvers. Specific individual joints can be tested using these maneuvers.

There are other specific tests to guide the surgeon in making a diagnosis such as the Regan shuck test, Kleinman shear test, piano key test, and ulnocarpal stress test.

One last diagnostic tool available to the surgeon is the imaging study. This could include standard X-rays of the wrist, CT scans, or magnetic resonance arthrography (MRA). 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.

When the diagnosis has been made, then the surgeon chooses the best treatment for that problem. Conservative care with splinting to immobilize the wrist may be advised. Surgery (when needed) may be as simple as debridement (removing loose fragments or shaving off ragged edges). Or in more complex injuries, surgical reconstruction may be needed.

The author provides a detailed review of the surgical options for these three causes of ulnar-sided wrist pain. Advantages and limitations of each procedure are outlined. The most challenging cases have more than one type of injury present and may require more than one surgical approach. Arthroscopic surgery yields positive results for most patients.

Two Important Factors in Results of Treatment for Perilunate Injuries of the Wrist

In this special focus article featuring the hand and wrist, hand surgeons from the New York University Hospital for Joint Diseases present information on perilunate injuries. They discuss the complex anatomy of these injuries, management, and two important factors that affect long-term outcomes. Information is presented from their review of the latest research on this subject.

The word perilunate means “around the lunate” (wrist bone). 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 lunate have been disrupted. 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.

Treatment is usually aimed at putting the bone(s) back in place (a process called reduction). In some cases, this can be done manually (by hand as the surgeon gently manipulates the bones) while the patient is asleep under anesthesia. Pressure on the nerve or inability to reduce the bones may point to the need for open surgery. The surgeon assesses the damage and repairs any torn ligaments using wires or screws to hold the bones in place until healing occurs. The procedure is called open reduction and internal fixation or ORIF.

There are many different ways to do this surgery. No one method has been identified as the best or only way to do it. The authors of this review discuss the various surgical techniques and offer their opinions based on what the literature says and their own experiences. Types of incisions, approach (from the front of the wrist, back of the wrist or combination of the two), and open versus arthroscopic repair are a few of the decisions the surgeon must make.

The last important message of this article has to do with factors affecting results of treatment. 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.

Wrist Replacement Now Available

You probably know someone who has a hip or knee replacement. You may have heard there are also shoulder and elbow joint replacements. And now there are wrist replacements also known as total wrist arthroplasty or TWA. 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.

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 used a walking aid (cane, walker) was 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 this 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.

After reviewing the results of their own study, the authors made the following suggestions:

  • Patients with highly active disease may not be good candidates for total wrist arthroplasty (TWA).
  • Anyone with severe bone loss or carpal (wrist) subluxation should not be treated with TWA.
  • The Maestro system has a locking screw option that may decrease the risk of implant loosening.
  • To avoid wrist joint contracture (stiffness and loss of motion), a wrist splint that puts the wrist in 30-degrees of extension should be used after surgery.
  • TWA should not be used in young adults (younger than 50 years old), anyone using a walking aid, or who is unable to follow directions for activity restrictions.

    More long-term studies are needed before all aspects of TWA (and especially individual implant designs) are known. For now, it looks like the Maestro system can be used successfully with those 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.

  • What Happens to Untreated TFCC Wrist Injuries?

    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.

    In this study, hand surgeons took a look at what happened to a group of patients with a displaced distal radial fracture that also caused a 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.

    The question they asked was, “What happens to untreated TFCC injuries?” We call this 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. 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.

    Easier Way to Repair Triangular Fibrocartilage Tears in the Wrist

    Hand surgeons from the University of Hong Kong report on the use of a new, easier way to repair damage to the triangular fibrocartilage complex (TFCC) of the wrist. A TFCC injury can be a very disabling wrist condition. Current surgical treatments are not always successful in restoring pain free wrist motion and function. This new approach had good results in a small group of 10 patients.

    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.

    Triangular fibrocartilage complex (TFCC) injuries of the wrist can affect the ulnar (little finger) side of the wrist or the radial (thumb) side. Radial-sided TFCC tears have a more difficult time healing because of a natural (anatomic) lack of blood supply. And arthroscopic repair of radial-sided TFCC present some interesting challenges for the surgeon.

    This new surgical approach was found to be just as useful for radial-sided TFCCs as for ulnar-sided tears, which makes it a very useful treatment tool for hand surgeons. The authors describe the technique step-by-step, including patient position, insertion sites for the arthroscope, type and size of surgical tools used, and of course, details of suture type and location.

    For surgeons who are interested, this method uses a curved tip meniscal-double-barrel using an outside-inside technique. The procedure takes less time than other approaches. The technique is simple enough that new surgeons learning how to do it catch on quickly. And the method brings the torn TFCC back to its normal insertion point, which allows for better ligament-to-bone healing. It is believed that improved healing means a good outcome with restoration of function in the end.

    A successful result is also one that provides the patient with pain free motion, grip strength, and return to a pre-injury level of employment. For the 10 patients in this study treated with this type of TFCC repair, 50 per cent had a good-to-excellent result. The remaining five patients received a “fair” score using the Mayo Modified Wrist test.

    The authors conclude that their new method as described in this article for repair of radial- or ulnar-sided TFCCs is easy and successful. Patients having this procedure can expect to be immobilized in a wrist/forearm brace for three or four weeks. Hand therapy to keep the fingers moving is advised during this period of immobilization. Therapy continues after the brace is discontinued until normal movement and strength are restored (usually about six weeks). Vocational rehab to prepare the patient for return-to-work may take another six-to-eight weeks beyond that.

    Tendon Rupture After Wrist Fracture

    Wrist fractures involving the radius bone of the forearm has a well-known complication associated with it. And that is 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 this study, surgeons from one institution (Brigham and Women’s Hospital in Boston) report a five per cent incidence. This is much higher than previously thought and bears mention as well as closer study.

    The authors devised a three-step process to identify patients for the study. First, they looked through their database (information collected on all patients at their hospital) and found all patients within a three-year period of time who had a radial fracture.

    In particular, they were looking for nondisplaced radial fractures. Nondisplaced means the bones did not separate or shift after the break occurred. The reason for finding nondisplaced radial fractures is because extensor pollicis longus (EPL) rupture is most likely to happen with this type of fracture. We will explain the connection between nondisplaced wrist fractures and EPL ruptures in just a moment.

    Once they identified patients for inclusion in the study, then they looked at everyone’s X-rays (step two). Four separate physicians independent of each other reviewed the films. They were looking at the angle and height of the radial bone as well as alignment of the wrist joint to make sure no one in the study had a displaced fracture.

    In the third and final step, they reviewed the medical records of each person with a nondisplaced radial fracture. They were looking for those patients who had a documented EPL rupture. They found three of the total 61 patients who had an EPL rupture. This is a five per cent incidence rate. All EPL ruptures occurred approximately six weeks after the fracture. All were in women ranging in ages from 18 to 88.

    Now, what is the significance of an EPL tendon rupture after a nondisplaced radial fracture? We did promise to explain this. 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.

    Knowing the incidence of EPL rupture after nondisplaced radial (wrist) fractures may be higher than previously thought suggests the need for surgeons to watch closely for this complication. Usually a nondisplaced wrist fracture is immobilized in a splint or cast. The risk of a tendon rupture isn’t in the forefront of the surgeon’s mind. This report points out the need to be aware of this potential problem.

    Ulnar Styloid Impaction Syndrome

    What is ulnar styloid impaction syndrome? Not exactly a household word. But certainly one that patients with ulnar-side wrist pain become familiar with rather quickly. First of all, ulnar-sided wrist pain is located on the little finger side. Ulnar styloid impaction refers to a condition causing that 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.

    For example, 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 as in the case series presented in this study. Five patients with confirmed ulnar styloid impaction syndrome had a surgical procedure called an oblique osteotomy. In any osteotomy procedure, the surgeon cuts out a wedge- or pie-shaped piece of bone from the side of a bone. In the case of the ulnar styloid osteotomy, the piece of bone was removed from the extra long tip of the styloid (the styloid process).

    Removing this piece of bone allows the surgeon to collapse the remaining pieces of the bone together, effectively shortening the bone. The fact that this was an oblique osteotomy tells us the entire procedure was 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. The exact steps of the surgical procedure are outlined complete with pre- and postoperative MRIs and X-rays to show the before and after effects.

    The patients were all followed for almost four years. Four of the five patients returned to their previous (pre-styloid impaction syndrome) level of activity and sports. These patients were very satisfied with the results (rated as “excellent” and said they would recommend this surgery to others. Only one patient labeled the results as good due to persistent wrist pain. Two of the patients were completely pain free. The other three had mild pain that came and went.

    The authors conclude that an oblique ulnar styloid osteotomy (OUSO) for the treatment of ulnar styloid impaction syndrome 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.

    New Information on How Cutting the Nerves in the Wrist Affects Motion

    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.

    In this study, researchers from the Division of Orthopaedic Research at the Mayo Clinic in Rochester, Minnesota took a closer look at wrist kinesthesia. 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.

    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 is 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.

    This finding provides further 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 results of this study suggest that partial denervation of sensory nerves in the wrist is a safe procedure. But more study is needed before this conclusion can be completely proven. Proprioception (including kinesthetic sense) is a complex phenomenon.

    This study just looked at one aspect of proprioception. Similar studies are needed to assess the effect of denervation on other components of proprioception and kinesthesia. For example, sensation of force and heaviness during muscle contraction, timing of motor control, and

    Advice From a Hand Surgeon on Wrist Fractures

    No one knows better than a surgeon who specializes in hand surgery the difficulties of repairing some wrist fractures. In this article, distal radial fractures are the focus. In particular, the surgical treatment of comminuted distal radial fractures is discussed and demonstrated.

    The radius is one of the two bones in the forearm. Distal radius refers to the end closest to the wrist (rather than the top of the bone closest to the elbow). Comminuted tells us the bone is broken into many tiny pieces.

    When trauma causes the radial bone to fracture, split and explode apart, the hand surgeon is faced with some complex challenges. For example, how do you 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. 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 can be explained in words. So a series of photos and description are provided complete with some of the surgeon’s own clever adaptations of carabiners (metal clips used by rock climbers to hold things). Keeping everything sterile at all times is also discussed.

    And just try operating on a hand suspended in mid-air. The position is awkward for the surgeon. To help other surgeons navigate this tricky surgery, the case of one patient with a comminuted articular distal radial fracture is presented. Articular fractures affect the bone where it meets to join the joint surface.

    A complete description of the procedure and even a video are available with this article. The use of dry versus wet arthroscopy and combination of vertical traction and hand lying on the surgical table are presented. Dry arthroscopy refers to completing the surgery without using saline solution or other fluids to flush out the area being operated on.

    Wet arthroscopy relies on the use of fluid flushing as part of the procedure. Fluid inside the joint helps keep the area open and easier to work inside. The author advocates using a combination approach of dry and wet to keep a clear view of the joint while at the same time removing debris and blood. Specific tips are given to help the surgeon know how to do this using the benefits of both irrigation and suction.

    The surgeon provides photos taken inside the wrist during the procedure to demonstrate repair of bone fragments, especially when the interface of cartilage and bone at the wrist joint are affected. The difficulties of drilling holes in the bone fragments for nails or screws that are used to hold everything together is discussed. This part of the procedure can drive the bones apart again. X-rays, MRIs, and photographs taken before, during and after the procedure can help. Examples of each are included for this case.

    The surgeon (author) provides what he calls pearls and pitfalls. Here are a few examples:

  • When unstable bone fragments sink down into the joint, it is possible to create a hammock to support them. The hammock is formed using a metal plate and locking pegs into the plate under the bone.
  • A special surgical tool called a grasper can be used to reach in and grab and twist fragments that have shifted and twisted in the process.
  • Sometimes it just isn’t possible to reduce (put back together and realign) all the broken pieces at once. The surgeon must piece everything back together one fragment at a time. Figuring out which fragment to begin with and the order to proceed with can be very challenging. The best approach isn’t always clear. The process then becomes one of trial-and-error.
  • It may be necessary to improvise by using surgical instruments not ordinarily intended for wrist surgery. In one illustration, the surgeon shows how to use a knee probe to hook under a bone fragment in the wrist and pull it up out of the hole created by broken, shifted bone fragments. Once it is lined back up where it belongs, screws or wires can be used to hold it in its proper (anatomic) place.
  • Ask for help from another hand surgeon. This is often essential with the more complex fractures.

    He summarizes by saying the operation described to repair a comminuted distal radial wrist fracture in this article consists of four steps. First, the surgeon uses fluoroscopic (real-time) X-rays to guide him in order to temporarily place the articular pieces together. 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.

    Second, the surgeon must take the time to fine-tune the reduction by lining each fragment up one at a time. Third, now is the time 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.

    The author encourages hand surgeons to 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.

  • Finding New Ways to Treat Kienböck Disease of the Wrist

    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.

    In this study, surgeons treating Kienböck Disease investigate the use of a procedure 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.

    Before going on to discuss the results of the procedure, the authors reviewed other types of treatment used for this disease. One of those procedures is called 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 treatment approaches is a vascularized bone graft. A piece of bone with its blood supply still intact is removed from one part of the body and transplanted to the area of the lunate. Bone grafts don’t always “take” and the bone dies anyway.

    That’s why this study is so important. Lunate core decompression is a simple procedure that doesn’t involve bone graft or removing bone. If successful, this type of surgery could be of real value to patients with early stages of Kienböck Disease.

    Results of decompression for 20 patients with early stages of Kienböck Disease were measured using pain, wrist range-of-motion, function, disability, and X-ray images. All measures were taken before surgery and again five years later (after surgery). The results were very favorable for most of the patients. Only two of the 20 patients had a failed result requiring additional surgery.

    Three of the patients still reported some tenderness at the wrist but this was much improved from the previous pain. Before surgery, 18 of the 20 patients reported tenderness over the lunate. X-rays showed no change in the alignment of the carpal (wrist) bones meaning that there was no collapse of the bones (something that happens as the disease gets worse). Best of all, there were no complications with the decompression procedure.

    The authors concluded that lunate core decompression may be an acceptable and successful (simple) surgical treatment of early stages of Kienböck Disease. It may be possible to avoid the more invasive joint-leveling procedures. Likewise, complications such as nonunion, infection, and ulnar impingement are reduced and possibly even eliminated.

    Hand Surgeons Review Evidence for Treatment of Triangular Fibrocartilage Complex Tears

    In this case report, hand surgeons from the University of Pittsburgh School of Medicine (Department of Orthopedic Surgery) use the patient example of a 49-year-old man with a triangular fibrocartilage complex tear (TFCC) to discuss current concepts of treatment for this condition. The patient had chronic wrist pain for seven months. Conservative (nonoperative) care did not relieve his pain.

    Surgery was a consideration but the surgeons had questions whether the surgery would give any better results than the cortisone injections, immobilization, and hand therapy he had already tried. They looked to see what evidence current research had to offer in making this treatment decision. Let’s take a look at the condition and what is known about it and see what they decided to do.

    Triangular fibrocartilage complex (TFCC) injuries of the wrist affect the ulnar (little finger) side of the wrist. The triangular fibrocartilage complex (TFCC) suspends the ends of the two bones of the forearm (radius and ulna) 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.

    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. For a more detailed description and understanding of this wrist problem, see A Patient Guide to Triangular Fibrocartilage Complex (TFCC) Injuries.

    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.

    Even with a complete diagnosis, treatment decisions aren’t easy. Each case of TFCC injury must be examined one-by-one. The exact location of the injury and extent of damage are important factors. Whether the injury is the result of trauma or degeneration will also be taken into consideration. The presence of other associated injuries (e.g., torn ligaments, bone fractures) can influence both the treatment and results.

    Taking a close look at the current evidence available was a challenge. Most of the studies are based on small series of case studies. Large studies comparing different treatment approaches for similar TFCC injuries just aren’t available. That leaves surgeons lacking the evidence they need to guide treatment.

    The authors of this case report suggest the need for studies to compare nonoperative care with sham treatment and operative treatment. They also point out the fact that different operative approaches must be compared (e.g., debridement, use of open incision versus minimally invasive technique). Other factors that might affect outcomes (e.g., age, cause: traumatic or degenerative) must also be investigated.

    What did they decide in the end to do for this patient? The patient had not responded to conservative care but the wrist was stable and the surgeon felt there was potential for healing. With no known trauma, it seemed best to try another round of immobilization for four to six weeks. If there’s no improvement at the end of that time, further evaluation (probably with diagnostic arthroscopy) was planned. Any further treatment decisions would have to wait pending the results of these first two steps.