Understanding Scaphoid (Wrist) Fractures That Don’t Heal

The wrist is made up of two rows of small bones. One row of bones articulate (move) against the two bones of the forearm. The second row lines up with the base of the fingers and thumb. A fracture of any of the carpal (wrist) bones in these two rows can create problems — especially if the bone doesn’t heal. That’s called a fracture nonunion.

In this Canadian study, a surgeon from the University of Toronto Hand Program reviewed the charts of 96 patients with nonunion fractures of the scaphoid bone. The scaphoid is the most common carpal bone to break. It is located on the thumbside of the wrist next to the radius (larger of the two forearm bones).

The goal of this study was to find out why this particular bone fails to heal. Is there something about these particular patients that creates a nonhealing response? Does their age or sex (male versus female) make a difference?

Did the medical care they received fail to treat the problem correctly? Having a better idea of how and why scaphoid fractures result in a nonunion may help surgeons manage these cases more effectively in the future.

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

Other studies have also looked at the ability of X-rays and other imaging studies to accurately diagnose scaphoid fractures. In fact, the high rate of false negatives (X-rays don’t show the fracture when it’s really there) contributes to the problem. The injury isn’t treated at all and the result can be a nonunion.

But there are also cases where the wrist is put in a splint or cast to immobilize it and the fracture still doesn’t heal. So, the question is: why don’t scaphoid fractures heal? As this Canadian hand surgeon found out, there are two groups of important factors.

The first is biologic factors. The location and severity of the fracture make a difference. Fractures closer to the radial bone are more likely to result in a nonunion. The blood supply to this area is also very fragile so a fracture that disrupts blood flow can also be a significant reason why the bone doesn’t heal.

The second major reason why scaphoid fractures don’t heal is referred to as clinical factors. Patients may not have painful symptoms so they don’t go to a physician for diagnosis and treatment. Or if they are diagnosed, they may not follow the recommendation to immobilize the wrist for four to six weeks. And, of course, as we already mentioned — delaying treatment by four weeks or more is a definite risk factor.

What about other patient characteristics like age or sex (male or female)? As it turned out in this group of patients, the majority (89 per cent) of the fractures were in young men (ages 25 to 29). Some didn’t even know they had injured their wrists.

One-third of the group did not seek medical attention. They either didn’t think it was much of a problem or the painful symptoms got better without treatment. Pressure to return to sports participation in this age group may have led some to minimize their symptoms.

The authors concluded it’s no wonder diagnosis and treatment for scaphoid wrist fractures go undetected and/or untreated. With such a wide variation in symptoms, a high rate of false negative X-rays, and fractures that occur without a known injury, it’s easy to see how this could happen.

What can be done to change this clinical picture? Education of primary care physicians, emergency staff, physical therapists, athletic trainers, and other sports personnel may help. Health care professionals working with sports athletes need to know that scaphoid wrist fractures can be painless and that they have a tendency toward nonunion.

Better evaluation and closer monitoring of wrist injuries and painful wrists (without known trauma) may result in better outcomes with fewer cases of scaphoid nonunion. The results of this study highlight patient characteristics, biologic factors, and clinical factors that might be red flags to help guide patients to an earlier diagnosis and more effective treatment.

High Rate of Failure with Wrist Replacement

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

Most often both wrists are affected — not just one. Personal hygiene can become a huge problem. Whether in the bathroom, bedroom, or kitchen, even a few degrees of motion can make a big difference in function. What can be done to help these patients?

Conservative care with medications to control symptoms and even slow down the destructive effects of the disease comes first. But when the bones erode so much that the wrist becomes unstable, then surgery may be the next step.

For a long time, patients were offered two courses of action. First, removal of destroyed bones and replacement with bone graft. In some cases, a complete fusion called arthrodesis was necessary. Over time, other reconstructive procedures were developed. Eventually, an implant arrived on the market to replace the joint.

Total wrist replacement or arthroplasty is now more of a reality than a possibility. Manufacturers of implants have modified the shape and improved the design of their implants. Results are gradually improving, too.

If that last statement raises your eyebrows a bit, you’re not alone. Surgeons are still reporting a pretty high complication and failure rate. In this study of 24 wrist arthroplasties, the failure rate was 50 per cent. And those were early failures — not after the patient had the wrist implant for years and years.

What happened and what went wrong? A study like this can be very helpful in making changes that could result in improved outcomes. All the wrist implants were the Universal brand or design. Each one was put in place by one surgeon at the University of Iowa Department of Orthopaedic Surgery and Rehabilitation.

The biggest problem was loosening of the implant on the hand side (as opposed to the component part on the forearm side). The second most common problem was something called subsidence — the implant literally sinks down into the bone. Most of those patients had to have another surgery to either remove and replace the implant or remove the implant and fuse the joint.

When the implant was removed, the surgeon could see how high pressure and uneven wear resulted in flecks of plastic from the liner of the implant being rubbed away. That type of debris entered the joint, rubbed against the bone, and loosened the implant away from the bone.

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

The results of this study (along with other similar studies) have shown the need for the next generation of Universal implants. In fact, that re-designed implant is now available (called the Universal 2).

A slight change in the shape of the implant surface that is acting as the joint surface has made a significant difference. Another surgeon who reported on patients receiving the Universal 2 indicated a much lower rate of loosening.

What’s the next step? Of course, more studies would be helpful. Larger studies are needed, too. But with only a small number of people venturing into this treatment, it may be necessary to conduct multi-center studies where the same implant is used and results pooled.

A 50 per cent failure rate just isn’t acceptable to most patients. Once an implant is developed with a much lower complication rate, then long-term survival will become another important variable. Studies over 10 to 20 years will show which implant has the best track record for the greatest number of patients.

Patients Satisfied After Total Wrist Replacement

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

In this study, the results are reported for 21 patients who received the Universal 2 Total Wrist Implant System. Two-thirds of the patients had joint destruction from rheumatoid arthritis. The remaining one-third had loss of motion and deformity from other causes such as lupus, Kienböck disease, and psoriatic arthritis.

Any age was accepted and patients ranged from 32 to 75 years old. They had to have good enough bone stock to support the implant and they had to be able to follow the surgeon’s advice. For example, there was to be no carrying or lifting of anything heavier than 15 pounds for at least six weeks. After that there were some other restrictions on heavy work like lifting or moving heavy objects, gardening, or bowling.

As more and more studies are done involving wrist replacements, surgeons are getting a better idea of what works best. The implant is cemented in with a thin layer of cement. The cement is also used to fill in any holes or areas where the implant and bone don’t match exactly.

Results are better if the distal row of wrist bones (closest to the fingers) are fused together. Sometimes the surgeon uses bone to fill in and fuse the area around the base of the thumb where it meets the wrist.

Outcomes were measured using several different tools. X-rays, of course, showed the status of the healing bone. The surgeon can use X-rays to look for any bone fractures around the implant, fractures of the implant itself, subsidence (implant sinking down into the bone), union of any fusion, and overall integrity of the joint. X-rays also show signs of osteolysis (resorption of the bone around any part of the implant) with any loosening of the implant itself.

Pain, motion, strength, function, and any complications were recorded. Any pain or discomfort reported was usually from other joints affected by arthritis or the other diseases. Complications were very minimal with one wound infection and one hematoma (pocket of blood inside the body). There were no dislocations!

Motion and function were improved such that patients rated their results as satisfactory or completely satisfactory. Patients reported that it is possible to get used to doing things without full wrist motion but much better to have a wrist replacement that allows motion and function once again. They say the happiness of being able to fasten buttons, pick up loose change, and even walk the dog can’t be measured!

Some changes made in the shape of the implant have improved the fit, contact surface (between implant and bone), and joint stability. A tighter fit has also eliminated the need for prolonged postoperative immobilization in a cast. The wrist is still held immobilized for 10 days up to two weeks.

Patients should be prepared for a few “less than perfect” results. For example, the implant does not allow enough wrist extension to push up from a chair with that hand. The wrist may be improved, but the fingers remain the same and that might be with pain and deformities. Grip strength might not return to normal either when other fingers are involved.

In summary, wrist joint replacement has improved greatly since it was first introduced over 20 years ago. There are fewer problems after surgery and implants are lasting longer. A wider range of potential patients is now possible, too. This means more people qualify for this type of surgery.

Results of Wilhelm’s Wrist Denervation Technique

Patients with severe wrist pain limiting function who don’t improve with conservative (nonoperative) care may benefit from surgery. In this study, hand surgeons performed the Wilhelm’s wrist denervation on 54 patients and report the results.

Wilhelm’s wrist denervation is a surgical procedure used to cut tiny branches of the sensory nerves to the wrist and hand. By cutting these nerve pathways, pain signals to the brain can be stopped. Since motor nerves are not disturbed, there’s no loss of motion or strength. In fact, in all cases, grip strength, wrist motion, and pain all improved.

The procedure takes about 45 minutes and involves four small incisions on both the front and back of the wrist and hand. The authors provide drawings of the incision locations and describe the procedure.

The three main reasons patients in this study were having severe wrist and hand pain included degenerative osteoarthritis, Kienböck disease, and osteoarthritis from trauma. Anyone with a diagnosis of rheumatoid arthritis was not included in the study.

Patients ranged in age from 29 to 65. No one had any previous wrist or hand surgeries. The group was young enough that most were still working. Symptoms were severe enough to limit daily activities and function at work.

Everyone was treated for a minimum of six months with a nonsurgical approach. A hand therapist worked with the patients to teach them how to modify their activities and reduce the stress and workload on the wrist and hand.

Splints, range-of-motion exercises, nerve mobilization, and manual therapy were part of the program. The goals were to help realign the wrist and strengthen the muscles to stabilize (hold) everything in place.

For this group of patients, pain was still severe after nonoperative care. A local injection of a numbing agent into the wrist gave enough pain relief to suggest denervation would be helpful.

And, in fact, the surgery was a success for everyone. They all experienced pain relief with improved grip strength and wrist range-of-motion. As might be expected, function was also much improved.

What didn’t change was the underlying cause of the problem. X-rays taken during follow-up visits showed no change in the degeneration present in the wrist. It is possible that over time, continued progression of disease will affect joint motion once again. But as this group of patients showed, even after six years, the effects of the denervation were still very positive.

The authors conclude by saying it is possible to almost completely denervate sensory nerves to the wrist using a limited surgical approach in patients with severe wrist pain. They showed that using the Wilhelm’s wrist denervation technique with its four small incisions could yield very good mid-term results with no complications.

Case Number Seven of Wrist Osteochondritis Dissecans

There are only six cases of osteochondritis dissecans (OCD) reported in the medical literature. Oops, make that seven with this report from South Korea. With so few cases of any condition, surgeons are at a disadvantage for knowing what treatment is optimal.

In this study, two surgeons report on the results of osteochondral autograft transplantation or the OATS treatment for osteochondritis dissecans (OCD) of the wrist. In particular, the scaphoid bone of the wrist is affected. The scaphoid is the first bone in the wrist next to the radius (forearm bone on the thumb side).

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

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

A joint surface damaged by OCD doesn’t heal naturally. Even with surgery, OCD usually leads to future joint problems, including degenerative arthritis and osteoarthritis. Treatment has changed and progressed quite a bit in the last 10 years. One of the newer surgical approaches is the osteochondral
autograft transplantation (OATS) already mentioned.

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

In this case report, a 36-year-old man with a history of manual labor developed significant wrist pain and loss of motion. A clinical examination along with imaging studies led to the diagnosis of osteochondral dissecans. The surgeons ruled out the possibility of Preiser’s disease, another
rare disease affecting the scaphoid bone of the wrist.

X-rays showed a defect in the bone. CT scans show abnormal signal intensity to confirm the loss of blood flow to the area. Arthroscopic exam at the time of the surgery confirmed the presence of osteochondritis dissecans along with a partial tear of a supporting ligament (the scapholunate ligament) and tear in the stabilizing triangular fibrocartilage of the wrist.

Following surgery, this particular patient was able to get back to work as a hard manual laborer requiring a six-day work week (eight to 10 hours per day). It’s likely that his job requiring repetitive motion of the wrist was a factor in the development of this condition. Although he was able to perform his job once again without discomfort and with full return of wrist motion and strength, he may be at increased risk for another episode of this problem.

The authors make note of the fact that not everyone is a good candidate for osteochondral autograft transplantation. Patients with smaller cartilage lesions are the most likely to benefit from this procedure. When other areas of the joint are damaged, it may be necessary to remove other bones in the wrist along with the scaphoid. Tears in the soft tissues may require additional surgical procedures.

Three Things to Know About Wrist Ganglions

So you have the telltale bump on the back of your wrist that comes and goes. It hurts when you move your wrist as far as it will go into extension. Any movement that puts pressure into the palm (like doing a pushup) aggravates it. The surgeon says it’s a wrist ganglion.

A ganglion is a small, harmless cyst, or sac of fluid, that sometimes develops in the wrist. Doctors don’t know exactly what causes ganglions. How do you know for sure that’s what you have instead of something more serious like cancer?

X-rays are of no proven value in detecting ganglion cysts. The physician’s clinical exam is often sufficient to make a diagnosis. Imaging studies (ultrasound and MRIs) have been shown to be reliable and accurate — most of the time.

There are cases where neither one shows a cyst when there really is one present. Only surgical removal and examination of the tissue is 100 per cent accurate. Ultrasound may be preferred over MRIs because it is a less expensive diagnostic procedure.

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

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

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

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

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

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

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

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

Surgeons agree that more research into this problem is really needed. It’s important to be able to sort through all the patient variables and find the right treatment for each person. Physical as well as psychologic aspects of illness must be considered. Patient satisfaction may be defined and measured differently by patients and surgeons across the board. These variables need further study as well.

A Surgeon’s Look at Wrist Arthritis

In this article, Dr. R. J. Strauch from the Department of Orthopedic Surgery at Columbia University Medical Center in New York City presents an update on the treatment of two causes of wrist arthritis. Both types involve the scaphoid (wrist) bone. The scaphoid is a key player in wrist arthritis because of its location. It sits in the center of the wrist.

Any trauma, injury, or other disease process that affects the scaphoid can also potentially affect the other bones and ligaments in contact with the scaphoid. Damage (tears or ruptures) of the scapholunate ligament (between the scaphoid and lunate bones) puts the wrist at risk for uneven wear, joint degeneration, and wrist arthritis. Fractures of the scaphoid bone that don’t heal (called a nonunion fracture) can result in the same process of joint destruction and arthritis.

Dr. Strauch focuses his attention on the treatment of two specific scaphoid conditions that can lead to wrist arthritis. The first problem is called scapholunate advanced collapse (SLAC).

As the name suggests, both the scaphoid and the lunate wrist bone shift out of alignment. The wrist becomes painful, tender, and unstable. Wrist motion and quality of movement become abnormal. Abnormal wear and tear lead to joint destruction and arthritis as described.

The main cause of scapholunate advanced collapse (SLAC) is trauma resulting in a tear of the scapho-lunate ligament. Crystals from pseudogout that form inside the joint can also create a SLAC condition.

The second problem is called scaphoid nonunion advanced collapse (SNAC) arthritis. A fracture of the scaphoid bone that doesn’t heal creates a joint that is unstable. Trauma is the main cause of this type of scaphoid collapse.

Treatment for these two wrist problems is similar with a few key differences. Conservative (nonoperative) care can be tried first for either condition. A hand therapist (occupational or physical therapist) can fit the patient with a special splint. The splint is meant to hold and protect the joint giving it time to heal.

Pain is managed with pain relievers and heat, cold, or electrical stimulation. The surgeon may try steroid injections to reduce pain and inflammation. Steroid injection is limited by the fact that this medication can cause breakdown of the soft tissues and joint.

Surgery can be done to fuse the joint, remove the affected bones, or denervate (destroy) the sensory nerve sending pain messages to the brain. Wrist fusion or arthrodesis can be done in one of several ways. In one approach, the scaphoid bone is removed.

Then the four remaining bones around the scaphoid (lunate, hamate, capitate, triquetrum) are wired or held together with a round metal plate and screws. Bone graft may be used to help stimulate bone growth in the spaces between the bones. This wrist fusion procedure is called a four-corner arthrodesis.

Studies have shown the importance of clearing out any debris in the joint during the bone removal and fusion procedure. Using enough screws (at least two per bone) to hold the bones together is another key to a successful outcome. Using the right sized screws is equally important.

Over the years, surgeons have tried many different ways to fuse the wrist with varying results. The goal is to get a stable joint while maintaining as much motion as possible. Other methods being studied and compared to the four-corner arthrodesis include fusing just the capitate and lunate together and removing different bones (sometimes removing the scaphoid, sometimes the lunate or triquetrum) and seeing the results.

Results are measured and compared using joint range-of-motion, pain, tenderness, grip strength, and wrist function.

Some surgeons prefer to remove the row of wrist bones closest to the forearm. This procedure is called a proximal row carpectomy (PRC). The advantages to this treatment approach include quick return of wrist motion, no hardware, and of course, no limitations normally caused by a fusion. No hardware also means no complications such as screws breaking or backing out or the need for a second surgery to remove the hardware later after healing is complete.

Choosing between a proximal row carpectomy (PRC) versus four-corner arthrodesis is done on a case-by-case basis. PRC has several advantages over the four-corner fusion. There are fewer complications and better overall results with PRC.

The downside is a weaker grip strength and a greater chance of developing arthritis later. If strength is important for daily activities or work tasks, then the four-corner arthrodesis is the preferred treatment choice.

In summary, wrist arthritis from scaphoid bone or scapholunate ligament injuries can be treated in a step-wise fashion. The least invasive (nonoperative) method can be tried first. (splint, hand therapy). If the patient fails to improve or has only limited change in pain, then injection therapy or nerve denervaton can be tried.

Surgery is the last option when pain and weakness and loss of function persist or progress. Surgery can also be done in stages. Removal of the damaged scaphoid and a four corner-fusion allow for some wrist motion to be saved. Alternately, the affected row of carpal (wrist) bones can be removed completely.

Further treatment failure may lead to total fusion of the wrist joint. Future studies comparing the results of each treatment method based on patient age, strength, activity level, and work requirements may help guide treatment decisions for these two problems (scaphoid lunate advanced collapse and scaphoid nonunion advanced collapse).

How to Handle Rare Hand and Wrist Infections

It’s tough to know what to do about something that doesn’t happen very often. That’s the case with hand and wrist infections from mycobacteria (a type of bacteria). Sometimes problems that seem like carpal tunnel syndrome, trigger finger, tenosynovitis, or abscesses of the wrist or hand are really caused by one of these agents.

This article was written in order to help hand surgeons identify and treat mycobacterial infections of the hand and wrist. The authors reviewed all recently published studies on this topic and report their findings. Because it’s so rare, the level of evidence is only case reports and case series.

The two most common bacterial bugs that cause hand and wrist infections include mycobacterium tuberculosis and mycobacterium marinum. Both of these bacteria are slow growing, which is one reason why they are not identified early. They don’t show up on lab studies at first. The diagnosis can be delayed six months or more, so treatment is directed elsewhere. Without the right antibiotics, the condition will not get better.

The patient shows up with wrist and hand swelling, pain, and nodules. Fever may be present. The swelling progresses (gets worse) as it spreads through the lymphatic system. There may even be pus draining from an open wound.

Antibiotics are used but not necessarily the type that will combat these specific bacteria. If the condition goes on long enough, surgery may be needed to debride (clean out) the joint. The surgeon may even have to remove some of the damaged synovium and soft tissues.

In the case of tuberculosis, there may not be signs and symptoms of lung involvement. Instead, the soft tissues and bones are affected. This is called extrapulmonary tuberculosis. There may be a previous history of pulmonary (lung) tuberculosis or HIV (human immunodeficiency virus).

Anytime tuberculosis is the underlying agent causing infection, a group of four medications must be taken for a long period of time (up to 18 months) before the bacteria can be eradicated (completely killed). Even with multidrug treatment, if the symptoms don’t improve after six to eight weeks, then surgery may be needed as well.

With hand/wrist infections from mycobacterium marinum, there is often a past history of exposure to fish (e.g., fish tank or aquarium, sushi chef preparing fish, contact with river water) or contaminated water.

As with tuberculosis, patients infected with this type of bacteria can go months to years without an accurate diagnosis. Some even have multiple surgeries before the tissue cultures are positive for the bacteria and the correct antibiotic is given.

There are other types of bacteria (e.g., M. kanasaii, M. leprae, M. abscessus, M. arupense) that can cause similar hand/wrist problems. Again, these cases are rare. Diagnosis is delayed and treatment with multiple drugs is required before symptoms resolve.

Most of the patients in the case series who were infected by other types of mycobacteria were immunocompromised. That means they had some other disease, illness, or condition that had weakened their immune systems. For example, one woman had a long history of psoriatic arthritis. Another patient had rheumatoid arthritis. Others had a history of diabetes, organ transplantation (taking immune suppressing drugs), HIV-positive, and tuberculosis.

In summary, successful treatment of rare hand/wrist infections requires accurate diagnosis. It may be necessary to retest tissue cultures many times before the growing organism shows itself and the specific antibiotics can be used.

The authors advise physicians to suspect mycobacterium when patients don’t respond to the first course of antibiotics. Risk factors such as contact with fish, past history of tuberculosis, and current immunocompromise or immune deficiency are additional red flags.

When surgery is done, hand therapy is recommended. Case studies show that patients who do not see a therapist often end up with a stiff hand and loss of function. With splinting and exercises, range-of-motion is more likely to be restored. Return of normal grip strength and full use of the wrist, hand, and fingers is the final outcome of therapy.

What’s the Evidence Behind Treatment of a Septic Wrist?

Most people know bacteria like streptococcus (“strep”) and staphylococcus (“staph”) can cause all kinds of infections — strep throat, inflamed nailbeds, skin infections, and so on. These same agents can also cause joint infections referred to as septic arthritis. Any puncture, wound, bite, surgical procedure, or body infection (e.g., urinary tract or upper respiratory) can result in an infectious joint. The bacteria move along through the blood system to the joint.

Recognizing and diagnosing septic joint arthritis isn’t always easy. The patient may not have a known history, trauma, or other event they can link with the new symptoms of joint pain, redness, and swelling. It’s not until the physician draws some of the fluid from the joint and sends it to the lab that a diagnosis can be made.

In this article, hand surgeons from Columbia University Medical Center in New York City review the evidence for diagnosing and treating a septic wrist. They try to pinpoint the best way to diagnose this problem but research results are limited. Many surgeons rely on their own clinical expertise for this one. Lab tests (blood work, joint fluid analysis) give some idea of what’s going on but are not accurate enough to be used as the only means of diagnosis.

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

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

So, what do the experts recommend? Start with an X-ray of the joint followed by needle aspiration and lab analysis. Put the patient on a broad spectrum intravenous antibiotic. Broad spectrum means that until the specific “bug” (bacteria) is identified, choose an antibiotic that will kill them all (or as many as possible). As soon as the lab culture comes back with the exact bacteria present, switch the patient to an oral antibiotic that will specifically target those bacteria.

Is there any scientific evidence to support these guidelines? Not really. Whether or not this approach is what works best has never really been studied. Likewise, the use of intravenous (IV) versus oral antibiotics for a septic wrist is based on “conventional” wisdom (i.e., it makes sense and that’s the way it’s been done for a long time).

What other treatment or management techniques are used for a septic wrist? The fluid can be aspirated (removed) as many times as needed. In some cases, one time is all that’s required. With the antibiotics, aspiration is followed by pain relief, decreased swelling, and improved joint motion.

Surgery may be needed to irrigate and debride (clean out) the joint. This procedure helps remove bacteria and infection (pus) and give the joint a chance to heal. Just like with the aspiration procedure, surgical drainage may be done more than once.

Surgical drainage is almost always needed when the bacterial infection occurs as a result of a joint replacement. The implant may actually have to be removed, the wrist cleared of infection, and a new implant (or wrist fusion) procedure performed. In all cases, surgery is recommended if the infection has progressed to the point of erupting through the joint or when needle aspiration doesn’t yield the expected results (i.e., the patient doesn’t get better quickly).

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

Studies are needed to compare types and timing of antibiotics, number of aspirations to do before considering surgery, and most effective lab tests for diagnosis. Patients will have to be followed for several years to see what kind of outcomes are possible with different treatment protocols. Of course, the goal is to find the fastest, most effective treatment with the lowest cost and fewest complications or problems.

New Treatment Option for Wrist Instability

There’s a new kid on the block and his name is distal radioulnar joint or DRUJ. In plain English that means a replacement of the wrist joint. More specifically, we’re talking about the place where the radius (forearm bone on the thumb side of the wrist) connects to the ulna (forearm bone on the little finger side).

What’s so special about this guy? Well, his predecessor (the joint replacement used before this one was designed) failed too many times — the previous prosthesis (replacement device) loosened, broke, backed out, or had to be removed because the patient was still in so much pain.

This new C-type prosthesis is a simple rod made of chromium cobalt that is inserted down the length of the ulnar bone. It is attached to the radius with a shorter cross piece also made of chromium cobalt. The shorter radial component has a circle-shaped head with a plastic lining on the inside of the round end. That ring is placed inside a hole cut into the radius just above the wrist.

What makes this device unique is the fact that it has only two parts. Other wrist replacements have four pieces. In the new C-type units, both pieces are coated with hydroxypatite, a calcium crystal that helps form bone mineral. When placed inside or next to the bone, this coating gives new bone cells a compatible surface to attach to. In other words, the hydroxypatite surface promotes bone growth filling in and around the prosthesis.

The new prosthesis is also unusual in that it allows the ulnar rod to move up and down inside the bone (piston-like action) while still turning (rotating) around the radius. Rotation is made possible by the ring on the end of the radial component. Each prosthesis was custom made (sized) for individual patients.

Not all 19 C-type prosthetic devices were the same. The surgeons fiddled around with the design a bit. Some of the radial units had rounded corners; others were rectangular. From start to end of the study, they used three different models of the same basic prosthesis type. Over time, they were able to increase the tolerance of the ring. Tolerance refers to the amount of force the part can withstand without bending or breaking.

The success of this new distal radioulnar joint prosthesis was measured in 19 patients using before and after measurements of wrist pain, grip strength, wrist range-of-motion, hand and wrist function, and disability. Disability was measured using a specific assessment tool called the Disabilities of the Arm, shoulder, and Hand (DASH) questionnaire.

Everyone was followed at regular intervals during the first year (three, six, and 12 months after surgery). Annual measurements were recorded after that first year. Some patients were followed for as long as seven years. An occupational therapist did all of the clinical measurements. X-rays were also taken to look at bone formation and position of the prostheses.

Of the 19 patients enrolled in the study, 12 still had the new distal radioulnar joint (DRUJ) prosthesis at the end of the first year. Those patients who had the implant removed either had ongoing pain during movement, loosening, or just didn’t want the device left in. For the patients who still had the DRUJ implant, results were good-to-excellent with decreased pain, increased movement, and improved function.

The authors compare the results of their patients in this study with patient results using other types of implants. They conclude that their two-part implant is superior to the main alternate choice still left on the market: the Alkmaar and Schecker four-piece prosthesis. After they modified the new C-type implant to improve ring tolerances, the number of implants that had to be removed for any reason dropped to zero.

This new C-type distal radioulnar joint replacement isn’t the final word on wrist replacements. It is more likely a stepping stone from a device that didn’t work to one that will be even more superior to the one just studied.

Relieving pain while improving motion, strength, and function are fairly easy items to measure. So there should be no problem obtaining data needed to compare current options to future prostheses that come available.

The availability of improved implants is good news for anyone with a painful, weak, and unstable wrist joint. In time, the failure rate for wrist artificial joints will drop closer to zero. It’s also possible that more patients will be eligible for this type of wrist replacement. Right now, it’s fairly limited to those who develop osteoarthritis after trauma or injury to the wrist and to patients who have the tip of the ulna (at the wrist end) removed for any reason.

Wrist Fractures in the Elderly: Is Surgery Necessary?

Wrist fractures are common in older adults. In particular, distal radial fractures receive a lot of attention. The radius is one of two bones in the forearm (located on the thumb side of the forearm).

With a fall or traumatic injury, fracture at the end of the bone at the wrist can be considered unstable if the broken pieces have shifted and no longer line up as they should. Is it okay to put a cast on an unstable distal radial wrist fracture and let it heal as is? Or is surgery really needed to reset the bone perfectly?

That’s the question orthopedic surgeons from the New York University Hospital for Joint Diseases asked. Their specific interest was in the older population. All patients included in the study were at least 65 years old. The average age was in the mid-70s. The goal was to compare results in patients with a distal radial fracture treated with cast immobilization to results for patients with the same diagnosis who were treated surgically.

You may wonder: doesn’t putting an unstable wrist fracture in a cast cause the bone to heal crooked or with some kind of misalignment? Yes, that is exactly what happened with one group. The other group had surgery to reset the break and hold it together with a metal plate and wires or an external device and pins. Anyone with an open fracture (bone poking through the skin) was automatically placed in the surgical group.

The results were measured (before and after treatment) in several different ways. X-rays were taken. A special test of function was given called the Disabilities of the Arm, Shoulder, and Hand (DASH). Grip strength and wrist motion were measured and recorded. Pain intensity was recorded at regular intervals (at two, six, 12, 24, and 52 weeks after treatment was started).

In the end, the differences between the two groups were negligible. In other words, the differences in motion, pain, function, and strength were so small, there was no difference. Complications (e.g., nerve compression, tenosynovitis, stiffness, wrist pain) were equal between the two groups. Carpal tunnel syndrome was more of a problem in the group treated without surgery but the symptoms went away and were not permanent. Scores for the DASH test were basically the same for patients in both groups each time they were tested.

The two differences seen during follow-up didn’t amount to anything significant. These included better grip strength in the group that had surgery when measured at the end of the first year. But this apparent weakness didn’t seem to affect function. The X-rays showed a cleaner, more stable fracture site for the operative group. The break in the bones was set so that the surgical group had a more normal angle and length of bone. But again, the less optimal radiographic findings in the nonoperative group only translated into a small decrease in wrist motion that didn’t affect function.

The researchers were careful to match patients between the two groups by age, sex, hand dominance, fracture pattern, socioeconomic status, and general health. That way comparing the two groups was not affected by these outside factors giving a more accurate look at the results. They summarized their findings by saying the following about the operative versus nonoperative treatment of distal radial (wrist) fractures:

  • Surgeons must evaluate each patient individually taking all factors into consideration.
  • Restoring normal wrist and forearm anatomy in distal radial fractures is not always necessary to get good results.
  • Malunion isn’t linked with poor function a year later.
  • These statements apply to older adults who are likely less active, lower-demand patients.
  • Wrist deformity doesn’t mean the final results of conservative care will be less than for patients who have surgery.

    Surgeons, patients, and family members can work together to decide when an older family member with a distal radial (wrist) fracture is going to need surgery or not. Given the likelihood that older adults have additional health concerns (e.g., diabetes, heart disease, high blood pressure), having a nonoperative approach available with positive outcomes is good news indeed.

  • Combined Wrist Injury Requires Combined Surgical Approach

    As a result of this study, hand surgeons from Duke University (North Carolina) are suggesting the use of both arthroscopic and open incision surgery for one kind of painful wrist fracture that doesn’t heal. Bone fractures that don’t heal are called nonunion fractures. The nonunion fracture in this study was of the ulnar styloid.

    A little bit of wrist anatomy will help us understand what they found and why they make this recommendation. At the end of the forearm, two bones meet the first row of bones in the wrist. The two bones in the forearm are the radius (on the thumb side) and the ulna (on the little finger side).

    The ulnar styloid is a small projection of bone at the bottom of the ulna. You can see and feel this as a bump on the back of your wrist on the little finger side. A fall on to the outstretched hand is the most common way this bone gets broken. Nonunion ulnar styloid fractures aren’t always painful. But when they are, there is usually a reason. It might be because there is abnormal motion at the nonunion site. Or there could be a tear of the triangular fibrocartilage complex (TFCC).

    The triangular fibrocartilage complex (TFCC) describes a group of tough ligaments that hold the radius and ulnar together. The TFCC also connects the ulnar styloid to the bones in the wrist. The TFCC is a major stabilizer of the radioulnar and wrist joints.

    Surgery to repair the broken styloid hasn’t been very successful. For patients who have a painful nonunion, the surgeon just removes the broken pieces and smoothes down any jagged edges that remain. But pain will persist if the TFCC is torn. The surgeon has to decide what approach to take: an open incision or an arthroscopic procedure? That’s where this study comes in.

    The surgeons treated eight different patients with ulnar styloid nonunion fractures who also had a tear of the triangular fibrocartilage complex. They used an open incision approach to remove the bone fragments and an arthroscopic technique to repair the torn soft tissues. They report both their findings (what they saw during the procedure) and the results or outcomes patients experienced after surgery.

    The authors also described the surgical technique used for both procedures. In the process of repairing the torn TFCC, they had to avoid injury to any of the sensory nerves in the area. Once the procedures were completed, the patients were put in a custom-molded orthosis (brace) for four weeks. Then they enrolled in a rehab program with a hand therapist. The therapist guided the patients through exercises to regain motion, strength, and function.

    Although X-rays and MRIs were done on each patient, the triangular fibrocartilage complex (TFCC) tear was only observed before surgery in five of the eight patients. Arthroscopic exam remains the only way to be 100 per cent sure there is a TFCC tear. During the scoping procedure, the surgeon can find where the tear is located, how deep (partial thickness or full thickness) and long it is, and look for any other signs of damage. Several of the patients did have tears of other wrist ligaments.

    Outcomes as measured by pain reduction and improved function were good-to-excellent for everyone. The radioulnar joint was stable. All of the patients said they would do it again if they had it to do over. The surgeons say they recommend combining these two surgical procedures.

    In other words, when there is a fracture of the ulnar styloid process, the surgeon should take the time to insert a scope and look for damage to the soft tissues, ligaments, and cartilage around the radioulnar and wrist joints.

    The results of this study confirm that tears of the triangular fibrocartilage complex (TFCC) are possible with ulnar styloid fractures. Although imaging studies done after the injury and before the surgery are helpful, they don’t always show damage to the TFCC. Left unrepaired, TFCC pathology is likely to leave patients with chronic wrist pain and possible joint instability.

    No Surgical Treatment Best for Kienbock’s Disease

    Kienbock’s disease is a disease that prevents the blood flow to a small bone in the hand, the lunate. Kienbock’s disease was identified in 1910, but doctors and researchers don’t understand yet what actually causes the disease, although there are suggestions that it is the result of trauma or of systemic causes. Because the cause of Kienbock’s disease isn’t understood, treatment isn’t always effective and no-one treatment seems to be better than another. Presently, treatment is aimed at reducing pain, improving function in the hand, and limiting the disease progression.

    Usually, conservative, or nonsurgical, treatment is tried first, when a patient develops the disease. This could mean immobilizing the wrist with a brace for up to three months. However, a surgical procedure called vascularized bone grafting has been developed to fix the actual area injured by the disease, which doctors may feel is a better option. Other surgeries include joint-leveling, partial wrist athrodesis (fusing the bone), proximal row carpectomy (removal of some of the bone), and total wrist athrodesis, although the last two procedures are reserved for late-stage Kienbock’s disease. The authors of this study compared pain, motion, grip strength, and x-rays after various treatments for Kienbock’s disease to see validate the theory that there is no one treatment that is better than another.

    Researchers reviewed studies that had been done testing the various types of treatments and available procedures. They were able to find 37 articles that fit their criteria of patient-reported subjective outcomes and follow-up of at least 12 months. Sixteen studies followed patients who had early-stage disease and the remaining 25 for late-stage disease.They add up to more than 37, because some articles included both early and late stages.

    The articles identified the stages of Kienbock’s disease as Lichtman stage I, II, and IIIa. These were the early stages. The later stages were identified as Lichtman stage IIIb and IV.

    Surgical procedures used in the studies for early-stage included:

    vascularized bone grafting
    metaphyseal core decompression
    radial osteotomy.

    For later-stage, surgical procedures included those just listed plus:

    – partial arthrodesis
    – proximal row carpectomy
    – tendon or muscle ball arthroplasty (replacement)

    Some late-stage patients were also treated non-surgically, but this was not so in the early-stage group.

    The various studies measured patient-reported outcomes differently. The ultimate goal is to find out the patients’ response to pain, range of motion, grip strength, and carpal height index.

    When the researchers interpreted the data, they found there was no significant differences in how the patients in all studies felt after their procedures when reporting pain levels. Objectively, when the patients were seen by their individual study researchers, the reports say that the patients had significant improvements in their range of motion and grip strength if they had undergone a radial osteotomy or a vascularized bone grafting (for early-stage disease) and in all procedures except for partial arthrodesis and non-surgical patients for the late-stage groups. For the late-stage disease, only patients who had non-surgical treatments did not increase in grip strength.

    Once the data were analyzed, the researchers came to the conclusion and agreed with the thought that there is no superior surgical procedure to treat either early-stage or late-stage Kienbock’s disease.

    Treatment for Wrist Fractures in Older Adults

    You might think that a broken bone is a simple affair: set it, put a cast around it, wait six weeks and it’s healed. But that isn’t always the case. Sometimes fractures separate and the two ends have to be brought back together and held in place until the bone heals.

    Surgeons are always trying to figure out the best way to treat displaced (separated) fractures. There are all kinds of factors to consider like the patient’s age, location of the fracture (does it include the joint?), and severity of the break.

    In this study, adults between 60 and 85 years of age with displaced distal radial fractures were treated in one of two ways. Distal radial fractures occur in the wrist at the end of the lower arm. The two groups were followed for at least one year and the results compared.

    Group one was treated with closed reduction and a plaster cast up to (but not including) the elbow. Closed reduction means the two ends of the bone could be put back together without an open incision and surgery.

    Group two had open surgery to line the bones back up and then were placed in an external fixator. The type of external fixator used had two pins through the radius (forearm bone) and two more pins through the bones of the hand. The pins were attached at both ends to a metal rod outside the arm.

    The goal was to see which type of treatment might be better for low energy trauma wrist (radial) fractures in older adults. Bone breaks from low energy trauma refer to fractures that occur when the person falls from a standing position. They could have tripped over something on the floor or lost their balance and fallen.

    Four main measures were used to compare the results: pain, range of motion, function, and grip strength. Since this was an older group of retired adults, function was defined as doing ordinary, every day activities. This could include carrying groceries, shoveling snow, cleaning house, or lifting a heavy pot or pan while cooking.

    It turns out that there was no difference in outcomes between the two treatment groups. For this older age group, it didn’t matter whether they were treated with a plaster cast or external fixation. At least that was true when using the four measures mentioned.

    There were some differences between the two treatment groups when comparing complication rates. For example, skin or wound infections (at the pin sites) were more common in the external fixation group. Patients in the external fixation group were also more likely to develop nerve damage or carpal tunnel syndrome.

    Patients in the plaster cast group had more cases of fracture redisplacement (i.e., bones separate again). This problem suggests that the plaster cast doesn’t stabilize the displaced fracture as well as external fixation does.

    Other studies have taken a look at types of fractures and differences in fixation devices (e.g., interlocking plates, internal pins, external pins). Results have had some wide ranging differences leaving some doubt as to whether those differences were age related or based on treatment chosen or both.

    The results of this study make it easy to see that at least for simple but displaced distal radial fractures, immobilization technique (cast vs. external fixation) doesn’t yield different results.

    The authors pointed out one other significant finding in both groups: grip strength and range of motion were still problems a year after treatment. Likewise, wrist stiffness and mild pain were persistent symptoms reported in both groups. It’s possible that with a different method of fixation, these lingering symptoms could be reduced. Further study is needed to find out for sure.

    Mayo Surgeons Review Surgical Treatment of Wrist Septic Arthritis

    With newer ways of performing surgery, surgeons often have a choice between using the traditional open incision versus the minimally invasive arthroscopic approach. In this article, surgeons from the Rochester, Minnesota Mayo Clinic discuss how these two methods compare when treating septic arthritis of the wrist.

    Septic arthritis refers to infection that has developed inside the joint, sometimes extending into the surrounding soft tissue structures. Surgery is done to wash out the infection and clean out any remaining damaged tissue. A sample of synovial fluid is taken from the joint and sent to the lab to identify the infectious organisms. Once the culture has been analyzed, the most appropriate antibiotic can be prescribed.

    This type of surgery called irrigation and debridement is considered a surgical emergency when septic arthritis has been diagnosed. The goal is to prevent destruction of the joint, spread of the infection to the bones (a condition called osteomyelitis), and necrosis (death of the wrist bones).

    Irrigation and debridement for septic arthritis usually involves two of the wrist joints: the radiocarpal joint (between the forearm bone on the thumb side and the base of the thumb) and the midcarpal joints (bones that form the mid-section of the wrist). A saline solution is used to gently flush affected areas, then the surgeon scrapes away any signs of infection or damage from the infection.

    Arthroscopy allows for a smaller incision than the open incision method. Patients are usually released from the
    hospital sooner and end up having fewer operations when this approach is used. But sometimes arthroscopy is contraindicated — in other words, it shouldn’t be done. The open incision method is used in those cases. Contraindications to arthroscopic wrist irrigation and debridement for septic arthritis include:

  • Previous surgery was done on the wrist
  • There is osteomyelitis of the bones
  • Infection has spread to other parts of the wrist that can’t be seen or reached with an arthroscope
  • Severe joint destruction is already present
  • Joint is too small to enter with a scope (e.g., infant or small child)

    The surgeon must always be aware of the potential for arthroscopic surgery to miss areas of infection or bone osteomyelitis. Failure to remove even a tiny portion of these infected areas will mean the infection can continue to spread and cause more problems.

    If fixation was used to hold the wrist in place during previous surgery (metal plate, screws, pins), infection can get under, around, or on the hardware. The arthroscope can’t show the surgeon these areas. And if surgery was already done on that same wrist, scar tissue and altered anatomy can prevent the surgeon from inserting the scope correctly without damaging nerves, blood vessels, bones, or soft tissue structures that have shifted from their normal anatomic location.

    To aid surgeons in performing arthroscopic wrist surgery, the authors provide color photos of the surgical set up (including patient in place and placement of television monitor for viewing by the surgeon). A special traction tower is used to hold the hand, wrist, and forearm in place during the procedure.

    A device called a finger trap applies traction to the wrist through the fingers. The set up makes sure there is equal pressure applied to all four fingers There is a photo of the assembled lens, camera, and light source. And a step-by-step description of the procedure is also included.

    The surgeons are careful to draw right on the patient’s skin an outline of the bones, tendons, and best spot for the scope to enter the joints. They provide specific directions for the placement of holes called portals where the scope can be inserted to give the best view but without damage to any of the structures. Angle of entry for each portal is described, amount of irrigation and technique to use, and even where and how to take photos of the joint structures are all points included in this review of surgical techniques.

    The authors conclude that the arthroscopic technique works best for patients with just one area of infection. When there are multiple sites of infection, an open procedure is advised. Patients do well with either approach but the chances of repeat operations are greater when there are multiple sites involved requiring open incision surgery. Length of hospitalization, potential for post-operative problems or complications, and costs are all greater for open incision surgery.

  • Can Titanium Plates Be Left in the Body Safely?

    Patients who have metal plates, pins, and screws in the body are rightfully concerned about the safety and long-term effects of these devices left inside. Surgeons share those concerns but do not want to perform an additional surgery to remove them if unnecessary. And sometimes when plates are used to hold bone together after a fracture, bone grows around them embedding this fixation device too much to remove it easily.

    So just how s
    afe are these devices? In this article, Dr. David G. Dennison from the Orthopedic Surgery department of Mayo Clinic in Rochester, Minnesota summarizes what we know from research and clinical studies on this topic. In particular, Dr. Dennison zeroes in on titanium volar plates used to treat distal radius fractures.

    Titanium has replaced stainless steel these days for fixation devices. It is more compatible with the human biology, which means it’s less likely to cause a reaction. When an inflammatory response does occur, it is mild and limited (doesn’t last). Titanium can also be combined with other metals such as cobalt, chromium, and molybdenum to create a lighter but more durable material.

    Volar plates refer to the location of fixation devices — placed on the front or inside of the forearm. Radius fracture tells us the radial bone in the forearm is broken. There are two bones in the forearm: ulna and radius. The radius is on the thumb-side of the forearm. Distal means the break is down toward the hand rather than up by the elbow.

    There are all kinds of concerns about metal plates. Animal studies show there is an effect on the immune system. There is evidence that the metal can cause the entire immune system to be suppressed (under functioning). This immune system shut down could result in infections. Some studies have shown that metal implants can cause an increase in white blood cells called lymphocyte reactivity. There is a worry that this effect could cause implant loosening or failure, though it hasn’t been proven yet.

    Another potential problem with titanium plates is the debris that occurs. Tiny flakes of this metal chip off and enter the bloodstream, nearby soft tissues, and/or joint. Both titanium and stainless steel have been found in all these anatomical areas of the human body (titanium slightly more often and in greater amounts than stainless steel). Metal debris is more likely to develop when the implant is rubbing against another surface. This wearing or rubbing phenomenon is called fretting.

    Then the question arises: can this metal debris lead to the formation of cancer? Studies in mice show there is the potential for metal wear debris to damage chromosomes making it a potential carcinogen (cancer producing). Next, developers of these products asked if coating the plate would protect the body from corrosion or metal debris? This question remains unanswered so far.

    One thing we do know from studies — placing a long titanium or metal pin down through the middle of a bone to stabilize it is linked with a much higher increase in the amount of metal found in the bloodstream. Chromium seems to have the highest levels reported for these intramedullary nails. Intramedullary titanium nails also increase the amount of titanium found in blood samples, but not as much as chromium. Evidently, the large surface area of the intramedullary nail exposes the bone to more titanium, thus the higher levels of serum (blood) metal.

    Removing titanium plates does slowly reduce the levels of metal in the blood and soft tissues. But it can take a year or more after removal to bring these elevated levels back down to normal. Dr. Dennison reports that there aren’t specific studies of the effects of titanium plates (prolonged use or removal) from the treatment of distal volar radial fractures.

    Summarizing, Dr. Dennison says that the information found on this topic seems to suggest that the overall level of risk when leaving titanium plates in the forearm is acceptable. The volar surface plate is not a large implant and doesn’t usually involve nails down through the bone. Instead, small screws placed perpendicular to the plate to hold it in place are more typical. Still, there are concerns and risks reported that deserve specific study and more conclusive answers. Future studies are needed to address these concerns and questions.

    Kienbock’s Disease: Staging and Treatments

    Kienbock’s disease is a disease that affects the small bones in the hand, near the wrist. For reasons that doctors and researchers don’t yet understand, the blood supply to the bone, the lunate is cut off. Without that blood supply, the cells in the bones die. At first, the person who has Kienbock’s disease may think he or she has sprained the wrist; it is only after it doesn’t get better when they seek help and a diagnosis. The authors of this article reviewed the case of a 30-year-old man who experienced wrist pain for three months, but did not do anything to the wrist to cause it.

    Upon reviewing the x-rays of the man’s wrist, the authors saw sclerosis (hardening or thickening) of the lunate bone and a possible fracture, but no other obvious problems. To determine if he had Keinbock’s disease, they had to review the classifications, staging, and if treatment was necessary.

    Staging Keinbock’s disease means identifying how far it has developed. The classification most often used is the Lichtman classification. Stage 1 of the disease doesn’t show any damage on x-ray or scans, while stage 2 shows some sclerosis and maybe a fracture line, as with the man identified above. Stage 3 is divided into 3A and 3B. Stage 3A has no collapse of the carpal tunnel, the tunnel through which the nerves run from the arm to the hand, while stage 3B does have carpal collapse. Finally, stage 4 involves the collapse along with arthritis.

    Treating the disease depends usually on these stages and begins with non-surgical treatments for stage 1 through to 3A. Splinting and/or casting may be all that is needed in stage 1, while medications may be introduced for stages 2 and 3A. Stages 3B and 4 usually need surgery. Many studies have been done to see which treatment is best. One study, by Delaere and colleagues, looked at 65 patients who were treated over a five-year period. Twenty-two did not have surgery and the rest were treated with some sort of surgery. The researchers found that those who did have surgery ended up with more change in social activities and a lesser range of motion in the affected wrist. While this may show that surgery may not be the best options, the authors of this article point out that in order to have surgery, the patients must have had a more advanced case of Kienbock’s disease. Other studies had similar findings but also had the same criticism. There is also more than one type of surgery that can be done for Keinbock’s disease. Some involve grafting bone or pinning the bones, while others shorten the affected bone, to name a few.

    Obviously, there is a need for more research into this uncommon disease.

    Returning to the patient described at the beginning, one author wrote that he does not treat asymptomatic disease, or Kienbock’s disease that is not showing any symptoms, but only those who are staged at stage 2 or higher. These, if they come in within six weeks, may get a splint or cast. If the symptoms don’t improve, surgery involving shortening the bone may be recommended.

    Wrist Fracture: Experts Say to Take Vitamin C

    Patients with fractures of the distal radius (wrist) are advised to take vitamin C to prevent a condition called complex regional pain syndrome (CRPS). Vitamin C may have the added bonus of speeding up healing. But how much should you take? And for how long — the rest of your life?

    These are questions addressed by the authors of this review article on the use of oral (by mouth) intake of vitamin C after distal radial fractures. Let’s define a few terms here starting with distal radius. There are two bones in the forearm that help make up the wrist joint (radius and ulna). The proximal end of those two bones is closest to the elbow. The distal end refers to the bottom of the bone at the wrist.

    Complex regional pain syndrome (CRPS) is a common problem after distal radial fractures but no one knows why exactly. The patient develops wrist and hand pain, swelling, and skin color changes. The pain and swelling are accompanied by a loss of motion and function. There can even be changes in skin temperature (warm or cold) and increased hair growth on the arm compared to the other (healthy) side.

    The first inkling anyone had that vitamin C could help prevent complex regional pain syndrome (CRPS) after wrist fracture came in 1999. The same researchers published a second study in 2007 confirming the benefits of vitamin C to prevent this condition. By comparing two groups with wrist fractures (those taking Vitamin C and patients who didn’t take the vitamin), it was clear that the group taking the vitamin had far fewer cases of CRPS.

    The group taking vitamin C in these two studies were further divided by how much (dosage) they took. Some took 200 mg daily, others 500 mg, and a third portion took 1500 mg of vitamin C. The results showed that 200 mg wasn’t enough to make a difference. That’s about how much the average person gets just through diet with four to five servings of fruits and vegetables. A difference wasn’t observed until patients took 500 mg. That’s called a beneficial dose-response. No further benefits were seen when patients took more than 500 mg of Vitamin C each day.

    How does the vitamin C work to prevent complex regional pain syndrome (CRPS)? Scientists aren’t entirely sure but vitamin C may reduce the number of free oxygen radicals that form as a result of the fracture and subsequent inflammatory healing process.

    Free radicals form when a normal oxygen atom loses an electron. Electrons like to be paired and the loss of one in the pair makes the oxygen atom unstable (a free radical). Vitamin C comes in and gives up an electron without becoming unstable itself. That makes vitamin C an antioxidant.

    A daily dose of 500 mg is advised for a period of 50 days. That’s about seven weeks and without any complicating factors, the average fracture heals within six weeks’ time. Not everyone should bump up their vitamin C intake. It’s best to consult with your doctor about his or her recommendations.

    There are some health problems for which large doses of vitamin C are not advised. For example, too much vitamin C can cause kidney stones in patients with diabetes. Anyone taking extra Vitamin C who develops diarrhea and/or abdominal bloating may be experiencing some mild adverse effects of this supplement. Patients are usually advised to back off on the dosage until the symptoms are gone.

    In summary, vitamin C is a safe, effective, and relatively inexpensive way to prevent complex regional pain syndrome following fracture of the distal radius. Taken in the recommended dosage, it may also speed up healing and recovery when there aren’t complicating factors. It’s not a magic cure — patients must still wear a splint or cast and receive follow-up hand therapy when needed.

    Sports Specialists Must Be Prepared for Athletes’ Wrist Injuries

    Sports medicine specialists such as orthopedic surgeons, physical therapists, and athletic trainers will find this article of interest. Sports-related wrist injuries are reviewed from top to bottom in order to prepare these health care professionals to help affected athletes recover quickly and successfully.

    Examination of the wrist and hand requires good knowledge of anatomy and understanding of biomechanical function. The authors use line drawings, photographs, X-rays, and CT scans to aid in presenting these concepts. For example, ligaments on all sides of the wrist (front, back, sides) link the many bones of the wrist together and hold them in place next to the bones of the forearm. Damage to any of these soft tissue structures can disrupt thumb, wrist, or forearm function.

    The most common soft tissue injuries include tears of the scapholunate ligament, triangular fibrocartilage complex (TFC or TFCC), and extensor carpi ulnaris (ECU) tendon rupture. Each of these injuries leads to shifts in the adjacent anatomical structures resulting in additional problems.

    Disruption of the scapholunate ligament allows two bones (the scaphoid and the lunate) in the wrist to shift and unlink from each other. Athletes who fall on an extended and slightly tilted wrist sustain this type of injury. The tilt is called an ulnar deviation — the hand is tilted toward the pinkie (little finger) side, which also happens to be on the same side as the ulna (one of two bones in the forearm). If the force of the injury is severe enough, the injury can extend through to other nearby ligaments causing a dislocation of the lunate carpal (wrist) bone. This additional injury is referred to as a perilunate dislocation.

    A particularly difficult injury to diagnose is the triangular fibrocartilage complex (TFC or TFCC) tear. This group of ligaments and cartilage forms a triangle along the ulnar side of the wrist holding several bones in place. The athlete with a TFC tear presents with a very painful wrist with loss of grip strength and tenderness to palpation (touch with pressure). X-rays and MRIs may be needed to confirm the diagnosis and direct treatment.

    Another injury mentioned (the extensor carpi ulnaris subluxation) creates a tear in the sheath or lining around the extensor carpi ulnaris (ECU) tendon. This sheath plays an important role in maintaining stability of the wrist where the radius (forearm bone on the thumb side) attaches to the wrist. A sudden, acute rupture of the ECU sheath is reported most often in tennis players, golfers, and baseball players.

    With all of these soft tissue injuries, the goal is to get the player back in the game as soon as possible. Early recognition of the problem and immediate treatment can help keep the injury from becoming severe and/or chronic. In some cases, a period of rest and immobilization may be necessary. Nonsteroidal antiinflammatory drugs (NSAIDs), steroid injections, and physical therapy are the mainstays of conservative (nonoperative) care.

    If the athlete does not get better, then surgery may be needed. Most of the surgical procedures can be done arthroscopically. The final (and most accurate) diagnosis can be made during the arthroscopic exam. Some players will do everything the can to put off surgery until the end of the season. This is called deferral of treatment and may not be advised. But coach, therapist, trainer, and surgeon work together to make the best recommendations.

    Some of the factors that will guide the decision include severity of injury, stability of the joint, type of sport, and position played. Of course, consideration is given to what might happen down the road if treatment is delayed putting the player at increased risk of another injury or reinjury. Pressure to return-to-play should not override player safety and health (both physical and mental health).

    Depending on the sport, some athletes can return-to-play with a cast on the arm, wrist, and hand. But if reconstructive surgery was done to repair the damage, then the player is on the bench for six to eight weeks or until X-rays show that everything has healed up nicely and the wrist is stable once again.

    Because sports-related wrist injuries are common, the authors presented this review to help sports health care specialists be prepared to recognize, evaluate, and treat these injuries. Delayed diagnosis, deferred treatment, or mistreated injuries can end an athlete’s career or end a college player’s scholarship opportunities. Reviews such as are presented in this article can assist sports medicine specialists keep up with details and information needed to handle common wrist injuries encountered during practice or competition.

    The Times Are A Changing With Today’s Seniors

    The authors of this study start out by saying, Approximately 10 per cent of 65 year-old white women in the United States will sustain a distal radial fracture during the remainder of their lifetime. A distal radial fracture is a wrist fracture. Ouch! That seems like a lot. And with the aging Baby Boomers now part of that statistic, that could be you, not your mother. So, now that they have our attention, what’s the message?

    Treatment for this problem seems to be changing. The authors review Medicare data for two separate time periods (1996-1997 and 1998-2005) to find out how this condition is being treated and by whom. They used the Medicare records to count up how many patients in this age group had open (surgery) versus closed (casting) treatment, type of surgery, and type of medical specialist treating the patient.

    With new treatment available now like the locking plate system to stabilize fractures, treatment can be more aggressive. But does it need to be? Does a more invasive, but potentially more stabilizing treatment improve function or speed up recovery? Do the benefits of surgery outweigh the cost? If not, then a study of the Medicare population like this can help guide patients, concerned family members, and physicians evaluating the cases.

    Sample data of patient information is collected routinely from Medicare Part B records by the Dartmouth Institute for Health Policy and Practice. The dataset is made available to other researchers like the authors of this study at the University of Michigan in Ann Arbor upon request for research purposes. Medicare Part B is especially useful because it includes patients ages 65 to 99, gender, race, diagnosis, and information on claims for fee-for-service patients. Age brackets are further broken down into groups less than 70 years old, 70 to 74, 75 to 79, 80 to 84, and 85 and older.

    There are also number codes to show what kind of doctor treated the patient (orthopedic surgeon, hand surgeon, family practice, emergency medicine) and to explain what services the physicians provided. Code numbers are given to each medical procedure so it is possible to use the codes to see how many people had what kind of surgery. The overall treatment options included: 1) closed treatment (cast or other immobilization), 2) percutaneous (through the skin) pinning, 3) internal fixation (plates, screws, pins, wires inside the arm), or 4) external fixation (screws placed through the bones with connecting rods outside the body).

    Here are a few key findings from this study. First, closed treatment was the most common way to treat a wrist fracture (specifically fracture of the radius bone, one of the two bones in the forearm). The use of external fixation was very low throughout the study period. But over time, there was a definite trend as surgeons started using internal fixation more and closed treatment less. Towards the end of the study, the use of cutaneous pin fixation started to go down, too.

    Most of the differences in what type of surgery was done seem to be based on the surgeon’s specialty. For example, hand surgeons were more likely to do open surgery; orthopedic surgeons were more likely to use closed reduction (set the bone and cast it without surgery). The hand surgeons were four times more likely to use internal fixation than the orthopedic surgeons. Treatment didn’t differ based on gender (male versus female) or based on race but age did seem to make a difference. Older patients were less likely to have surgery and more likely to be immobilized.

    The biggest surprise was the number of people treated for distal radial fractures by nonsurgeons, such as the primary care (family) doc or a physician in the emergency department. Of course, none of these medical doctors performed surgery, so all of those patients (about 10 per cent of the total number in the study) were treated with closed reduction (immobilization).

    There is come concern about treating older adults with closed reduction. It doesn’t realign the bones if they are separated or misaligned. The senior heals (if at all) with what’s called a malunion. This can result in stiffness, loss of motion, and decreased functional use of that hand. That’s why when the new volar locking plating system came on the market in 2000, more surgeons took advantage of this technique to get a better fracture healing and function in this age group. Volar just refers to the side of the arm the plates are put in (palmer side rather than the back of the hand/wrist side).

    The plating system is a contoured stainless steel implant that looks like a wrench with multiple holes in the rounded top end and all the way down the stem. It is used when there are complex fractures with multiple bone fragments. The system is laid flat against the bone. Screws can be placed in any of the holes where extra stability is needed.

    The implant can be slipped under the skin and placed where it’s needed, so it’s an internal fixation device that doesn’t require wide open incision and dissection of all the soft tissues. Studies done so far show the plating system speeds up recovery and reduces the amount of time immobilized. But the present study had no way to compare results, so whether or not this treatment approach is better must be determined by other researchers.

    The authors predict that future treatment of distal radial fractures in Medicare-aged patients will continue to shift toward more aggressive approaches as active seniors ask for treatment that won’t slow them down too much. Many of the methods previously used only in younger patients (e.g., internal fixation) will be used in older adults. And more innovative surgical approaches will be designed to take care of this age group efficiently yet safely.